Antibiotic prescription practices and stewardship readiness among private practitioners in India: A cross sectional study

Background In the majority of the LMICs, the private sector accounts for a substantial proportion of antibiotic use but remains weakly integrated into antimicrobial stewardship and surveillance systems. Understanding the stewardship practices in this sector requires examination of both provider behaviour and system level enablers. Methods This is a cross-sectional study conducted among private medical practitioners in the Udupi district of South India, using a validated knowledge, attitude, and practice questionnaire, assessing prescribing behaviour for common infectious syndromes, and evaluating the availability of stewardship-enabling infrastructure. Antibiotic prescriptions are assessed using the WHO Access, Watch, Reserve (AWaRe) classification. Descriptive and comparative analysis is conducted. Results A total of 141 practitioners participated in the survey (response rate 65.2%). KAP scores were generally favourable for antimicrobial resistance and stewardship. However, watch category antibiotics were commonly prescribed for self-limiting infections and community-acquired infections, whereas Access category antibiotics remained low. Despite access to a microbiology laboratory, there was limited utilisation of culture and sensitivity tests. Formal sterwadship structures, training and resistance patterns were uncommon. Overall, KAP scores did not differ significantly across individual practitioner level characteristics, suggesting systemic drivers for inappropriate use rather than individual factors. Conclusion In private health care settings, antibiotic prescription practices are shaped less by knowledge deficits and more by the structural gaps, such as the absence of guidelines, limited diagnostic stewardship, and weak stewardship governance. Effective AMS strategies should extend beyond education to address system-level enablers and accountability in the private health care. Trial Registration: The study was registered in the Clinical Trial Registry of India (CTRI/2021/01/030448) on 14th January, 2021 URL:https://ctri.nic.in/Clinicaltrials/regtrial.php?trialid=50974&EncHid=24540.89288&modid=1&compid=19