A multi-seasonal mixed-method point-prevalence study of antibiotic prescription patterns in a tertiary healthcare facility in India

Background Point prevalence surveys (PPS) are a core tool of the WHO Global Action Plan on antimicrobial resistance (AMR), yet their implementation in low- and middle-income countries (LMICs) remains limited by weak prescribing and surveillance systems. We conducted a multiseasonal mixed-method PPS, integrating quantitative prescribing data with qualitative ward observations, and the behavioural and operational factors shaping antibiotic prescribing and use of culture testing in a tertiary-care hospital in northern India. Methods A hospital-wide PPS was conducted across autumn (November 2023), summer (April 2024), monsoon (August 2024), and winter (January 2025), with each phase comprising a two-week data collection episode, following WHO Global-PPS methodology. Data were collected from five inpatient departments (Medicine, Surgery, Obstetrics-Gynaecology, adult, paediatric, and neonatal intensive care units (ICUs) using standardised forms. Quantitative data on indications, routes, and AWaRe categories were supplemented with ward observations and inpatient follow-up to assess culture testing, antibiotic sensitivity test (AST) use, and treatment modifications. Results A total of 1,680 inpatients were surveyed. Ceftriaxone (30–33%), Piperacillin–tazobactam (9–20%), and Doxycycline (8–16%) were the top prescribed antibiotics. Azithromycin use dropped sharply after the first phase. Amikacin (6–9%) and Meropenem prescribing (4–7%) remained low. Empirical prescribing dominated (63–67%), while culture-guided therapy remained ≤ 6%. Over 80% of antibiotics were given parenterally. Watch antibiotics accounted for 46–56% of prescriptions, Access 35–51%, and Reserve ≤ 4%. Prophylactic use ranged from 24–30%, and combination therapy was common in the ICU. Clinical diagnoses showed seasonal variation, with gastrointestinal (20–22%) and chronic conditions (17–23%) most frequent, and respiratory infections (3–9%) peaking in monsoon and winter. Antibiotic modification following AST occurred in only 4.7–6.5% of cases. Qualitative findings highlighted stock-outs of oral antibiotics, delays in culture sampling, and documentation gaps during patient transfers, limited stewardship activities, collectively reinforcing broad-spectrum empirical use. Conclusions This PPS found high empirical and broad-spectrum antibiotic use, limited culture-based prescribing, and systemic gaps hindering stewardship. Strengthening diagnostic access and use, ensuring drug availability, and embedding multidisciplinary stewardship teams with real-time feedback are essential to promote evidence-based prescribing in resource-limited settings.