Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death.

As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat.[1]

The emergence and spread of drug-resistant pathogens that have acquired new resistance mechanisms, leading to antimicrobial resistance, continues to threaten our ability to treat common infections. Especially alarming is the rapid global spread of multi- and pan-resistant bacteria (also known as “superbugs”) that cause infections that are not treatable with existing antimicrobial medicines such as antibiotics.[1]

AMR occurs naturally over time, usually through genetic changes. The main drivers of antimicrobial resistance include the misuse and overuse of antimicrobials; lack of access to clean water, sanitation and hygiene (WASH) for both humans and animals; poor infection and disease prevention and control in health-care facilities and farms;  poor access to quality, affordable medicines, vaccines and diagnostics; lack of mawareness and knowledge; and lack of enforcement of legislation.[1]

Antimicrobial resistance has the potential to affect people at any stage of life, as well as the healthcare, veterinary, and agriculture industries. This makes it one of the world’s most urgent public health problems.[2]

Antimicrobial stewardship program                                                                                                            

Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.[3]

The aim of an AMS programme is:

• to optimize the use of antibiotics;
• to promote behavior change in antibiotic prescribing and dispensing practices
• to improve quality of care and patient outcomes;
• to save on unnecessary health-care costs;
• to reduce further emergence, selection and spread of AMR; to prolong the lifespan of existing antibiotics;
• to limit the adverse economic impact of AMR;
• to build the best-practices capacity of healthcare professionals regarding the rational use of antibiotics.[4]

Aim

To assess awareness on antimicrobial drug resistance in Undergraduate and Postgraduate medical students in a teaching hospital.

Objectives

1.To assess the knowledge and attitudes among various year medical students regarding anti-microbial resistance.

2. Knowledge and awareness about antimicrobial stewardship programme among undergraduate students.

3. To determine how we can improve their practices and knowledge to reduce anti-microbial resistance.

Study design: Prospective cross-sectional survey.

Setting: Kamineni Institute of Medical Sciences, Narketpally, Telangana, India.

Study period: 3 months

Population and sampling: Undergraduate (all MBBS years and interns) and postgraduate medical students. Convenience sampling was used due to feasibility and online mode; all accessible students were invited via institutional channels for participation.

Inclusion criteria : Enrolled medical students willing to participate.

Exclusion criteria : Incomplete responses. Students who have not given consent.

Sample size: The minimum sample size was estimated using the single population proportion formula assuming p=0.5 (conservative), 95% confidence level, and 5% margin of error, yielding 291 for N=1200. To account for non-response (~10–20%), requirements for subgroup/year-wise analysis, and desire for higher precision (effective margin ~3–3.5%), a larger target was aimed for. A total of 662 voluntary responses were obtained, exceeding minimum requirements.

Data collection: Online Google Forms questionnaire with mandatory voluntary consent page. Responses were anonymous and confidential.

Tool: 16-item questionnaire adapted and modified from the WHO 2015 Antimicrobial Resistance Multi-Country Public Awareness Survey, with added items on ASP. Knowledge scored as 1 point per correct answer (maximum 16); multiple-correct questions (Q14, Q15) awarded full point only if all correct options selected. [5]

Ethics: Approved by the Institutional Ethics Committee of Kamineni Institute of Medical Sciences.

Analysis: Descriptive statistics (means ± SD, percentages). Differences across years assessed via one-way ANOVA or trend test (p < 0.05 significant).

Questionnaire

1)What are Antibiotic agents?

1. Drugs used to kill or retard bacterial growth
2. Drugs used to kill or retard viral growth
3. Both A and B
4. None of the above

2) What is antimicrobial resistance?

1. Drugs are effective in killing the microbes
2. Drugs are not effective in killing the microbes
3. Do not know

3) Can you get antibiotics from a pharmacist, without prescription as over the counter the drugs?

1. Yes
2. No
3. Under special circumstances

4) Is it necessary to take antibiotics for common cold and diarrhea ?

1. No
2. Yes, if the infection doesn’t subside for a long time.
3. Only when prescribed by a doctor

5) Can we stop antibiotic therapy after the symptoms subside?

1. Yes, therapy can be stopped.
2. No, we should complete the regimen

6) Can we take same antibiotic for all the members of a family for a particular symptom?

1. Yes, if both persons’ age is similar
2. Yes, if the symptoms are very similar
3. No, can’t be used

7) Can we take the same antimicrobial drug for subsequent appearance of similar symptoms?

1. Yes
2. No

  8) Can you start antibiotic therapy before collecting samples for microbiological examinations?

1. Can be started before giving sample
2. Can be started if the patient’s condition is serious
3. Can be started after giving the sample
4. Can’t be started under any circumstances

 9) People should use antibiotics only when they are prescribed by a doctor?

1. Yes
2. No
3. Can be taken by asking the pharmacist

10) Who needs to take responsibility for using antibiotics responsibly?

1. Only doctors are responsible
2. Only medical personnel such as doctors, nurses and paramedics are responsible
3. Everybody including medical personnel and patients are responsible

11) There is not much people like me can do to stop antibiotic resistance

1. A) Strongly disagree
2. B) Slightly disagree
3. C) Neither agree nor disagree
4. D) Slightly agree
5. E) Strongly agree

12) Can we increase or decrease the dose and duration of antibiotics depending upon the age of the person?

1. A) Yes
2. B) No
3. C) Do not know

13) Have you heard about antimicrobial stewardship programme?

1. Yes
2. No
3. Can’t remember

14) If yes, what is the function of antimicrobial stewardship programme? (Multiple correct)

1. Do not know
2. Promote the appropriate use of antimicrobials
3. Improve patient outcomes
4. Stoppage of use of antimicrobial agents
5. Reduce microbial resistance
6. Decrease spread of infection

15) Who all comprise the antimicrobial stewardship team? (multiple correct)

1. Medical students
2. Prescribing physician
3. Pharmacist
4. Nurse
5. Microbiologist
6. Patients

16) Would you, as a  medical student educate your family and friends about antimicrobial resistance and it’s role in treatment failures?

1. No
2. When possible
3. Yes

Key

1. A
2. B
3. B
4. C
5. B
6. C
7. B
8. C
9. A
10. C
11. A
12. B
13. A
14. B, C, E, F
15. B, C, D, E
16. C.

A total of 662 students has participated in the study with voluntary consent, of which 602 students were undergraduates and 60 students were postgraduates.

Percentage of participants from each year as follows

Average scores of each year students are given

The overall mean knowledge score was 9.01 ± 2.82 out of 16 (56.3%; 95% CI for mean: 8.80–9.22). Scores increased progressively with academic year. One-way ANOVA revealed significant differences across years (F = 48.15, p < 0.0001). Post-hoc Tukey HSD confirmed first 9and second-year students scored significantly lower than later years, while postgraduates scored highest (p < 0.01 for relevant pairs).

Awareness of antimicrobial stewardship programmes was limited: only 45% had heard of ASP, with a strong increasing trend across years (χ² = 82.13, p < 0.0001). Correct understanding of ASP functions and team composition was ≈40.0% (95% CI 36.3–43.7%) and ≈30%, respectively. Encouragingly, 80% (95% CI 77.0–83.0%) expressed willingness to educate others about AMR

The present study assessed the awareness of antimicrobial resistance (AMR) and antimicrobial stewardship programs (ASP) among 662 medical students at Kamineni Institute of Medical Sciences, Narketpally, Telangana, India, using a 16-item questionnaire adapted from the World Health Organization’s multi-country public awareness survey on AMR [5]. Overall, participants achieved a mean correct response rate of approximately 65%, reflecting moderate knowledge, with a clear year-wise progression from first-year students to postgraduates.

Notably, first- and second-year undergraduate students demonstrated the lowest mean scores (7 and 8, respectively), likely because they have limited or no clinical exposure and have not yet been adequately introduced to AMR and antimicrobial stewardship concepts in the curriculum. In contrast, knowledge levels improved progressively in later years, reaching a mean score of 10 among third-year and fourth-year students, and peaking at 11 among postgraduates. Postgraduate students exhibited greater knowledge due to their extensive clinical exposure and direct hands-on experience in patient management and antimicrobial prescribing. These patterns highlight that knowledge increases substantially with targeted training and practical exposure during clinical phases.

Undergraduate students showed a foundational understanding of key AMR principles—such as the ineffectiveness of antibiotics against viral infections and the necessity of completing prescribed courses—but revealed gaps in practical application and stewardship-specific knowledge. These findings are consistent with recent cross-sectional surveys among Indian medical students. A 2025 study by Saksena et al. among 208 undergraduate students reported an overall knowledge score of 73.75%, with high awareness of antibiotics’ bacterial specificity but low knowledge levels regarding practices like self-medication and dose-skipping [6]. Our questionnaire mostly emphasises public health aspects aligned with India’s National Action Plan on AMR.

Similarly, a multicentric intervention study of 599 final-year students across five Chennai colleges found baseline knowledge at 46.4% (mean pretest score 11.6/25), improving to 56% post-education (20% gain, P < 0.001), underscoring curriculum gaps in stewardship despite theoretical foundations [8].

A systematic review of 19 studies involving 2,776 medical students further corroborated this, reporting knowledge scores ranging from 52.69% to 96.00%, with higher scores in later years but consistent gaps in translating knowledge to practical use [9].

Awareness of ASP was notably lower in our cohort, with only ~40% of undergraduates correctly identifying its core functions (e.g., promoting appropriate antimicrobial use, improving patient outcomes, reducing resistance spread—question 14), and ~30% recognizing the multidisciplinary composition of stewardship teams (question 15). This aligns with a 2025 cross-sectional study of 500 Indian undergraduates, which revealed strong theoretical AMR knowledge but low ASP engagement, with only 47.6% receiving formal training and 16.8% participating in stewardship initiatives; trained students scored higher in knowledge (P=0.006), yet attitudes and practices showed no significant differences [7]. The Rana et al. review similarly highlighted lower positive attitudes toward AMR among students (52.78–89.00%) compared to other healthcare workers, despite good practices in some contexts (up to 83.45%), emphasizing the need for targeted stewardship education to bridge knowledge-practice disparities [9].

The moderate awareness observed in our study has implications for future prescribers in India, where AMR contributes to prolonged hospital stays, increased mortality, and escalating healthcare costs—exacerbated by over-the-counter antibiotic availability and empirical prescribing practices [1]. Training of MBBS students is particularly important for preventing AMR in the general population by reducing the misuse of antibiotics from the early stages of their careers. Encouragingly, 80% of participants expressed willingness to educate family and friends about AMR and its role in treatment failures, consistent with favorable attitudes reported in recent surveys (e.g., 85–97% viewing AMR as a health risk and supporting curriculum enhancements) [6,7].

Evidence-based interventions such as online modules have demonstrated 20% knowledge gains in final-year cohorts and should be piloted in teaching hospitals [8].

This cross-sectional survey of 662 medical students at Kamineni Institute of Medical Sciences demonstrated moderate awareness of antimicrobial resistance, with clear improvement across academic years driven by increasing clinical exposure. While foundational concepts of AMR were reasonably understood, awareness and comprehension of antimicrobial stewardship programmes remained limited, particularly among undergraduates.

These gaps highlight the urgent need to strengthen structured, practical training in antimicrobial stewardship from the early years of medical education. Such integration—through case-based learning, ward-based teaching, and multidisciplinary exposure—can equip future prescribers with the knowledge and mindset required to promote rational antimicrobial use.

Encouragingly, the strong willingness (80%) of participants to educate family and friends about AMR reflects a genuine commitment to collective responsibility. By acting on this potential through curriculum reform and sustained awareness efforts, medical training can better contribute to curbing antimicrobial resistance and protecting patient outcomes in India and beyond.

1. World Health Organization. Antimicrobial resistance [Internet]. Geneva: WHO; 2023 [cited 2025 Nov 12]. Available from: https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
2. Centers for Disease Control and Prevention. About antimicrobial resistance [Internet]. Atlanta: CDC; 2024 [cited 2025 Nov 12]. Available from: https://www.cdc.gov/drugresistance/about.html
3. Infectious Diseases Society of America. Antimicrobial stewardship [Internet]. Arlington: IDSA; 2023 [cited 2025 Nov 12]. Available from: https://www.idsociety.org/policy–advocacy/antimicrobial-resistance/antimicrobial-stewardship/
4. World Health Organization. Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: a WHO practical toolkit. Geneva: WHO; 2019. Available from: https://apps.who.int/iris/bitstream/handle/10665/329404/9789241515481-eng.pdf
5. World Health Organization. Antimicrobial resistance: multi-country public awareness survey. Geneva: WHO; 2015. Available from: https://apps.who.int/iris/bitstream/handle/10665/194460/9789241509817_eng.pdf?sequence=1&isAllowed=y
6. Saksena R, Parida A, Jain M, Gaind R. Antibiotic use and antimicrobial resistance: Knowledge, Attitude and Practices survey of medical students to evaluate undergraduate training curriculum. Access Microbiol. 2025;7(1):000638. doi:10.1099/acmi.0.000638.v4
7. Narasimha Murthy KM, Arun Hebbar JN, Naveen Kumar. Knowledge, attitudes, and practices toward antibiotic use and resistance among medical students: a cross-sectional study. Int J Basic Clin Pharmacol. 2025;14(5):760-4. doi:10.18203/2319-2003.ijbcp20252573
8. Vijayaraghavan BKT, Ranganathan L, Venkataraman R, Ramasubramanian V, Ramanathan Y, Sanmarkan AD, et al. Improving Antimicrobial Resistance Awareness Among Medical Students in India: The Sensitization of Medical Students on Antimicrobial Resistance (SOS-AMR) Study. J Med Educ Curric Dev. 2024;9:23821205241239842. doi:10.1177/23821205241239842
9. Rana S, Kaur KN, Narad P, Walia K, Saeed S, Chandra A, et al. Knowledge, attitudes and practices of antimicrobial resistance awareness among healthcare workers in India: a systematic review. Front Public Health. 2024;12:1433430. doi:10.3389/fpubh.2024.1433430.