Diagnosing antimicrobial stewardship needs in a pluralistic health system in India: Why Local Evidence Must Guide Implementation

Objective. To identify antimicrobial stewardship targets by triangulating provider knowledge and practice, government-facility prescribing indicators and patient-reported treatment experience in three districts of Chhattisgarh, India. Methods. We analysed three independently sampled cross-sectional components: a provider survey (171 providers), a World Health Organization and International Network for Rational Use of Drugs assessment (600 encounters at 20 government facilities) and patient exit interviews (371 consultations). We used descriptive indicators and multivariable ordinal or binary logistic regression. Findings. Among providers, 149 of 163 (91.4%) recognized antimicrobial resistance, but 131 of 163 (80.4%) reported providing antibiotics for colds or sore throats to at least some patients. Guideline familiarity was not associated with less frequent provision (adjusted common odds ratio [aOR], 1.13; 95% confidence interval [CI], 0.57-2.24; P=0.725). Government facilities prescribed antibiotics in 329 of 600 encounters (54.8%), with a facility range of 16.7-80.0%. In exit interviews, 131 of 142 informal-provider consultations (92.3%) involved a reported injection; informal providers accounted for 131 of 181 reported injections (72.4%). Clear or very clear instructions were associated with satisfaction (aOR: 13.66; 95% CI: 6.37-29.28; P<0.001). Conclusion. High awareness coexisted with frequent self-reported antibiotic provision, wide facility variation and sector-specific injection exposure. Stewardship programmes should diagnose local drivers before selecting interventions and prospectively evaluate adapted decision support, audit and feedback, independent drug information, informal-provider engagement and communication training.