Adherence to CDC Antimicrobial Stewardship Core Elements and Barriers to stewardship practices among Healthcare Workers at a Tertiary Care Hospital Uttarakhand, India

This study of 355 healthcare workers at a tertiary care hospital in Uttarakhand, India, reveals moderate adherence (52.3%) to CDC antimicrobial stewardship core elements, which is significantly hindered by systemic barriers such as drug shortages, personnel deficits, delayed lab reports, and insufficient training.

The Gist

Imagine a hospital as a massive, high-tech kitchen. In this kitchen, the chefs (doctors and nurses) use powerful spices called antibiotics to cure infections. But here's the problem: if they use too much, or the wrong kind, the "bugs" (bacteria) learn how to dodge the spices. They become super-bugs that no spice can kill. This is called Antimicrobial Resistance (AMR), and it's a global emergency.

To stop this, the CDC (the health rule-makers) created a Stewardship Program. Think of this as a "Master Recipe Book" and a set of strict kitchen rules to ensure the spices are used wisely, only when needed, and in the right amounts.

This study took place at a big teaching hospital in Uttarakhand, India. The researchers wanted to answer two simple questions:

1. Are the chefs actually following the Master Recipe Book?
2. What is stopping them from following it?

Here is the story of what they found, explained simply.

1. The Scorecard: How are they doing?

The researchers gave the hospital staff a checklist based on the CDC's rules.

• The Result: The hospital scored about 52 out of 100. That's a "C" grade. It's not failing, but it's definitely not passing with flying colors.
• The Good News: The chefs were pretty good at the action parts. When a patient had a specific infection (like a bad urinary tract infection or sepsis), the doctors knew which antibiotic to pick. They were good at the "cooking" part.
• The Bad News: They were struggling with the "kitchen management" part.
  • Leadership: The head chef wasn't always giving the team enough time or money to manage the spices properly.
  • Accountability: There wasn't always a specific person in charge of watching the spice usage.
  • Education: The staff wasn't getting enough training on why the rules matter.
  • Reporting: They weren't sharing their data with the rest of the hospital network to learn from each other.

2. The Roadblocks: Why aren't they doing better?

You might ask, "If they know the rules, why aren't they following them perfectly?" The study found that the chefs are trying to cook in a kitchen with broken ovens and missing ingredients.

Here are the biggest barriers, using our kitchen analogy:

• The "Empty Pantry" (89%): The most common complaint was that they simply didn't have the right spices (antibiotics) in stock. You can't follow a recipe if the ingredients aren't there!
• The "Missing Staff" (88.5%): They didn't have enough specialized helpers. They needed more expert pharmacists and microbiologists (the "spice scientists") to guide the chefs, but those roles were empty.
• The "Slow Delivery" (85.1%): When a chef needs to know if a specific spice will work, they send a sample to the lab. But the lab reports were taking too long to arrive. By the time the answer came, the patient was already getting sicker, so the doctor just guessed and used a strong spice anyway.
• The "No Training Manual" (83.9%): Many staff members had never been taught the new rules. They were cooking by instinct, not by the Master Recipe Book.
• The "Boss Who Doesn't Care" (79.2%): The administration (the restaurant owners) wasn't giving enough support, time, or money to make the program work.

3. Who is struggling the most?

The study found that the barriers weren't felt equally by everyone.

• Where you work matters: Doctors in the emergency room or intensive care units felt the pressure and lack of resources more than those in quieter departments.
• Your job title matters: Nurses and junior doctors felt the lack of training and support more acutely than senior experts.
• Experience matters: Even experienced staff felt stuck because the system (the kitchen) wasn't set up to help them.

The Big Takeaway

The study concludes that while the doctors and nurses want to do the right thing, they are fighting a losing battle against a broken system.

The Analogy: Imagine trying to drive a race car (saving lives) with a flat tire, no fuel, and a map that's missing half the pages. The driver (the doctor) is skilled, but the car (the hospital system) is holding them back.

What needs to happen?
To fix this, the hospital needs to:

1. Stock the pantry: Ensure antibiotics are always available.
2. Hire the experts: Bring in more pharmacists and lab scientists.
3. Speed up the delivery: Make lab reports come back faster.
4. Train the team: Teach everyone the new rules clearly.
5. Get the boss on board: The hospital leadership needs to promise time, money, and support to make these changes stick.

If they fix the kitchen, they can stop the super-bugs from taking over, ensuring that when people get sick, the medicine still works.

Technical Summary

1. Problem Statement

Antimicrobial Resistance (AMR) is a critical global health threat driven largely by the inappropriate and irrational use of antimicrobial agents. While Antimicrobial Stewardship Programs (ASPs) guided by the Centers for Disease Control and Prevention (CDC) core elements are the standard framework for optimizing antimicrobial use, their implementation remains inconsistent, particularly in resource-limited settings like India.

• The Gap: There is a paucity of evidence regarding the specific level of adherence to CDC stewardship checklists and the multifaceted barriers (systemic, resource-related, and behavioral) faced by frontline healthcare workers in tertiary care hospitals in India.
• Objective: To assess the adherence to the CDC antimicrobial stewardship checklist and identify the specific barriers hindering effective stewardship practices among healthcare workers at a tertiary care hospital in Uttarakhand.

2. Methodology

• Study Design: A quantitative, cross-sectional descriptive study.
• Setting: A tertiary care teaching hospital in Uttarakhand, India.
• Participants: 355 healthcare workers, comprising nursing officers and physicians, recruited via convenience sampling from selected clinical areas.
• Data Collection Instruments:
  1. Sociodemographic Questionnaire: Captured age, gender, designation, qualification, experience, and committee membership.
  2. CDC Antimicrobial Stewardship Checklist: Assessed adherence across seven core domains (Leadership, Accountability, Pharmacy Expertise, Action/Interventions, Tracking, Reporting, and Education).
  3. Self-Structured Barrier Assessment Tool: A 14-item questionnaire evaluating perceived barriers. It demonstrated acceptable reliability (test–retest $r = 0.78$) and content validity via expert review.
• Data Collection Period: October 2024 to February 2025.
• Statistical Analysis: Data were analyzed using SPSS version 23.0. Descriptive statistics (frequencies, percentages, means) summarized adherence and barriers. Inferential statistics (Chi-square, Mann–Whitney U, Kruskal–Wallis, Spearman's correlation) assessed associations between barriers and sociodemographic variables. Significance was set at $p \leq 0.05$.

3. Key Contributions

• Contextual Evidence: Provides one of the few empirical assessments of CDC core element adherence specifically within an Indian tertiary care setting, bridging a gap in literature regarding resource-constrained environments.
• Barrier Profiling: Moves beyond general observations to quantify specific systemic barriers (e.g., supply chain, personnel shortages) and behavioral barriers (e.g., fear of patient deterioration) affecting ASP implementation.
• Demographic Correlations: Identifies that adherence and perceived barriers are not uniform but are significantly influenced by professional designation, qualification, work experience, and departmental location.

4. Key Results

A. Adherence to CDC Core Elements

• Overall Adherence: The mean adherence to the CDC checklist was 52.3%, indicating moderate compliance.
• Domain-Specific Performance:
  • High Adherence: Action-oriented interventions showed the best performance. Notably, specific protocols for Urinary Tract Infections (78.3%) and Sepsis (73.5%) were well-established. Documentation policies (dose, duration, indication) were followed in 67.9% of cases.
  • Low Adherence: Structural and organizational domains were significantly weaker:
    • Accountability: Only 45.4% had designated program leaders.
    • Pharmacy Expertise: Only 45.6% had pharmacists leading implementation, and 45.4% had specific stewardship training.
    • Reporting & Feedback: Less than half of the facilities shared data with prescribers or reported to national surveillance systems (NHSN).
    • Education: Only 43–47% of facilities provided regular education to prescribers.

B. Identified Barriers

The study identified a high burden of barriers, with the top five being:

1. Lack of Antimicrobial Supply: 89.0%
2. Shortage of Key Personnel (ID specialists, pharmacists, microbiologists): 88.5%
3. Delays in Laboratory Reports (specifically sensitivity testing): 85.1%
4. Lack of Training/Orientation: 83.9%
5. Inadequate Administrative Support: 79.2%

Other significant barriers included financial constraints (80.3%), lack of reliable institutional antibiograms (78.9%), and time constraints (78.6%). A notable behavioral barrier was the reluctance of 73.2% of workers to change prescriptions due to fear of patient deterioration.

C. Associations with Sociodemographics

• Significant Factors: Working area, designation, qualification, and total work experience showed statistically significant associations ($p < 0.05$) with the perception of barriers. For instance, seniority and specific qualifications influenced the perception of administrative support and training gaps.
• Non-Significant Factors: Age and gender showed no significant association with the perceived barriers.

5. Significance and Conclusion

• Clinical Implication: The study highlights that while clinical interventions (like treating sepsis) are relatively well-managed, the infrastructure required to sustain stewardship (leadership, accountability, tracking, and education) is critically underdeveloped.
• Policy Recommendation: To combat AMR effectively, interventions must move beyond clinical guidelines to address systemic failures. The authors recommend:
  • Strengthening institutional leadership and accountability frameworks.
  • Investing in workforce capacity (training for pharmacists and ID specialists).
  • Improving laboratory infrastructure to reduce diagnostic delays.
  • Establishing robust national and institutional guidelines and IT infrastructure for surveillance.
• Conclusion: Adherence to antimicrobial stewardship in this setting is moderate but hindered by a complex interplay of resource limitations and organizational gaps. Targeted, multi-level interventions focusing on infrastructure, training, and administrative commitment are essential to optimize antimicrobial use and mitigate the threat of AMR.

Note: This paper is a preprint (posted March 28, 2026, on medRxiv) and has not yet undergone peer review.