Antimicrobial Stewardship Knowledge Trails Practice at an Ethiopian Tertiary Hospital
At Tikur Anbessa Specialized Hospital in Addis Ababa, healthcare professionals expressed broad support for guideline-based antibiotic prescribing, yet their knowledge of antimicrobial stewardship and the WHO AWaRe classification lagged behind that favorable attitude. The gap matters because stewardship fails when clinicians approve the principle but cannot consistently apply the classification system that is meant to shape everyday antibiotic choice, dose selection, and escalation decisions.
This institution-based cross-sectional study, conducted in 2025, included 319 records from 321 submitted questionnaires after informed consent review. Responses were collected with a structured self-administered tool and analyzed in SPSS version 28. The design does not measure prescribing behavior directly, but it does capture the front-end conditions that determine whether stewardship can function inside a busy tertiary hospital: baseline knowledge, shared terminology, and willingness to work within guidelines.
Over half of participants, 59.6%, had heard of AMS, yet only 150 respondents, or 47%, selected the correct description of the term. Awareness of AWaRe was even thinner. Just 114 participants, 35.7%, had heard of the classification, 105, or 32.9%, correctly identified WHO as its publisher, and 97, or 30.4%, recognized the WHO Model List of Essential Medicines as the source of AWaRe-classified antibiotics. In a system built around rational antibiotic use, those gaps can slow down the move from abstract policy to real bedside decision-making.
AWaRe Familiarity Was Uneven Across Antibiotic Classes
The clearest strength in knowledge appeared in the Access category. Amoxicillin was correctly classified by 86.4% of respondents, and ampicillin by 71.8%. Those are familiar agents in routine care, and their relative simplicity may help explain the stronger performance. Their classification is clinically consequential because Access antibiotics are intended to anchor empiric therapy where appropriate, reducing unnecessary reliance on broader-spectrum agents.
Performance worsened as the classification moved into the more complex and restrictive groups. Misclassification was common for Watch and Reserve antibiotics, the very categories that demand the most restraint because they are more vulnerable to overuse and resistance selection. In practical terms, weak recognition of these groups can lead to therapeutic drift: broader agents are used too early, de-escalation is delayed, and the pressure that drives antimicrobial resistance remains unchecked.
One result cuts through the rest of the data. Only 54.16% of participants correctly classified antibiotics according to WHO AWaRe.
Positive Prescribing Attitudes Outran Institutional Capacity
Attitude data told a different story. A large majority, 293 participants or 91.8%, expressed a positive attitude toward guideline-based antibiotic prescribing. That is encouraging, but attitude alone does not deliver stewardship. When clinicians lack training, tools, or institutional reinforcement, favorable opinions can remain detached from actual prescribing behavior.
The most frequently cited barrier was inadequate training, reported by 75.2% of respondents. Limited resources followed at 37.6%, while inadequate access to monitoring tools and technology affected 27.6%. Insufficient patient awareness and engagement was cited by 27%. Each of these barriers reflects a different failure point in stewardship infrastructure. Training shapes knowledge. Monitoring tools shape accountability. Patient engagement shapes adherence and the ability to explain why a narrow-spectrum choice may be the safer choice.
The pattern suggests a hospital workforce that is not resistant to stewardship in principle; it is under-supported in practice. That matters in a tertiary referral setting, where complex infections, high antibiotic turnover, and frequent empiric treatment decisions can quickly magnify small gaps in knowledge.
Training Priorities Point to the Most Repairable Weaknesses
Participants also identified the areas where they most wanted education. AMS principles topped the list at 69.3%, followed by antibiotic classification at 48.3%, and appropriate antibiotic selection and dosing at 45.5%. Those priorities are clinically useful because they map closely onto the observed weaknesses in the dataset. If staff are asking first for AMS fundamentals and classification training, the institution has a clear target for intervention rather than a vague call for awareness-building.
The stewardship implications are straightforward. A hospital that can strengthen familiarity with AWaRe terminology, reinforce the logic behind Access, Watch, and Reserve choices, and provide accessible prescribing support tools is more likely to reduce inappropriate broad-spectrum use. Infections do not wait for policy documents, so the operational value lies in training that changes what clinicians do during routine prescribing decisions, not merely what they believe in theory.
Local Stewardship Programs Need Institutional Backing
The study was confined to a single tertiary hospital, so the findings should not be treated as a national estimate for Ethiopia. Even so, the hospital setting makes the results hard to ignore. Tertiary centers often carry the heaviest antimicrobial burden and set prescribing norms for surrounding facilities. If knowledge gaps are already visible there, similar or greater gaps may exist in less resourced settings where formal stewardship infrastructure is thinner.
The data also point to a familiar implementation problem in antimicrobial stewardship: awareness campaigns are not enough when systems for audit, feedback, monitoring, and decision support are weak or absent. AWaRe is designed to be practical, not decorative. Its value depends on whether clinicians can locate the classification, recognize where a drug sits within it, and translate that information into prescribing restraint when a Watch or Reserve agent is being considered.
Clinical stewardship succeeds when knowledge, tools, and institutional expectation move in the same direction. Here, the attitude was already largely favorable. The remaining task is to supply the training and infrastructure that allow that attitude to reach the prescription pad.