Antimicrobial Stewardship in a Low Middle Income Country: Neurosurgeon’s Knowledge, Attitudes, and Practices Regarding Surgical Antimicrobial Prophylaxis in Pakistan

Surgical antimicrobial prophylaxis (SAP) is critical for preventing surgical site infections (SSIs), yet compliance with guidelines remains suboptimal in low-and middle- income countries (LMICs). This study aims to assess knowledge, attitude, and practices (KAP) regarding SAP among neurosurgeons in Pakistan. A prospective cross-sectional study was conducted among neurosurgeons in Sindh province, Pakistan (N=60). A questionnaire based on American Society of Health-System Pharmacists (ASHP) guidelines was used to assess demographics, knowledge (12 items), attitudes (11 items, 5-point Likert scale), and self-reported practices (13 items). Knowledge was categorized using Bloom’s cut-off (<60% correct = poor). Independent predictors of KAP scores were identified through multivariate linear regression. Most respondents were male (87%), FCPS-qualified (88%), with <6years’ experience (52%), 85% of neurosurgeons were classified as having poor knowledge. Although 92% agreed that SAP guidelines are needed and 88% acknowledged antimicrobial stewardship (AMS) importance, only 20% demonstrated positive attitudes (>72% score). Compliance with ASHP guidelines was 50%. Ceftriaxone was preferred over cefazolin (67% vs. 15%). FCPS qualification independently predicted higher knowledge (B=1.73, p=0.032), and government institutions independently predicted better practice (B=-0.94, p=0.023). Knowledge-practice correlation was moderate (r=0.54, p<0.001). Pakistani neurosurgeons demonstrate poor SAP knowledge, limited positive attitudes, and suboptimal compliance with guidelines. Knowledge is a stronger driver of practice compared to attitude. Targeted educational interventions and national/institutional guideline development are urgently needed.