Knowledge, attitude and practice regarding antibiotics and antimicrobial resistance among healthcare workers in western China: a COM-B-based cross-sectional study

Antimicrobial resistance (AMR) is largely driven by inappropriate antibiotic use. Healthcare workers (HCWs) are central to antimicrobial stewardship, but evidence from under-resourced multi-ethnic regions of China is limited. We used the Capability-Opportunity-Motivation-Behaviour (COM-B) framework to examine HCWs’ knowledge, attitudes and practices regarding antibiotics and AMR in Sichuan’s Tibetan areas. We conducted a cross-sectional survey from 6 to 15 May 2026 across 20 hospitals in Aba and Garzê Tibetan Autonomous Prefectures. Data were collected via a locally validated online questionnaire adapted from a 30-country European survey. Antimicrobial knowledge was analysed using ordinal logistic regression adjusting for hospital level, sex, profession, title and practice years; Firth correction was applied for sparse data. Attitudes and behaviours were summarised descriptively. Among 365 participants, the average correct rate for 14 knowledge items was 83.4% (95% CI 81.8%–84.9%, average proportion of correct answers per participant), yet only 37.5% (95% CI 32.7%–42.6%) answered all eight core questions correctly (physicians 50.3% [95% CI 42.8%–57.8%], pharmacists 33.3% [95% CI 23.5%–44.8%], nurses 23.3% [95% CI 16.2%–32.3%]), with marked variation by profession and years of experience. Nurses had higher error risk than physicians on basic items; pharmacists were more error-prone on resistance transmission; junior staff had nearly four times the error risk of senior colleagues (aOR = 3.83). Notably, those with 0–10 years’ experience outperformed veterans with > 20 years on newer AMR concepts. Although 99.2% supported rational prescribing, substantial behavioural gaps existed. Approximately one-third prescribed empirically, either due to deterioration concerns or against their judgment; nearly all reported willingness for public health education, yet far fewer implemented such activities routinely. Among recent prescribers, positive attitudes did not always translate into practice when self-reported access to guidelines and continuing education remained incomplete. Antimicrobial knowledge varies substantially by occupation and seniority. Notably, many participants relied on informal digital platforms (e.g., WeChat, Baidu, Douyin) for knowledge acquisition, a finding that should inform future stewardship interventions. Stewardship programmes should consider stratified training and better diagnostic support to reduce AMR risks.