Veterinary antimicrobial stewardship in coastal Karnataka: A mixed-methods district-level assessment of prescribing practices, system gaps, and One Health implications

Background and Aim: Antimicrobial resistance (AMR) is a growing global health threat with significant implications across human, animal, and environmental sectors. In veterinary settings, inappropriate antimicrobial use accelerates the emergence and dissemination of resistant pathogens through the food chain, direct contact, and environmental pathways. Despite national action plans, evidence on antimicrobial stewardship (AMS) at subdistrict levels remains limited, particularly in low-and middle-income countries. This study aimed to assess veterinarians' knowledge, attitudes, and practices (KAP) regarding AMS and to identify system level drivers influencing antibiotic prescribing in the Udupi district of coastal Karnataka, India. Materials and Methods: A cross-sectional mixed-methods design was employed between April 2021 and March 2023. Quantitative data were collected using a structured KAP survey administered to all registered veterinarians in the district, while qualitative insights were obtained through in-depth semi-structured interviews. Descriptive statistical analysis was conducted for survey data, and thematic analysis was applied to qualitative data to explore contextual determinants of prescribing behavior. Results: Of 43 eligible veterinarians, 27 participated (response rate: 62.7%). Mean scores for knowledge, attitude, and practice were 16.7, 47, and 9, respectively, indicating moderate knowledge and attitudes but suboptimal practices. High reliance on the highest priority critically important antibiotics, including enrofloxacin (77.8%) and ceftriaxone (66.7%), was observed for common conditions such as mastitis and enteritis. Although 59.3% reported access to microbiology laboratories, only 37.1% regularly utilized culture and sensitivity testing. Qualitative findings revealed that prescribing practices were shaped by interconnected systemic, economic, and socio-cultural factors, including diagnostic constraints, treatment costs, client expectations, and informal antibiotic access. A notable gap between awareness and implementation of AMS principles was identified. Conclusion: This study highlights critical gaps in veterinary AMS at the district-level, characterized by overreliance on critical antibiotics, limited diagnostic utilization, and systemic barriers to evidence-based prescribing. Effective AMS implementation requires context-specific interventions, including mandatory training, improved diagnostic infrastructure, locally tailored prescribing guidelines, and multisectoral coordination under a One Health framework.