Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia

Introduction

Antimicrobial Resistance (AMR) has emerged as a critical global health threat contributing to increased morbidity and mortality, with projections estimating up to 10 million deaths annually by 2050 (Bajpai et al. 2025; Belay et al. 2025). The rise of multidrug-resistant bacterial infections leads to prolonged hospital stays, higher mortality rates, and limited treatment options. Standard therapeutic regimens are becoming less effective as drug-resistant pathogens complicate the management of common infections, rendering routine medical procedures such as surgeries, childbirth, and treatments for immunocompromised patients significantly riskier (Stewart, Wright, and Hajkowicz 2019; Tang, Millar, and Moore 2023). Furthermore, the emergence and spread of multidrug-resistant “superbugs” exacerbate the challenge of infection control, particularly within healthcare settings, posing a serious barrier to achieving optimal health outcomes and sustainable antimicrobial management (Bava et al. 2024; Hossein and Ripanda 2025). Antimicrobial Resistance (AMR) significantly increases healthcare costs due to prolonged hospitalizations, the need for intensive care, and the use of costly alternative drugs, with projections indicating a potential global GDP decline of 1.1% to 3.8% by 2050 (Bajpai et al. 2025; Dadgostar 2019; Majumder et al. 2020).

The growing prevalence of antimicrobial resistance (AMR) is largely driven by the excessive and inappropriate use of antibiotics that often fail to adhere to clinical guidelines, creating selective pressure that fosters the emergence of resistant bacterial strains (Getahun 2023; Romero-Rodríguez et al. 2024; Singh et al. 2024). This issue is further intensified by the limited availability of laboratory facilities for antimicrobial sensitivity testing, compelling healthcare professionals to depend on empirical or broad-spectrum antibiotic therapy (Khaitovych et al. 2025; Koroma et al. 2023; Mathew, Ranjalkar, and Chandy 2020). Such practices accelerate the survival and propagation of resistant bacteria, thereby exacerbating the global AMR crisis and highlighting the urgent need for strengthened antibiotic stewardship, improved diagnostic infrastructure, and stricter adherence to evidence-based prescribing practices (Sain, Manohar, and Gowda 2020; Sharma et al. 2024; Sinha and Upadhyay 2025).

Pharmacists play a pivotal role in Antimicrobial Stewardship (AMS) programs by optimizing antimicrobial use and contributing to the global effort to reduce antimicrobial resistance (Donaldson and Mefford 2024; Parente and Morton 2018; Wong et al. 2021). Their involvement has been shown to significantly improve patient outcomes, enhance the appropriateness of antibiotic prescribing, and support the rational use of antimicrobials (Qian et al. 2025; Sadeq et al. 2021). However, challenges such as limited training opportunities, insufficient institutional support, and interprofessional collaboration barriers continue to hinder their full participation in AMS initiatives. Building mutual understanding among pharmacists, nurses, and physicians is essential to ensure the success of antimicrobial stewardship efforts (Manning et al. 2022; Wakob, Schiek, and Bertsche 2023). Therefore, sustained institutional support, specialized education, and the development of innovative, collaborative care models are essential to strengthen and expand the pharmacists’ role in advancing effective AMS implementation (Sneddon, Gilchrist, and Wickens 2014; Waters 2015; Wong et al. 2021).

National efforts to strengthen the implementation of the Antimicrobial Stewardship Program (ASP) in Indonesia have been initiated through the development of locally adapted, evidence-based antibiotic use guidelines. The application of these guidelines has been shown to reduce antibiotic consumption by up to 77% in intensive care units, decrease mortality rates, and shorten patients’ length of hospital stay (Herawati et al. 2020; Karyanti, Pudjiadi, and Faisal 2020; Lutfiyati et al. 2022).

Surveys indicate that although most pharmacists in Indonesia demonstrate high awareness of the importance of ASP, many still lack confidence in performing their clinical roles due to limited training opportunities and insufficient institutional support (Muteeb et al. 2023; Wali et al. 2025). Enhancing pharmacists’ competencies through continuous professional education and structured ASP training is essential to reinforce antimicrobial resistance control efforts in Indonesian hospitals (Qian et al. 2025; Tahoon et al. 2020; Teoh et al. 2020). Therefore, this study aims to evaluate the impact of ASP training interventions on the improvement of hospital pharmacists’ competencies and to examine their relationship with the achievement of ASP objectives at the institutional level.

Methods

Result

Discussion

This study demonstrated that the Antimicrobial Stewardship Program (ASP) training intervention significantly enhanced hospital pharmacists’ competence, particularly in qualitative and quantitative antibiotic use audits. Nearly all participants exhibited improved knowledge, analytical skills, and understanding of rational antibiotic use principles. However, this increase in individual competence did not translate into a statistically significant improvement in hospital-level ASP implementation scores. Similar to findings by Setiawan et al, challenges such as hierarchical culture, limited interprofessional collaboration, and power asymmetry between physicians and pharmacists may hinder the translation of individual learning into institutional change (Setiawan et al. 2022). Hashad et al. also emphasized that successful ASP implementation depends not only on the competence of pharmacists but also on leadership engagement, structured planning, and effective communication among ASP teams (Hashad et al. 2023). While training successfully improved pharmacists’ capabilities especially in performing qualitative and quantitative antimicrobial audits sustainable ASP progress in hospitals requires stronger managerial support, resource allocation, and an integrated, multidisciplinary culture that empowers pharmacists to apply their enhanced competencies in practice (Chitavi et al. 2025).

Most of the pharmacists who participated in this study were graduates of professional pharmacy programs, while the number of those with master’s degrees remained very limited. Only a small proportion held a Master’s degree in Clinical Pharmacy, a discipline crucial for integrating clinical pharmacology and microbiology knowledge to support evidence-based antibiotic therapy decisions. The scarcity of pharmacists with advanced clinical expertise limits their active involvement in antimicrobial stewardship (AMS) teams. This finding aligns with the conclusions of Sakeena et al., who emphasized that in many developing countries, pharmacists’ roles in AMS remain suboptimal due to the lack of advanced clinical training and institutional barriers that restrict their participation (Sakeena, Bennett, and McLachlan 2018). Similarly, Vrinda et al. found that pharmacists in India and South Africa often face challenges such as insufficient AMS education, limited empowerment, and weak interprofessional recognition, which constrain their ability to lead stewardship programs (Nampoothiri et al. 2024). Enhancing structured clinical education and formal AMS training pathways for hospital pharmacists in Indonesia could substantially strengthen their competence and active participation in stewardship initiatives.

This study revealed that most hospitals in the study region lacked clinical microbiologists and adequately equipped microbiology laboratories. The absence of such facilities resulted in limited access to reliable microbiological data such as pathogen culture results, antibiotic susceptibility profiles, and antibiograms which are essential for guiding evidence-based antimicrobial therapy. Consequently, empirical antibiotic prescribing remains the predominant practice, often conducted without culture confirmation or local resistance data. Consistent with these findings, Hellen et al. reported that in resource-limited settings such as Kenya, approximately 40% of empirically prescribed antibiotics for urinary tract infections were inappropriate due to the absence of susceptibility testing, underscoring the urgent need to enhance diagnostic capacity (Onyango et al. 2024). Likewise, Sautter-Thomson emphasized that the consolidation or underdevelopment of clinical microbiology laboratories in low- and middle-income countries significantly limits the timeliness and accessibility of diagnostic information, thereby impeding effective antimicrobial stewardship implementation (Bielicki, Cromwell, and Sharland 2017). Collectively, these findings highlight that strengthening diagnostic infrastructure and ensuring the availability of clinical microbiology expertise are pivotal to optimizing antibiotic utilization and mitigating antimicrobial resistance at the institutional level.

Another identified weakness is the limited structural support from hospitals, both in policies and resources. In many institutions, AMS programs are not yet strategic priorities and are handled administratively by committees. Only a few hospitals have structured teams, clear SOPs, and measurable indicators. According to WHO, AMS success depends on organizational commitment, funding, and managerial oversight (WHO 2023). Alghamdi et al. showed that top management support was crucial for successful ASP implementation in Saudi hospitals (Alghamdi et al. 2021). Likewise, Sato et al. found that many São Paulo hospitals lacked consistent feedback and evaluation metrics (Sato 2021). Both studies highlight leadership engagement as a determinant of program sustainability. Sautter and Thomson added that consolidated microbiology laboratories enhance diagnostic efficiency supporting AMS decisions (Sautter n.d.).

Before the intervention, most pharmacists had never received formal training on antimicrobial resistance prevention programs. The lack of continuous education resulted in low awareness and self-confidence among pharmacists to actively participate in AMS activities. The training conducted in this study proved effective in improving both knowledge and individual skills. The Wilcoxon test demonstrated a significant increase in competence scores, while the McNemar test confirmed that nearly all participants showed an improvement in their competence categories. These findings are consistent with those of Wong et al., who reported that structured training programs significantly enhanced pharmacists’ abilities to assess the rationality of antibiotic use, communicate clinical recommendations, and collaborate effectively within AMS teams (Wong et al. 2021).

The Spearman correlation analysis indicated that the increase in pharmacists’ competence was not significantly associated with improvements in hospital ASP outcomes (r = 0.046; p = 0.813). This suggests that although pharmacists demonstrated significant individual skill enhancement, such progress has not yet been effectively reflected in systemic implementation at the hospital level. These findings reaffirm that ASPs are inherently multidisciplinary programs, whose success depends on the synergy between various professional roles and organizational structures. As highlighted by Morency et al., antimicrobial stewardship represents a set of integrated interventions designed to optimize antimicrobial use through collaboration among infectious disease physicians, clinical pharmacists, and microbiologists. Clinical microbiologists, in particular, contribute critically by providing cumulative susceptibility reports, guiding pre-analytical processes, ensuring rapid diagnostic testing, and supporting continuous provider education and surveillance systems (Morency-potvin, Schwartz, and Weinstein 2017).

The effective implementation of Antimicrobial Stewardship Programs (ASPs) requires active engagement of hospital stakeholders, including leadership, physicians, nurses, and pharmacists. Hospital management establishes policies and allocates resources, while physicians and nurses ensure appropriate prescribing and monitoring. Pharmacists act as key stewards to promote evidence-based antimicrobial use and optimize patient outcomes. However, pharmacist competence alone is insufficient without multidisciplinary collaboration and managerial commitment. In Japan, Samura et al. demonstrated that ward-based infectious disease–certified pharmacists improved antimicrobial practices even without infectious disease physicians (Samura 2019). Similarly, Hashad et al. emphasized that leadership engagement and interprofessional collaboration were vital facilitators of ASP success in UAE hospitals. These findings highlight that effective ASPs depend on empowered clinical pharmacists supported by strong institutional governance (Hashad et al. 2023).

The structured three-session training model implemented in this study—comprising data preparation, core face-to-face instruction, and online evaluation—proved highly effective in enhancing professional awareness and promoting the integration of AMS principles into daily practice. This practice-oriented approach not only improved theoretical understanding but also cultivated proactive and collaborative attitudes among healthcare professionals, essential for the sustainability of AMS initiatives. Similar to findings by Schrier et al., who emphasized that continuous education and interdisciplinary training are critical for effective antimicrobial stewardship across healthcare settings, this study supports embedding AMS education throughout professional development (Schrier et al. 2018). Furthermore, Suzanne et al. highlighted that experiential learning and case-based training significantly improve participants’ confidence in antibiotic decision-making and adherence to stewardship protocols (Kuijpers et al. 2025). Collectively, these findings suggest that structured, practice-based AMS training should be institutionalized as part of mandatory Continuing Professional Development (CPD) programs for hospital pharmacists, particularly in resource-limited settings.

To ensure the successful and sustainable implementation of antimicrobial stewardship (AMS), establishing regional collaborative networks among hospitals is imperative. Hospitals with well equipped microbiology laboratories can function as referral and surveillance centers, facilitating regional antibiogram-based decision-making and promoting evidence-informed antibiotic practices. Such collaborations not only bridge disparities in institutional resources but also accelerate the translation of local data into actionable policies and clinical guidelines. Consistent with the findings of Nori et al., effective ASP implementation depends on sustained partnerships among hospital administration, clinical departments, pharmacy, infection prevention units, and microbiology services, as well as external collaborations with national health authorities and professional organizations (Nori, Guo, and Ostrowsky 2018). These cooperative frameworks enable the development of harmonized policies, enhance research capacity, and expand the regional impact of stewardship initiatives. Overall, the present study underscores that while pharmacist-focused AMS training effectively strengthens individual competence, systemic and enduring improvements in hospital ASP performance can only be achieved through coordinated multidisciplinary engagement and robust institutional support.

Conclusion

This study found that structured antimicrobial stewardship (AMS) training significantly improved pharmacists’ competence in knowledge, skills, and professional attitudes, demonstrating its effectiveness as a capacity-building strategy. However, these individual improvements did not translate into systemic progress in hospital ASP implementation, emphasizing the need for stronger institutional and managerial support. Sustainable AMS outcomes require multidisciplinary collaboration, leadership commitment, and adequate diagnostic infrastructure. Integrating AMS education into mandatory Continuing Professional Development (CPD) programs and expanding regional hospital collaboration can enhance implementation consistency. These findings highlight that empowering pharmacists must be aligned with organizational and policy reforms to ensure long-term antimicrobial resistance control.

Ethical considerations

Ethical clearance for this study was obtained in the form of an exemption from the Health Research Ethics Committee, Faculty of Medicine, Andalas University, Indonesia (Ref. No. 561.layaketik/KEPKFKEPUNAND). The committee reviewed the research protocol and determined that the study met the criteria for exemption, as it involved minimal risk, non-invasive procedures, and voluntary participation of adult pharmacists. All procedures were conducted in accordance with the ethical standards of the committee and the principles outlined in the Declaration of Helsinki (2013 revision).

Written informed consent was obtained from all pharmacists who took part in the study before their participation. Each participant received a clear explanation of the study’s purpose, procedures, voluntary nature, and the measures taken to maintain data confidentiality. The study did not involve any minors or vulnerable populations.