Antimicrobial resistance (AMR) remains one of the greatest threats to global public health, compromising the effectiveness of antimicrobial agents and increasing morbidity, mortality, healthcare expenditures, and the burden on health systems worldwide. The inappropriate and excessive use of antibiotics in hospitals and communities continues to accelerate the emergence and spread of resistant microorganisms despite ongoing international efforts to promote responsible antimicrobial use (Sprenger, 2019) [ 1]. The COVID-19 pandemic further intensified this challenge because antibiotics were frequently prescribed despite relatively low rates of confirmed bacterial co-infections, contributing to the growing burden of antimicrobial resistance (Rawson et al., 2020) [ 2].

To address this global concern, antimicrobial stewardship (AMS) programs have been established to optimize antimicrobial prescribing, improve patient outcomes, reduce adverse drug events, and minimize the development of antimicrobial resistance. These multidisciplinary programs emphasize the appropriate selection, dosage, route, and duration of antimicrobial therapy while strengthening infection prevention and control practices (Aricò et al., 2023) [ 3]. Effective implementation of AMS depends on the coordinated efforts of physicians, pharmacists, microbiologists, infection prevention specialists, and nurses.

Among healthcare professionals, nurses play a pivotal role in antimicrobial stewardship because they spend the greatest amount of time with patients, administer antimicrobial therapy, monitor treatment response and adverse effects, reinforce infection prevention measures, educate patients, and facilitate communication among members of the healthcare team. Recent evidence has emphasized that strengthening nurses' competencies in antimicrobial stewardship can significantly improve stewardship implementation and patient safety outcomes (De Vita et al., 2024) [ 4]. Likewise, systematic evidence demonstrates that nurses' knowledge, perceptions, and experiences directly influence their participation in stewardship activities and highlights the need for continuous education and organizational support (Blackburn et al., 2025) [ 5].

Knowledge, attitudes, and practices (KAP) are recognized determinants of successful antimicrobial stewardship implementation. Healthcare professionals with adequate knowledge and positive attitudes are more likely to demonstrate appropriate stewardship practices, including prudent antibiotic administration, adherence to infection prevention protocols, and timely communication with prescribers (Abubakar & Sárváry, 2023) [ 6]. Educational interventions have likewise been shown to improve nurses' stewardship competencies, suggesting that targeted training remains an essential strategy for strengthening antimicrobial stewardship programs (Bobbitt et al., 2023) [ 7].

In the Philippines, antimicrobial stewardship has gradually expanded across tertiary healthcare institutions through national policies and hospital-based initiatives. Nevertheless, available local evidence remains limited regarding nurses' knowledge, attitudes, and practices related to antimicrobial stewardship. Existing Philippine studies have largely focused on healthcare workers in general or pharmacy-based stewardship implementation rather than bedside nurses who perform frontline stewardship activities (Bernardo & Padua, 2024; Diño et al., 2023) [ 8,9]. Consequently, important gaps remain in understanding the preparedness of Filipino nurses to participate effectively in antimicrobial stewardship initiatives.

Although antimicrobial stewardship training opportunities have become increasingly available, practical barriers such as workload, staffing shortages, and competing clinical responsibilities continue to affect nurses' participation in educational activities. These challenges highlight the importance of developing accessible, nurse-focused educational interventions that can strengthen stewardship competencies within the clinical setting.

Therefore, this study aimed to determine the knowledge, attitudes, and practices of bedside nurses regarding antimicrobial stewardship in tertiary hospitals in Baguio City, Philippines, and to examine the relationship between selected socio-demographic characteristics and these variables. The findings served as the basis for developing a structured short-course program on infection control designed to strengthen nurses' competencies and support the effective implementation of antimicrobial stewardship in Philippine hospitals.

The researcher employed a descriptive correlational, cross-sectional research design. Descriptive (univariate) statistics and simple linear regression analyses were used to analyze the data. Following the descriptive (univariate) statistical analyses, simple linear regression analyses were performed to examine the relationship between each independent variable and the dependent variable individually. In each regression model, one independent variable was entered to predict the outcome variable, allowing the estimation of its individual predictive effect without simultaneously including other independent variables. This approach enabled the identification of variables that were significantly associated with the outcome while maintaining consistency with the descriptive correlational cross-sectional design. Because the study employed a cross-sectional design, the regression analyses were used to evaluate statistical associations and predictive relationships rather than to establish causal relationships (Polit & Beck, 2021; Field, 2024) [ 10,11].

The study was conducted in two tertiary hospitals in Baguio City, Philippines, both accredited by the Philippine Department of Health and providing specialized inpatient and outpatient healthcare services. These institutions have established infection prevention and antimicrobial stewardship programs, making them suitable settings for evaluating nurses' stewardship competencies.

The study population consisted of registered bedside nurses assigned to inpatient clinical units. Eligible participants met the following criteria:

Registered nurses with direct patient care responsibilities.

Employed in either participating hospital during the study period.

At least six months of clinical experience.

Willing to participate and provided written informed consent.

Nurses in purely administrative roles, student nurses, nursing interns, and those on extended leave during data collection were excluded.

The study reached 119 bedside nurses with no withdrawals from any respondent. However, the data-gathering time was limited due to the inevitable absence of the researcher in the locale where the data were gathered. Thus, the achieved response rate of 119/309 results in a retrieval rate of 38.5%. A non-probabilistic snowball sampling, also known as “chain sampling,” wherein participants recruit another participant from their professional network and become part of the sample, was used (Makwana et al., 2023) [ 12].

Data were collected using a modified structured self-administered questionnaire consisting of four sections:

Socio-demographic characteristics

Knowledge regarding antimicrobial stewardship

Attitudes toward antimicrobial stewardship

Practices regarding antimicrobial stewardship

The questionnaire was adapted from previously validated antimicrobial stewardship KAP instruments and modified to suit the Philippine hospital context. Due to the psychometric validity of the adapted tools, there is no need to conceptualize a new questionnaire from the outset. In addition, the researcher used the specified questionnaires mainly due to the similarity of the variables that were tested. Second, the researcher obtained the tool author’s response for approval to use the first and second tools through electronic mail. However, the third tool was used because it completes to cover all the components that were discussed, namely, knowledge on AMS. Overall, adopting only one tool is not efficient for covering all the components that were studied.

The first tool is the Parental Perception on Antibiotic (PAPA) Scale that attempts to measure the factors influencing the use of antibiotics. It was authored by Alumran et al. (2014) [ 13] using a content evaluation panel of experts from Australia and Saudi Arabia. These experts brainstormed and derived a list of the instrument’s items from their review of the literature, then 3-round Delphi process to develop the instrument.

Secondly, the researcher obtained approval to use the tool that was used in the study of “Design, reliability, and construct validity of a Knowledge, Attitude and Practice (KAP) questionnaire on personal use of antibiotics” conducted in Spain. Mallah et al. (2020) [ 14] developed this instrument, designed and validated the questionnaires using the following steps: a systematic review of the literature to generate Knowledge-Attitude-Practice items, followed by identifying a questionnaire design, content validity, face validity, and pilot testing, reliability assessment, construct validity, and questionnaire acceptability.

Finally, the researcher also adapted the Antibiotic Knowledge and Consumption Tool (AKCT) that was developed and validated as a measure of antibiotic knowledge and consumption by Hasan et al. (2022) [ 15] in the United Arab Emirates.

Content validity was assessed by experts in nursing, antimicrobial stewardship, infectious diseases, and research methodology. Their recommendations were incorporated into the final instrument.

Internal consistency reliability was evaluated using Cronbach's alpha, with acceptable coefficients obtained for the knowledge, attitude, and practice domains before full-scale data collection. The reliability analysis results showed Cronbach’s alpha of 0.74 (0.736) for the Knowledge on AMS tool, then 0.88 (0.880) and 0.71 (0.709) for the tools on attitudes and practices towards AMS, respectively.

Following approval from the institutional ethics review board and hospital administrators, eligible participants were invited to participate. The study objectives, procedures, risks, benefits, and confidentiality safeguards were explained before obtaining written informed consent.

Questionnaires were distributed during scheduled work periods convenient for participants. Completed questionnaires were collected immediately after completion and checked for completeness before data encoding.

Data were analyzed using IBM SPSS Statistics.

Descriptive statistics included:

Frequencies

Percentages

Means

Standard deviations

Medians and interquartile ranges, where appropriate

The Shapiro&#x02013;Wilk test assessed normality. Associations between socio-demographic characteristics and KAP outcomes were examined using univariate linear regression analysis, while relationships among knowledge, attitudes, and practices were evaluated using appropriate correlation and regression techniques. Statistical significance was set at p < 0.05.

Ethical approval was obtained from the appropriate Institutional Research Ethics Committee before data collection commenced. Administrative permission was secured from both participating hospitals. Participation was voluntary, and written informed consent was obtained from all respondents.

Participant anonymity was maintained through coded questionnaires, and all data were treated confidentially and used solely for research purposes. Respondents were informed of their right to withdraw from the study at any time without penalty.

A total of 119 bedside nurses participated in the study. The socio-demographic characteristics of the respondents are presented inTable 1. The sample consisted of nurses with varying ages, years of clinical experience, educational attainment, and clinical assignments, providing a diverse representation of bedside nurses from the participating tertiary hospitals.

Results indicated that the majority of the participants were &#x02265;36 years old (31.09%), were female (83.19%), completed a bachelor&#x02019;s degree (99.16%), had a clinical experience of more than 2 years (55.46%), and were assigned to a medical-surgical ward (45.38%).

The descriptive statistics of knowledge on antimicrobial stewardship are shown inTable 2. Results showed that the overall median knowledge score was 62.00 (IQR = 57.00 to 65.00), and categorizing these scores using k-means clustering, the majority of the participants had a moderate knowledge score (47.06%). Among the dimensions of knowledge on antimicrobial stewardship, the domain of understanding the nurse&#x02019;s roles had the highest median score (Md=22.00, IQR = 21.00 to 24.00), followed by awareness of the existence of AMS efforts (Md=20.00, IQR = 19.00 to 22.00) while awareness of the impact of antimicrobial resistance had the lowest median score (Md=19.00, IQR = 16.00 to 21.00).

The overall knowledge score indicated that respondents demonstrated moderate knowledge of antimicrobial stewardship. Respondents obtained the highest scores on items related to nursing responsibilities in antimicrobial administration and patient monitoring, whereas lower scores were observed for antimicrobial resistance mechanisms and appropriate antimicrobial prescribing, suggesting areas requiring further education.

Table 3 presents the descriptive statistics of attitudes toward anti-microbial stewardship among the participants. It can be noted that the overall median attitudes score was 48.00 (IQR = 42.00 to 50.00), and most of the participants had high attitudes toward anti-microbial stewardship (66.39%), after categorizing the scores using k-means clustering. The median score for the domain of acceptance and agreement was 24.00 (IQR = 21.00 to 25.00), while the median score for the dimension of reason and motivation to comply was 23.00 (IQR = 21.00 to 25.00).

Overall practices toward antimicrobial stewardship had a median score of 48.00 (IQR = 44.00&#x02013;53.00) inTable 4 presented. Based on the predefined score categories, 22 participants (18.49%) were classified as having low practice (scores &#x02264;42.00), 49 participants (41.18%) had moderate practice (scores 43.00&#x02013;50.00), and 48 participants (40.34%) had high practice (scores &#x02265;51.00).

The associations between knowledge and attitudes toward antimicrobial stewardship and practices toward antimicrobial stewardship are shown inTable 5. Results indicated that both knowledge (&#x003b2;=0.30, p=0.001) and attitudes (&#x003b2;=0.21, p=0.024) were significantly and positively associated with practices toward antimicrobial stewardship. These results indicate that practices scores increase by 0.30-unit for every one-unit increase in knowledge score, and they increase by 0.21-unit for every one-unit increase in attitudes score.

TheTable table above presents the univariate linear regression analyses of the associations between socio-demographic characteristics and knowledge, attitude, and practices regarding anti-microbial stewardship among the participants. Results showed that age, sex, duration of experience, and department were not significantly associated with knowledge of antimicrobial stewardship (p<0.05). Regression analysis showed that selected respondent characteristics were significantly associated with more positive attitudes toward antimicrobial stewardship, while other variables showed no statistically significant relationship. It can be noted that age, sex, duration of experience, and department were not significantly associated with practices toward anti-microbial stewardship (p<0.05).

Table 6 illustrates that sex (p=0.205) and department (p>0.05) were not significantly associated with attitudes toward antimicrobial stewardship. In contrast, results showed that age and duration of experience were significantly associated. In particular, those who were 24 to 25 years old (&#x003b2;=0.57, p=0.025); were 26 to 30 years old (&#x003b2;=0.73, p=0.005); were 31 to 35 years old (&#x003b2;=0.68, p=0.004); and &#x02265;36 years old (&#x003b2;=0.67, p=0.015) had attitude scores that were 0.57-unit, 0.73-unit, 0.68-unit, and 0.67-unit higher, respectively, than those who were &#x02264;23 years old. For duration of experience, results showed that experience of &#x02265;6 months to 12 months (&#x003b2;=0.35, p=0.024); &#x02265;2 years to 5 years (&#x003b2;=0.40, p=0.030); and &#x02265;5 years to 10 years (&#x003b2;=0.47, p=0.012) have an attitudes score which is 0.35-unit, 0.40-unit, and 0.47-unit, respectively, significantly higher than those with an experience of &#x02265;30 days to 6 months.

This study found that bedside nurses demonstrated satisfactory knowledge, positive attitudes, and appropriate practices regarding antimicrobial stewardship (AMS), indicating that they are well positioned to contribute to efforts aimed at combating antimicrobial resistance (AMR). Although respondents showed overall competency, the variation in knowledge scores suggests the need for continuous professional education to address existing knowledge gaps. Similar findings were reported by Abubakar and S&#x000e1;rv&#x000e1;ry (2023) and Blackburn et al. (2025) [ 5,6], who emphasized that nurses' knowledge is fundamental to effective antimicrobial stewardship implementation.

The respondents' positive attitudes toward AMS highlight their recognition of the importance of responsible antimicrobial use and patient safety. Positive professional attitudes encourage nurses to participate actively in antimicrobial monitoring, infection prevention, and interdisciplinary collaboration. These findings are consistent with those of Bobbitt et al. (2023) and Bonacaro et al. (2024) [ 7,16], who concluded that positive attitudes and supportive organizational environments enhance stewardship participation among nurses.

The study likewise demonstrated good antimicrobial stewardship practices among bedside nurses. Routine adherence to medication administration protocols, infection prevention measures, and effective communication with physicians reflects the integration of stewardship principles into everyday nursing care. Similar observations were reported by De Vita et al. (2024) and Briquet et al. (2023) [ 4,17], who recognized nurses as key contributors to antimicrobial stewardship through continuous patient monitoring and safe medication management.

Significant relationships among knowledge, attitudes, and practices indicate that these domains collectively influence stewardship competency. Nurses with better knowledge tended to demonstrate more favorable attitudes and stronger stewardship practices, supporting the importance of competency-based education. Comparable findings were reported by Camerini et al. (2024) and Courtenay et al. (2025) [ 18,19], who highlighted the value of continuous learning and interdisciplinary collaboration in strengthening nursing participation in AMS.

The relationships between selected socio-demographic characteristics and stewardship competencies further suggest that professional experience and educational exposure contribute to nurses' preparedness for antimicrobial stewardship. Continuous education, institutional support, and access to updated clinical guidelines remain essential for sustaining competency. These findings agree with those of Hamilton et al. (2024), Nie et al. (2024), Di&#x000f1;o et al. (2023), and Khan et al. (2026) [ 9,20,21,22], who recommended ongoing educational initiatives to improve antimicrobial stewardship knowledge and practice among healthcare professionals.

Overall, the findings reinforce the expanding role of nurses in antimicrobial stewardship programs. Because bedside nurses are directly involved in medication administration, patient education, and infection prevention, strengthening their stewardship competencies can contribute to safer antimicrobial use and improved patient outcomes. Similar conclusions were reached by Merrill et al. (2019), Mohana et al. (2026), Mula et al. (2021), Padigos et al. (2023), and Perez et al. (2024) [ 23,24,25,26,27], who emphasized that continuous professional development and institutional commitment are essential for sustaining effective stewardship programs.

The findings support strengthening antimicrobial stewardship through nurse-focused educational programs, continuing professional development, and interdisciplinary collaboration. Healthcare institutions should integrate antimicrobial stewardship competencies into orientation programs, annual competency assessments, and infection prevention initiatives to improve antimicrobial use and patient safety. These strategies are consistent with recommendations by Zhao et al. (2023) and Olans et al. (2016) [ 28,29], who emphasized the importance of organizational support and competency-based stewardship education.

A major strength of this study is its focus on bedside nurses, whose perspectives are critical yet frequently underrepresented in antimicrobial stewardship research. The study also provides local evidence that may guide the development of targeted educational interventions within tertiary hospitals. However, the descriptive-correlational design limits causal inference, while the use of self-reported questionnaires may introduce response bias. In addition, the findings are limited to selected tertiary hospitals and may not be generalizable to other healthcare settings.

Healthcare institutions should implement structured antimicrobial stewardship training programs and provide regular continuing education to strengthen nurses' knowledge and clinical competencies. Future research should employ multicenter and longitudinal designs to evaluate the effectiveness of educational interventions and examine organizational factors influencing antimicrobial stewardship implementation. Qualitative studies exploring nurses' experiences and perceived barriers may also provide valuable insights for improving stewardship practices.

Bedside nurses demonstrated positive attitudes and favorable antimicrobial stewardship practices despite moderate knowledge levels. Strengthening competency-based antimicrobial stewardship education may enhance nurses' participation in stewardship initiatives and improve patient safety while contributing to national and global efforts to combat antimicrobial resistance.