Objective: To establish a better understanding of physicians' knowledge and beliefs, and to compare distinctions in knowledge, attitude and perception of junior and senior doctors regarding rational use of antibiotics.
Methods: The cross-sectional study was conducted at a tertiary care hospital in Karachi, from June 1 to July 31, 2016, and comprised senior and junior doctors. A 26-item questionnaire divided in three sections was used to test knowledge, attitude and perception of the subjects regarding rational use of antibiotics. Data was analysed using SPSS 23.
Results: Of the 200 subjects, 132(66%) were senior doctors; 68(34%) were junior; 116(58%) were females; 84(42%) were males; and the highest number of respondents were from General Medicine 65(32.5%). While 182(91%) doctors realised that antibiotic resistance was a pressing issue, only 131(65.5%) felt confident about their prescriptions and 94(47%) admitted that they over-prescribed antibiotics. Among young physicians, 13(19.1%) believed that antibiotics did not cause side effects even when prescribed unnecesarily. Also, 47(69.1%) junior doctors felt that patients' demands influenced their prescriptions compared to 66(50%) senior doctors (p=0.01).
Conclusion: Although physicians were found to be knowledgeable about rational use of antibiotics, there were gaps in knowledge and perception.
Keywords: Antimicrobial resistance, Antibiotic stewardship, Public health, Misuse of antibiotics. (JPMA 70: 1023; 2020)
Antibiotic resistance is a phenomenon that has been known to the world for the past six decades. Initially touted as 'wonder drugs', the increasing use of the same antibiotics has led to natural selection of bacteria to produce resistant descendants to combat them, reducing their efficacy. Antibiotics are one of the most frequently prescribed drugs, making them susceptible to abuse; approximately 20-50% of antibiotics prescribed to patients are either unmerited or inappropriate.1,2 The frequent misuse of antibiotics has become one of the major factors in the development of antibiotic resistance worldwide. The United States S Centres for Disease Control and Prevention (CDC) estimates that antibiotic-resistant organisms infect more than two million people in the US alone, resulting in approximately 23,000 deaths annually, and these numbers are estimates which means the true burden of resistance is much higher.3 What makes the prospect of global antibiotic resistance a bleak one is the fact that there are no immediate solutions in sight.
The World Health Organisation (WHO) defines rational drug use as medication that is received by the patient appropriate to their clinical needs, in doses that meet their individual requirements, for an adequate period, which is available at the lowest cost to them and their community.4 However, this idea is primitive to the developing world. The excessive use of antibiotics, over-the-counter availability of antibiotics without a prescription from a licensed doctor, and poor policies for infection control are the three main contributing factors to antibiotic resistance in society.5 This unrestricted access to antibiotics escalates the problem of resistance among the general population, along with poor sanitation, overcrowding, and a warm, humid climate.6 Hospitals are equally responsible for antibiotic misuse as primary healthcare practitioners. Discrepancies in the knowledge, attitude and perception of physicians are at the helm of incorrect and excessive antibiotic prescription, and correcting these may be the key to a possible solution. However, they have not been researched adequately on a national level. In Pakistan, an average of 1-4 antibiotics per prescription was being prescribed by physicians among 45.19% of the patient population.7 Furthermore, a study conducted in Pakistan to analyse the prescriber's approach towards reasonable drug practice found that doctors were erroneously prescribing medication to patients on a daily basis, and the medicine prescribed was irrational with respect to patient's illness with high levels of error in choosing a medication.8
Pakistan lacks a national surveillance programme for antibiotic resistance. Furthermore, research on the root cause of antibiotic resistance, and the general physicians' point of view in the country are scarce.
The current study was planned to assess the knowledge, attitude and perception of doctors about proper use of antibiotics, and to compare distinctions on all three counts between junior and senior doctors.
Subjects and Methods
The cross-sectional study was conducted at a tertiary care hospital in Karachi, from June 1 to July 31, 2016, and comprised senior and junior doctors. After approval by the institutional ethics committee, the sample size was calculated using frequency of physicians who agreed that antibiotics are overuse in general as 88% with margin of error 5% at 95% confidence interval (CI).9 The computed sample size was 163 to which 5% non-response rate was added.
The sample comprised senior doctors, including consultants and postgraduates (PGs), and junior doctors who were house officers working in the hospital. The PGs were included as senior doctors since they were in the final year of their structured fellowship programme and were working alongside the consultants in running the clinics and managing in-patients, hence having a greater knowledge on the subject than the house officers. Departments that had less than 15 participants were excluded, as the small number of responses from these departments could have resulted in a bias conflicting with responses from the departments with a much greater number of participants.
A self-designed, pilot-tested, self-administered questionnaire was distributed among all the participants after taking informed consent from each of them. All doctors working in the hospital understood simple English, and, hence, that was the language of choice for the questionnaire which had 26 items that were to be answered by the physicians based on their knowledge (8 questions), attitude (7 questions), and perception (11 questions) towards antibiotic use and resistance. Each question was a statement to which the respondents had to either agree or disagree.
Data was analysed using SPSS 23, and was expressed as frequencies and percentages. No imputation techniques were used for the missing values. P<0.05 was considered statistically significant.
Of the 250 doctors among whom the questionnaire was distributed, 200(80%) completed the questionnaire. Of them, 132(66%) were senior and 68(34%) were junior doctors. Female participants were 116(58%) and 84(42%) were male. The highest number of respondents were from the Department of General Medicine 65(32.5%) (Figure-1).
In terms of knowledge, 182(91%) doctors believed that antibiotic resistance was a pressing issue, but only 131(65.5%) felt confident about their optimal use of antibiotics; 42(62%) junior and 89(67%) senior doctors (p=0.426).
Overall, 94(47%) participants thought they overprescribed antibiotics; 30(44%) junior and 64(48.5%) senior physicians (p=0.537).
Also, 83(41.5%) participants stated it was difficult to select a single antibiotic for a specific infectious agent, and all (100%) juniors doctors thought that better education will lead to better selection of antibiotics, while 126(95.5%) of the seniors doctors also agreed.
Of the total, 197(98.5%) subjects agreed that strong knowledge of antibiotics was essential and better education on antibiotic use will lead to decreased resistance. Also, 53(78%) junior and 113(85.6%) senior accepted that poor infection control by practitioners was the main culprit behind antibiotic resistance. The greatest variation in knowledge between the two groups was on the statement that newer antibiotics will cut down on antibiotic resistance in the future, to which 41(60.3%) junior and 61(46.2%) senior doctors agreed (p=0.06) (Figure-2).
With regards to the attitude, 178(89%) subjects believed that antibiotics were overused nationally, but only 111(55.5%) agreed that it was a trend in their own hospital. Among the junior physicians, 49(72%) and among the senior doctors, 87(65.9%) were providing awareness to their patients about completing the antibiotic course at the time of prescription. Among the young physicians, 13(19.1%) believed that antibiotics did not cause any harm to the patients even if prescribed without the need. The corresponding number among seniors doctors was 12(9.1%) (p=0.043). Awareness of the hospital formulary was present in 23(33.8%) junior and 24(18.2%) senior doctors (p=0.014).
Besides, 34(50%) junior doctors and 72(54.5%) seniors doctors agreed that local guidelines were more beneficial than international guidelines regarding antibiotic use. The attitude of physicians did not vary based on experience in the remaining questions (p>0.05) (Figure-3).
In term of perception, 193(96.5%) participants agreed that inappropriate use of caused antibiotic resistance, and 184(92%) agreed that better use and feedback on antibiotic selection will reduce the problem. Besides, 70(35%) doctors believed that pharmaceutical representatives provided useful information on antibiotic selection. Among the junior doctors, 27(39.7%) and among the senior doctors, 50(37.9%) agreed that residents overprescribed antibiotics more than faculty members. Also, 47(69.1%) junior doctors felt that patients' demands influenced their prescriptions compared to 66(50%) senior doctors (p=0.01). Among the junior doctors, 64(94.1%) were more inclined towards consulting fellow physicians before prescribing antibiotics than their seniors 102(77.3%) (p=0.003). Overall, 86(43%) doctors believed that the use of antibiotics in the agricultural industry supported the spread of antibiotic resistance in the community. There were no other significant differences in perception between junior and senior doctors (Figure-4).
Antimicrobial resistance (AMR) and spread of multidrug-resistant organisms (MDROs) are major public health concerns. Physicians can play a central role in preventing the spread of AMR and dissemination of awareness about rational use of antibiotics, hence saving antibiotics to be available for treatment of infections for future generations.
Majority of participants in the current study had good understanding of issues related to antibiotic prescription, and supported the need of good infection control practices and antibiotic stewardship programme (ASP) to decrease the spread of MDROs.
ASP is an organised intervention to increase and measure the appropriate use of antimicrobial agents and helps in the proper selection of the best antibiotics regimen, including dosing, duration of therapy, route of administration etc.9 Successful implementation of infection prevention and control practices also decreased the spread of MDROs and contained the spread of AMR.10 There is an urgent need of ASP and proper infection control practices in every hospital to combat the threat of DMRO spread in the community. Educating and creating awareness among freshly medical graduates and senior doctors is the key to counter this detrimental issue.11,12
Although most of the physicians in the study knew that antibiotic resistance was a pressing issue, a little more than half felt confident about their optimal use of antibiotics, including over-prescription of antimicrobial agents with no difference between junior and senior doctors. This is in contrast with findings of previous studies which showed senior doctors to be more confident than junior doctors in their antimicrobial use.5,13 The probable reason for less confidence among senior doctors in our study may be due to the increased incidence of MDROs in our country, particularly in hospitalised patients, with only a few antibiotic choices left to treat the patients.
Furthermore, greatest variation in knowledge between the two groups was seen when more than half of senior doctors did not feel that newer antibiotics will cut down resistance. Multiple years of practising and daily prescription may have made senior doctors too comfortable in their own way to welcome newer drugs. If used optimally, older antibiotics may be the key in treating multi-drug resistant infections,14 which senior doctors may have seen in practice with positive results and, hence, they see no reason to change. Fresh graduates are given immense knowledge about the rise of antibiotic resistance and, thus, are open to the idea of using newer antimicrobials that can combat this problem.
We found that most doctors, regardless of their experience, believed that misuse of antibiotics and antibiotic resistance are more of national problems than a problem at their own institution, indicating that clinicians may be disregarding or overlooking antibiotic resistance present in their hospitals due to a lack of awareness about their institution's data on incidence of MDROs, lack of active surveillance of MDRos in the healthcare facility, lack of ASM, lack of organization's antibiotics guidelines and policy or simply due to bias. These findings were similar to previous studies which also reported that doctors agree on the magnitude of antibiotic resistance on a theoretical basis, but not a practical one when considering their own practices.13,15
Our data showed that a significantly higher proportion of junior doctors felt that antibiotics do not cause adverse effects even if the patient does not need them. Inexperienced doctors do not realise that taking antibiotics when unnecessary can result in resistance due to the effects of antibiotics on harmless microbial ecosystems within the human body.16 This attitude may, in turn, be contributing to their over-prescription of antibiotics and AMR. A substantial proportion of study participants were not aware of hospital formulary and did not consider that local antibiotics guidelines were more beneficial than international guidelines, which the doctors can depend on while choosing an appropriate management option for their patients. Local guidelines are more helpful in cases where a specific organism is seen having a higher resistance rate to an antibiotic compared to other regions, where the resistance rate is less of a problem. This has been noted among urinary tract infection (UTI)-causing organisms in certain Latin American countries.17 Another example is the recent outbreak of extensively drug-resistant (XDR) Salmonella Typhi in Sindh.18 However, doctors may prefer international guidelines because they are more reliable and heavily researched than the local ones.
A significant number of physicians do not counsel their patients about proper use of antibiotics. Patients' influence on the doctors for prescribing antimicrobials was more noticed with doctors; a fact also observed in other studies.19,20 Physicians through proper communication can play an important role in educating the patients about appropriate use of antibiotics and can have a positive impact on decreasing AMR incidence.21
A large and compelling body of scientific evidence demonstrates that injudicious use of antibiotics in agriculture, particularly in animal food, contributes to the emergence of resistant bacteria and their spread to humans.22,23 One intervention of the global action plan on antimicrobial resistance by WHO is to reduce use of all classes of medically important antimicrobials in food-producing animals.24
A significant number of participants stated that pharmaceutical representatives influenced the selection of an appropriate antibiotic for their patients, which is a fact very well recognised.11,25 It points out that pharmaceutical representatives do play a major role in antibiotic resistance which may be due to inadequate knowledge, or an ulterior motive to increase the marketing value of their drug.
We found that junior doctors also tend to consult their fellow physicians much more often than senior doctors in order to avoid inappropriate prescription, which correlates with a previous study.8 This finding was also in line with other studies done in Pakistan showing irrational drug practices among physicians7,8,26-29 (Table).
Consultation with infectious disease physicians is associated with decrease in mortality secondary to MDROs as well as the re-admission rate.30
The current study has significant limitations. Since it was a survey-based study, it is possible that the respondents gave socially desirable answers even if they did not believe that particular response to be true. To avoid this, choice of anonymity was offered to the respondents. Besides, the study was conducted at a single centre with a small sample size, which means the results cannot be generalised, and there remains a need of a multi-centre study with a large sample size to validate the results. Finally, the study provided a description of decisions and attitudes at only one point in time, which is a limitation that can be taken care of only with interventional studies.
Physicians were knowledgeable about the appropriate use of antibiotics and AMR, but there were many gaps that needed to be plugged. The importance of an ASP as well as infection prevention and control protocols in healthcare facilities cannot be overemphasised.
Conflict of Interest: None.
Source of Funding: None.
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