Physicians’ knowledge, perceptions and behaviour towards antibiotic prescribing: a systematic review of the literature

'Some patients demand for a prescription of an antibiotic': an assessment of barriers and facilitators to rational antimicrobial use in a private health facility in Uganda

Background

Antimicrobial misuse and overuse propagate antimicrobial resistance, yet data on factors influencing antibiotic prescription decisions in low-resource settings are limited. We describe factors influencing antimicrobial prescription at a large tertiary care private not-for-profit hospital in Uganda.

Methods

We conducted a descriptive phenomenology qualitative study involving face-to-face in-depth interviews of 12 purposively selected prescribers (four intern doctors, six medical officers and two Internal Medicine physicians) in a private not-for-profit hospital in Kampala, Uganda. Audio recordings and filed notes were transcribed verbatim and analysed manually by content analysis. Emerging themes and sub-themes were recorded and reported.

Results

Three broad themes emerged: experience with antimicrobial use in Uganda, barriers and facilitators to rational antimicrobial prescription and measures to address irrational antimicrobial use. Participants recognized that antibiotics are often used irrationally, prescribed even when there is uncertainty regarding clinical evidence for infection, and influenced by drug promoters, and noted high levels of antibiotic resistance. Patients' symptoms and clinical signs, previous experience using antibiotics, fear of bad outcomes, patient demand and expectations, influence from senior colleagues, the turnaround time of clinical investigations and drug marketers were the barriers and facilitators to antimicrobial prescription. Prescribers also acknowledged the need to update clinical guidelines, set up hospital antibiograms, and provide continuous medical education on rational antimicrobial use.

Conclusions

A complex interplay of intrinsic and extrinsic factors influences antibiotic prescribing decisions in this hospital. Targeted interventions through continuous education and training for prescribers, providing local prescription guidelines and antibiograms and implementing regulations on over-the-counter antibiotic sales are needed to implement robust antimicrobial stewardship programmes to curb antimicrobial resistance successfully.

Assessment of knowledge and perception of prescribers towards rational medicine use in the Ashanti Region of Ghana

BACKGROUND

Prescribers must possess extensive knowledge and maintain a positive attitude towards the rational use of medicines to achieve desirable treatment outcomes and effectively prevent treatment failures, increased costs, drug toxicities, and interactions. The objective of this study was to evaluate prescribers' understanding and perception concerning the rational use of medicines in public hospitals. Additionally, the study aimed to identify the factors that influence rational prescribing practices.

METHODS

A structured data instrument was developed to collect demographic data and evaluate participants' knowledge and perception of rational medicine use, in line with the study objectives. Chi-squared statistics and Fisher's exact test were utilized to identify factors associated with good knowledge and perception among participants. Logistic regression was then employed to assess the strength of the associations, with odd ratios reported at a significant level of 0.05.

RESULTS

Out of 192 participants, 85.4% held a positive view of rational medicine use, stressing patient safety and recognizing risks like antimicrobial resistance and polypharmacy. Perception was influenced by factors such as prescriber profession, access to references, and drug bulletin updates. Additionally, 65.6% demonstrated good knowledge of rational medicine use, which was notably influenced by factors like using standard prescribing guidelines, having a functional Drug and Therapeutics Committee, prescriber profession, and the frequency of drug bulletin updates.

CONCLUSION

The study emphasizes the critical need to address knowledge gaps among healthcare professionals, especially nurses and other prescribers, to ensure the safe and effective use of medications. It highlights the positive influence of utilizing preferred prescribing references and the existence of functional Drug and Therapeutics Committees in hospitals on knowledge levels. However, the unexpected findings regarding the limited impact of frequent updates of drug bulletins require further investigation.

Prescription Practices and Usage of Antimicrobials in a Tertiary Teaching Hospital in Rwanda: A Call for Antimicrobial Stewardship

Background: Antimicrobial resistance (AMR) is a global problem that results in high morbidity and mortality, particularly in low- and middle-income countries. Inappropriate use of antimicrobials is a major driver of AMR. This study aimed to evaluate the rate and quality of antimicrobial prescription and use at the University Teaching Hospital of Kigali (CHUK), a tertiary-referral teaching hospital. Methodology: A point prevalence survey (PPS) of antimicrobial prescription was conducted using the Global PPS tool, including a healthcare-acquired infection (HAI) module. Results: On the day of the PPS, 39.3% (145/369) of inpatients were prescribed at least one antimicrobial. Out of the 259 prescribed antimicrobials, 232 (89.6%) were antibacterials, of which 151 (65.1%) belonged to the watch group of the WHO AWaRe classification. The top three antibiotics prescribed were cefotaxime (87; 37.5%), parenteral metronidazole (31; 13.4%), and meropenem (23; 9.9%). Stop or review dates for the prescribed antimicrobials were documented in 27/259 prescriptions (10.4%). Surgical prophylaxis (SP) was prescribed for longer than one day in 83.3% of 61 patients. Samples for culture were sent for 27.1% (63/232) of all the patients prescribed antibiotics. Conclusion: This PPS demonstrates multiple indicators of the poor use of antimicrobials, including the high prevalence usage of watch antibiotics and prolonged surgical prophylaxis and other poor-quality indicators. Thus, there is an urgent need for intervention to improve antimicrobial stewardship.

Primary Healthcare Physicians' Insufficient Knowledge Is Associated with Antibiotic Overprescribing for Acute Upper Respiratory Tract Infections in China: A Cross-Sectional Study

OBJECTIVES

Overuse of antibiotics in healthcare remains prevalent and requires urgent attention in China, particularly in primary healthcare (PHC) facilities. This study aimed to describe the patterns of antibiotic prescriptions for acute upper respiratory tract infections (URTIs) in PHC facilities in China and to investigate how PHC physicians' knowledge influences their antibiotic prescribing behavior.

METHODS

A cross-sectional survey linking physician questionnaire responses and their prescription data was conducted in Shaanxi Province, China. The proportions of URTI visits that received at least one antibiotic, combined antibiotics, and broad-spectrum antibiotics were the main outcomes reflecting antibiotic prescribing behavior. Multivariate mixed-effects logistic regressions were applied to analyze the relationship between PHC physicians' knowledge about antibiotics and their antibiotic prescribing behavior.

RESULTS

A total of 108 physicians filled out the questionnaires between February 2021 and July 2021, and a sample of 11,217 URTI visits attended by these physicians from 1 January 2020 to 31 December 2020 were included in the analysis. The overall mean score of our respondents on the knowledge questions was 5.2 (total score of 10). Over sixty percent (61.2%; IQR 50.2-72.1) of the URTI visits received antibiotics. The percentages of URTI visits prescribed with combined and broad-spectrum antibiotics were 7.8% (IQR 2.3-10.2) and 48.3% (IQR 36.7-58.7), respectively. Third-generation cephalosporins were the most frequently used antibiotics. Physicians with lower antibiotic knowledge scores were more inclined to prescribe antibiotics (p < 0.001), combined antibiotics (p = 0.001), and broad-spectrum antibiotics (p < 0.001).

CONCLUSIONS

Physicians' insufficient knowledge was significantly associated with antibiotic overprescribing. Professional training targeting physicians' knowledge of antibiotics is urgently needed to improve the rational use of antibiotics in grassroots healthcare facilities in China.

Prevalence of inappropriate antibiotic doses among pediatric patients of inpatient, outpatient, and emergency care units in Bangladesh: A cross-sectional study

The heterogeneous pediatric populations, their physiological differences, along with the necessity of performing additional dose calculation, make the pediatric population more vulnerable to the incidences of inappropriate antibiotic doses. This study was conducted to examine and evaluate the appropriateness of antibiotic doses. A cross-sectional study with a quantitative approach was conducted in three hospitals located in Savar from January 06, 2021 to October 17, 2022. This study had used a convenient sampling method to collect 405 filled prescription orders from heterogeneous pediatric patients prescribed by physicians from emergency, inpatient, and outpatient care units of various clinical settings. The Harriet Lane Handbook was used as reference to investigate inappropriate doses of antibiotics. Subsequently, all analyses were conducted using the RStudio 1.3.959 software. Binary logistic regression was used to assess the risk of inappropriate antibiotic prescription in pediatrics. The overall prevalence of inappropriate antibiotic dosing in pediatrics was 335 out of 545 (61.5%). Overdosing (36.3%) and oral antibiotic prescriptions (64%) were more common than underdosing (20.4%) and parenteral antibiotics (36%). The majority (230 out of 405, 56.8%) of pediatric patients had prescriptions with inappropriate antibiotic doses, with prevalence rates of 33.8% for inpatients, 86.7% for outpatients, and 50% for emergency pediatrics. The results also indicated that pediatric patients in outdoor and emergency care units, infants, toddlers, and early childhood, those prescribed two antibiotics simultaneously, and those receiving parenteral antibiotics, were less likely to have inappropriate antibiotic dosages in their prescriptions. This study demonstrated that about one out of every two prescriptions had inappropriate antibiotic doses; in particular, prescriptions containing only one antibiotic exhibited a substantial proportion of inappropriate antibiotic doses. Inappropriate antibiotic doses may result in therapeutic failure, patient harm, and antibiotic resistance. Good clinical pharmacy practice and careful adherence to pediatric dosing standards may minimize inappropriate antibiotic doses.

Health care professionals' knowledge and attitudes towards antibiotic prescribing for the treatment of urinary tract infections: A systematic review

PURPOSE

Previous models identify knowledge and attitudes that influence prescribing behaviour. The present study focuses on antibiotic prescribing for urinary tract infections (UTIs) to describe levels of health care professionals' knowledge and attitude factors in this area and how those levels are assessed.

METHODS

A systematic search was conducted to identify studies assessing the identified knowledge or attitude factors influencing health care professionals' antibiotic prescribing for urinary tract infections up to September 2022. Study quality was assessed using the Newcastle-Ottawa scale. Data were extracted about the types of factors assessed, the levels indicated and how those levels were assessed. Data were synthesized using counts, and levels were categorized as 'poor', 'moderate', 'high' or 'very high'.

RESULTS

Seven studies were identified, six of which relied entirely on closed-ended items. Levels of knowledge factors assessed were poor, for example, their 'knowledge of condition' and 'knowledge of task environment' were poor. Levels of the attitude factors assessed varied, for example, while health care professionals expressed moderate confidence in providing optimal patient care and appropriate attitude of fear towards the problem of antibiotic resistance, they expressed a poor attitude of complacency by giving into patient pressure to prescribe an antibiotic.

CONCLUSIONS

Present evidence suggests that clinicians have poor levels of knowledge and varying levels of attitudes about antibiotic prescribing for UTIs. However, few studies were identified, and assessments were largely limited to closed-ended types of questions. Future studies that assess more factors and employ open-ended question types could better inform future interventions to optimize antibiotic prescribing.

Antibiotic use in tertiary care hospitals in Bangladesh: Revealing the extent through a point prevalence survey

BACKGROUND

Prevalent use of antibiotics in hospitals results in antimicrobial resistance (AMR), rising mortality, and substantial financial burden. This study assessed the current pattern of antibiotic use among inpatients in tertiary hospitals in Bangladesh.

METHODS

Between August and November 2022, we conducted a point prevalence survey in 4 tertiary hospitals in Dhaka, Bangladesh. The World Health Organization-directed point prevalence survey methodology and tools were followed for the data collection. Descriptive and multivariate statistics were performed using Stata version 15.

RESULTS

Of 1,063 hospitalized patients, antibiotics were prescribed to 73.5% (781/1063, 95% confidence interval: 70.8-76.1) of patients. A total of 1,164 antibiotics were prescribed, and 49.1% of patients consumed multiple antibiotics. Only 31.4% of patients were prescribed antibiotics based on microbiology results. The reasons for antibiotic prescribing were mentioned only in 19.3% of patients. Infants (adjusted odds ratio: 8.52, P-value: <.001) and neonates (adjusted odds ratio: 4.32, P-value: <.001) were more likely to consume antibiotics compared to adults. Cephalosporins accounted for the majority (54.0%) of antibiotics used in hospitals. None of the hospitals had any antibiotic use guidelines.

CONCLUSIONS

Consumption of Watch group antibiotics empirically among all age groups demonstrates irrational antibiotic usage in Bangladeshi hospitals. Implementation of a tailored stewardship program, antibiotic use guidelines, and prescriber-patient awareness could improve the rational use of antibiotics.

Communicating diagnostic uncertainty reduces expectations of receiving antibiotics: Two online experiments with hypothetical patients

The overprescription of antibiotics due to diagnostic uncertainty and inappropriate patient expectations influence antimicrobial resistance. This research assesses (i) whether communicating diagnostic uncertainty reduces expectations of receiving antibiotics and (ii) which communication strategies minimise unintended consequences of such communication. In two experimental online studies conducted in January and April 2023, participants read a vignette describing a doctor consultation for an ear infection and expressed their expectations of receiving antibiotics, trust in their doctor, rated the doctor's reputation and provided their intention to get a second doctor's opinion. Study 1 (N = 2213) investigated whether communicating diagnostic uncertainty and social externalities of antibiotic use (the negative social impacts of developing antibiotic resistance) decreases expectations for antibiotics and explores potential unintended consequences on the doctor-patient relationship. In Study 2 (N = 527), we aimed to replicate and extend the findings by adding specific treatment recommendations. Disclosing diagnostic uncertainty (vs. certainty) and communicating (vs. not communicating) the social externalities of antibiotic overuse reduced patients' expectations of receiving antibiotics. Yet, communicating uncertainty impaired trust in the doctor and the doctor's reputation. Combining the communication of uncertainty with specific treatment recommendations-particularly delayed antibiotic prescriptions-showed important to prevent these unintended consequences.

Understanding patient demand for and use of antibiotics for upper respiratory tract infection: A qualitative application of the Necessity-Concerns Framework in Saudi Arabia

Background

Reducing antimicrobial resistance (AMR) is a priority for public health. Inappropriate patient demand is an important driver of unnecessary antibiotic use. To develop an effective intervention to reduce inappropriate demand for antibiotics in upper respiratory tract infections (URTIs), it is important to identify patient perceptions that influence demand for, and appropriate use of antibiotics.

Aim

To identify and describe the beliefs about antibiotics necessity and concerns that patients with URTIs have, in Riyadh, Saudi Arabia.

Method

An exploratory qualitative approach was used. One-to-one, face-to-face or telephone semi-structured interviews were conducted with participants recruited using purposive sampling (based on age and gender) from primary healthcare centre in Riyadh, Saudi Arabia were conducted. Only adult patients who currently experience URTIs symptoms and agreed to participate were recruited. Recruitment for interviews continued until data saturation point was reached. The interview guide explored patients' necessity beliefs and concerns about antibiotics, AMR perceptions, and expectations from URTIs consultation. Interview transcripts were coded using QSR NVivo 12 using framework analysis informed by the Necessity-Concerns Framework to identify key motivations driving antibiotic requests and consultations.

Results

the study interviewed 32 participants (44% were male, average age was 36.84). Results identified that the patients often relate their personal need for antibiotics when encountering an URTIs symptoms to the type, severity and duration of symptoms. Patients also linked antibiotics with quicker recovery, generally expressing few concerns about antibiotics mainly because of its short duration of use. However, some conveyed their concern about frequent administration of antibiotics and effect on the body's immune system function, which may make them more prone to infections in the future. Participants varied widely in their awareness of AMR; this was associated with many misconceptions, such as confusing AMR with antibiotics efficacy and tolerance. Interestingly, the interplay between necessity beliefs and concerns was observed to influence the decision to start and stop antibiotic, potentially impacting inappropriate antibiotic demand and unnecessary use.

Conclusion

This study highlighted important beliefs and misconceptions about antibiotics and AMR in Saudi population which can be targeted in future interventions to reduce inappropriate demand for antibiotics and optimise appropriate usage.

Prescribing antibiotics prudently-A survey of policy implementation drivers among physicians and veterinarians

Background

As the antimicrobial resistance (AMR) problem accelerates, humans and animals are suffering from the consequences of infections with diminishing antimicrobial treatment options. Within the One Medicine and One Health mandate, which denotes a collaborative, multisectoral, and transdisciplinary approach to improve medicine and health across human and animal sectors, we investigate how human and veterinary medical practitioners apply their medical and policy knowledge in prescribing antimicrobials. Different regions and locations establish different intermediary policies and programs to support clinicians in that pursuit. In Hong Kong, there are locally adapted programs at governance and clinical levels in the human medical field. However, there is no locally adapted veterinary antibiotic prescription guideline or stewardship program, and veterinarians adopt overseas or international professions' antimicrobial use guidelines. Such a policy environment creates a natural experiment to compare local policy implementation conditions and clinicians' knowledge, perception, and practice.

Method

We construct the investigative survey tool by adaptation of Knowledge, Attitude, and Practice (KAP) and Capacity, Opportunity, and Motivation-Behavior (COM-B) models. We identify, compare and contrast factors that influence clinicians' antimicrobial prescription behavior. The factors are considered both intrinsically, such as personal attributes, and extrinsically, such as societal and professional norms.

Findings

The absence of locally adopted antimicrobial guidelines influences AMR stewardship program implementation in local Hong Kong veterinary community. As medical allies, physicians and veterinarians share similar demographic influence, organization considerations and perception of public awareness. Both cohorts prescribe more prudently with more years-in-practice, time available to communicate with patients or caretakers, and public awareness and support.

Antibiotic Use Among Hospitalized Patients in Africa: A Systematic Review of Point Prevalence Studies

BACKGROUND

There is paucity of data describing the rate and quality indices of antibiotics used among hospitalized patients at continental level in Africa. This systematic review evaluated the pooled prevalence, indications, and types of antibiotics used in hospitals across Africa.

METHODS

Three electronic databases, PubMed, Scopus, and African Journals Online (AJOL), were searched using search terms. Point prevalence studies of antibiotic use in inpatient settings published in English language from January 2010 to November 2022 were considered for selection. Additional articles were identified by checking the reference list of selected articles.

RESULTS

Of the 7254 articles identified from the databases, 28 eligible articles involving 28 studies were selected. Most of the studies were from Nigeria (n = 9), Ghana (n = 6), and Kenya (n = 4). Overall, the prevalence of antibiotic use among hospitalized patients ranged from 27.6 to 83.5% with higher prevalence in West Africa (51.4-83.5%) and North Africa (79.1%) compared to East Africa (27.6-73.7%) and South Africa (33.6-49.7%). The ICU (64.4-100%; n = 9 studies) and the pediatric medical ward (10.6-94.6%; n = 13 studies) had the highest prevalence of antibiotic use. Community-acquired infections (27.7-61.0%; n = 19 studies) and surgical antibiotic prophylaxis (SAP) (14.6-45.3%; n = 17 studies) were the most common indications for antibiotic use. The duration of SAP was more than 1 day in 66.7 to 100% of the cases. The most commonly prescribed antibiotics included ceftriaxone (7.4-51.7%; n = 14 studies), metronidazole (14.6-44.8%; n = 12 studies), gentamicin (n = 8 studies; range: 6.6-22.3%), and ampicillin (n = 6 studies; range: 6.0-29.2%). The access, watch, and reserved group of antibiotics accounted for 46.3-97.9%, 1.8-53.5%, and 0.0-5.0% of antibiotic prescriptions, respectively. The documentation of the reason for antibiotic prescription and date for stop/review ranged from 37.3 to 100% and 19.6 to 100%, respectively.

CONCLUSION

The point prevalence of antibiotic use among hospitalized patients in Africa is relatively high and varied between the regions in the continent. The prevalence was higher in the ICU and pediatric medical ward compared to the other wards. Antibiotics were most commonly prescribed for community-acquired infections and for SAP with ceftriaxone, metronidazole, and gentamicin being the most common antibiotics prescribed. Antibiotic stewardship is recommended to address excessive use of SAP and to reduce high rate of antibiotic prescribing in the ICU and pediatric ward.

The portrayal of antimicrobial resistance in Bangladeshi newspapers during 2010-2021: Toward understanding the narrative

BACKGROUND

Antimicrobial resistance (AMR) is a major global public health crisis and around the last decade, newspapers were one of the main sources of public dissemination of information for so. This study highlights how Bangladeshi mainstream newspapers represented AMR-related news and how they created the narrative of AMR in Bangladesh.

METHODS

We conducted both quantitative and qualitative content analysis on 275 AMR-related news articles published in the twelve highest circulated dailies (January 2010 to September 2021). We divided the articles into report, opinion, and editorials and analyzed how their contents built the narrative of AMR in Bangladesh.

RESULTS

Bangladeshi newspapers reported misuse of antibiotics by the consumers the most (32.2%), followed by selling without prescriptions (29%), and over-prescription by the health providers (26.1%). There were hardly any news reports describing the impact of pharmaceutical companies in prescribing and selling antibiotics. Around 45% of the news articles were event-oriented. Moreover, they suggested inadequate recommendations to battle AMR.

CONCLUSION

Valid, consistent, and reliable AMR news coverage can play a crucial role in creating mass awareness, making providers accountable, and supporting national action plan in mitigating AMR threat. The Bangladeshi journalists interested in reporting AMR-issues should focus on disseminating more Bangla articles with scientific information, and reporting causes and recommendations responsibly.

Antibiotic prescribing practices of medical doctors in a resource-limited setting and the influence of individual perceptions and stewardship support: a survey in three tertiary hospitals in Vietnam

Objectives

To understand antibiotic prescribing and influencing factors to inform antimicrobial stewardship (AMS) interventions to reduce unwanted consequences of antibiotic use in hospitals in Vietnam, a lower-middle-income country in Asia.

Methods

We conducted a cross-sectional study of doctors at three tertiary hospitals using non-probability convenience sampling, through a paper-based (Hospitals 1 and 2) or electronic (Hospital 3) survey. Questions included items on perceptions regarding antibiotic resistance and AMS, prescribing practices, knowledge, demographics and training. We used principal components analysis and mixed-effects models to examine practices and identify influencing factors.

Results

Among 314 surveyed participants, 61%, 57% and 59% in Hospitals 1, 2 and 3, respectively, felt certain about the appropriateness of their antibiotic prescriptions. In total, 9% reported sometimes prescribing antibiotics when not needed to meet patients' expectations, and 13% reported doing so to avoid perceived complications. Higher prescribing confidence was found among those with positive perceptions about AMS (P < 0.0001), whereas negative perceptions about colleagues' practices reduced this confidence (P < 0.0001). Individual preference for branded antibiotics was associated with more unnecessary prescribing whereas having higher prescribing confidence decreased the habits of prescribing when not needed.

Conclusions

This study provides important implications for design of hospital interventions to address influencing factors on antibiotic prescribing in Vietnam and similar resource-limited settings. Specific interventions should target improving knowledge through education and training for doctors, enhancing the support from the AMS team, and promoting guidelines and policies for appropriate antibiotic use in hospital.

Antibiotics in Catalan Primary Care: Prescription, Use and Remedies for a Crisis of Care

Antimicrobial resistance is one of the twenty-first century's major health challenges. Linked to the extensive use of antibiotics and other antimicrobials, resistance occurs when microbes stop responding to medications. Rates of antibiotic consumption in Spain are among the highest in Europe. Drawing on research conducted in Catalonia, in this article we present findings from ethnographic fieldwork and semi-structured interviews with general practitioners, residents of Barcelona, and professionals who have worked in antibiotic stewardship. We argue that the circulation of antibiotics should be understood in relation to broader historical processes and the deficient systems of health and social care provision they have produced.

Misconceptions and Knowledge Gaps on Antibiotic Use and Resistance in Four Healthcare Settings and Five European Countries-A Modified Delphi Study

Misconceptions and knowledge gaps about antibiotics contribute to inappropriate antibiotic use and antimicrobial resistance. This study aimed to identify and prioritize misconceptions and knowledge gaps about antibiotic use from a healthcare professionals' perspective. A modified Delphi study with a predefined list of statements, two questionnaire rounds, and an expert meeting was conducted. The statements were rated by healthcare professionals from France, Greece, Lithuania, Poland, and Spain, and from general practice, out-of-hour services, nursing homes, and pharmacies. A total of 44 pre-defined statements covered the following themes: (1) antimicrobial resistance in general, (2) use of antibiotics in general, (3) use of antibiotics for respiratory tract infections, and (4) use of antibiotics for urinary tract infections. Consensus was defined as ≥80% agreement between the professionals during the second Delphi round. For 30% of the statements, professionals from the four settings together reached consensus. In each setting individually, at least 50% of the statements reached consensus, indicating that there are still many misconceptions and knowledge gaps that need to be addressed. Six educational tools (leaflets, posters, checklists) were developed to address the knowledge gaps and misconceptions. These can be used by patients and healthcare professionals to improve the use of antibiotics in practice.

Trends and Patterns of Antibiotic Prescriptions in Primary Care Institutions in Southwest China, 2017-2022

Purpose

To explore the prescription patterns and usage trends of antibiotics within primary care institutions located in underdeveloped regions of China from 2017 to 2022.

Methods

A retrospective analysis of antibiotic prescriptions was conducted from 25 primary care institutions in Guizhou Province during the period of 2017-2022. Antibiotic prescriptions were categorized into appropriate and inappropriate use. Appropriate use is further categorized into preferred medication, and antibiotics can be used or substituted. Inappropriate use is further categorized into unnecessary use, incorrect spectrum of antibiotics and combined use of antibiotics. Factors associated with inappropriate use were investigated using generalized estimation equations. Holt-Winters and SARIMA models were employed to predict the number of inappropriate antibiotic prescriptions as the alternative model.

Results

A total of 941,924 prescriptions were included, revealing a decreasing trend in both the number and inappropriate rates of antibiotic prescriptions from 2017 to 2022. Diseases of the respiratory system (70.66%) was the most frequent target of antibiotic use, with acute upper respiratory infections of multiple and unspecified sites representing 52.04% of these cases. The most commonly used antibiotics were penicillins (64.44%). Among all prescriptions, inappropriate antibiotic prescriptions reached 66.19%. Physicians aged over 35, holding the title of associate chief physician and possessing more than 11 years of experience were more likely to prescribe antibiotics inappropriately. The phenomenon of inappropriate antibiotic use was commoner among children aged five or younger. By comparing model parameters, it was determined that the SARIMA model outperforms the Holt-Winters model in predicting the number of inappropriate antibiotic prescriptions among primary care institutions.

Conclusion

The number and inappropriate rates of antibiotic prescriptions in southwest China exhibited a downward trend from 2017 to 2022, but inappropriate prescription remains a serious problem in primary care institutions. Therefore, future efforts should focus on strengthening physician education, training, and clinical practice. Additionally, physicians' awareness of common misconceptions about inappropriate antibiotic use must be improved, and the prescribing behavior of physicians who fulfill patients' expectations by prescribing antibiotics needs to be modified.

Antibiotic-Prescribing Patterns Among Patients With Respiratory Symptoms in the Eastern Province, Kingdom of Saudi Arabia

Background Upper respiratory tract infections (URTIs) represent the most common diagnosis in ambulatory care settings. Some of these infections are properly treated with antibiotics, but evidence points to an inappropriate overuse of antibiotics in URTI management. This overuse is linked to antibiotic resistance, drug-related adverse effects, and increased costs. Objective This study evaluated the prevalence and predictors of antibiotic prescription for patients with URTI symptoms at the primary healthcare centers (PHCCs) and pediatric emergency department (ED) of the Maternity and Children Hospital (MCH) in Dammam, Saudi Arabia. Methods A prospective study was conducted in the PHCCs and pediatric ED of MCH. Trained physicians collected data on patients with URTI symptoms aged three years and older. Scores based on modified Centor criteria were calculated, and rapid antigen detection tests (RADTs) were conducted for all study participants. Results Out of 469 patients with a URTI, 141 (30.1%) received a prescription for an antibiotic, with a smaller proportion in the PHCCs (n=85; 24.4%) than in the pediatric ED (n=56; 46.3%). The main significant predictors of antibiotic prescription in terms of odds ratio (OR) and 95% confidence interval (95%CI) were a positive RADT result (OR=41.75, 95%CI=4.76-366.28), the presence of tonsillar exudate (OR=5.066, 95%CI=3.08-8.33), tender and/or swollen anterior cervical lymph nodes (OR=4.537, 95%CI=1.96-10.54), and fever (OR=3.519, 95%CI=2.33-5.31). A higher Centor score was also a predictor (2 to 5 vs. -1 to 1) (OR=2.72, 95%CI=1.8-4.12). The absence of a cough was not a significant predictor (OR=1.13, 95%CI=0.74-1.72). Conclusions Although a positive RADT increased the likelihood that a patient would be prescribed an antibiotic at the time of assessment, most antibiotic prescriptions were not justified. To control expenses, prevent adverse effects, and limit the spread of antibiotic resistance, efforts should be made to reduce unnecessarily high antibiotic usage.

Antibiotic prescription among children with common cold at a district hospital in Uganda

BACKGROUND

Most childhood infections are of viral origin making antibiotics unnecessary. They are, however, the most frequently prescribed drugs dispensed to children, resulting in inappropriate antibiotic prescriptions, which are one of the main drivers of antibiotic resistance.

AIM

The study aimed to determine the prevalence of antibiotic prescriptions and identify its associated factors among children below 5 years with common cold who attend the outpatient department in Tororo General Hospital.

SETTING

The study was carried out in Tororo General Hospital, Eastern Uganda.

METHODS

A cross-sectional survey using consecutive sampling was performed among children below 5 years with common cold attending the outpatient department. Data were collected using an interviewer-administered, structured questionnaire and analysed using STATA version 14.0. Prevalence of antibiotic prescriptions was calculated. Bivariate analysis using chi-square test and multivariate analysis using logistic regression was performed to establish factors associated with antibiotic prescription.

RESULTS

The prevalence of antibiotic prescriptions for common cold among children below 5 years was 23.3%. Factors associated with antibiotic prescription for common cold were duration of symptoms of more than 5 days (OR, 95% CI: 4.49; 1.16-17.23, p = 0.029) and being attended to by a clinical officer (OR, 95% CI: 0.19; 0.04-0.91, p = 0.038).

CONCLUSION

There is inappropriate antibiotic prescription among children with common cold in Tororo General Hospital. There is need for antibiotic stewardship programmes to promote optimal antibiotic use in primary care facilities.Contribution: The study's findings can be used to develop context-specific antibiotic stewardship programmes tailored to promote judicious use of antibiotics in primary care.

Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa

Although overprovision of antibiotics in primary care is a key driver of antibiotic resistance, little is known about its determinants in low-income and middle-income countries. Patient demand and financial incentives for providers are often held responsible for overprovision. Yet, inadequate provision exists in their absence and could be fuelled by quality of care issues and incorrect beliefs of providers regarding patients' expectations. We explored these issues in the private and public sector in South Africa, by conducting a cross-sectional study using standardised patients (SPs)-healthy individuals trained to portray a scripted clinical case to providers-presenting with symptoms of a viral respiratory infection in a sample of public and private sector clinics. We linked data from SP visits to rich survey data to compare the practices and their predictors in the two sectors. Unnecessary rates of antibiotics were similarly high in the public (78%) and private sector (67%), but private providers prescribed more antibiotics at higher risk of resistance development. In the private sector, overprescription of antibiotics diminished when consultations were more thorough, but increased for consultations scheduled later in the day, suggesting contrasting effects for provider effort and decision fatigue. We observed differences in beliefs that could be responsible for overprescription: in the public sector, a majority of providers (nurses) wrongly believed that antibiotics would help the patient recover more quickly. In the private sector, a majority of doctors thought patients would not come back if they did not receive antibiotics. Overall, this evidence suggests that different factors may be responsible for the high overprescribing rates of antibiotics in the public and private sectors. Tailored stewardship interventions are urgently needed that tackle providers' engrained habits and incorrect beliefs.

Understanding of Final Year Medical, Pharmacy and Nursing Students in Pakistan towards Antibiotic Use, Antimicrobial Resistance and Stewardship: Findings and Implications

Antimicrobial resistance (AMR) is a leading public health threat, which is exacerbated by the high and inappropriate use of antibiotics. Consequently, there is a need to evaluate knowledge regarding antibiotic use, AMR and the readiness to implement antimicrobial stewardship programs (ASPs) among final year medical, pharmacy and nursing students in Pakistan. This reflects the high and increasing rates of AMR in the country, and students as future healthcare professionals (HCPs). A cross-sectional study was conducted among 1251 final year students from 23 public and private educational institutions in Punjab. The majority of the surveyed participants possessed good knowledge of antibiotic use, AMR and the potential causes of AMR. The most common sources of the information on antibiotics were smartphones (69.9%), peers (35.9%) and medical textbooks (30.6%). However, most surveyed participants were not fully prepared to participate in ASPs. They knew, though, how to reduce AMR by educating HCPs about appropriate prescribing, implementing ASPs and improving laboratory facilities. There was a significant association between antibiotic knowledge and causes of AMR with sex, family income and student type (p < 0.05). Being a student at a public sector university (OR = 4.809; CI = 3.261−7.094; p < 0.001) and age (OR = 0.524, CI = 0.327−0.842; p < 0.008) were among the key factors impacting students’ training on ASPs. Educational curricula must be improved to include more information about appropriate antibiotic use and ASPs, along with sufficient training, workshops and clinical rotations in the final year, to fully equip students by graduation.

Point prevalence survey of antibiotic use among hospitalized patients across 41 hospitals in Thailand

Objectives

To describe the antibiotic use among hospitalized patients in Thailand.

Methods

A standardized cross-sectional point prevalence survey (PPS) modified from the WHO PPS protocol was conducted in 41 selected hospitals in Thailand. All inpatients who received an antibiotic at 9 a.m. on the survey date were enrolled. The total number of inpatients on that day was the denominator.

Results

Between March and May 2021, a total of 8958 inpatients were enumerated; 4745 inpatients received antibiotics on the day of the survey and there were 6619 prescriptions of antibiotics. The prevalence of antibiotic use was 53.0% (95% CI 51.1%-54.0%), ranging from 14.3% to 73.4%. The antibiotic use was highest among adults aged >65 years (57.1%; 95% CI 55.3%-58.9%). From 6619 antibiotics prescribed, 68.6% were used to treat infection, 26.7% for prophylaxis and 4.7% for other or unknown indications. Overall, the top three commonly used antibiotics were third-generation cephalosporins (1993; 30.1%), followed by first-generation cephalosporins (737; 11.1%) and carbapenems (703; 10.6%). The most frequently used antibiotics for community-acquired infections were third-generation cephalosporins (36.8%), followed by β-lactam/β-lactamase inhibitors (11.8%) and carbapenems (11.3%) whereas for the patients with hospital-acquired infections, the most common antibiotics used were carbapenems (32.7%), followed by β-lactam/β-lactamase inhibitors (15.7%), third-generation cephalosporins (11.7%) and colistin (11.7%). The first-generation cephalosporins were the most commonly used antibiotics (37.7%) for surgical prophylaxis. Seventy percent of the patients received surgical prophylaxis for more than 1 day post surgery.

Conclusions

The prevalence of antibiotic use among hospitalized patients in Thailand is high and one-quarter of these antibiotics were used for prophylaxis. The majority of surgical prophylaxis was inappropriately used for a long duration post operation. Therefore, it is recommended that local guidelines should be developed and implemented.

Assessment of knowledge, attitude, and practice of antibiotics prescription among healthcare residents at King Abdulaziz medical City, Jeddah, Saudi Arabia

Introduction

Antibiotic resistance (ABR) is defined as bacteria's resistance to therapy despite therapeutic levels of antibiotics. It is a global health concern. Data on the antibiotic prescription practice of physicians, in general, are limited in Saudi Arabia. Therefore, we aim to assess the knowledge, attitude, and practice of antibiotic prescription between surgical and non-surgical residents at King Abdulaziz Medical City (KAMC).

Methods

A cross-sectional study was conducted at KAMC in Jeddah, Saudi Arabia, from September 2019, until March 2020. The questionnaire contained demographic information and 31 questions based on the studied variables: knowledge (17), attitude (4), and practice (10).

Results

The response rate was 83 %. Male to female response rates were 54 % and 46 %, respectively. The majority of respondents (72 %) were non-surgical residents. Positive practice skills showed that 55 % of all healthcare residents always used practice guidelines for antibiotic prescription in their daily work (P-value < 0.001). Most residents (50 %) sometimes used delayed prescriptions. Non-surgical residents discussed ABR with patients more than surgical residents (P-value = 0.028). Lack of patient interest was the common cause for not discussing ABR with patients (42 %). Non-surgical residents had significantly more training on antibiotic prescription (p-value = 0.001). The fear of infection spread due to not prescribing an antibiotic was significantly higher in non-surgical residents (P-value < 0.001). Non-surgical residents (76 %) took a past medical history of antibiotic consumption more than surgical residents (24 %) (P-value = 0.003). Antibiotic prescription for residents was not influenced by advertisements (91 %). The most common resistant organisms reported by residents were insignificant between the two groups. The results also showed that the residents' common choice of antibiotics was not statistically different between surgical and non-surgical residents in most antibiotic classes.

Conclusions

We found that practice guidelines, formal training, and taking patients' past medical histories were significantly higher among non-surgical residents. In contrast, surgical residents were prescribing more antibiotics due to the fear of the spread of the infection. Proper training is essential for all healthcare residents to overcome differences among different specialties.

Nurses’ knowledge, motivation, behaviors, and information sources on antibiotic use and resistance in Jordan

<b>Aim:</b> This study aims to examine the nurse knowledge, motivation, and behavior about antibiotics and antibiotic resistance. A secondary objective was to study the preferred information sources used by Jordanian nurses, as well as their knowledge of the information available to promote rational prescription practices in the Jordanian health system.<b> </b><br /> <b>Method: </b>The study was cross-sectional in design and nurses (n=1,093) completed an online survey using Google Forms. Participation in the study was completely optional, and participants were free to drop out at any point. During the months of February-May 2022, nurses were asked to participate in a survey<br /> <b>Results:</b> The study found 48.2% of nurses given prescribed antibiotics to the patients daily or multiple times a day in the preceding week; 13.3% of nurses provided support on daily or more frequent antibacterial drugs use or infection management. The reason for not giving advice regarding antibiotics were no leaflet regarding the use of the antibiotics (42.3%) and the patients do not get attention for the information (30.4%).<br /> <b>Conclusion:</b> In conclusion, the findings of this study show that public health actions are needed (e.g., educational or communication campaigns). Nurses must be educated on the proper use of antibiotics and the emergence of antibiotic resistance. Antibiotic stewardship can benefit from the findings, which can be used to develop interventions aimed at improving antibiotic usage.

Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review

Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.

Antibiotic Use and Stewardship Indicators in the First- and Second-Level Hospitals in Zambia: Findings and Implications for the Future

Introduction: There are increasing concerns with growing rates of antimicrobial resistance (AMR) across Africa, including in Zambia, enhanced by inappropriate utilization of antibiotics across the sectors. There is a need in hospitals to document current prescribing patterns via point prevalence surveys (PPS) alongside recognized indicators to improve future use. The findings can subsequently be used to develop and instigate appropriate antimicrobial stewardship programs (ASPs) to improve the quality of future antimicrobial prescribing across Zambia. This includes encouraging the prescribing of 'Access' over 'Watch' and 'Reserve' antibiotics where pertinent. Methods: A PPS was undertaken using the WHO methodology among 10 first- and second-level public hospitals across the 10 provinces of Zambia. A sampling process was used to select the hospitals. Results: The prevalence of antibiotic use among the in-patients was 307/520 (59.0%), with a high rate of empiric prescribing of ceftriaxone at 36.1% of all antibiotics prescribed (193/534). The reason for antibiotic use was recorded in only 15.7% of occasions and directed treatment prescribed in only 3.0% of occasions. Compliance with the national standard treatment guidelines (STGs) was also low at only 27.0% of occasions. Conclusion: High empiric prescribing, limited documentation of the rationale behind antibiotic prescribing, high use of 'Watch' antibiotics, and limited compliance to STGs among surveyed hospitals requires the urgent instigation of ASPs across Zambia to improve future prescribing.

Knowledge, Attitude, and Behavior about Antimicrobial Use and Resistance among Medical, Nursing and Pharmacy Students in Jordan: A Cross Sectional Study

The present study aimed to survey medical, nursing and pharmacy students' knowledge, attitude and practice regarding antimicrobial use and resistance. Additionally, the study assessed the teaching and assessment activities received regarding antibiotic use. A cross sectional online survey was distributed to undergraduate students currently in clinical studies in their degree program. A total of 716 medicine, nursing and pharmacy undergraduate students were included. Respondents scored more than 76% on knowledge on effective use, unnecessary use and associated side effects of antibiotics, and 65.2% regarding knowledge on the spread of antibiotic resistance. Some participants (21.0%) agreed or strongly agreed that there has been good promotion of prudent antimicrobial use. Students were aware (13.1%), unaware (29.1%), or unsure (57.8%) that there is a national action plan relating to antimicrobial resistance. A total of 62.8% of the respondents strongly agreed or agreed that they have a key role in helping control antibiotic resistance. Participants reported that they require more information about resistance to antibiotics (53.9%), medical conditions for which antibiotics are used (51.7%) and how to use antibiotics (51.0%). Discussion of clinical cases and vignettes and small group teaching were reported as very useful or useful teaching strategies (79.9% and 74.2%, respectively). The findings from this study determined the current situation in relation to education on prudent antimicrobial use for undergraduates and highlighted areas for informing better curriculum design.

Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework

INTRODUCTION

Overprescription of antibiotics poses a significant threat to healthcare globally as it contributes to the issue of antibiotic resistance. While antibiotics should be predominately prescribed for bacterial infections, they are often inappropriately given for uncomplicated upper respiratory tract infections (URTIs) and related conditions, such as the common cold. This study will involve a qualitative systematic review of physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care settings and synthesise the findings using a theoretical basis.

METHODS AND ANALYSIS

We will conduct a systematic review of qualitative studies that assess physicians' reported barriers to following evidence-based antibiotic prescription guidelines in primary care settings for URTIs. We plan to search the following databases with no date or language restrictions: MEDLINE, Web of Science, CINAHL, Embase, the Cochrane Library and PsycInfo. Qualitative studies that explore the barriers and enablers to following antibiotic prescription guidelines for URTIs for primary care physicians will be included. We will analyse our findings using the Theoretical Domains Framework (TDF), which is a theoretically designed resource based on numerous behaviour change theories grouped into 14 domains. Using the TDF approach, we will be able to identify the determinants of our behaviour of interest (ie, following antibiotic prescription guidelines for URTIs) and categorise them into the 14 TDF domains. This will provide the necessary information to develop future evidence-based interventions that will target the identified issues and apply the most effective behaviour change techniques to affect change. This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at conferences.

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020−March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35−44 years (OR: 3.38; 95%CI: 1.15−9.88), >55 years (OR: 4.75; 95% CI 1.08−21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08−4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.

Antibiotic Prescribing Practices for Treating COVID-19 Patients in Bangladesh

Although national and international guidelines have strongly discouraged use of antibiotics to treat COVID-19 patients with mild or moderate symptoms, antibiotics are frequently being used. This study aimed to determine antibiotics-prescribing practices among Bangladeshi physicians in treating COVID-19 patients. We conducted a cross-sectional survey among physicians involved in treating COVID-19 patients. During September-November 2021, data were collected from 511 respondents through an online Google Form and hardcopies of self-administered questionnaires. We used descriptive statistics and a regression model to identify the prevalence of prescribing antibiotics among physicians and associated factors influencing their decision making. Out of 511 enrolled physicians, 94.13% prescribed antibiotics to COVID-19 patients irrespective of disease severity. All physicians working in COVID-19-dedicated hospitals and 87% for those working in outpatient wards used antibiotics to treat COVID-19 patients. The majority (90%) of physicians reported that antibiotics should be given to COVID-19 patients with underlying respiratory conditions. The most prescribed antibiotics were meropenem, moxifloxacin, and azithromycin. Our study demonstrated high use of antibiotics for treatment of COVID-19 patients irrespective of disease severity and the duty ward of study physicians. Evidence-based interventions to promote judicious use of antibiotics for treating COVID-19 patients in Bangladesh may help in reducing an overuse of antibiotics.

Determinants of prescribing decisions for off-patent biological medicines in Belgium: a qualitative study

BACKGROUND

A competitive market for off-patent biologicals leads to more affordable and high-quality healthcare. In recent years, Belgium has been characterized by its low use of biosimilars and by its shifts from off-patent biologicals toward new alternative therapies. Yet, the prescribing decisions involved in these observations are poorly understood. This study aims to better understand prescribing choices among Belgian physicians in the ambulatory care setting.

METHODS

This study consisted of two phases. First, a scoping literature review to identify determinants of prescribing choices was conducted. Scientific databases (Embase and PubMed) were searched until 4 November 2021. Second, the nominal group technique (NGT) was employed during focus group discussions with Belgian physicians to consider and validate these determinants for off-patent biologicals in the Belgian context. The qualitative data resulting from the literature review and focus group discussions were analyzed using the thematic framework method.

RESULTS

Fifty-three scientific articles that discussed elements that determine prescribing choices were identified. Out of these, 17 determinants of prescribing choices were found. These were divided into five categories: (1) product-related, (2) physicians' personal, (3) healthcare system-related, (4) patient-related, and (5) determinants related to the pharmaceutical company or brand. Nineteen Belgian physicians from different therapeutic areas that regularly prescribe biologicals then participated in focus group discussions. Using the NGT, the group discussions revealed that prescribing choices for off-patent biologicals are determined by a complex set of elements. Clinical data, geographical region, working environment, pharmaceutical marketing, patient profile, clinical guidelines, and preference of key opinion leaders (KOL) were considered most influential. Physicians indicated that the importance of these determinants differs depending on product classes or therapeutic domain.

CONCLUSIONS

Multiple elements determine the choice of an off-patent biological or biosimilar product. The importance of each of these determinants varies depending on the context in which the prescribing choice is made. To increase the prescription of best-value biologicals in the Belgian ambulatory care, a set of synergistic measures is required including information for healthcare providers (HCP) and patients, prescribing feedback, prescribing targets, tangible incentives, KOL involvement, guidelines regarding pharmaceutical promotion, and regular revision of reimbursement modalities.

Factors affecting the use of antibiotics and antiseptics to prevent maternal infection at birth: A global mixed-methods systematic review

Background

Over 10% of maternal deaths annually are due to sepsis. Prophylactic antibiotics and antiseptic agents are critical interventions to prevent maternal peripartum infections. We conducted a mixed-method systematic review to better understand factors affecting the use of prophylactic antibiotics and antiseptic agents to prevent peripartum infections.

Methods

We searched MEDLINE, EMBASE, Emcare, CINAHL, Global Health, Global Index Medicus, and Maternity and Infant Care for studies published between 1 January 1990 and 27 May 2022. We included primary qualitative, quantitative, and mixed-methods studies that focused on women, families, and healthcare providers’ perceptions and experiences of prophylactic antibiotic and antiseptics during labour and birth in health facilities. There were no language restrictions. We used a thematic synthesis approach for qualitative evidence and GRADE-CERQual approach for assessing confidence in these review findings. Quantitative study results were mapped to the qualitative findings and reported narratively.

Results

We included 19 studies (5 qualitative, 12 quantitative and 2 mixed-methods studies), 16 relating to antibiotics, 2 to antiseptic use, and 1 study to both antibiotic and antiseptic use. Most related to providers’ perspectives and were conducted in high-income countries. Key themes on factors affecting antibiotic use were providers’ beliefs about benefits and harms, perceptions of women’s risk of infection, regimen preferences and clinical decision-making processes. Studies on antiseptic use explored women’s perceptions of vaginal cleansing, and provider’s beliefs about benefits and the usefulness of guidelines.

Conclusion

We identified a range of factors affecting how providers use prophylactic antibiotics at birth, which can undermine implementation of clinical guidelines. There were insufficient data for low-resource settings, women’s perspectives, and regarding use of antiseptics, highlighting the need for further research in these areas. Implications for practice include that interventions to improve prophylactic antibiotic use should take account of local environments and perceived infection risk and ensure contextually relevant guidance.

Drivers of irrational use of antibiotics among children: a mixed-method study among prescribers and dispensers in Tanzania

Background

Misuse of antibiotics has been associated with poor knowledge, attitude and practice (KAP). Therefore, this study aimed to assess if KAP of prescribers and dispensers could drive irrational use of antibiotics among children in Tanzania.

Methods

A convergent parallel mixed-methods study design that employed quantitative and qualitative approaches was conducted in 14 regional referral hospitals (RRHs). A total of 108 participants, prescribers [54] and dispensers [54] working with the pediatric population in the respective regions participated in a quantitative survey, by filling the standard questionnaire while 28 key informant interviews were conducted with in-charges of units from the pharmacy and pediatric departments. Two key informants (prescriber and dispenser) were selected from each RRH.

Results

Overall, among prescribers and dispensers, there was adequate knowledge; 81.5% and 79.6%, p = 0.53, those with positive attitudes were 31.5% and 81.5%, p < 0.001 and poor practices were among 70.4% and 48% p = 0.0312 respectively. Among prescribers, 14.8% agreed and strongly agreed that prescribing antibiotics that a patient did not need does not contribute to resistance. Moreover 19% disagreed to prescribe antibiotics according to local guidelines. Among dispensers, a-quarter of the dispensers thought individual efforts to implement antibiotic stewardship would not make a difference, 17% agreed and strongly agreed that antibiotics can treat viral infection and 7% agreed and strongly agreed antibiotics can be stopped upon resolution of symptoms. From qualitative interviews, both participants displayed an adequate understanding of multi-contributors of antibiotic resistance (AR) including polypharmacy, community self-medication, among others. Regardless, both professions declared to prescribed and dispensed antibiotics according to the antibiotics available in stock at the facility. Furthermore, prescribers perceived laboratory investigation took a long time, hence wasting their time. On the other hand, Dispensers reported not to provide adequate instruction to the patients, after dispensing antibiotics.

Conclusions

Both prescribers and dispensers had adequate knowledge, few prescribers had positive attitudes and the majority had poor practices. Few dispensers had poor attitude and practice. These findings highlight the need to provide adequate training on antimicrobial stewardship and enforce regulation that foster appropriate medical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08359-7.

Exploring Barriers to One Health Antimicrobial Stewardship in Sri Lanka: A Qualitative Study among Healthcare Professionals

Antimicrobial resistance (AMR) is a global health threat, but little is known about the perceptions regarding antimicrobials and AMR among healthcare professionals in Sri Lanka. This research aimed to take a One Health approach to explore the knowledge, attitudes and perceptions of antibiotic stewardship and AMR among healthcare professionals in Sri Lanka. A qualitative study, using telephone interviews, allowing for an in-depth exploration of attitudes, beliefs and perspectives was conducted. Healthcare professionals from both the medical and veterinary sectors were included (n = 29). Interviews were conducted by an independent interviewer and were audio-recorded and transcribed. Conventional qualitative content analysis was undertaken. Four main categories were identified: (1) understanding of AMR and observing AMR, (2) barriers to antimicrobial stewardship, (3) personal factors in, and as a result of, inappropriate antibiotic usage and (4) how to tackle AMR. Healthcare professionals showed poor awareness regarding the spread of AMR and identified inappropriate prescribing behaviours by their inter- and intra-professional colleagues. Patient demands and the influence of pharmaceutical companies were factors contributing to poor prescribing behaviour. Suggestions for the future are stricter regulation of AMR control policy, effective government involvement, and awareness campaigns for healthcare professionals and the public.

Exploring Knowledge of Antibiotic Use, Resistance, and Stewardship Programs among Pharmacy Technicians Serving in Ambulatory Care Settings in Pakistan and the Implications

Antimicrobial resistance (AMR) is a leading global health threat, increasing morbidity, mortality, and costs, with excessive and irrational use of antimicrobials contributing to the development of AMR. Consequently, the aims of this study were to evaluate the understanding of antibiotic use, AMR, and antimicrobial stewardship programs (ASPs) among pharmacy technicians serving in ambulatory healthcare settings in Pakistan. A cross-sectional survey was conducted among pharmacy technicians serving in 144 ambulatory care settings in seven districts of Punjab province using a validated questionnaire. Overall, 376 technicians completed the survey (85.8% response rate). The majority were men (89.1%), aged 25−35 years (45.1%), serving in emergency departments (43.9%) and filling 31−60 prescriptions per day (37.5%). Most (79.5%) knew that antibiotics were one of the most frequently prescribed drug classes, while 59.8% believed antibiotics for common colds did not speed up recovery. Inadequate duration (59.6%) and inadequate dosages (57.7%) of antibiotic therapy were reported as the leading causes of AMR. Terms including ‘superbugs’, ‘multidrug resistance’, and ‘extensively drug resistance’ were known to 42.0%, 25.3%, and 20.7% of participants, respectively; however, <10% knew about ASPs, including their core elements and purpose. Our study revealed that pharmacy technicians have adequate awareness of antibiotic use but are currently unaware of AMR and ASPs, which is a concern.

Optimizing antibiotic use in Indonesia: A systematic review and evidence synthesis to inform opportunities for intervention

Background

A major driver of antimicrobial resistance (AMR) and poor clinical outcomes is suboptimal antibiotic use, although data are lacking in low-resource settings. We reviewed studies on systemic antibiotic use (WHO ATC/DDD category J01) for human health in Indonesia, and synthesized available evidence to identify opportunities for intervention.

Methods

We systematically searched five international and national databases for eligible peer-reviewed articles, in English and Indonesian, published between 1 January 2000 and 1 June 2021 including: (1) antibiotic consumption; (2) prescribing appropriateness; (3) antimicrobial stewardship (AMS); (4) consumers' and providers' perceptions. Two independent reviewers included studies and extracted data. Study-level data were summarized using random-effects model meta-analysis for consumption and prescribing appropriateness, effect direction analysis for antimicrobial stewardship (AMS) interventions, and qualitative synthesis for perception surveys. (PROSPERO: CRD42019134641).

Findings

Of 9323 search hits, we included 100 reports on antibiotic consumption (20), prescribing appropriateness (49), AMS interventions (13), and/or perception (25) (8 categorized in >1 domain). The pooled estimate of overall antibiotic consumption was 134.8 DDD per 100 bed-days (95%CI 82.5-187.0) for inpatients and 121.1 DDD per 1000 inhabitants per day (10.4-231.8) for outpatients. Ceftriaxone, levofloxacin, and ampicillin were the most consumed antibiotics in inpatients, and amoxicillin, ciprofloxacin, and cefadroxil in outpatients. Pooled estimates for overall appropriate prescribing (according to Gyssens method) were 33.5% (18.1-53.4) in hospitals and 49.4% (23.7-75.4) in primary care. Pooled estimates for appropriate prescribing (according to reference guidelines) were, in hospitals, 99.7% (97.4-100) for indication, 84.9% (38.5-98.0) for drug choice, and 6.1% (0.2-63.2) for overall appropriateness, and, in primary care, 98.9% (60.9-100) for indication, 82.6% (50.5-95.7) for drug choice and 10.5% (0.8-62.6) for overall appropriateness. Studies to date evaluating bundled AMS interventions, although sparse and heterogeneous, suggested favourable effects on antibiotic consumption, prescribing appropriateness, guideline compliance, and patient outcomes. Key themes identified in perception surveys were lack of community antibiotic knowledge, and common non-prescription antibiotic self-medication.

Interpretation

Context-specific intervention strategies are urgently needed to improve appropriate antibiotic use in Indonesian hospitals and communities, with critical evidence gaps concerning the private and informal healthcare sectors.

Funding

Wellcome Africa Asia Programme Vietnam.

What you need to know about microbiology referrals

Microbiologists are frequently consulted for guidance on the investigation and management of infection, including antimicrobial prescribing in hospital settings. There is a rising demand for timely microbiology advice in the context of increasing global travel and antibiotic resistance, which give rise to complex cases. However, junior doctors are seldom trained in making effective referrals. Improving confidence in this key skill saves time for both the referring clinician and the specialist, and results in more accurate advice being given. This benefits patients who are more likely to receive appropriate treatment. This article presents guidance, developed in consultation with specialists, to improve the quality of referrals to microbiologists. This includes the information required for a high-quality referral, and signposts referring clinicians to existing resources which are suitable for simpler cases not requiring specialist input.

Impact of Pharmacist-Led Implementation of a Community Hospital-Based Outpatient Parenteral Antimicrobial Therapy on Clinical Outcomes in Thailand

Few studies have analyzed community hospital-based parenteral anti-infective therapy (CohPAT). We aimed to assess the clinical impact of a pharmacist-led implementation of a clinical practice guideline (CPG) for CohPAT, and to determine the pharmacist’s role in CohPAT medication management. The prospective-period patients (post-implementation group) were compared with the historical control-period patients (pre-implementation group) for receiving a continuous antimicrobial parenteral injection. A CPG was used for laboratory testing for efficacy and safety, the monitoring of adverse drug events during admission, microbiology results coordination, and dosage adjustment. For any antimicrobial drug-related problems, the pharmacist consulted with the clinicians. Over 14 months, 50 participants were included in each group. In the pre-implementation period, 7 (14%) and 4 (8%) out of 50 patients received an inappropriate dosage and nonlaboratory monitoring for dose adjustment, respectively. The patients received the proper dosage of antimicrobial agents, which increased significantly from 78% pre- to 100% post-implementation (p = 0.000). The pharmacist’s interventions during the prospective-period were completely accepted by the clinicians, and significantly greater laboratory monitoring complying with CPG was given to the postimplementation group than the pre-implementation group (100% vs. 60%; p = 0.000). Significantly less patients with unfavorable outcomes (failure or in-hospital mortality) were observed in the post-implementation than in the pre-implementation (6% vs. 26%; p = 0.006) group. For the logistic regression analysis, lower respiratory infection (adjusted OR, aOR 3.68; 95%CI 1.13–12.06) and the post-implementation period (aOR 0.21; 95%CI 0.06–0.83) were significant risk factors that were associated with unfavorable outcomes. Given the better clinical outcomes and the improved quality of septic patient care observed after implementation, pharmacist-led implementation should be adopted in healthcare settings.

Perceptions, views and practices regarding antibiotic prescribing and stewardship among hospital physicians in Jakarta, Indonesia: a questionnaire-based survey

OBJECTIVES

Antibiotic overuse is one of the main drivers of antimicrobial resistance (AMR), especially in low-income and middle-income countries. This study aimed to understand the perceptions and views towards AMR, antibiotic prescribing practice and antimicrobial stewardship (AMS) among hospital physicians in Jakarta, Indonesia.

DESIGN

Cross-sectional, self-administered questionnaire-based survey, with descriptive statistics, exploratory factor analysis (EFA) to identify distinct underlying constructs in the dataset, and multivariable linear regression of factor scores to analyse physician subgroups.

SETTING

Six public and private acute-care hospitals in Jakarta in 2019.

PARTICIPANTS

1007 of 1896 (53.1% response rate) antibiotic prescribing physicians.

RESULTS

Physicians acknowledged the significance of AMR and contributing factors, rational antibiotic prescribing, and purpose and usefulness of AMS. However, this conflicted with reported suboptimal local hospital practices, such as room cleaning, hand hygiene and staff education, and views regarding antibiotic decision making. These included insufficiently applying AMS principles and utilising microbiology, lack of confidence in prescribing decisions and defensive prescribing due to pervasive diagnostic uncertainty, fear of patient deterioration or because patients insisted. EFA identified six latent factors (overall Crohnbach's α=0.85): awareness of AMS activities; awareness of AMS purpose; views regarding rational antibiotic prescribing; confidence in antibiotic prescribing decisions; perception of AMR as a significant problem; and immediate actions to contain AMR. Factor scores differed across hospitals, departments, work experience and medical hierarchy.

CONCLUSIONS

AMS implementation in Indonesian hospitals is challenged by institutional, contextual and diagnostic vulnerabilities, resulting in externalising AMR instead of recognising it as a local problem. Appropriate recognition of the contextual determinants of antibiotic prescribing decision making will be critical to change physicians' attitudes and develop context-specific AMS interventions.

Assessment of without prescription antibiotic dispensing at community pharmacies in Hazara Division, Pakistan: A simulated client's study

Antibiotics dispensing without a prescription is an irrational practice and can increase the risk of antibiotic resistance, which is a significant public health concern around the globe. This study was aimed to determine the extent to which antibiotics are supplied without prescription in the community pharmacies (CPs) at Hazara Division from November 2020 to February 2021. The simulated client method (SCM) was used, and the data were gathered, recorded, and analyzed through different statistical methods with descriptive and inferential techniques. The antibiotic dispensing was observed in CPs (90.5%), the most dispensed antibiotics were azithromycin (29.4%) and ciprofloxacin (46.5%) respectively. Furthermore, visited medical stores/ drug outlets, 9.5% of the visited stores denied dispensing of antibiotics because they preferred a referral to visit physicians (23. 9%) and (12.8%) did not had the antibiotics at the time of visits. Antibiotics were more obtainable in retail medical stores (AOR = 8.6, 95 percent Cl: 3.0–24.7; p = 0.001) than in pharmacies. In rural areas antibiotics dispensing was more (p = 0.004) as compared to urban areas. Staff members also had asked about patient’s (17.7%) symptoms and drug allergies (12.3% and 3.9%), and (1.5%) they consoled them about their medications. The findings of this study indicate that nonprescription antibiotic sales are very common, despite national rules prohibiting this activity. When the simulated Client requested for any medication to relieve his or her discomfort, many antibiotics were given out without a prescription. Pharmacies/medical stores in Hazara Division selling antibiotics without a prescription are worrying and need immediate action by regulators.

Prescribing Patterns and Variations of Antibiotic Use for Children in Ambulatory Care: A Nationwide Study

The aim of this study was to analyse characteristics of paediatric antibiotic use in ambulatory care in Hungary. Data on antibiotics for systemic use dispensed to children (0–19 years) were retrieved from the National Health Insurance Fund. Prescribers were categorised by age and specialty. Antibiotic use was expressed as the number of prescriptions/100 children/year or month. For quality assessment, the broad per narrow (B/N) ratio was calculated as defined by the European Surveillance of Antimicrobial Consumption (ESAC) network. Paediatric antibiotic exposure was 108.28 antibiotic prescriptions/100 children/year and was the highest in the age group 0–4 years. Sex differences had heterogenous patterns across age groups. The majority of prescriptions were issued by primary care paediatricians (PCP). The use of broad-spectrum agents dominated, co-amoxiclav alone being responsible for almost one-third of paediatric antibiotic use. Elderly physicians tended to prescribe less broad-spectrum agents. Seasonal variation was found to be substantial: antibiotic prescribing peaked in January with 16.6 prescriptions/100 children/month, while it was the lowest in July with 4 prescriptions/100 children/month. Regional variation was prominent with an increasing west to east gradient (max: 175.6, min: 63.8 prescriptions/100 children/year). The identified characteristics of paediatric antibiotic use suggest that prescribing practice should be improved.

Provider views on rapid diagnostic tests and antibiotic prescribing for respiratory tract infections: A mixed methods study

BACKGROUND

Respiratory tract infections (RTIs) are often inappropriately treated with antibiotics. Rapid diagnostic tests (RDTs) have been developed with the aim of improving antibiotic prescribing but uptake remains low. The aim of this study was to examine provider knowledge, attitudes and behaviors regarding RDT use and their relationship to antibiotic prescribing decisions across multiple clinical departments in an urban safety-net hospital.

METHODS

We conducted a mixed methods sequential explanatory study. Providers with prescribing authority (attending physicians, nurse practitioners and physician assistants) who had at least 20 RTI encounters from January 1, 2016 to December 31, 2018. Eighty-five providers completed surveys and 16 participated in interviews. We conducted electronic surveys via RedCap from April to July 2019, followed by semi-structured individual interviews from October to December 2019, to ascertain knowledge, attitudes and behaviors related to RDT use and antibiotic prescribing.

RESULTS

Survey findings indicated that providers felt knowledgeable about antibiotic prescribing guidelines. They reported high familiarity with the rapid streptococcus and rapid influenza tests. Familiarity with comprehensive respiratory panel PCR (RPP-respiratory panel PCR) and procalcitonin differed by clinical department. Qualitative interviews identified four main themes: providers trust their clinical judgment more than rapid test results; patient-provider relationships play an important role in prescribing decisions; there is patient demand for antibiotics and providers employ different strategies to address the demand and providers do not believe RDTs are implemented with sufficient education or evidence for clinical practice.

CONCLUSION

Prescribers are knowledgeable about prescribing guidelines but often rely on clinical judgement to make final decisions. The utility of RDTs is specific to the type of RDT and the clinical department. Given the low familiarity and clinical utility of RPP and procalcitonin, providers may require additional education and these tests may need to be implemented differently based on clinical department.

Antibiotic Prevalence Study and Factors Influencing Prescription of WHO Watch Category Antibiotic Ceftriaxone in a Tertiary Care Private Not for Profit Hospital in Uganda

Background: Excessive use of ceftriaxone contributes to the emergence and spread of antimicrobial resistance (AMR). In low and middle-income countries, antibiotics are overused but data on consumption are scarcely available. We aimed to determine the prevalence and factors influencing ceftriaxone prescription in a tertiary care private not-for-profit hospital in Uganda. Methods: A cross-sectional study was carried out from October 2019 through May 2020 at Mengo Hospital in Uganda. Patients admitted to the medical ward and who had been prescribed antibiotics were enrolled. Sociodemographic and clinical data were recorded in a structured questionnaire. Bivariate and adjusted logistic regression analyses were performed to determine factors associated with ceftriaxone prescription. Results: Study participants were mostly female (54.7%). The mean age was 56.2 years (SD: 21.42). The majority (187, 73.3%) presented with fever. Out of the 255 participants included in this study, 129 (50.6%) participants were prescribed ceftriaxone. Sixty-five (25.5%) and forty-one (16.0%) participants had a prescription of levofloxacin and metronidazole, respectively. Seven participants (2.7%) had a prescription of meropenem. Out of 129 ceftriaxone prescriptions, 31 (24.0%) were in combination with other antibiotics. Overall, broad-spectrum antibiotic prescriptions accounted for 216 (84.7%) of all prescriptions. Ceftriaxone was commonly prescribed for pneumonia (40/129, 31%) and sepsis (38/129, 29.5%). Dysuria [OR = 0.233, 95% CI (0.07-0.77), p = 0.017] and prophylactic indication [OR = 7.171, 95% CI (1.36-37.83), p = 0.020] were significantly associated with ceftriaxone prescription. Conclusions: Overall, we observed a high prevalence of prescriptions of ceftriaxone at the medical ward of Mengo Hospital. We recommend an antibiotic stewardship program (ASP) to monitor antibiotic prescription and sensitivity patterns in a bid to curb AMR.

Decreasing Unnecessary Antibiotic Usage in Patients Admitted With Bronchiolitis

BACKGROUND AND OBJECTIVES

Bronchiolitis is a viral syndrome that occurs in children aged <2 years and is a common reason for admission to children's hospitals. The American Academy of Pediatrics bronchiolitis guideline discourages routine antibiotic therapy for bronchiolitis. Despite this, there is high use of antibiotics in this patient population.

METHODS

We performed a retrospective chart review of all patients aged ≤2 years admitted to our tertiary care center with bronchiolitis during 2 subsequent respiratory seasons. Between the 2 seasons, we provided an intervention to our hospital medicine group, which included a didactic review of American Academy of Pediatrics bronchiolitis guideline followed by subsequent, ongoing reinforcement from antibiotic stewardship weekday rounds.

RESULTS

We were able to achieve a 40% decrease in overall antibiotic use between the 2 study periods (25% vs 15%, P < .001).

CONCLUSIONS

Provider education, along with focused antibiotic stewardship audits with real-time feedback, resulted in decreased use of antibiotics in patients admitted with bronchiolitis.

An investigation of new medications initiation during ambulatory care visits in patients with dementia

Background

Objectives

Methods

Results

Conclusion

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What was already known?•

Dementia remains responsible for a large economic burden; research has shown that patients with dementia have increased utilization of ambulatory care visits before and after diagnosis.

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Prior research in patients with dementia has focused on inappropriate prescribing, adverse drug interactions, and polypharmacy, but little work has been published investigating new medications prescribed at outpatient visits.

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Opportunities exist for pharmacists to manage medications in the outpatient setting for patients with complex medication regimens.

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What the study adds?•

Though fewer visits for patients with dementia provided new medications compared to visits for patients without dementia, there was no statistically significant difference in odds of a new medication being provided after adjustment for important confounders.

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Some of the new medications more commonly provided to dementia patients include anticoagulants and antipsychotics that often require close monitoring and dosage adjustments.

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Pharmacist led services would likely improve the care of the dementia population in an outpatient setting, but further investigation of new medication usage and the utility of pharmacists is needed.

Antibiotic use and irrational antibiotic prescriptions in 66 primary healthcare institutions in Beijing City, China, 2015-2018

Objectives

To identify the patterns of antibiotic use and irrational antibiotic prescriptions in primary healthcare institutions (PHIs) in Dongcheng District of Beijing, China.

Materials and methods

All primary healthcare institutions (7 community healthcare centres and 59 community healthcare stations in total) in Dongcheng District were included in the study. Prescription data from January 2015 to December 2018 was derived from the Beijing Prescription Reviewing System of Primary healthcare institutions and analysed retrospectively. The antibiotic prescription rate was calculated and cases of irrational antibiotic prescriptions were identified.

Results

We extracted 11,166,905 prescriptions from the database. Only 189,962 prescriptions were included in the study, among which 9167 (4.8%) contained antibiotics. The antibiotic prescription rate fell from 5.2% in 2015 to 4.1% in 2018 while irrational antibiotic prescription rate increased from 10.4 to 11.8%. Acute Bronchitis was the most prevalent diagnosis (17.6%) for antibiotic prescriptions, followed by Unspecified Acute Respiratory Tract Infection (14.4%), Acute Tonsillitis (9.9%), and Urinary Tract Infection (6.4%). Around 10% of the prescriptions for the top 7 diagnoses identified were rated as irrational. Cephalosporins, fluoroquinolones, and macrolides were the most prescribed antibiotics, which accounted for 89.3% of all antibiotic prescriptions. Of all the antibiotic prescriptions, 7531 were reviewed, among which 939 (12.5%) were rated as irrational because of antibiotic use. Among all the irrational prescriptions, prescriptions with inappropriate antibiotic use and dosage accounted for the majority (54.4%).

Conclusion

Although a relatively low level of antibiotic utilization was found in PHIs in Dongcheng District of Beijing, the utilization patterns differed considerably from developed countries and irrational prescriptions remained. Considering the imbalanced allocation of medical resources between primary healthcare setting and secondary and tertiary hospitals, there need to be more efforts invested in regions with different levels of economic development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06856-9.

Exploring Information Available to and Used by Physicians on Antibiotic Use and Antibiotic Resistance in Jordan

Evidence based information sources for physicians are needed for informed antibiotic prescribing practices. The aim of this study was to explore physicians' preferred sources of information and evaluate physicians' awareness of available information and initiatives on prudent antibiotic prescribing in Jordan. A cross-sectional study was conducted utilizing an online questionnaire and included physicians (n = 409) from all sectors and specialties in Jordan. Published guidelines (31.8%), the workplace (25.7%), colleagues or peers (20.0%), group or conference training (18.3%), and the medical professional body (18.1%) were the main sources of information about avoiding unnecessary antibiotic prescribing, with the influence of these sources on changing prescribers' views being 34.7%, 17.1%, 11%, 13.4%, and 7.6%, respectively. One-third of physicians (33.7%) reported no knowledge of any initiatives on antibiotic awareness and resistance. Regarding awareness of national action plans on antimicrobial resistance, 10.5%, 34%, and 55.5% of physicians were aware, unaware, and unsure of the presence of any national action plans, respectively. Physicians showed interest in receiving more information on resistance to antibiotics (58.9%), how to use antibiotics (42.2%), medical conditions for which antibiotics are used (41.3%), prescribing of antibiotics (35.2%), and links between the health of humans, animals, and the environment (19.8%). The findings can inform interventions needed to design effective antimicrobial stewardship, enabling physicians to prescribe antibiotics appropriately.

Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications

Introduction: The emergence of antimicrobial resistance (AMR) is a threat to public health. In 2015, the World Health Organization (WHO) introduced a global action plan to tackle AMR in the World Health Assembly. Pakistan's national action plan (NAP) for AMR was released in May 2017 by the Ministry of National Health Services. Based on the NAP, strategies have been initiated on a national and provincial scale in Pakistan.Areas covered: This narrative review of the five components of the Pakistan NAP has been undertaken to discuss some of the challenges in implementation of the NAP for AMR in Pakistan including different opinions and views of key stakeholders, combined with suggestions on potential ways to reduce the burden of the AMR.Expert opinion: Going forward, healthcare authorities should focus on screening and monitoring of all the objectives of the NAP by establishing proper policies as well as promoting antimicrobial stewardship interventions and Infection prevention and control (IPC) practices. Overall, the comprehensive strengthening of the healthcare system is required to adequately implement the NAP, tackle continued inappropriate antimicrobial use and high AMR rates in Pakistan.

Perspectives of Healthcare Professionals Regarding Factors Associated with Antimicrobial Resistance (AMR) and Their Consequences: A Cross Sectional Study in Eastern Province of Saudi Arabia

Factors reported in the literature associated with inappropriate prescribing of antimicrobials include physicians with less experience, uncertain diagnosis, and patient caregiver influences on physicians’ decisions. Monitoring antimicrobial resistance is critical for identifying emerging resistance patterns, developing, and assessing the effectiveness of mitigation strategies. Improvement in prescribing antimicrobials would minimize the risk of resistance and, consequently, improve patients’ clinical and health outcomes. The purpose of the study is to delineate factors associated with antimicrobial resistance, describe the factors influencing prescriber’s choice during prescribing of antimicrobial, and examine factors related to consequences of inappropriate prescribing of antimicrobial. A cross-sectional study was conducted among healthcare providers (190) in six tertiary hospitals in the Eastern province of Saudi Arabia. The research panel has developed, validated, and piloted survey specific with closed-ended questions. A value of p < 0.05 was considered to be statistically significant. All data analysis was performed using the Statistical Package for Social Sciences (IBM SPSS version 23.0). 72.7% of the respondents have agreed that poor skills and knowledge are key factors that contribute to the inappropriate prescribing of antimicrobials. All of the respondents acknowledged effectiveness, previous experience with the antimicrobial, and reading scientific materials (such as books, articles, and the internet) as being key factors influencing physicians’ choice during antimicrobial prescribing. The current study has identified comprehensive education and training needs for healthcare providers about antimicrobial resistance. Using antimicrobials unnecessarily, insufficient duration of antimicrobial use, and using broad spectrum antimicrobials were reported to be common practices. Furthermore, poor skills and knowledge were a key factor that contributed to the inappropriate use and overuse of antimicrobials, and the use of antimicrobials without a physician’s prescription (i.e., self-medication) represent key factors which contribute to AMR from participants’ perspectives. Furthermore, internal policy and guidelines are needed to ensure that the antimicrobials are prescribed in accordance with standard protocols and clinical guidelines.