Azib Shahid ( Services Institute of Medical Sciences (SIMS), Lahore, Pakistan. )
Fatima Iftikhar ( Services Institute of Medical Sciences (SIMS), Lahore, Pakistan. )
Mohammad Kamil Arshad ( Services Institute of Medical Sciences (SIMS), Lahore, Pakistan. )
Zainub Javed ( Services Institute of Medical Sciences (SIMS), Lahore, Pakistan. )
Muhammad Sufyan ( Services Institute of Medical Sciences (SIMS), Lahore, Pakistan. )
Resham Sajjad Ghuman ( Services Institute of Medical Sciences (SIMS), Lahore, Pakistan. )
Zenab Tarar ( Services Institute of Medical Sciences (SIMS), Lahore, Pakistan. )
A cross sectional study was conducted in Services Hospital, Lahore using a self administered questionnaire to test the knowledge, attitude and prescribing practices of residents and attending physicians using non-probability convenience sampling. A total of 116 questionnaires were filled (Response rate=77.3%). Knowledge was below average (mean score of 3.66±1.1). Only 18 physicians (16%) could correctly estimate the rates of resistance of Klebsiella pneumoniae and pseudomonas aeruginosa to cephalosporin. Mostly physicians reviewed their decisions to prescribe an antibiotic by discussing with a senior colleague (n=93; 80%). When they did, the senior colleague sometimes recommended a different antibiotic (n=106; 91%). Seventy seven physicians (66%) reported that they prescribed more than one antibiotic per day. Physicians also stated that their decision of antimicrobial prescription was influenced by patient\\\'s socioeconomic status (n=108; 93.1%) and patients\\\' demands (n=24; 20.7%).
This study highlighted the importance of Antimicrobial stewardship and revealed topics to address during future antimicrobial prescribing interventions such as dissemination of information about local resistance rates and encouraging knowledge about antimicrobials.
Keywords: Antimicrobial resistance, Pakistan, Lahore, KAP study.
Irresponsible prescription of antimicrobials (AMs) is the driving factor for the growing antimicrobial resistance (AMR) crisis. Appropriate utilization of drugs necessitates optimal prescription habits. Prescriptive mishaps include inappropriate usage of drugs in the form of polypharmacy, inadequate dosage, failure to adhere to medical guidelines and inappropriate selection of drugs.1 Among the most commonly inappropriately prescribed drugs are antimicrobials with the problem of bacterial resistance to commonly used antibiotics becoming a world-wide burden.2 Consequences of such resistance are grave, affecting both the economical and health sectors. These may take several forms including increased morbidity and mortality, reduction in quality of antibiotic therapy, increased treatment costs, and un-justified loss of resources. These effects are more prominent in developing countries like Pakistan suffering both economical challenges and weak institutional foundations.2,3
Adherence to appropriate prescriptive habits necessitates following the rational steps for optimal prescription including defining the correct diagnosis, planning a safe and effective treatment plan, appropriate drug selection, choosing the effective dosage and duration, writing the prescription, conveying enough information to the patients and evaluation of the treatment procedures according to the patient\\\'s responses.4 In an effort to hinder antimicrobial resistance several parameters should be targeted including the inappropriate prescriptive practices. In order to achieve an improvement in this regard, an effective change in physician\\\'s behaviour should be sought. This requires a detailed understanding of the physician\\\'s knowledge about antibiotic resistance, factors influencing their decisions and their actual day to day prescriptive practices. This understanding is fundamental for development of optimal intervention strategies.5 KAP studies offer a great tool to investigate the driving forces behind the antibiotic prescriptive habits. They represent a valuable tool among other data collection methodologies including surveillance for actual antibiotic resistance and antibiotic consumption by patients providing the base-line for counter-interventions planning.2 However, little KAP-information exists regarding prescribers in hospital settings compared to publications reporting from community settings (Table-1).
Methods and Results
One hundred and fifty self-administered KAP questionnaires, consisting of 34 questions were distributed among residents and attending physicians in 5 different wards in proportion to the volume of doctors in each ward. Of these 120 were returned, and 4 were discarded due to incomplete information. The study results are based on the analysis of data collected from 116 doctors. Questionnaires were distributed by non-probability convenience sampling on-site during working hours and the respondents were asked to fill and return it within 15 minutes after receiving informed consent from them. There was no incentive for subjects to participate. Participants were instructed to use no external sources to help them answer the questions. If there was a suspicion, that questionnaire was excluded from the study. The identity of the physicians was kept anonymous. The questionnaire content was based on a previous study described in the United States,6 Malaysia,7 Peru8 and Egypt9 and was adapted to the Pakistani system to maximize relevance. Prior to release, it was reviewed by community medicine physicians of services institute of medical sciences to assess the relevance and wording of the questions. The results section shows the different questions asked.
Data was entered and analyzed by using SPSS software version 23.0 for appropriate statistical analysis. T-test was used to assess if any association among variables of different questions had any statistical significance or not. P value of 0.05 or less was taken as significant.
Knowledge based questions were scored by giving a correct answer 1 mark and a wrong answer was given 0 marks, there was no negative marking. Then the sum of the scores was added for each participant and mean and standard deviation was calculated. Similar scoring technique has been used in previous researches.7,8,10 Questions testing attitude used a 5-point Likert scale.
Professional profile of participants
Participants were grouped according to their specialty and position in the hospital. Unless otherwise stated, there were no significant differences between the participants belonging to different professional categories, levels or departments for the results presented below. All physicians agreed that knowledge of antibiotics is important for their medical career (currently and in the future). Of these, 112 (96.6%) acknowledged that antimicrobial resistance is a problem, 2 (1.7%) said it\\\'s not a problem while 2 (1.7%) said they did not know.
Out of the 7 questions that tested the knowledge of the physician, the highest score was 6/7 (n=4; 3.4%) and the lowest score was 1/7 (n=4; 3.4%). The mean score was 3.66±1.1. About one-sixth of the physicians (n=20; 17%) scored 5/7 and 45 physicians (39%) scored 4/7 in the knowledge section which was the mode.
As for the individual questions, there were 3 case-based questions, 1 question addressing safety of antimicrobials during pregnancy and 3 questions addressing the spectrum of antimicrobials and their ability to cross the blood-brain barrier.
Table-2 shows the mean score of residents and attending physicians to individual questions and the p-value as a test of significance between the acquired results (obtained by the independent t-test).
Confidence and seeking input
Most of the physicians (n=107; 92%) felt either very confident or at least somewhat confident about the optimal use of antibiotics. Only 9 physicians (7.8%) felt hesitant about the optimal use of antibiotics.
It was found out that majority of the respondents (n=93; 80%) review their decision to prescribe antibiotics with their senior colleagues once or more than once a day. Seven physicians (6%) reported that they reviewed their decision less than once a week with a senior colleague.
Majority of the respondents (n=106; 91%) admitted that when they discuss their decision for an antimicrobial prescription with a senior colleague, occasionally, they recommend a different antibiotics.
Acceptability of potential interventions
Respondents were asked how many times they had received any teaching on antibiotics in the last year. Thirty seven (31.9%) physicians responded that they had not received any teaching while 53 (45.7%) physicians said that they only received some guidance about 1-3 times in the previous year. Around 102 (96.6%) physicians desired educational programmes on use of antibiotics
Majority of participants agreed that general knowledge on AMR should be considered when antibiotics are prescribed to a patient (n=101; 95.7%) and that local guidelines would be more helpful than international ones (n=94, 81%).
Factors limiting optimal antimicrobial prescription
Sixty three (54%) physicians were of the opinion that prescribing antimicrobials to a patient who does not need it is harmful, 31 (27%) physicians said that was not harmful while 22 (19%) physicians were neutral on this issue.
The questionnaire had 2 questions which assessed the attitudes of physicians about the factors which limit the optimal prescription of antibiotics. It was found that 98 (84.5%) physicians thought that some antibiotics available in their hospital are of poor quality and for that reason they are not effective and 59 (50.9%) physicians did not know which antibiotics were available in their hospital because the formulary was always being altered.
Awareness about antimicrobial resistance
Most of the respondents agreed that antimicrobial resistance is a worldwide concern (n=114; 98%). One hundred twelve (95%) physicians agreed that antimicrobial resistance is a problem in Pakistan while 104 (90%) physicians admitted that it is a problem in their daily practice. Nine (8%) physicians were neutral on this aspect. Furthermore, 102 (88%) physicians believed that antibiotics are overused in the hospitals in Pakistan and a majority of the physicians (n=79; 68%) also agreed that antimicrobial resistance is a significant problem in their hospital.
The respondents of the study were asked 2 knowledge-based awareness questions on the burden of antimicrobial resistance in the community, and the rate of resistance of Klebsiella pneumoniae and pseudomonas aeruginosa to cephalosporin in their hospital. Majority of them (68% and 73% respectively) responded that they did not know. Among the rest, the most popular answer for the rate of resistance of Klebsiella pneumonia to cephalosporin (n=8; 16%) was "more than 50%" and the most frequent answer for the rate of resistance of pseudomonas aeruginosa to cephalosporin (n=18; 16%) was "20%-50% both of which were the correct responses.
Frequency of Antimicrobial Prescription
Physicians were asked about the frequency of their antimicrobial prescription and whether they felt it was difficult to select the correct antibiotic. The answer in the affirmative was stated by 46% (n=53). It was evident from the survey that majority of the physicians (n=76; 66%) prescribed antibiotics more than once a day.
Factors Influencing Antibiotic Prescription Practice
Three different factors which might influence the decision of a doctor in prescribing an antibiotic were assessed. Only 27 (23.3%) physicians said their selection of an antibiotic was based on the expiry date/availability than the causative pathogen. It was also found that a patient\\\'s socioeconomic status (n=108; 93.1%) and a patient\\\'s demands (n=24; 20.7%) also influence some physicians decisions of AM prescription.
This study highlights the requirement of Antimicrobial stewardship with decisive long-term objective of reduction in antimicrobial resistance by providing the baseline knowledge attitude and prescribing practices of physicians. The results of this study acknowledge the problem of the spread of antimicrobial resistance through the irresponsible prescribing practices and warrants interventions to solve this issue. This study has revealed facts which should be addressed in future antimicrobial prescribing interventions such as dissemination of information about local resistance rates, promoting confidence in the quality of locally available antibiotics and encouraging a good grasp of the basic pharmacology of antibiotics.
Disclaimer: This research has not been published or presented in a conference.
Conflict of Interest: None to declared.
Funding Disclosure: None to declared.
1. World Health Organization; 2002. Promoting rational use of medicines: Core components (WHO policy perspectives on medicines). [online] [Cited 2016 August 5]. Available from: URL: http://www.apps.who.int/medicinedocs/pdf/h3011e/h3011e.pdf .
2. WHO. The evolving threat of antimicrobial resistance: options for action. [online] 2012 [Cited 2016 August 5]. Available from: URL: http://www.who.int/patientsafety/implementation/amr/publication/en/.
3. Bhartiy SS, Shinde M, Nandeshwar S, Tiwari SC. Pattern of prescribing practices in the Madhya Pradesh, India. Kathmandu Univ Med J 2008; 6: 55-9.
4. De Vries TP, Henning RH, Hogerzeil HV, Fresle DA. Treating your patients. Guide to Good Prescribing: A Practical Manual. WHO/DAP/94.11. Geneva: World Health Organization; 1994, 33-66.
5. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don\\\'t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 1458-65.
6. Giblin TB, Sinkowitz-Cochran RL, Harris PL, Jacobs S, Liberatore K, Palfreyman MA, et al. Clinicians\\\' perceptions of the problem of antimicrobial resistance in health care facilities. Arch Intern Med 2004; 164: 1662-8.
7. Tan WL, Siti R, Shahfini I, Zuraidah A. Knowledge, attitude and practice of antibiotics prescribing among medical officers of public health care facilities in the state of Kedah, Malaysia. Med J Malaysia 2015; 70: 307-11.
8. García C, Llamocca LP, García K, Jiménez A, Samalvides F, Gotuzzo E, et al. Knowledge, attitudes and practice survey about antimicrobial resistance and prescribing among physicians in a hospital setting in Lima, Peru. BMC Clin Pharmacol 2011; 11: 18.
9. Fathi I, Sameh O, Abu-Ollo M, Naguib A, Alaa-Eldin R, Ghoneim D, et al. Knowledge, Attitudes, and Beliefs Regarding Antimicrobial Therapy and Resistance Among Physicians in Alexandria University Teaching Hospitals and the Associated Prescription Habits. Microb Drug Resist 2016; 23:71-8
10. Thriemer K, Katuala Y, Batoko B, Alworonga JP, Devlieger H, Van Geet C, et al. Antibiotic prescribing in DR Congo: a knowledge, attitude and practice survey among medical doctors and students. PloS one 2013; 8: e55495.
11. Abera B, Kibret M, Mulu W. Knowledge and beliefs on antimicrobial resistance among physicians and nurses in hospitals in Amhara Region, Ethiopia. BMC Pharmacol Toxicol 2014; 15: 26.
12. Pulcini C, Williams F, Molinari N, Davey P, Nathwani D. Junior doctors\\\' knowledge and perceptions of antibiotic resistance and prescribing: a survey in France and Scotland. Clin Microbiol Infect 2011; 17: 80-7.
13. Guerra CM, Pereira CAP, Neves Neto AR, Cardo DM, Correa L. Physicians\\\' perceptions, beliefs, attitudes, and knowledge concerning antimicrobial resistance in a Brazilian teaching hospital. Infect Control Hosp Epidemiol 2007; 28: 1411-4.
14. Srinivasan A, Song X, Richards A, Sinkowitz-Cochran R, Cardo D, Rand C. A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med 2004; 164: 1451-6.