International Journal of Research in Medical Sciences

Nishat S et al. Int J Res Med Sci. 2023 Jan;11(1):195-203

www.msjonline.org

pISSN 2320-6071 | eISSN 2320-6012

Original Research Article

DOI: https://dx.doi.org/10.18203/2320-6012.ijrms20223636

Knowledge, attitude and practicing behaviour regarding antimicrobial use and awareness of antimicrobial resistance among clinicians

Samreen Nishat1, Javeria Jalal2, Maleha Butul3, Syeda Neha Akhter1, Syeda Ayesha Siddiqua3*

1Shadan Institute of Medical Sciences, Hyderabad, Telangana, India

2Kamineni Academy of Medical Sciences, Hyderabad, Telangana, India

3Department of Pharmacology, Shadan Institute of Medical Sciences, Hyderabad, Telangana, India

Received: 30 October 2022

Revised: 30 November 2022

Accepted: 03 December 2022

*Correspondence:

Dr. Syeda Ayesha Siddiqua,

E-mail: ayesharesearch123@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Antimicrobials' irrational use is leading to antimicrobial resistance. This situation has become a public health care issue and must be tackled by clinicians. The awareness about antimicrobial resistance and proper usage by patients must be looked after by clinicians. Hence, the present study was taken to determine the knowledge, attitude, and practicing behaviour regarding antimicrobial use and awareness of antimicrobial resistance among clinicians.

Methods: The study was conducted on clinicians in a tertiary care hospital. A standardized questionnaire was distributed to 110 participants and ethical approval was taken before the study. Data was analyzed using SPSS software. For data comparisons, chi-square tests were used. P≤0.05*, considered significant.

Results: The study showed a majority in the 25-34 years of age group with male predominance. Many belonged to the 1-0 years of practicing group and the majority were physicians. The antibiotic resistance subject was highly relevant to clinicians, according to them awareness can be spread by proper and precise intake of antibiotics by patients. The relationship between the predominant age group and years of practice revealed good knowledge (χ2=56.703, p=0.01), fair attitude (χ2=69.556, p=0.01), and good practicing behavior (χ2=43.047, p=0.01).

Conclusions: Clinicians were aware of antimicrobial resistance issue globally but irrelevant in their own practice. Patient awareness campaigns and educational programs need to be conducted. Lack of time and patient interest are the barriers to be overcome to spread awareness. The prescribing of antimicrobials should be in a controlled way with the implementation of ethical principles for better patients' health safety.

Keywords: Antimicrobial use, Antimicrobial awareness and resistance, Knowledge, Attitude, Practicing behaviour

INTRODUCTION

Antimicrobials are the most histrionic examples of the developments of modern-day medicine.1 Overuse and misuse of various antimicrobials have fueled a prime rise in the prevalence of antimicrobial resistance.2 An inevitable consequence of such inappropriate usage had made antimicrobial resistance a serious public health care concern.3

India is known as one of the largest and most regular consumers of antibiotics.4 Current state of antimicrobial resistance in India is relatively worrisome and irrational use of antimicrobials along with the high incidence of infection, insignificant infection prevention and control are some of the reasons for putting the Indian public healthcare system in a very perilous situation.5

The responsibility of sensibly prescribing antimicrobials and implementing strategies to prevent antimicrobial resistance is on the shoulders of clinicians and health care providers.6 There has been sufficient proof that clinicians although aware of the antimicrobial resistance problem, do not follow proper guidelines in their prescribing behavior.7 Specifically, newly practicing clinicians are trained incompetently to prescribe antimicrobials carefully.8

Encouraging awareness regarding antimicrobials use and resistance among patients by clinicians and various health care providers must be a vital priority.9 A plan of action to fight and spread awareness about the inappropriate use of antimicrobials and their resistance must be implemented by clinicians at an individual level.10 Through this study we aim to assess the knowledge, attitude and practicing behavior regarding antimicrobial use and awareness of antimicrobial resistance among clinicians.

METHODS

Study design and population

A questionnaire-based, cross-sectional study was conducted among clinicians in a tertiary care hospital from June 2022 to August 2022 at Shadan Institute of Medical Sciences (SIMS), teaching hospital and research center. Clinicians belonging to a tertiary care hospital, who were willing to participate in the study were enrolled. Those who were not willing to participate and refused to take questionnaire were excluded from the study. A sample size of 110 was analyzed. It comprises, physicians, surgeons, dentists, pathologists, pharmacologists, dermatologists, orthopedics, microbiologists, and biochemists. Both male and female populations participated in the study.

Data collection

The knowledge, attitude and practicing behavior of the clinicians regarding antimicrobial use and awareness of antimicrobial resistance was assessed based on the 20 questions. They were categorized into four sections. Section-I (6 questions) acquired information on the sociodemographic characteristics of respondents, Section-II (5 questions) is based on the awareness of antimicrobial resistance, Section-III (6 questions) is about practicing behavior of clinicians and lastly, Section-IV (3 questions) is depicting the guidelines/sources of information of the clinicians. The response rate to the study was hundred percent and the responses marked by the study participants were analyzed accurately. The comparison of knowledge, attitude, and practicing behavior of participants is done on the scale of good (≥70%), fair (51-69%), and poor (≤50%) based on the percentage of correct responses.

Statistical analysis

The collected data was analyzed with the help of SPSS software. The descriptive analysis of the data is represented as frequency (N) and percentages (%). For data comparisons Chi-square tests were used. P≤0.05*, considered significant. The data is depicted in the form of tables and figures.

Ethical approval

The ethical committee letter was obtained before the initiation of the study, (012/SIMS/Research/2022).

RESULTS

A questionnaire of 20 questions highlighting the holistic outlook of knowledge, attitude, and practicing behavior regarding antimicrobial use and awareness of antimicrobial resistance was provided to the study population in a tertiary health care center (100%). A total of 110 clinicians participated from various departments.

Sociodemographic characteristics of participants are shown in Table 1, where male participants (56.4%) were more than female participants (43.6%).

Most of the participants (41.8%), were aged between 25 to 34 years. A high percentage (39.1%) of participants belonged to the practicing group of 1 to 10 years followed by 21 to 30 years (24.5%) of the practicing group. More than half of the participants (54.5%) were physicians, followed by surgeons (18.2%).

Table 1: Socio-demographic characteristics of participants (n=110).
Table reproduced from source PDF page 2, part 1 of 2
Table reproduced from source PDF page 3, part 2 of 2
Table 2: Awareness of antimicrobial resistance (n=110).
Table reproduced from source PDF page 3
Figure 1: Awareness of anti-microbial resistance. | 13.6% 9.1% 7.3% 4.5% 30% 25.5% 10% Hospital hygiene Animal farm hygiene Private food hygiene Antibiotic use in hospitals Antibiotic intake by patients Antibiotic prescriptions by doctors Antibiotic use in livestock
Figure 1: Awareness of anti-microbial resistance.
Table 3: Actual knowledge of participants.
Table reproduced from source PDF page 4
Table 4: Addressing the problem of antibiotic resistance.
Table reproduced from source PDF page 4

Awareness of antimicrobial resistance can be seen in Table 2, a majority (44.5%) agreed that the subject of antibiotic resistance is highly relevant to them. In their daily practice, a high percentage (39.1%) of clinicians said to have monthly contact with patients having multidrug-resistant infections. Figure 1 reveals a majority percentage (30%), according to them the means to spread awareness on the development of antimicrobial resistance can be through appropriate antibiotic intake by patients. The actual knowledge of the participants is tested in Table 3, the highest percentage (83.6%) of responses were for the statement, “If bacteria are resistant to antibiotics, it can be extremely difficult or impossible to treat the infections, they cause”. Table 4 is about, addressing the problem of antibiotic resistance, where most of the participants strongly agreed that healthcare workers should wash their hands regularly (61.8%) and prescribers should only prescribe antibiotics when they are needed (70.9%).

Table 5 is depicting the practicing behavior, where many of the participants (76.4%) said, the influence of prescribing behavior on the development of antibiotic resistance within a region is a crucial factor while practicing. A majority agreed that lack of patient interest (58.2%) and lack of time (20.9%) are key barriers to discussing antimicrobial resistance while prescribing. According to 32.7% the use of delayed antibiotic prescribing strategy is implemented by them often. The participants during their practice observed that the patients understanding about antimicrobial resistance is good (85.5%), but they lack the knowledge about superbugs (14.5%). For the majority (32.7%), the reason for prescribing antibiotics without an indication is to be on the safe side. Skin or wound infection is an indication for an antibiotic prescription for a high percentage (24.5%) of the participants (Figure 2).

Table 6 is revealing about the guidelines/sources of information for the participants. 43.6%, used practicing guidelines for antibiotic therapy during daily work moderately. Highest percentage (96.4%) of participants, desired to have more evidence-based therapy guidelines. Most of the participants (78.2%) considered online scientific journals as their means to get current information on antibiotic therapy and resistance (Figure 3).

The comparison of knowledge, attitude, and practicing behavior of participants is done on the scale of good (≥70%), fair (51-69%), and poor (≤50%) based on the percentage of correct responses.

Table 5: Practicing behavior (n=110).
Table reproduced from source PDF page 5
Figure 2: Indications for an antibiotic prescription. | 2.7% 2.7% 4.5% 6.4% 6.4% 8.2% 9.1% 15% 20% 25% Measles Gonorrhea HIV/AIDS Malaria Fever Diarrhoea Cold and flu Sore throat Urinary tract infection Skin or wound infection
Figure 2: Indications for an antibiotic prescription.
Table 6: Guidelines/sources of information (n=110).
Table reproduced from source PDF page 6
Figure 3: Sources to get current information on antibiotic therapy and resistance. | 5.5% 3.6% 13.6% 30% 11.8% 9% 10% 16.4% Internet forums Digital information platforms Textbooks Online Scientific journals Clinical practice guidelines Direct communication with peer colleagues Direct communication with expert Continuing education
Figure 3: Sources to get current information on antibiotic therapy and resistance.
Table 7: Knowledge, attitude and practicing behavior of predominant age group (25-34 years) and years of practice group (1-10 years) on scale of good, fair and poor.
Table reproduced from source PDF page 6

Frequency=n, percentage=%, p≤0.05* is considered as significant. The comparison of knowledge, attitude, and practicing behaviour of participants is done on the scale of good (≥70%), fair (51-69%), and poor (≤50%) based on the percentage of correct responses.

Relationship between predominant age group and years of practice regarding knowledge of antibiotic resistance

The results were significant with a Chi-square test of 56.70 and a p value of 0.01*. In our study the predominant age group (25 to 34 years) and predominant years of practice group (1 to 10 years), both have good knowledge about antibiotic resistance (Table 7).

Relationship between predominant age group and years of practice regarding attitude towards antibiotic resistance

The results were significant with a Chi-square test of 69.56 and a p value of 0.01*. In our study the predominant age group (25 to 34 years) and predominant years of practice group (1 to 10 years), both have fair attitude towards antibiotic resistance (Table 7).

Relationship between predominant age group and years of practice regarding practicing behavior

The results were significant with a Chi-square test of 43.047 and a p value of 0.01*. In our study the predominant years of practice group (1 to 10 years), have good practicing behavior when compared to the predominant age group (25 to 34 years) (Table 7).

DISCUSSION

The main goal of our study is to assess the knowledge, attitude and practicing behavior regarding antimicrobial use and awareness of antimicrobial resistance among clinicians. A rise in antimicrobial resistance is causing dreadful rates of morbidity and mortality at a comprehensive level.11 The clinicians and health care providers being the frontline fighters, need to update their way of prescribing antimicrobials by implementing appropriate guidelines to decrease the threat of antimicrobial resistance.12 Constant training and conduction of educational programs for clinicians and health care providers can be an effective method for incorporating proper and appropriate prescribing behavior in their practices regarding antimicrobial use and awareness of antimicrobial resistance.13,14

In our study, the sociodemographic characteristics of participants reveal that the majority (41.8%), were from the age group 25-34 years and a male predominance (56.4%) was noticed. This is parallel to a KAP survey on antimicrobial use and resistance among Indian clinicians where the majority were from the age group >30 years and showed the male population in the majority.15 The study population included clinicians, with the mainstream being physicians (54.5%), followed by surgeons (18.2%). This is like a survey study conducted in Peru, where a high number of professionals were physicians followed by surgeons.16 In our study, many were from the group with years of practice between 1 to 10 years (39.1%), which is a similar observation in cross- sectional study done in Nepal.17

In our study, the subject of antibiotic resistance is highly relevant to the participants (44.5%), it is in agreement with a study conducted in Bangalore where the participants have good knowledge about antimicrobial resistance subject.18 A majority (39.1%), responded that they may have monthly contact with patients having multidrug-resistant infections. The clinicians in the healthcare centers should prioritize the settings to manage multidrug-resistant infections sensibly.19

A majority (30%), responded that the awareness of antimicrobial resistance can be spread by proper and precise intake of antibiotics by patients. This highlights the need for public awareness campaigns and educational programs. It can be carried out in hospitals, and social media can also be a vital tool for widespread antimicrobial resistance awareness to the public.20

The actual knowledge of the participants can be predicted by the following statement, “if bacteria are resistant to antibiotics, it can be extremely difficult or impossible to treat the infections, they cause,” which the majority (83.6%), of them, seem to respond to. Many clinicians and healthcare providers agreed that they face this challenge in their practice, as it becomes tricky for a clinician to give treatment while maintaining the antimicrobial stewardship principles and narrowing further resistance.21,22

Our study addressed the problem of antibiotic resistance, where most of the participants strongly agreed that healthcare workers should wash their hands regularly (61.8%), which is in similarity to the studies done on hand hygiene in 1999 and 2010. In these studies, hand hygiene was successful for the prevention and control of healthcare-associated infections with a big effect.23,24 A majority said, prescribers should only prescribe antibiotics when they are needed (70.9%).25

Regarding the practicing behavior, a high percentage (76.4%), agreed that there is an influence of prescribing behavior on the development of antibiotic resistance within a region.26 Most of the clinicians’ agreed that lack of patient interest (58.2%) and time (20.9%) are key barriers to discussing antimicrobial resistance while prescribing. These barriers should be overcome by improving communication and by giving ample enlightenment regarding this issue as patients are the ultimate consumers.27

Many (32.7%) approved the implementation of a delayed antibiotic prescribing strategy which is related to lower consumption of antibiotics and can be valid for lowering resistance.28 In clinicians’ observation, the patient's understanding of antimicrobial resistance is good (85.5%), when compared with their superbug’s knowledge (14.5%). Among patients, the knowledge and awareness about superbug is necessary as it causes delayed hospital admissions due to 100% resistance of superbugs.29 It is found that the clinicians (32.7%), prescribe antibiotics without an indication to be on the safe side, this is in contrast to the study done in 2014, where it is suggested that clinicians should control antibiotic prescribing while valuing the ethical principles without patients’ health compromise.30

For most of the participants (24.5%), in our study, skin or wound infection is an indication for an antibiotic prescription. Skin infections are high targets for antimicrobial stewardship interventions intended to avoid needless antibiotic exposure.31

According to our study, the practicing guidelines for antibiotic therapy by clinicians during their daily work are followed moderately (43.6%). It is a matter of concern, as all the clinicians should follow the antibiotic practicing guidelines in a responsible manner with an ethical consideration for the benefit of patients.32,33

Our study reveals that majority (96.4%), would like to have more evidence-based therapy guidelines for antibiotic therapy with lesser limitations.34,35 The participants read online scientific journals (78.2%) as a major information source on antibiotic therapy and resistance.36

Limitation

Small sample size and short duration of study time were the major limitations of our study. The study participants were from only tertiary care hospital, and not from any peripheral health care centers.

CONCLUSION

Our study concludes that clinicians are very aware of the burning issue of antimicrobial resistance as a global issue but irrelevant in their own practice. There is a need to prioritize the settings to manage multidrug-resistant infections in institutions. Patient awareness campaigns and educational programs need to be conducted by clinicians. Lack of time and patient interest are the barriers to be overcome by clinicians to spread awareness. The prescribing of antimicrobials should be in a controlled way with the implementation of ethical principles for better patients' health safety.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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