Physicians’ knowledge, perceptions, and attitudes toward antimicrobial prescribing in Riyadh, Saudi Arabia

Discussion

The study assessed the perception, attitudes, and knowledge of physicians in selected hospitals in Riyadh City toward antimicrobial prescription, whereas previous studies from Saudi Arabia focused mainly on prescribing and utilizing patterns, and to a lesser extent on the determinants of misuse.14-20 Similar to physicians from other parts of the world, our participants were aware of the growing challenge of antimicrobial resistance at local and national levels.5,21 Most, however, were unaware of the specific antimicrobial resistance rates and patterns in their own institutions. This may be the result of inadequate surveillance of the multi-drug resistant organisms or limited data sharing. Surveillance systems of antimicrobial usage and resistance should include efforts to ensure timely dissemination of information to all health care workers and stakeholders.

Most (92.0%) of our participants believed that inappropriate use of antimicrobial agents may result in antimicrobial resistance, and almost half (103, 48.6%) of the respondents believed that inadequate knowledge is the most important contributor to poor antimicrobial practices. However, it is important to note that we did not attempt to assess the appropriateness of prescribing, but rather focused on the physician’s views and perception to help plan appropriate interventions. Unrestricted access to antimicrobials and inadequate supervision were other important reasons for concern among our respondents. These findings highlight the urgent need for carefully planned education and training programs to address the knowledge gaps and support appropriate evidence-based antimicrobial prescribing practices.

Most of the participants stated that their empiric antimicrobial prescribing is usually limited to a period of one week or less. Only a minority used longer empiric courses. It is reassuring that the main driver for decisions to initiate antimicrobial therapy is the patient’s clinical condition. Tenuous factors such as wanting to please seniors and unfounded concerns were rarely selected as drivers for such decisions. Others identified psychosocial and behavioral factors, including self-prescription, over-the-counter availability and parents’ or patients’ pressure as the key factors for prescribing antimicrobials.22,23 Training and educational programs should aim to reinforce such appropriate beliefs and to emphasize areas of good practice that already exist.

Interestingly, cost effectiveness was mostly not considered while making antimicrobial prescribing decisions. It is possible that because our respondents were from public sector hospitals, where comprehensive services are provided freely to all eligible patrons, cost was not perceived as an important consideration. Similar findings were reported by other groups, who identified limited knowledge of actual drug costs among physicians.9,24 Our results indicate a clear need for training in cost-effective prescribing to minimize a direct and indirect financial burden on the health care systems.

Although most respondents had some confidence in their knowledge and practice in relation to antimicrobial prescribing, around one third (74, 34.9%) do not receive regular training in their area. It is therefore, not clear if such high confidence is well founded. One cause for concern in our findings was the unavailability or limited utility of local antimicrobial therapy guidelines. Of even greater concern is the fact that less than 5% of respondents feel that the availability of local antimicrobial therapy guidelines is an important tool in controlling antimicrobial resistance. It appears that appropriate training and education programs need to include elements that help physicians recognize the important contribution of evidence-based guidelines in helping guide appropriate choices and decisions to address their well-recognized concern of poor knowledge as one of the main contributors to poor antimicrobial prescribing. The overwhelming confidence in one’s prescribing abilities while not recognizing the importance of locally developed guidelines suggests that some physicians may be oblivious to their own shortcomings. Similar observations were reported by Charani et al,25 who found that some physicians based their prescribing decision on personal knowledge and experience rather than formal policy.

Another encouraging finding in our study was that most respondents feel that their local infectious diseases services are readily accessible and very helpful. This is an ideal starting point for pro-active training activities that are likely to gain the target physician’s confidence and interest. Such programs should attempt to combine knowledge enhancement with regular competency evaluation for physicians from different specialties. It is well established that successful antimicrobial stewardship programs involve elements of organized and opportunist training, engage all stakeholders and share successes across the institution. Restrictive policies have been shown to be least effective tools, whereas education and feedback are associated with long-term effectiveness.4,5,26

The study has some limitations; as a survey, it is possible that respondents gave socially acceptable answers. We tried to include questions that allow respondents to state their true views without any suggestion that there are right and wrong answers. We also ensured that responses did not include any identifiers to help respondents express themselves freely. Most participants were from 4 tertiary care centers in one city, and therefore the results may not be generalizable. We are however, unaware of any similar work in the region and therefore feel that the findings are of generalized interest.

In conclusion, our study identified considerable unmet training and education needs for physicians in the area of antimicrobial prescribing. Furthermore, it appears that local antimicrobial guidelines need revision to ensure they are more relevant and helpful for medical practitioners. Local infectious diseases services and antimicrobial stewardship programs should take this data into account when planning and executing their activities.