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

* Abeer M. Baadani
* Kamran Baig
* Wafa A. Alfahad
* Sultan Aldalbahi
* Ali S. Omrani

## Abstract

**Objectives:** To assess knowledge, perceptions, and attitudes toward antimicrobial prescribing among physicians practicing in Riyadh, Saudi Arabia.

**Methods:** A questionnaire was developed and distributed to physicians working in hospitals in Riyadh, Saudi Arabia between June and August 2013. The results were analyzed using Stata 12 software.

**Results:** Two hundred and twelve (84.8%) full responses were returned. Most respondents perceived antimicrobial resistance as a significant problem in their daily practice (119, 56.1%) and at a national level (148, 69.8%). Inappropriate empirical therapy (101, 47.6%) and excessive use of antimicrobials in healthcare settings (66, 31.1%) were believed to be the main contributors to increasing bacterial resistance. Respondents favor treating infection rather than colonization (98, 46.2%), and physician education (74, 34.9%) as the most effective interventions to reduce antimicrobial resistance. Many respondents (95, 44.8%) do not feel confident in their knowledge of antimicrobial prescribing. Two-thirds of the respondents (135, 63.7%) have local antimicrobial guidelines, of which 90 (66.7%) felt were useful. Most respondents (160, 75.5%) considered their local infectious diseases service to be very helpful.

**Conclusion:** There are considerable unmet training and education need for physicians in the area of antimicrobial prescribing. Local antimicrobial guidelines need revision to ensure they are more relevant and helpful for medical practitioners.

The importance of judicious clinical use of antimicrobial agents and increasing rates of antimicrobial resistance have been the subject of numerous studies in the last decade.1-6 These studies involved either health care workers such as physicians, medical students, or pharmacists, or the general public. Several factors may contribute to inappropriate antimicrobial usage, including doctors’ knowledge and experiences, uncertain diagnosis, patients’ expectations, pharmaceutical marketing influences, and unregulated antibiotic dispensing.1 Despite continuous efforts to improve antimicrobial prescribing and address issues such as self-prescribing, unnecessary use for viral infections, dosing errors, and excessive treatment durations, rates of antimicrobial resistant infections continue to rise globally.7-10 Investigators from different parts of the world have identified knowledge gaps regarding antimicrobial prescribing and growing concern over the increasing antimicrobial resistance among healthcare workers.6,11,12 The development and implementation of wide ranging educational programs for both physicians and the general population are among the commonly recommended strategies to help address those concerns.13 In Saudi Arabia, accurate, denominated antimicrobial prescribing data is not available. It is however, important to note that antimicrobials are the third most commonly prescribed group of medications in the country.14 Furthermore, antibiotics are prescribed to 44-88% of patients who present to primary healthcare centers with upper respiratory tract infections (URTI).15 In dental practice, Al-Harthi et al16 found that healthcare workers believed that antimicrobials are excessively used and that their participants did not find hospital guidelines as helpful as other resources. Family and caretakers beliefs, especially among parents of young children, along with peer pressure are also significant contributing drivers of antimicrobial misuse.17 Better understanding the physicians’ knowledge, perception, and attitude toward antimicrobial prescribing is essential for formulating effective antimicrobial stewardship programs. The objective of this study was to assess knowledge, perceptions, and attitudes in relation to antibiotic prescribing among physicians practicing in hospitals in Riyadh, Saudi Arabia.

## Methods

The study was conducted between June and August 2013 and involved physicians from tertiary care centers in Riyadh, designated in this report as hospitals A, B, C, D, and others (Appendix 1). An electronic invitation letter was sent to physicians in various clinical specialties including internal medicine, cardiology, neurology, general surgery, urology, obstetrics and gynecology, primary health care, critical care, and emergency medicine. Participants were invited to complete a self-reported questionnaire either online or on hard copy. Participation in the study was voluntary and anonymous. The questionnaire consisted of 30 items and was designed to investigate various aspects of the physicians’ antimicrobial prescribing practices and the beliefs on which they are based. The questionnaire was validated using a small group from medical residents and fellows before it was distributed among the target population. We collated the participants’ demographic data including age, gender, professional status, specialty, and duration of medical practice. Responses for questions related to perception and attitude were graded on a 5-point Likert scale, agreement scale ranging from ‘1’ for do not agree to ‘5’ for strongly agree; or helpfulness scale from ‘1’ not available to ‘5’ for very helpful (Appendix 2). Participant ages were categorized into 4 groups; less than 25 years, 25-30 years, 31-40 years, and more than 40 years. Similarly, years of experience were categorized as 2 years or less, 3-5 years, 6-10 years, and more than 10 years.

Data were entered into a Microsoft Excel 2007 spreadsheet (Microsoft Inc., Seattle, Washington, USA) and analyzed using Stata 12 (Stata Corp, College Station, TX, USA). The institution’s Research Ethics Committee approved the study.

## Results

Two hundred and twelve (84.8%) of the 250 distributed questionnaires were returned successfully. The number of male respondents was slightly higher than females. Forty-eight percent of respondents were 25-30 years of age. The largest proportion of responses was from Hospital A. The largest group of respondents was residents (105, 49.5%), followed by consultants (48, 22.6%), and specialists (31, 14.6%). Most of the respondents were from medical specialties (126, 59.4%). The demographic details of the respondents are summarized in Table 1. One hundred and eighty-three respondents (86.3%) believed that inappropriate antibiotics prescribing did put patients at risk of developing antimicrobial resistance. Just over half the respondents (107, 52.9%) did not agree that over prescription of antibiotics is better than under prescribing, and 178 (83.9%) did not believe that over-the-counter sale of antibiotics is appropriate (Table 2). Over half of the respondents (119, 56.1%) agreed that antimicrobial resistance was a problem in their daily practice, and almost two-thirds (139, 65.6%) believed it to be a significant problem in their hospitals. Only 16 (7.5%) respondents strongly agreed that they were aware of the antimicrobial resistance rates and patterns in their hospitals. Less than half (95, 44.8%) of the respondents had firm confidence in their knowledge and practice of antimicrobial prescribing. Slightly more than half of the respondents (116, 54.7%) did not agree that they receive regular infectious diseases training and education at the work place. Most respondents (142, 66.9%) found their hospital infectious disease service easily accessible and very helpful (160, 75.5%). In terms of duration of antimicrobial therapy, 107 (50.5%) stated that they usually prescribed empiric antimicrobial therapy for one week, while for approximately one third (77, 36.3%) the usual duration was 3-5 days. For most respondents (181, 85.4%), the patient’s clinical condition was the most important factor to influence the decision to initiate antibiotics. The cost effectiveness of antibiotics was always considered by only a minority (10, 4.7%) of the participants, whereas 88 (41.5%) sometimes took that into consideration. Almost half (103, 48.5%) the participants believed that poor skills and knowledge were important causes of inappropriate use of antibiotics (Table 3). When making decisions related to antimicrobial prescribing, hospital guidelines were the most commonly used resource (83, 39.2%) followed by quick reference guides or booklets (63, 29.7%) such as the Sanford Guide to antimicrobial therapy ([www.sanfordguide.com](http://www.sanfordguide.com)) and John Hopkins Antibiotic Guide ([www.hopkinsguides.com](http://www.hopkinsguides.com)). Only 33 respondents (15.6%) used online resources such as UpToDate ([www.uptodate.com](http://www.uptodate.com)) and Medscape ([www.medscape.com](http://www.medscape.com)). Among online resources, UpToDate was most frequently used reference (126, 59.4%) (Table 4). When assessing the availability, accessibility, and utilization of hospital guidelines for diagnosis and management of infectious management, 135 (63.7%) indicated that they have local antimicrobial therapy guidelines. However, only 34 (16%) respondents considered local guidelines to be comprehensive. Moreover, only 56 (26.4%) were described as widely accessible, and 86 (40.6%) were considered helpful (Table 5).

View this table:
[Table 1](http://smj.org.sa/content/36/5/613/T1)

Table 1 
Demographic details of 212 physicians who responded to a questionnaire on knowledge, perceptions, and attitudes toward antimicrobial prescribers.

View this table:
[Table 2](http://smj.org.sa/content/36/5/613/T2)

Table 2 
Responses of 212 physicians to questions related to their perceptions and attitudes in relation to antimicrobial prescribing.

View this table:
[Table 3](http://smj.org.sa/content/36/5/613/T3)

Table 3 
Responses of 212 physicians to questions related to their antimicrobial prescribing practices.

View this table:
[Table 4](http://smj.org.sa/content/36/5/613/T4)

Table 4 
Resources most commonly used by 212 physicians who responded to a questionnaire on knowledge, perceptions, and attitudes toward antimicrobial prescribers.

View this table:
[Table 5](http://smj.org.sa/content/36/5/613/T5)

Table 5 
Responses of 212 physicians to questions related to availability, accessibility, and utility of local antimicrobial therapy guidelines.

## 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.

## Appendices

View this table:
[Appendix 1](http://smj.org.sa/content/36/5/613/T6)

Appendix 1 
List of hospitals to which the study participants were affiliated.

View this table:
[Appendix 2](http://smj.org.sa/content/36/5/613/T7)

Appendix 2 
Likert’s scale for the questionnaire provided to the study participants regarding antimicrobal perscribing practices.

## Footnotes

*   **Disclosure.** Authors have no conflict of interests, and the work was not supported or funded by any drug company.

*   Received December 16, 2014.
*   Accepted March 16, 2015.


*   Copyright: © Saudi Medical Journal

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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