Knowledge, Attitude and Practices of Clinicians, Nurses and Pharmacists Regarding Antimicrobial Stewardship: A Five Center Survey from India

1. Medical Advisor, Department of Medical Affairs, Pfizer Ltd. Pfizer Biopharmaceuticals (Emerging Markets), Bandra East, Mumbai, Maharashtra, India. 2. Medical Lead, Department of Medical Affairs, Pfizer Ltd. Pfizer Biopharmaceuticals (Emerging Markets), Bandra East, Mumbai, Maharashtra, India. 3. Medical Advisor, Department of Medical Affairs, Pfizer Ltd. Pfizer Biopharmaceuticals (Emerging Markets), Bandra East, Mumbai, Maharashtra, India.

Abstract

Introduction: Increasing awareness and practice of Antimicrobial Stewardship (AMS) has gained immense importance in Indian hospitals for preventing the irrational use of antibiotics. India is one of the world’s largest consumers for antibiotics. Assessment of the local Knowledge, Attitude and Practices (KAP) of Antimicrobial Resistance (AMR) and AMS among Healthcare Providers (HCPs) will help in designing effective public health policies and engaging the community in campaigns against increasing microbial resistance.

Aim: To understand the status of AMS programs and practices in five private sector multispecialty hospitals situated in the East, West, North and South zones of the country and to assess the KAP of HCPs regarding AMR and AMS.

Materials and Methods: The cross-sectional survey was conducted to assess the implementation of AMS in five hospitals among clinicians, nurses and pharmacists across India using a predeveloped AMS checklist between June 2019 and October 2019. The analysis was done between July and August 2020. Responses were collected using a five-point Likert scale, with choices ranging from ‘strongly agree’ to ‘strongly disagree’.Descriptive analysis was done for the KAP survey to determine the percentages of participants under each response category.

Results: Total 32 clinicians, 55 nurses and eight pharmacists responded to the KAP survey (100% response rate). The clinicians were aware that AMR is caused by irrational prescribing of antimicrobials (n=31, 96.87%) and improper diagnosis of infective conditions (n=27, 84.37%). However, knowledge of clinicians on infection control practices (n=6, 18.75% disagreed) in controlling AMR and practice of referring local epidemiology before prescribing antimicrobials (n=7, 21.87% did not follow routinely) could be improved. The knowledge and practice of nurses and pharmacists on antibiotic use were spread over a wide range. According to the nurses, AMR was mainly caused by using antimicrobials for non bacterial infections (n=30, 54.54%) and deviations from their standard duration (~63.64%-72.73%). As per pharmacists, the lack of restrictions on antimicrobial usage and widespread use or overuse of antibiotics were major contributors to AMR (n=3, 37.5% strongly agreed). Both nurses and pharmacists could benefit from reinforced training on antibiotic usage.

Conclusion: Implementation of AMS was not adequate in private Indian hospitals. Although clinicians have good knowledge on antibiotic use, it was not equally reflected in their practice. The KAP data of nurses and pharmacists suggest that training and education on appropriate antibiotic usage should be emphasised. More efforts are required to improve AMS practices in hospitals.

Antibiotics, Antimicrobial resistance, Healthcare providers, Infection control practices

The AMR develops when bacterial strains become resistant to antibiotics. The emergence of AMR is worsened by the misuse and overuse of antibiotics (1). AMR has become a global concern and has been identified as a serious threat to global public health by the World Health Organisation (WHO). Southeast Asian countries, including India, have become hubs for AMR (2),(3),(4),(5). Recent AMR trends in India are quite alarming and there is increasing resistance to last-resort antibiotics (6). India is one of the world’s largest consumers of antibiotics (4). Different studies from India have reported antibiotic prescription rates between 49.9% and 81.8% (7),(8),(9).

The AMS has been identified as the primary intervention for curtailing AMR (3). The successful implementation of AMS in other countries has demonstrated a reduction in AMR rates, healthcare costs and mortality rates (6). The implementation of AMS helps to increase infection cure rates among patients, corrects prescription rates and prophylaxis and reduces treatment failure (10). However, the implementation of AMS in Indian healthcare institutions is still at a preliminary stage (6). A recent literature review on the implementation of AMS programs in different healthcare facilities in India reported low (35.2%) implementation of AMS practices in the country (11).

The frontline stakeholders, i.e., physicians and nurses, bear the dual responsibility in controlling AMR by rationalising antibiotic usage and sensitising the general population (1). Promoting awareness about AMR among these HCPs thus becomes a key priority from an Indian perspective (12). Given that physicians with higher knowledge and experience prescribe fewer antibiotics, filling the gaps in the knowledge of physicians is crucial (13),(14). Nurses have a critical role in patient care and their involvement in AMS has been highlighted by the Centres for Disease Control and Prevention (CDC) (15). However, their role and involvement in AMS are not clearly understood (16). An understanding of the local KAP of AMR and AMS among HCPs will aid in designing effective public health policies and engaging the community in campaigns against AMR (4).

Although there are a few reports on KAP in the context of AMR in the Indian setting (14),(17),(18),(19),(20), there is limited evidence regarding KAP on AMR and AMS among HCPs in hospitals across the country. With this background, an assessment of the implementation of AMS was done along with a KAP survey in five key hospitals selected from four zones (East, West, North and South) across the country to assess AMR awareness and AMS practices among clinicians, nurses and pharmacists regarding antibiotic usage.

Material and Methods

A cross-sectional survey was conducted among clinicians, nurses and pharmacists of five private hospitals representing four zones of India (East, West, North and South) between June 2019 and October 2019. The Analysis was done between July and August 2020. The survey was conducted during an ongoing AMS training session in these hospitals. The hospitals were selected based on their interest in successful implementation or improvisation of AMS practices in their institutions.

Study Procedure

The AMS checklist was filled in by one of the key stakeholders in AMS, i.e., the microbiologists. Those participants (clinicians, nurses and pharmacists) of the training session who voluntarily agreed to fill in the questionnaire were selected for the KAP survey. The anonymity of the participants was maintained since the questionnaire only asked for the designation of the HCP and half an hour was given to fill in the questionnaire.

A prevalidated checklist was used to assess the level of implementation of AMS and AMS-readiness in these five hospitals. The questions were consistent with the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) set of core and supplementary indicators for hospital AMS programs (21),(22). The checklist questions are also consistent with the CDC checklist for core elements of hospital AMS programs (15). The questions in the AMS checklist were aimed at evaluating different aspects of AMS implementation. Subsequently, a KAP survey on AMR and AMS was also conducted in these five hospitals, between June 2019 and October 2019. Based on previous studies, a self made KAP survey questionnaire was developed for the present study (23),(24),(25),(26),(27),(28). The questionnaire was distributed prior to the AMS training session. The survey involved key stakeholders closely involved with AMS implementation, viz., clinicians, pharmacists and nurses. All the participants were voluntarily involved in the study.

Data Collection

The KAP of the clinicians, nurses and pharmacists in the context of antibiotic usage were assessed by separate sets of questions for each category of responders. The questionnaire consisted of domains regarding KAP of participants towards AMR including the antibiotic usage and prescription practices. The survey was rolled out to all participants of the AMS training session and only the filled-in survey responses were considered for the analysis. Responses from the participants were collected using a five-point Likert scale and the choices ranged from ‘strongly agree’ to 'strongly disagree', thereby providing a holistic view of participants’ opinions.

Statistical Analysis

Descriptive analysis was used for the KAP survey to determine the percentages of survey participants under different categories of response.

Results

Study participants: The survey was conducted in five Indian tertiary care hospitals located in five different cities across the country: Andhra Pradesh and Tamil Nadu in South India, Maharashtra in Western India, Punjab in North India and Patna in East India. Hospitals from the North and West zones were superspecialty hospitals (≥300 bedded), while the remaining three were multispecialty hospitals (100-300 bedded). All participating hospitals were from tier two cities of the country. The study involved a total of 95 healthcare-associated personnel, including 32 clinicians, 55 nurses and eight pharmacists from the five hospitals. The response rate to the survey was 100%.

Assessment of Antimicrobial Stewardship (AMS): First, implementation of the AMS program was evaluated in the participating hospitals: Hospital 1 from North zone, Hospitals 2 and 3 from South zone, Hospital 4 from West zone and Hospital 5 from East zone. The AMS checklist revealed that for improving antibiotic use, all participating hospitals had a formal statement of support for AMS activities.

The majority of the hospitals (Hospitals 1 to 4) had a physician (or other) leader responsible for AMS activities with specialised training on infectious diseases (Hospitals 2, 3 and 4). All the hospitals had infection control, microbiology and nursing staff who worked with physicians or pharmacists to improve AMR and AMS.

In the context of AMS interventions, prospective audits and feedback for restricted antibiotics within 48 hours of prescription were mandatory for the majority of the hospitals (Hospitals 1, 2 and 3). These hospitals were equipped with facility-specific antibiotic treatment guidelines for specific infections and Hospitals 1, 3 and 4 had guidelines for the de-escalation of broad-spectrum antibiotics. But the hospital guidelines were not readily available at the point of care, except in Hospital 3.

The majority of the hospitals had unit-specific antibiograms (Hospitals 1, 2 and 3). Less than half of the hospitals implemented other aspects, such as monitoring the use of specific antibiotics by days of therapy or defined daily dose (Hospitals 1 and 3 answered yes), antibiotic expenditure (Hospital 3 said yes) and compliance with facility-specific treatment guidelines (Hospitals 2 and 3 answered yes). The hospitals did not regularly publish AMR data and outcome measures associated with AMS or share the results of antibiotic audits or reviews directly with prescribers (Hospitals 1 and 3 said yes).

Nearly all the hospitals had either an in-house microbiology laboratory or access to a timely and reliable microbiology service (Hospitals 1, 2, 4 and 5). However, the hospitals were not appropriately equipped with other infrastructure for AMS, e.g., Information Technology (IT) capabilities to gather and analyse AMS data (only Hospitals 1 and 2 said yes). Hospitals 1, 2 and 5 conducted educational activities for clinicians and other relevant staff on improving antibiotic prescribing; however, these were neither mandatory nor certified (only Hospitals 1 and 2 said yes).

The hospital-wise response to the AMS checklist is depicted in (Table/Fig 1).

Response to Knowledge, Attitude and Practices (KAP) Survey

The 39-point KAP survey questionnaire provided a holistic view of the KAP of different healthcare personnel toward AMR and AMS in hospitals across the country. A total of 32 clinicians, 55 nurses and eight pharmacists participated in the survey and filled in the 39-point questionnaire. However, if the participants had no answer to any particular question, they did not provide any response.

Overall, the clinicians had good knowledge of the contributing factors for AMR. They were aware that irrational prescribing of antimicrobials (n=31, 96.87%) and improper diagnosis of infective conditions (n=27, 84.37%) were important contributing factors for AMR. However, the attitude of the clinicians towards AMR could be improved in some aspects, e.g., role of poor infection control practices in overprescribing of antibiotics (n=6, 18.75% disagreed). The majority of clinicians advocated the need for more education (n=30, 93.75%) on appropriate use of antibiotics and opined that newer antibiotics would tackle the increase in AMR (n=26, 81.25%). Some clinicians did not regularly refer to the local epidemiological data or antibiogram while prescribing antibiotics (n=7, 21.87%). The detailed responses are mentioned in (Table/Fig 2).

The knowledge of nurses on the causes of AMR varied across a wide range. While half of the nurses were aware that the use of antimicrobials for self-limited non bacterial infections (n=30, 54.54%), or administration for a longer (n=35, 63.64%) or shorter than standard duration (n=40, 72.73%) causes AMR, 10 to 12 of them (~18.2%-21.8%) disagreed. Again, while nearly half of the nurses were aware of the role of appropriate infection control practices (n=29, 52.73%) and restrictions on antibiotic usage (n=36, 65.45%) and overuse of antibiotics (n=30, 54.54%) in controlling AMR, others believed that non adherence to antibiotic treatment by patients do not contribute to AMR (n=11, 20%). They also agreed that in case of earlier apparent recovery from symptoms, the antibiotic course should be stopped immediately (n=12, 21.82%) and that antibiotics should be given to speed up recovery from cough and cold (n=21, 38.18%).

According to the pharmacists, the lack of restrictions on antimicrobial usage (n=5, 62.5%) and widespread or overuse of antibiotics (n=6, 75%) were crucial factors for antibiotic resistance. They believed that AMS programs can improve patient care (n=7, 87.5%) and three of them strongly agreed (37.5%) that restriction of antimicrobial use can control AMR. Only a quarter of the pharmacists had sufficient knowledge of antibiotics (n=2, 25%). The responses of clinicians, nurses and pharmacists to the KAP survey are depicted in (Table/Fig 2).

Discussion

The increasing rate of AMR has become a global concern, but nowhere is it as alarming as in India. Multiple factors, such as poor infection prevention and control guidelines, high prevalence of infections and over-the counter and irrational use of antibiotics, contribute to the worsening AMR rates in India (1). Since the frontline people associated with AMR control are HCPs, understanding the KAP of these HCPs regarding AMR is a key step in formulating effective AMS measures (2). However, literature is limited on the implementation of AMS and the KAP of HCPs regarding AMR across Indian hospitals. The present study sought to assess the implementation of AMS and the KAP of HCPs, i.e., clinicians, nurses and pharmacists, in Indian hospitals regarding AMR and AMS.

Despite the implementation of the AMS program in all the participating hospitals, the study revealed that Indian hospitals need improved infrastructure along with mandatory and certified training for AMS practices and antibiotic usage. Similar findings have been described by Singh S et al., (3). This study revealed that although awareness of AMS has been increasing in India, several lacunae exist in its effective implementation (3), which is also reflected in the present study. For example, although infection control practices were followed and microbiologists and nursing staff were involved in the AMS programs of all the five hospitals studied, the involvement of IT staff was observed in only three hospitals. Health IT interventions comprehensively support AMS programs by providing opportunities such as access to relevant personal and local AMR pattern data, documentation of diagnoses, antimicrobial guidelines, selection of empirical treatment, review, audit, monitoring and feedback (29). In low and middle income countries, the lack of IT infrastructure is quite common. The implementation of appropriate IT infrastructure for AMR surveillance and antibiotic usage programs has been emphasised by the WHO (30),(31).

More than 90% of the clinicians had good knowledge regarding AMR. This indicated that the clinicians were highly aware of and concerned about the growing AMR rates in their hospitals. The availability of local epidemiological data and AMR rates is an integral component of the clinical decision-making process since they reflect the trends of AMR rates and guide the clinicians regarding the optimal use of antibiotics. Studies had shown that clinicians provided with periodic reports on local AMR data have a better knowledge of local microbiology and higher awareness of AMR and vice versa (32),(33),(34),(35). But the present study revealed that nearly one-fourth proportion of the doctors did not refer to local epidemiological data or antibiogram regularly, similar to previous reports from Southern India (36). Moreover, the practice of consulting local epidemiological data before prescribing antibiotics should be encouraged and its importance should be emphasised among the clinicians.

As observed in earlier studies involving physicians, conducted in South India or multiple centres across India, good knowledge regarding AMR and the rational use of antimicrobials was observed (35),(37). Here, the clinicians perceived that knowledge is important to improve the judicious use of antibiotics and desired further education on the appropriate use of antibiotics, similar to previous reports (38),(39),(40),(41). Higher knowledge among clinicians is associated with lower antibiotic prescription rates (7).

An earlier report indicated a lack of infection control policy in Indian hospitals and over-prescription of antibiotics by the physicians (18). Poor hygiene and infection control practices have been associated with increased antibiotic prescriptions by physicians for ‘preventive purpose’ (42). Here, nearly 20% of the physicians disagreed to the fact that poor infection control practices could lead to antibiotic overuse, which indicated that physicians required formal training on infection control policy to promote the judicious use of antibiotics.

In the era of AMR, the development of newer antibiotics plays a major role in controlling AMR (43),(44). Thus, clinicians need to be aware of the importance of newer antimicrobial drugs in tackling AMR. In line with these, the clinicians in the present survey were aware of the need for newer antibiotics to keep resistance in check. These findings indicate that having good knowledge and attitude regarding AMR and AMS among the clinicians does not necessarily imply good antibiotic-usage practices. Similar to the present findings, a KAP survey from Eastern India reported that despite having good knowledge and attitude regarding AMR and AMS, clinicians performed poorly in practice, thereby implying that their knowledge did not translate into practice (2). Therefore, efforts should be made to bridge the gaps between AMS-related KAP among HCPs, such that good knowledge on AMS could be translated into good AMS practices for restraining AMR. It could be plausibly achieved through the successful implementation of AMS, along with regular training and education of the HCPs.

Nurses at the point of care have a critical role in AMS activities and containment of AMR (45). However, their role in AMS is suboptimal and largely unexplored (16),(46). In this study, the responses of nurses towards causes of AMR varied across a range, which emphasised the need for formal AMS education and training. Earlier studies also reported low awareness of AMS among nurses and highlighted the need of educating them for filling the gaps in their knowledge (16),(46),(47). Nearly one-third of the nurses participating in the present survey did not consider poor infection control practices, lack of antimicrobial restriction and overuse of antibiotics as contributing factors to AMR. Therefore, AMS education of nurses needs to emphasise the importance of hand hygiene and infection control practices and the contribution of antibiotic overuse to AMR.

Various factors, such as inappropriate dosage and duration of antibiotic treatment and lack of compliance, also contribute to AMR (36). However, several nurses in this survey did not agree on these factors. Many nurses believed that in case of apparently early recovery from disease symptoms, dispensing antibiotics should be stopped immediately and antibiotics should be given to speed up recovery from cough and cold. These findings highlight the need for proper training for the nurses, where knowledge on the appropriate use of antibiotics, including treatment adherence and duration, should be stressed upon. Also, approximately 80% of the nurses wanted to have more education on the appropriate use of antibiotics. Though there is limited data available on the awareness of nurses on AMS across Indian hospitals, the present survey revealed that there is an unmet need for formal education and training among the nurses on AMS practices.

Of the total number of pharmacists involved in the present survey, although few, only 25% had adequate knowledge of good antibiotic usage practices. Another survey from South India reported that as compared to other paramedical staff, nurses and pharmacists had four times better knowledge regarding antibiotics (12). A qualitative study from North India evaluating antibiotic dispensing practices and knowledge on AMR among community pharmacists revealed inappropriate antibiotic dispensing practices and a lack of knowledge on AMR and the use of antibiotics (48). Another study conducted across 261 pharmacies in an urban setting in South India reported that over-the-counter dispensing of antibiotics in the private sector was unacceptably high (49). Poor antibiotic usage practices among the pharmacists could be potentially improved by the implementation of mandatory and certified training courses similar to nurses, which is lacking in Indian hospitals, as evident from the present survey. Apart from more education and training, changes in attitude and practice could be achieved through robust implementation, evaluation and demonstration of AMS program outcomes, which will serve to instill confidence in different types of HCPs.

Limitation(s)

The limitations of the study include large differences in the number of participants between different categories of healthcare personnel. Moreover, the number of pharmacists was too low to reach any conclusion.

Conclusion

The study revealed that the implementation of AMS was not adequate in Indian hospitals. Improved infrastructure, antibiotic policy implementation and proper education are essential for improving AMR and AMS. Although clinicians had overall good knowledge, their attitude about antibiotic use and their practices were not equally satisfactory. As compared to the clinicians, the nurses and pharmacists did not catch up well in terms of KAP on antibiotic usage. Therefore, cumulatively, the findings of the survey reinforce the need for mandatory training for HCPs in Indian hospitals for improved AMS outcomes. Besides training, the successful implementation of the AMS program in Indian hospitals would also require improvement in infrastructural facilities, including effective IT solutions.

Acknowledgement

Authors would like to thank BioQuest Solutions Pvt., Ltd., Bengaluru for providing medical writing assistance and editorial support in the preparation of this manuscript, funded by Pfizer India.

DOI and Others

10.7860/JCDR/2021/47651.15203

Date of Submission: Nov 11, 2020
Date of Peer Review: Jan 20, 2021
Date of Acceptance: Apr 05 , 2021
Date of Publishing: Aug 08, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 12, 2021
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ETYMOLOGY: Author Origin