Background
Method
Study setting
Study design and study participants
Interview schema development
Data collection
Data analysis
Results
Participant’s characteristics
Respondent | Sex | Specialization | Interview duration |
---|---|---|---|
Doctor 1 | Female | Pulmonology | 32 |
Doctor 2 | Male | Medicine | 29 |
Doctor 3 | Male | Pulmonology | 22 |
Doctor 4 | Female | Pediatrics | 27 |
Doctor 5 | Male | Pediatrics | 22 |
Doctor 6 | Female | Gynecology | 23 |
Doctor 7 | Male | Cardiac surgery | 30 |
Doctor 8 | Male | Nephrology | 28 |
Doctor 9 | Male | Nephrology | 27 |
Doctor 10 | Male | Pediatrics surgery | 25 |
Doctor 11 | Female | Burn unit | 25 |
Doctor 12 | Male | Nephrology | 20 |
Doctor 13 | Male | Cardiac surgery | 30 |
Doctor 14 | Male | Pediatrics | 24 |
Doctor 15 | Female | Pediatrics | 30 |
Doctor 16 | Female | Pediatrics | 20 |
Doctor 17 | Male | Pediatrics | 20 |
Mean duration | 25.5 min |
Theme 1: perception about antibiotic use and antibiotic stewardship
Subthemes | Categories | Quotations |
---|---|---|
Familiarity with terms | Empirical therapy was perceived as rational use | R2: Proper use or rational use here is, if we suspect infection we start antibiotic even if we are not sure the infection is bacterial or viral. It is a tertiary care hospital so some time we do perform microbiology tests but not commonly. We suspect we prescribe the antibiotic which can work for everything. R11: Basically our hospital is teaching hospital we give antibiotic on proper time and with proper dose. We never give antibiotic without its need. Sometimes we do when have to give it prophylactically; patient is admitted and has exposure with infections. Here antibiotics are used rationally. |
Irrational use of antibiotics | R13: We give medicine on patient demand it happens. We don’t go for cultures and blindly give triple therapy or a broad spectrum antibiotic. | |
Only few were familiar with the term “antibiotic stewardship” Majority were not familiar with the term “antibiotic time-out” | R3: It is multidisciplinary programme, consist first starting from of physicians, pathologist/microbiologist and pharmacologist. They work together on incidence and prevalence of infection and on the basis of it form an antibiogram and then proper empirical treatment is decided and proper use of antibiotics takes place. R4: I don’t know anything about that programme. And that kind of system is not practiced here. R15: I don’t know.it is very difficult word? What does it mean? And nothing like this is practiced here or known about. |
Theme 2: antibiotic prescription practices
Subthemes | Categories | Quotations |
---|---|---|
Use of broad spectrum antibiotics | • Provides good cover • Prophylactic use | R3: When you don’t know which microorganisms it is, you fire all the guns and it’s safe. R4: We give broad spectrum to make sure that the patient does not acquire any hospital acquired infection. |
Why bacteriology is not performed? | Patient perspective • Affordability | R1: We live in a country with limited resources. We know that patient has, for example, respiratory or urinary tract infection, there might be known organisms and these antibiotics are effective so we will not tease a person with limited financial resources. |
Hospitals perspective • Limited resources • Diagnosis based on clinical judgement • Lack of inter department communication • Unreliable laboratory test results | R4: Everything is not diagnosed on base of culture sensitivity tests there are many clinical signs e.g. pneumonia, GI problem we start the treatment and if problem is not solved we go for further investigations and we have limited resources so we cannot send cultures for every patient. R10: Our bad scenario is that our labs are not up to date, you can conduct the same test from 3 different laboratories and all of the results will be different and culture tests reports take more than10 days so it is very time consuming. | |
Laboratory investigations performed | Before prescribing antibiotics • Only complete blood count as base line investigation • Culture tests were uncommon | R1: In government setup, we carry out basic investigations which indicate patient is having infection but what sort of infection what sort of organism he or she is having we cannot say anything about it. R11: No trend of culture tests. We only do it if condition of patient is worse and no medicine is working against it. |
Investigations adopted to check ‘antibiotic timeout’ • Improvement in apparent condition • Check leucocyte count • No specific investigations for ‘antibiotic timeout’ | R5: Mainly improvement of symptoms, and then urine culture, blood tests showing improvement in total leucocyte count shows medicine is effective. R3: In severe cases we have to give empiric treatment and it is recommended but after 72 h if you are asking about whether we check responses, we usually don’t. |
Theme 3: antibiotic resistance
Subthemes | Categories | Quotations |
---|---|---|
Alarming situation | Escalating resistance against various infectious disease | R3: Drug resistance is the major problem. In quinolone here drug resistance is up to 48% and this is very alarming. While sitting in South East Punjab, even in tuberculosis resistance has increased a lot. R4: I am working in neonatology unit most of the neonates are resistance to most of the broad spectrum antibiotics. if we see culture reports you can see that bacteria are resistant to 90% drugs. |
Reasons of resistance | Frequent use of antibiotics for minor ailments | R2: There is no need of antibiotics in viral infection like flu, and viral diarrhea in children, but antibiotics are used and prescribed for such ailments. |
Demand of antibiotic by patient for minor ailments | R4:Doctor just give them painkiller and then they ask why you have not given us antibiotic. | |
Improper dosing and poor compliance | R6: Patient does not take medicine in exact dose and for complete duration. Patients take it for 2 or 3 days and discontinue because of many reasons. | |
Lack of qualified professionals | R8: I worked in primary healthcare center. There antibiotics are used irrationally specifically in children by quacks, who are non-qualified and not licensed to prescribe. | |
Limited number of antibiotics in public healthcare sector | R3: In quinolone if we require ciprofloxacin we sometimes get moxifloxacin. And in the same way we do not get the required dosage form. Dose cannot be adjustment. We have not many options available. | |
Lack of experience drives inappropriate use | R3: There is no guidance for health care professionals. Junior doctors (having little or no experience) use broad spectrum antibiotics for minor infections. | |
Challenges associated with antibiotic resistance | Threat to effective antibiotic options for treatment Expensive drugs are the only option | R7: In next 10 years more than 60% antibiotics will become resistant and useless. After some years it may be impossible to treat patients with antibiotics that are available now. R9: New antibiotics are costly and new generations are not easily available. |
Effect on patient • Recurrent infection • Financial burden on patient | R1: Patients suffer financially and ends up having recurrent infection. R3: Patient remains untreated because we have limited options. Patients cannot afford to buy purchase new antibiotics from market and they end up having recurrent infection. |
Resistant organisms | |
---|---|
Gram negative bacteria | Salmonella spp |
Pseudomonas aeruginosa | |
Escherichia coli | |
Klebsiella pneumoniae | |
Stenotrophomonas maltophilia | |
Acinetobacter spp | |
Haemophilus influenza | |
Morganella morganii | |
Gram positive bacteria | MRSA (methicillin resistant Staphylococcus aureus) |
Acid fast bacteria | Mycobacterium tuberculosis |
Theme 4: limited strategies adopted by the hospital administration to ensure quality and safe distribution of antibiotics
Subthemes | Categories | Quotations |
---|---|---|
Reporting system | Adverse drug event reporting to hospital pharmacist is minimal | R1:Drug is showing serious side effect, dosage form is not proper, or drug is substandard we report it to pharmacist but it rarely happens that we report as there is no proper reporting system. |
If medicine is substandard • Report to company • Obligatory drug testing to ensure the quality | R5: There is protocol called recall medicine protocol. We fill the form and report it to company. And ideally district drug controller should be informed. R2: Drug testing laboratory for testing quality of antibiotics if we see any problem like even given in proper dose and medicine is not effective. |
Theme 5: implementation of antibiotic stewardship programme: barriers, suggestions and future benefits
Subthemes | Categories | Quotations |
---|---|---|
Barriers to successful implementation | Workshops on antibiotic stewardship were not conducted | R3: There are very few people in this setting who talk about this or know about this. But no one owns it and its importance is neglected. No awareness workshop has been conducted regarding this programme in this setting. |
Lack of proper audit system | R5: Accessibility to antibiotics is very easy that everybody can prescribe it like dispenser, junior doctors, trainee doctors, etc. | |
Lack of updated knowledge for qualified professionals | R8: Doctors are prescribing medicines that are not necessary and even those which are no more used in many other countries and are not necessary and no guidance for health care professionals is available. | |
Unavailability of antibiotic use guidelines and hospital antibiogram | R9: The hospital did not provide us antibiotic use guidelines. | |
R15: There is no antibiogram available in hospital to guide us about resistant organisms and treatment options. | ||
R3: Our hospital has no specific guidelines. For bronchitis we follow British Thoracic Society guidelines. | ||
Suggestions | Strict enforcement of ongoing and new legislations | R4: We can implement this programme by bringing policies and it will require a lot of effort and home work. We should also make our public and physicians aware that antibiotics are not those medicines which you should use causally. |
Active participation of health care professionals | R1: General practitioner should be made aware about rational use because patients visit them first. Pharmacist and doctor should collaborate and work together to ensure safe use of antibiotics. | |
Awareness among general public about antibiotic resistance and proper use | R5: We should educate our public that they should avoid self-medication of antibiotics and should not take it from unqualified professional. | |
Future benefits of antibiotic stewardship programme | Might help in current issue of antibiotic resistance Helps in rational prescribing | R4: Right medicine will be given to patient. R7: It will educate doctors about latest guidelines and about resistance of antibiotics and by utilizing that awareness we can save our people from further resistance. |