The knowledge, attitudes and practices of doctors regarding antibiotic resistance at a tertiary care institution in the Caribbean

A cross-sectional study was performed to identify the knowledge, attitudes and practices of Jamaican physicians towards antibiotic resistance and antibiotic prescribing practices. This information will help in the development of national antibiotic guidelines and workshops for healthcare workers. A problem with such strong global significance requires every country to define its challenges and make its voice heard.

This study was conducted across Jamaica, the third largest Caribbean island, 11,424 km², with a population of approximately 2.8 million [20, 21]. Approximately 4000 public and private doctors were identified as currently providing medical care from national registration records (Jamaican Medical Council). We targeted 20% or 800 doctors. With this sample size, we calculated that we would have a margin of error of 4% and a 99% confidence level, assuming a conservative response distribution of 50%. We recruited through medical conferences, hospital meetings and visits to private practices across the four Jamaican health regions- South, Southeast, Northeast and West. Physician registration with the local medical council requires regular attendance at conferences or meetings to obtain continuing medical education credits (CMEs). In addition, we did not target microbiological conferences or those on antibiotics or resistance, but included a wide cross-section of meetings. Therefore, we do not believe that our sample was biased towards physicians with better knowledge of ABR. Data collection was done between October 2014 and September 2015.

The instrument used was a 32-item self-administered questionnaire comprising questions related to demographics (eight questions), knowledge (six questions), attitudes (five questions) and practices associated with antibiotic use (13 questions). Ethical approval was obtained from the Faculty of Medical Sciences, UWI (ECP 183 13/14) and Ministry of Health (MOH) Ethics Committees (2014/26) and informed consent was obtained from each participant.

Physicians’ knowledge of factors contributing to development of ABR and factors useful in containing resistance were examined. Each factor was analyzed on a scale of 0 to 3 (0 = don’t know, 1 = minimally important, 2 = moderately important and 3 = very important) and showed how the respondents ranked their importance. Knowledge of antibiotics more prone to inducing resistance was also assessed, and each was scored between 0 and 2 (0 = don’t know, 1 = less likely, 2 = more likely).

The third score “Antibiotics more prone to inducing resistance” (which refers to the potential of an antibiotic to cause the emergence of resistance over time [22]) was created from 7 variables, each with three categories (0 = Don’t Know, 1 = Less likely, 2 = More likely). The overall score was calculated based on the number of correct responses, with a maximum of 14 points. This scale was recoded into three categories; (Poor knowledge = 0–4; Average knowledge = 5–9; Good knowledge = 10–14).

Reliability analyses using Cronbach alpha were done to determine the level of internal consistency among the items comprising the individual scales. Results indicated high Cronbach’s alpha scores of 0.749 to 0.859 for most of the scales. Only “Factors contributing to development of ABR” had a lower Cronbach’s alpha of 0.631, which is still acceptable [23].

A total of 695 physicians completed the questionnaire, a response rate of 87%, with 51% female. The majority stated that their practice was mainly hospital based (60%) and 51% had postgraduate training. About a third (32%) were less than four years post registration and 33% were residents. (Table 1) The Southeast region accounted for 62% of the respondents, the Western region 22%, the Northeast region 5% and the Southern region 11%. This corresponded fairly well with data from the Ministry of Health, which indicated the following distribution of physicians: Southeast region 55%, Western region 20%, Northeast 15% and South 10% (J Barnett, pers. comm.).

Eight out of 10 doctors (82%) recognized the magnitude of ABR globally, but less were convinced of this locally (73%) and even less so in their personal practice (53%). The danger of this finding is that physicians could become detached from the problem, making them less likely to try to contain it. ABR is more common in the hospital setting and this was reflected in the responses of the hospital doctors. The authors have observed that the prohibitive cost and delay in retrieving microbiology reports in some areas have adversely affected the Jamaican physicians’ perceptions of the value of obtaining routine cultures. This could explain why only 7% of physicians always take cultures for a suspected infection. Hence, there is little reminder of prevailing resistance patterns.

Most physicians appreciated the influence of widespread use, inappropriate choices and overuse of broad-spectrum antibiotics as drivers of ABR [4, 18]. However a significant number failed to recognize important drivers of resistance such as inadequate hand hygiene and antibiotic usage in the livestock industry [4, 5]. When the objective assessment of their overall knowledge of ABR was compared to their own personal assessment, there was good correlation with 57% receiving an average score objectively, and 54% perceiving their knowledge as average.

Ongoing educational programmes, the development of national antibiotic guidelines, access to microbiology consultation, as well as improved laboratory services were thought to be most useful in containing ABR. There are only two medical microbiologists and one infectious disease specialist for the public health sector across the entire island. This needs to be urgently addressed as part of a national programme. Access to timely laboratory reports continues to be a challenge in this resource limited setting, where there are only few laboratories with limited diagnostic capacity, often using manual systems. Although this problem would appear to be a local one, its potential impact could be global because of Jamaica’s position as a popular destination. The role of inadequate rapid point of care (POC) tests to differentiate between viral and bacterial infections was also clearly appreciated by the respondents as being an important factor to contain resistance. POC tests are those that are performed at the bedside and generate convenient and rapid results [24]. These would quickly differentiate between viral and bacterial infections such as Group A Streptococcus and urinary Streptococcus pneumoniae. Unfortunately there are only a few rapid POC tests and this is a problem internationally [25]. This is particularly highlighted by upper respiratory tract infections which are common worldwide and are often overtreated by antibiotics in the absence of rapid POCs [26]. Factors such as antibiotic cycling and restriction, that would confine the physicians’ prescribing practice, were not perceived to be as important. This was confirmed by the fact that only just over one third (36%) thought that current antibiotic restriction policies should be increased.

Just over half of the physicians (59%) surveyed understood that some antibiotics are more prone to inducing resistance than others. As expected, physicians in the hospital setting had better knowledge, but there is room for more education across the board, such as seminars, workshops, conferences, newsletters and official antibiotic guidelines. Although the third generation cephalosporins and fluoroquinolones have a high propensity towards resistance induction [27] they remain some of the more prescribed antibiotics. Ceftriaxone was the second most commonly chosen empiric antibiotic overall followed by ciprofloxacin. The response to optimal duration of antibiotic therapy varied widely and highlights the need for national and institutional guidelines.

Although 65% of the respondents identified MRSA as the most common resistant organism seen in their practice, it should be noted that at the major referral hospital in the island, MRSA prevalence rate for the past three years has been less than 4% [16]. This information has been widely communicated to local physicians through conferences and workshops. Typing of the MRSA isolates retrieved from this hospital showed that only 29% were scc mec IV type (E. Finlayson, unpub. Data [28]. It should also be noted that 30% and 24% of the MRSA isolates retrieved in 2008 were resistant to low level and high level mupirocin respectively [29] highlighting again the need for constant surveillance.

Similarly, the prevalence rates for VRE have been less than 1% for the past four years in the same hospital (A Nicholson, unpub. data), even though 19% of physicians reported having seen this organism in their practice. As to be expected, hospital physicians reported a higher incidence of MDROs, and PRSPs were more commonly seen in the community.

Although factors influencing choice were appropriate, knowledge of local antibiograms was not always included. Again, this could be related to limited laboratory resources that reduce the availability of culture results and objective data. In the absence of national guidelines, the tendency is for the physicians to use international guidelines, as evidenced by the empiric choices for community and hospital acquired pneumonia and urinary tract infections. This finding also corresponds with the physicians’ high use of the Internet for information (74%), far more than consulting local experts (54%). From the limited susceptibility data available, it is clear that local susceptibility patterns, eg Staphylococcus aureus (3.2% MRSA) and Enterococcus, (< 1% VRE) (are different from those reported in developed countries, and hence empiric choices should not be solely based on international guidelines. Streptococcus pneumoniae is recognized as the commonest cause of community acquired pneumonia and recent data showed a 8% resistance to penicillin (IV) for all isolates nationally (A. Foster, 2015 unpub. data), which is far less than the 24% resistance seen in North America [30]. Where penicillin resistance is low, the use of penicillin/amoxicillin-clavulanic acid for first line therapy is appropriate.

Physicians were more inclined to change to broad-spectrum antibiotics and reluctant to de-escalate, even in the face of laboratory data [31]. This type of practice is expensive, and ultimately drives resistance [32]. In this era of ABR it is important for physicians to achieve optimal outcomes by combining laboratory and clinical data. This study found that only 21% of physicians would de-escalate therapy, while a 2010 single-centre Jamaican study showed that only 7.7% actually practiced de-escalation [33]. There has been some improvement through education of physicians as to the importance of the practice, and attention had been drawn to the results of the 2010 study in conferences, workshops and small group sessions by local microbiologists. Encouragement to de-escalate should continue to be a target in future programmes.

It is encouraging to see that the physicians were paying attention to the need for patient education ranging from explanations of the dangers of unnecessary antibiotics to guiding them to seek follow-up care if necessary. Although 6% admitted to prescribing antibiotics on demand, a further 15% admitted to having done so in the past. This may be the result of increased of continuing education via conferences and workshops, some of which are mandatory. We would have expected more response to patient pressure, especially in the private setting. This is a positive finding, but more work is needed to further reduce this figure.

The majority of physicians were interested in further educational courses on antibiotic resistance. The results of this survey will guide the development of these courses, which could be in the form of hospital based workshops, orientation of new staff and medical conferences.

The major limitation of this study is that it relied on self-reporting by physicians as well as recall of past practices. This could have led to either under or over reporting and recall bias, which may have affected results. Further qualitative research using focus groups, for example, could highlight reasons for some of the practices seen, such as the reluctance to de-escalate therapy, and this could guide interventions.