The present study describes the results of a KAP-survey among 256 medical doctors (both residents in training and attending physicians) practicing in two large public teaching hospitals in the Lima area, Peru.
Knowledge on AMs and AMR
Overall, the theoretical knowledge about AMs including indications, administration and side effects ranged from very good to excellent. Despite this apparently good score for these questions, it should be noted that a quarter of participants still considered that it was correct to use AMs for upper respiratory tract infections. This suggests that this issue should be targeted in future educational interventions. Furthermore, it is known that in practice AM use may not reflect these results, and this can be illustrated by a recent study: in a rural Peruvian village, 58% of children with acute upper respiratory symptoms or watery diarrhoea (for which AMs are not recommended) were given AMs when they went to see a doctor . This contrasts with the survey's results, in which the majority of participants answered correctly that AMs are unnecessary for either of these conditions. Likewise, it should be noted that a quarter of participants agreed with the statement that unnecessary prescribing of AMs does not cause any harm. Although the participants' overall knowledge about AMs was appropriate, most of them incorrectly estimated the local resistance rates of two key-pathogens in the hospital setting, K. pneumoniae and P. aeruginosa. Similar findings have been described in other studies [7, 8]: Pulcini et al. showed that only 16% of young doctors in a French hospital knew the actual proportion of community acquired-Escherichia coli resistant to fluoroquinolones. Local microbiology laboratories are encouraged to maintain a database about the levels of resistance of key pathogens and diffuse it to prescribers: when reinforced by the local antibiotic committee, information may orient prescribing doctors .
Awareness about current scope of AMR
The awareness of AMR as a worldwide and national problem was very high among the participants. However, in contrast, AMR was much less recognised as a problem in participants' own practice. This trend has also been observed among physicians surveyed in the U.S. (Table 1) [9–11]. On the other hand, qualitative research among general practitioners in the U.S. showed that most of the physicians interviewed were aware that inappropriate use of AM in their own practice contributes to increasing AMR . Interestingly, the majority of participants recognized excessive use of AMs as a factor contributing to AMR in the community, but only half did so for the hospital settings.
Confidence and seeking of inputs
Compared to attending physicians, residents in training were less confident about AM prescribing. This correlates with the findings of Srinivasan et al.: in this study, senior residents were more confident about optimal use of antimicrobials compared with first year-residents . Moreover, residents tended to seek advice from their senior colleagues when prescribing, irrespective of their specialization (department) or hospital affiliation, compared with attending physicians who have more years of clinical experience. However, more residents declared that they consulted internet-based sources rather than approaching senior colleagues for advice. It is surprising than more than 50% of residents declared that they did not consult senior colleagues considering that both institutions were teaching hospitals. Other sources of AM guidance are discussed below.
Sources of information and continuing education about AMs
The present survey also revealed information about the sources of information for AM use. The popularity of the Sanford Guide illustrates the accessibility of pocket-based treatment guidelines. Internet sources were ranked as the second most useful source. In this scenario, distant learning technologies which have been used successfully in Peru for other disciplines [15, 16] may have a place in promoting educational AM prescribing programs. The poor appreciation of and familiarity with the national guidelines among the participants is striking and contrasts with the seemingly large demand for local AM guidelines.
Factors influencing decisions around AM prescription
Three quarters of participants identified patient demand for AMs as a key factor contributing to the overuse of AMs in the community, with half doing so for the hospital setting. Pressure from patients is indeed an important factor particularly in the middle- and low-income settings. A study among parents and paediatricians in Venezuela revealed that 87% of doctors felt pressured by parents into prescribing AMs; 48% of parents said that they had requested AMs and 33% revealed that they had obtained a prescription .
The high expectation about AM use from patients is very probably a consequence of their minimal understanding of AMR and AM side effects. Education of the general public through community-targeted media information is extremely important
More than half of participants agreed that AMs in their hospitals are of poor quality. Although we have not explored in detail the definition of "poor quality" according to the prescribers, there are several issues. Firstly, despite regional and national regulations for drug marketing, counterfeit (and probably substandard) drugs have been detected in Peru, but information was mainly distributed by the lay press and as such, it is difficult to estimate the magnitude of this problem. Secondly, in our experience, generic drugs are also frequently perceived to be less effective, an idea reinforced by recent studies from Colombia showing that generic vancomycin and oxacillin had a less therapeutic effect in animal subjects [18, 19]. This is of concern, as a lack of confidence in generic and locally market drugs may similarly affect confidence in following standard treatment guidelines and in the implementation of essential drug lists and may deflect patients and prescribers towards the private sector. The Peruvian Ministry of Health should build confidence in the quality of locally available AMs by circulating adequate information about locally marketed AMs. In line with the need to diffuse data on AMR rates among key-pathogens, it is clear from the present results that the hospital pharmacy should diffuse timely and accessible information about the availability of AMs.
Acceptability and appropriateness of potential interventions
Formal programs about AMR and AM prescribing were welcomed by the vast majority of participants suggesting a gap in knowledge about infectious diseases, microbiology and AM prescribing in university programs . There was also strong agreement about the usefulness of local AM guidelines, although concerns about the acceptability of the local antibiotic committee and its steering measures should be addressed in the future.
One of the main limitations of KAP-surveys is the fact that participants may tend to give socially desirable answers rather than expressing their true opinions. The present setting of teaching hospital may contribute to this bias. In order to minimize this potential bias anonymous participation was ensured and the case-based questions about AM prescription (which might have been suggestive) were presented at the end of the survey. The fact that this survey was based on a survey conducted among U.S. physicians may be another limitation, but it was countered by the pre-release validation. In addition, the survey was extended to the local context by adding questions relevant to the Peruvian situation. Another issue was that physicians working in hospitals were also questioned about their knowledge and attitudes towards community infections. However, the majority of doctors in the two hospitals were practicing in both the hospital and the community setting. Further studies should be done to study the knowledge, attitudes and practice surrounding AM use among physicians from community centres. Finally, one may question whether the attitude of doctors in other parts of Peru to AMs is reflected by the results of this survey. As this study was conducted in two large, public, tertiary-level teaching institutions and involved a large number of prescribing doctors, we are confident that the results may be applied to other public general hospitals in Peru. However, the generalizability of the results to other health care settings remains to be demonstrated.