Attitude and perception of medical interns about antimicrobial resistance: a multi center cross-sectional study in Ethiopia

Antimicrobials are the most commonly prescribed drugs in developing as well as many developed countries to treat and control infectious disease [1, 2]. Inappropriate use of antibiotics results in bacteria resistant to antibiotics in the community and hospital [3]. Antibiotic resistance is a worldwide problem, with a negative consequence on patient treatment outcomes [4]. Furthermore, patients infected with drug resistant bacterial infection need more expensive intervention, so antimicrobial resistance results in increased health care costs to families and societies [5]. Reducing the burden of antimicrobial resistance is highly challenging in low-income countries than developed countries due to high prevalence of infection, irrational uses of antimicrobials, over-the-counter availability of antibiotics and lack of clinical microbiology laboratories for antimicrobial susceptibility testing in the developing countries [6].

In most countries health care system physicians are responsible for prescribing antibiotics. However, junior medical doctors feel unprepared for the complexity of antibiotic prescribing in their daily practice [7]. Several international studies have identified areas of lack of confidence and gaps in antibiotic prescribing knowledge, and have shown that medical students perceive a need for further education and training on antibiotic prescribing and antimicrobial stewardship program [8]. Education can influence prescribing behavior and can provide knowledge that will enhance the acceptance of stewardship strategies among health care practitioners [9]. In most countries education system, there are no enough antimicrobial resistance education programs at undergraduate level and are still being conducted at the postgraduate level in healthcare institutions [10]. Evidence suggests that a multifaceted approach is favored at improving the organization of the healthcare system and changing physicians’ prescribing behavior and practice [11].

Reduction of antimicrobial resistance requires change in antimicrobial prescribing behavior of health workers, antimicrobial prescribing patterns and physicians’ behavior towards the magnitude of antimicrobial resistance problem [12]. The World Health Organization has recommended training for medical undergraduates students regarding appropriate prescription of antimicrobials [13]. It is necessary that our future doctors are better equipped with better knowledge, attitude towards antimicrobial use and resistance [14]. Unlike the senior physicians or infectious specialists who have a large amount of experience and knowledge in infection treatment, the junior doctors usually have limited knowledge and skills to reduce the potential risk of antimicrobial resistance [15]. Therefore, antimicrobial stewardship efforts should be made to standardize the prescribing behaviors of medical inters [16].

In Ethiopia, few studies were conducted concerning the prevalence and associated factors of inappropriate use of antibiotic [17, 18]. However, there is no study conducted in Ethiopia to assess the attitude and perception of medical inters towards antimicrobial resistance. Hence, the purpose of this study is to assess the attitude and perception of medical inters on antimicrobial resistance at teaching hospitals in Ethiopia. The information generated in this study would be instrumental in planning and implementing preventive and control interventions on antimicrobial resistance and applying antimicrobial stewardship program at regional and national levels.

Antimicrobial resistance imposes a substantial public health burden all around the globe [1]. In the current study, the vast majority of medical interns believed that antimicrobial resistance is a main concern in their hospitals as well as in the nation at large. A considerable number of participants reported over usage of antimicrobials nationally. Interestingly, a quarter of participants reported absence of antimicrobial over usage in their hospitals with a statistically significant difference between the participating institutions (p-value, 0.032). This result is in line with a study conducted in seven European medical schools which reported that majority of the participants (92%) believe antimicrobial resistance as a national concern [23]. Similarly, a study done at three US medical schools also reported majority (94%) of participants believe presence of antimicrobial usage nationally and 65% believe over usage in their hospital with substantial difference among medical schools [19].

Substantial number of participants perceived that strong knowledge of antimicrobials is important in their medical career and they would like to gain further education on antimicrobials use and resistance. Other studies conducted among medical students and junior physicians in china, USA, and Europe also come up with similar findings [14, 19, 23]. Less than one third of interns believed new antimicrobials will be developed that will alleviate the problem of antibiotics resistance with significant differences among educational institutes (p-value, 0.021). A multi-center study done in central China also reported a significant difference among participating medical schools regarding development of new antimicrobials [14]. .This could be due to lack of a standardized, comprehensive, and up to date training concerning antimicrobial stewardship.

One of the main components of reducing antibiotic resistance is administering a specific antimicrobial to cover a specific organism. This study demonstrated that only a quarter of interns believe they can describe the correct range of coverage for antimicrobials with a significant difference between institutions (p-value, 0.014). This finding is comparable with study done in other countries [14, 19]. Furthermore, less than a quarter believes they know when to switch from intravenous to oral antimicrobials and vice verse. Proportionally higher number of participants lacks confidence selecting the best antimicrobial for a specific infection. Medical schools are recommended to develop a locally validated protocols concerning switching from intravenous to oral antimicrobials and vice verse [24–26].

.Having a basic understanding of the mechanisms for the development of antimicrobial resistance and finding a reliable source of information to treat infections is vital to challenge the evolving issue of antimicrobial resistance. In the current study, almost three fourth of participants believe they have basic knowledge of mechanisms of antimicrobial resistance. Less than half of the interns believe they can find reliable sources of information to treat infections with statistically significant variation among the different sites (p-value, 0.039). This difference may be partially explained by variation in internet access and difference in curriculum interpretation between institutions.

Handling patients who demands antimicrobial therapy without any indication is also vital to reduce the inappropriate use of antimicrobials. Substantial number of participants lacks confidence on how to handle a patient who demands antimicrobial treatment while it is not indicated with a statistically significant difference among study institutions (p-value, 0.033). The significant difference between institutions may be due to differences in type of clients visiting the institutions [9, 27]. In Ethiopia medical students receive a detailed lectures and seminars concerning antibiotics, mechanisms of antibiotic resistance and preventing strategies of resistance as part of Pharmacology course in their pre-clinical year. A multi center survey conducted in South Africa illustrated the existence of a huge training gap among final year medical students [28]. The odds of having good attitudes and perceptions about antimicrobial resistance among interns attached at internal medicine wards were found to have 2.68 times better attitudes and perceptions about antimicrobial resistance than interns attached at surgical wards. It could be due to differences in the types of patients admitted at medical and surgical wards. Most of the patients admitted at medical wards in developed countries have infectious disease. Hence, interns at medical wards tend to know more about antimicrobial resistance. Interns who received antimicrobial stewardship training during the past 6 months tends to have better attitudes and perceptions about antimicrobial resistance then those interns who didn’t receive training in the 6 month period before the study. This result is in line with other studies conducted among a Varity of communities. In one randomized controlled trial conducted among general practitioners of France, standardized educational seminar on antibiotic improve the irrational prescription of antimicrobials [29, 30].

The current study demonstrates an enormous desire of medical interns for further education about antimicrobials stewardship. Medical interns believe the gained education concerning appropriate antimicrobial use and antimicrobial stewardship is not enough. Based on our finding we recommend that medical interns should acquire a comprehensive, regular, scheduled and up to date educational training on antimicrobial stewardship so as to answer their educational demand and to combat the issue of antimicrobial resistance by endowing the young physicians with sufficient knowledge. It is recommended to medical institutions and other stakeholders to advocate curriculums and policies that build up antimicrobial stewardship programs in the country. An arrangement should be made that can prepare and disseminate locally validated antimicrobial use guidelines with commonly available antimicrobials in the institution.