Table 2 Representative quotes from physician Interviews in Sri Lanka, Kenya, and Tanzania

Current practices

Discrepancies between desired and actual antimicrobial treatment

“I would have loved to actually choose a better or broader [antimicrobial], but they are unavailable, they are expensive for the patients to buy. So you choose what is available and of course it does not eradicate the infection, patients get worse, get septic, go into shock and then they just have mortality.” I-27

“Sometimes the culture report is sensitive for antimicrobials which are not available in the hospital at the moment. So we have to go with some antibiotics available at that time. And we are usually not asking the patient to buy from outside. So like if the patient is sensitive to meropenem if it is not available, we are using third generation cephalosporin.” I-11

The role of consultants, pharmacists, and other staff in antimicrobial prescribing

“Luckily for us, as oncology, we have a big team right now unlike in the past one month we have pharmacists who are doing clinical pharmacy and they are very helpful; they are asking very hard questions. Why don’t you give cefepime,…, they are really helping us in making that decision but before that we would just jump on what is available. We try to cover all the aspects be it gram-negative, gram-positive, anaerobes, protozoan we try to put that holistic picture that cover everything.” I-33

“[Pharmacists] don’t come to the wards. From them we only get to know whether the drugs are available.” -I-22

“For nurses, because they deal with the patient mostly, at least they have a better, one-on-one with the patient so they tell you this patient has reacted to this drug so please don’t give them.” I-28

“Nurses are the ones who are monitoring the patients… so once we find that the patient has been having persistent fevers, this is the time when we have to make decisions to broaden our investigations in order to find out what is causing the infection.” I-38

The impact of the clinical microbiology laboratory and laboratory diagnostics in the prescription of antimicrobials

“The microbiological data are very useful because without any data you will be stuck …you will not be able to treat the patient properly and adequately because you don’t know what you have. The results show you that this is what was found and then it will back-up my prescription and that will help me to be able to give the patient the correct medication.” I-40

“Although there's been a very recent improvement, part of the challenge again lies in the lab and part of it lies in other places. The fact that we don't have reliable cultures, phlebotomist taught how to do proper blood collection, enough nursing staff to collect samples within a reasonable period of time. There are lots of things that contribute to it, but I think the lab certainly historically has not been a very reliable source of information.” I-34

Education on antimicrobial resistance and ASPs

“Formally, I have never been trained in programs. If there is any influence it must be from professional discussions in the Department, presentations on the topic. In general I would say there is improvement going on… I-44

“Ok. Just through case report that’s the most common [form of education] and on my daily rounds you find instances which you find drugs that you expect to be sensitive like ceftriaxone which is most common. Here you prescribe ceftriaxone for a patient with just a UTI, patient does not get better later when you do culture it equally resistant to ceftriaxone which is not expected.” I-24

Barriers to implementation of ASPs

Diagnostic uncertainty and limited awareness of local antimicrobial resistance patterns

“I don't think we get as much data back. So it's mostly anecdotal, certainly there've been resistant gram negatives. They are certainly concerned about MRSA (methicillin resistant Staphylococcus aureus), but I've never actually seen a positive culture for it. It's really unfortunately hard to even approach this from an institutional perspective given the lack of data.” I-34

“I don’t know that [if the resistance patterns vary with wards]. Since there has been no research done about it, no research no right to speak. So I am not so sure.” I-38

Local clinical practice and customs regarding antimicrobial prescribing

“You know what is practiced for so long is hard to break, so even when you come in you say okay, so maybe a lot of people have been using a certain antibiotic throughout, you know, and it is a first line, so you have to look at different factors. So that is a big barrier. Or you find that in another department they have already started on antibiotics that are not appropriate. So those are cultural traditional use of antibiotics that has to be broken in that system so there is a need for educating the people” I-43

Unrestricted access to antimicrobials

“Very strong drugs are given over the counter that’s why nowadays we have very simple diseases that are resistant to the first line [antimicrobials], so we are left in such a difficult position in our prescription so I think that is where we need to follow and address, that is one of the challenges.” I-25

“Antimicrobials are available in the pharmacy in town without a prescription. So that's a major challenge I think for antimicrobial resistance, in casualty (on call) when patients present, I think they're often getting antimicrobials before a diagnostic workup, including cultures have been taken, and therefore makes it much harder to figure out what we're treating in the long run. So we're stuck with the empiric guesses and sometimes that leads to inappropriate continuation of antibiotics or broad spectrum of antibiotic use. That's broader than it needs to be.” I-34

Approach to ASP implementation

Creation of guidelines

“It will help us come up with a guideline for what antibiotics to use at what point instead of just people dispensing antibiotics freely without really waiting for lab results to come back. In that way we will reduce occurrence of antimicrobial resistance. “ I-28

Improving clinical documentation

“If I’m not available if somebody has to see the patient in clinical emergency they should be aware of why this person has started this [medicine]. So it’s really important to document.” I- 22

“The benefits will be many. Because you know this unnecessary prescribing will make doctors more aware that if I do this, someone will ask me… Why did I do this? So even the thought process will increase that instead of just giving an antibiotic, you’re thinking… Where; why this antibiotics will cover this area… And it will also help us know which antibiotics are right, you know, in collaboration with the stewardship program.” I-43

Structure of ASP leadership

“I absolutely agree that pharmacists have a major role to play in antibiotic stewardship again because they, they can serve as some of the link between the lab and the available formulary. And help advise the formulary actually and to also help limit a broad-spectrum antibiotic use, one that's not necessary.” I-34

“No they can’t, pharmacists will not decide which antibiotic to use. But they will provide information regarding which antibiotic available here and the drug doses and other things.” I-33

“Because a microbiologist is someone who has specialized in hospital microbiology so the expertise they have will go a long way in improving patient outcomes because of influencing my judgment strongly positively and in deciding what drugs to use so their input is very important.” I-30

Improving education on antimicrobial resistance and stewardship

“I think all prescribers at whatever level should undergo antibiotic stewardship training to enhance their knowledge on antimicrobials and to make sure that there is rational use of antibiotics, I think it's an important program and it should happen periodically, I think the other challenge is that it happens once in a while and you know that you are here for a time, once you go that is it, so it should happen periodically maybe quarterly or at some point.” I-32