Knowledge, attitude and practice of antibiotics prescribing among medical officers of public health care facilities in the state of Kedah, Malaysia

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1 ORIGINAL ARTICLE Knowledge, ttitude nd prctice of ntibiotics prescribing mong medicl officers of public helth cre fcilities in the stte of Kedh, Mlysi Tn Wei Leong, MD*, Siti Syhireen Mohmmed, Bchelor of Phrmcy (Hons.)*, Shhfini Ishk, Bchelor in Phrmcy (Hons.)**, Zuridh Ali, Bchelor of Phrmcy (Hons.)*** *Clinicl Reserch Centre Kedh, Alor Setr, Kedh, Mlysi, **Kubng Psu District Helth Office, Jitr, Kedh, Mlysi, ***Kul Mud District Helth Office, Sungi Petni, Kedh, Mlysi ABSTRACT Bckground: Antibiotic resistnce is rising problem in Mlysi. For instnce, high ntibiotic prescribing rte for upper respirtory trct infection nd inpproprite choice of ntibiotic is significnt helthcre concern in Mlysi. Our min objective ws to study knowledge, ttitude nd prctice of ntibiotic prescribing mong medicl officers in Kedh, Mlysi. Methods: A cross sectionl study ws conducted in outptient deprtments of helth clinics nd hospitls in Kedh from June 2013 until December Smple size ws 118 nd systemtic smpling ws conducted. Reserch tool used ws vlidted questionnire from studies conducted in Congo nd Peru. Results: Response rte ws 84.8%. Mjority of our respondents were femle doctors (71.0%), locl grdutes (63.0%), nd prcticed for 4 yers or less (61.0%). 52.0% of the respondents prescribed ntibiotics more thn once dily. Men knowledge score on ntibiotics ws 5.31 ±1.19 (95% CI: 5.06; 5.54). More thn hlf (62.0%) of our respondents were confident in ntibiotic prescribing nd there were merely 18.0% of them consulted ny collegues prior to prescription. There ws significnt difference in frequency of ntibiotic prescribing between junior doctors nd senior doctors (P-vlue: 0.036). In ddition, there ws lso significnt ssocition between frequency of ntibiotic prescribing nd wreness of ntibiotic resistnce in their dily prctice. (P-vlue: 0.002). Conclusion: Knowledge on ntibiotic ws moderte mong our medicl officers nd ntibiotic prescribing ws frequent. Trining nd courses on pproprite ntibiotic prescribing should be emphsized to ensure the best prctice in ntibiotic prescription. KEY WORDS: Antibiotic prescribing, ntibiotic prescription, knowledge, ttitudes, prctice INTRODUCTION Antibiotics hve given the modern medicine powerful mmunition ginst infection-relted illness nd deths. The emergence of ntibiotic resistnce, however, thretens to undo decdes of dvncements in modern medicine. Although multiple fctors cn be ccounted for ntibiotic resistnce, the prudent use of the once mircle drug is definite ctlyst to the rising spred of ntibiotic resistnces high ntibiotic consuming re showed higher resistnce rte. 1,2 The World Helth Orgniztion (WHO) reported high resistnce rte in bcteri ssocited with common illness in both hospitl-cquired nd community-cquired in ll WHO regions. 1 Ech yer in the United Sttes (US), n estimted 2 million reported cses of ntibiotic-resistnt infections resulted in 23,000 deths. 3 Dismlly, ccording to the US Centers for Disese Control nd Prevention, bout third of 150 million yerly outptient prescriptions for ntibiotics in the United Sttes re ctully cuseless. 3 In the Asin region, the reported resistnt rte of S. pneumoni towrds betlctm nd mcrolide re mong the highest in the world. 4,5 Mlysi is not n exception in fcing this epidemic, s there hs been stedy increse in ntibiotic resistnce rte of common orgnisms such s Stph. ureus, Acinetobcter nd H. influenz. 6 A locl study verified high ntibiotic prescribing rte for upper respirtory trct infection nd inpproprite choice of ntibiotics in Mlysi tht is consistent with the fct tht ntibiotics rnked mong top 10 of most utilised drugs ccording to Mlysin Ntionl Use Survey (NMUS) in ,8 It is hoped tht btement in the use of ntibiotics could be the cornerstone in the continment of ntibiotic resistnce esclting rte nd this cn be ddressed through chnges in prescribing behviour. As such, this knowledge, ttitude nd prctice surveys could provide window for concise comprehension behind ntibiotic prescribing. This study ws conducted with the min im to study knowledge, ttitude nd prctice of ntibiotic prescribing mong medicl officers. SUBJECTS AND METHODS A cross-sectionl study ws conducted in Kedh, stte in Northern Peninsul Mlysi involving ll medicl officers prctising in outptient deprtment of public helth clinics nd hospitls from Jnury 2013 until June Smple This rticle ws ccepted: 16 August 2015 Corresponding Author: Tn Wei Leong, Clinicl Reserch Centre Kedh, Km 6, Jln Lnggr, Alor Setr, Kedh 05460, Mlysi Emil: Alextnwl@Yhoo.Com / Alextnwl@Gmil.Com Med J Mlysi Vol 70 No 5 October

2 Originl Article size ws clculted using Smple Size Clcultor for Estimtion 9 with men knowledge score ± 1.009, level of confidence 95% nd precision 0.2 from pilot study conducted in Kubng Psu district. Smple size required ws 118 respondents fter 20% llownce for non-respondents. Inclusion criteri were medicl officers prctising in outptient deprtments either in public helth clinic or hospitl. Systemtic smpling ws done from complete list of medicl officers in public helthcre fcilities in Kedh. Questionnire used in the study ws dopted from two studies conducted in Peru nd Congo. 10,11 The English version questionnire ws vlidted in forementioned study. On top of tht, the questionnire ws reviewed by public helth physicins to ensure its relevnce in our locl setting before dt collection. The questionnire ws lso used in pilot study in Kubng Psu district. Feedbck from every respondent in the pilot study ws obtined nd no mendment ws done in view of positive feedbck. During dt collection, the questionnires were distributed nd nswered by emil. Sttisticl Pckge for Socil Sciences (SPSS) version 2011 ws utilised to nlyse the dt. Sttisticl tests utilised for inferentil nlysis included independent t-test nd Chi-squre test. This study ws pproved by Mlysin Medicl Reserch Ethics Committee nd registered under Mlysin Ntionl Medicl Reserch Registry (NMRR ). RESULTS A hundred doctors prticipted in the study with response rte of 84.8%. Among the respondents, mjority of were femle (71.0%), grduted loclly (63.0%) nd prcticed for 4 yers or less (61.0%). On top of tht, more thn hlf of respondents were from public helth clinic (66.0%) nd prcticed t outptient setting (70.0%). Knowledge on ntibiotic prescribing The highest score by our respondents ws 7 over 8 (19.0%) nd the lowest score ws 3 over 8 (7.0%). Men knowledge score for the respondents in the study is 5.31 ±1.19 (95% CI 5.06; 5.54). One third of our respondents scored 5 over 8 (29.0%) followed by 6 over 8 (26.0%). In the current study, independent t-test reveled no significnt difference in men knowledge score between junior nd senior doctors (p-vlue: 0.720). On top of tht, there ws lso no significnt difference in men knowledge score between confident doctors nd unconfident doctors (pvlue: 0.469). Attitude on ntibiotic prescribing Confidence nd input seeking More thn hlf of respondents n=62, 62.0% were confident of their knowledge on ntibiotics nd pproximtely threequrter of respondents did not think they hve ny problem choosing the right ntibiotics n=79, 79.0%. Merely, 18.0% of the respondents consulted ny collegues before prescribing ntibiotics while the remining 82.0% rrely seek ny opinion from fellow collegues. There ws no significnt difference in confidence of ntibiotic prescribing between junior nd senior medicl doctors (pvlue: 0.729). In ddition, we lso found no significnt ssocition between frequency of consulting collegues nd confidence level (p-vlue: 0.247). Acceptbility of potentil intervention Mjority of our respondents (97.0%) greed tht implementtion of trining progrmme bout ntibiotic would improve ntibiotic prescription. On top of tht, twothird of them greed tht locl ntibiotic guidelines would be more helpful s compred to the interntionl guidelines. In ddition, most of them (84.0%) did not gree tht ntibiotic guideline nd committee ws obstcle to correct prctise. Otherwise, there were only 11.0% of them perceived unnecessry ntibiotic prescription s hrmless prctise. Awreness of ntibiotic resistnce In this study, 56.0% nd 27.0% of the respondents strongly greed tht ntibiotic resistnce is worldwide nd ntionl problem. Respectively, merely 9.0% of our respondents strongly greed tht ntibiotic resistnce is problem in their dily prctice. Mjority of our respondents (98.0%) perceived tht non-dherence to ntibiotic contributes to ntibiotic resistnce, followed by self-mediction (92.0%). Prctice of ntibiotic prescribing Frequency of ntibiotic prescription Regrdless of durtion of prctise, 52.0% of the respondents prescribed ntibiotics more thn once dily followed by 1-2 times per week (25.0%) nd lstly 3-5 times per week (23.0%). In the current study, we found significnt difference of frequency in ntibiotic prescribing between junior nd senior medicl doctors (p-vlue: 0.036). In ddition, there ws significnt ssocition between frequency of ntibiotic prescribing nd wreness of ntibiotic resistnce in their dily prctice (p-vlue: 0.002). Source of informtion on ntibiotics Overll, the most frequent sought fter source of informtion ws internet n=89 (89.0%) followed by ntibiotic guidelines n=66 (66.0%), phrmceuticl compnies n=58 (58.0%) nd the lest source of informtion consulted ws through courses n=38, 38.0%. Hlf of the respondents n=51, (51.0%) believed tht there should be more source of informtion thn there is now. Fctors influencing ntibiotic prescription Most of our respondents (83.0%) perceived ptients demnds for ntibiotics contribute to ntibiotic overuse in community nd hospitl. In ddition, 86.0% of them thought tht it ws importnt to know the resistnce rte in locl setting before prescribing. Otherwise, 52.0% greed tht choice of ntibiotic ws not ffected by its vilbility in their setting. DISCUSSION Knowledge on ntibiotic prescribing Overll, the men knowledge score in this study ws 5.31 ± This vlue ws higher thn the study in DR Congo 4.9 ± 0.09 but lower thn the study in Peru 6.0 ± , 11 The higher score in Mlysin study ws minly ttributed by the better score on three questions tht were sid to be worstreplied in DR Congo nmely the questions on ntibiotic use 308 Med J Mlysi Vol 70 No 5 October 2015

3 Knowledge, ttitude nd prctice of ntibiotics prescribing mong medicl officers of public helth cre fcilities in upper respirtory trct infection, ntibiotic susceptibility to MRSA nd dosge djustment in renl impirment. 10 The respondents in this study scored higher on question regrding the rtionle of strting ntibiotics in virl dirrhoe nd upper respirtory trct infection s compred to DR Congo. However, this finding did not concur with different locl study by Teng et l. tht verified high ntibiotic prescribing rte in upper respirtory trct infection cses. 7 In their study, they included privte nd public helth clinics throughout Mlysi whereby they lso concluded tht ntibiotic prescribing ws higher mong privte clinics, prticulrly upper respirtory trct infection. On the other hnd, the medicl officers prticipted in our study were minly from public helth clinics. The different bckground of medicl prctitioners from both studies could hve ttributed to disgreement between level of knowledge nd prctise. This trend ws lso exhibited in Peru study in which the survey on theoreticl knowledge did not coincide with prctice evidence. 11 As for the question on susceptibility of ntibiotic towrds MRSA, Mlysin medicl officers responded well s compred to DR Congo. This ws ttributed to the fct tht locl microbiologicl fcilities re well equipped in contrst with the Congo study tht certified the bsence of such fcility in the republic.10 In West Indies of the United Sttes, Tennnt et l. found tht knowledge of resistnce-prone ntibiotic nd specific orgnisms t University Hospitl of West Indies ws poor, except for methicillin-resistnt Stphylococcus ureus. 12 As nlysed in the present study, there ws no sttisticl significnt difference in yers of service with regrds to knowledge score. Similrly, the study in Congo lso found out tht there ws no significnt difference in the men score ccording to yers of experience. 10 A study in Frnce nd Scotlnd by Pulcini C et l. reveled tht knowledge of prevlence rte on ntibiotic resistnce ws lso not influenced by pst trining experience. 13 In John Hopkins Hospitl, Srinivsn et l. found tht there ws no significnt difference in knowledge score for vrious yers of trining. 14 This significnt finding implies tht longer durtion of prctice does not ensure good knowledge on ntibiotic prescribing. Thus, pproprite trining nd updte re required for ll medicl prctitioners irrespective of their seniority in the institution. Attitude towrds ntibiotic prescribing In regrds of confidence level, the results in this study showed tht only 4.0% of the respondents were very confident in choosing the right ntibiotics. This number is comprtively low s compred to DR Congo with 11.4% nd Peru with residents nd ttending physicins were very confident 47.0% nd 82.0% with themselves in picking the pproprite ntibiotics. 10,11 On the contrry, junior doctors in Nice nd Dundee felt confident when prescribing n ntibiotic. 13 In West Indies, 29.0% of their physicins considered their knowledge on ntibiotic resistnce were good while 48.0% thought verge. 12 Sttisticlly in this study, there ws no significnt ssocition between yers of service nd confidence level (P-vlue: 0.729). The insignificnt ssocition between yers of service nd confidence level ws lso evident in DR Congo (P-vlue: 0.053). 10 The study in Peru however showed significnt sttisticl difference between the confidence level of residents nd specilists 47.0% vs 82.0%, (P-vlue<0.001). 11 On different note, more thn three qurter of respondents in Mlysi (77.0%) nd DR Congo (79.4%) nswered sometimes to the question on the frequency of seeking peer opinion on ntibiotic prescribing. 10 The percentge ws less for study in Peru with only 57.0% sought opinion from peers. 11 The locl result did concur with the fct tht this survey involved medicl officers in whom the respondents would hve verified their decision with specilists. Respondents from ll three studies were in greement tht they did not hve ny problems selecting ntibiotics in their prctice. 10,11 Notbly, this study lso hd positively shown tht our respondents were very receptive to intervention, which ws in line with low number of respondents who nswered very confident in their choice while prescribing ntibiotics. Most of the respondents would preferbly chose locl ntibiotic guidelines thn interntionl s they regrded locl dt would be more useful nd tilored to their prctice. In this context, locl guidelines will definitely be more focused nd discuss deeply on common infectious disese in the country. As such, the guidelines will definitely be helpful nd useful to medicl doctors who prctice loclly. Awreness on ntibiotic resistnce Pertining to wreness level on ntibiotic resistnce, ll three studies showed similr trends in which the issue of ntibiotic resistnce ws more recognised globlly nd ntionlly s compred to their very own prctice. 10,11 Sttisticl nlysis in this study exhibited ssocition between low wreness level of locl ntibiotic resistnce with high frequency of ntibiotic prescribing. This would be n interesting scope for possible future intervention. The low level of wreness on ntibiotic resistnce in own prctice might be due to the fct tht there ws limited ccess to dt on ntibiotic resistnce in their own locl prctice. Therefore, it is nturlly befitting to encourge more dt dissemintion on locl ntibiotic resistnce to prescribers s lso highlighted by the Peru study. 11 Prctice in ntibiotic prescribing Overll, the frequency of ntibiotic prescribing mong ll three countries; Mlysi, DR Congo, nd Peru ws more thn once dily. 10,11 High ntibiotic prescribing rte does not necessrily indicte irrtionl use s some ntibiotic prescription ws well justified. In Nice nd Dundee, Pulcini et l. reveled tht 23 out of 136 medicl doctors prescribed more thn five ntibiotic per week while 66 prescribed two or less per week. 13 In this context, frequency of ntibiotic prescribing vries t different setting nd it could be ffected by mny fctors such s plce of prctice, medicl prctitioners knowledge nd bckground nd ptients fctors. Unfortuntely, we minly probed into medicl prctitioners knowledge nd ttitude in the current study, thus, future study my explore into other fctors. In this present study, respondents were sked on the fctors tht influence their ntibiotic prescribing. As the result shown, respondents collectively greed on the usefulness of Med J Mlysi Vol 70 No 5 October

4 Originl Article Tble I: Demogrphic dt of doctors prticipted in the study Vrible Frequency, n (%) 1. Gender Mle 29 (29.0) Femle 71 (71.0) 2. Grdution Locl University 63 (63.0) Foreign University 37 (37.0) 3. Durtion of Prctice 4 yers Junior 61 (61.0) > 4 yers Senior 39 (39.0) 4. Plce of Prctice Ptient t outptient deprtment 70 (70.0) Both ptient t outptient deprtment nd hospitlised ptient 30 (30.0) 5. Institution Stte Hospitl 11 (11.0) District Hospitl with Specilist 11 (11.0) District Hospitl without Specilist 12 (12.0) Public Helth Clinic 66 (66.0) Tble II: Comprison of men knowledge score between different ctegories Vrible Knowledge Score Men difference t sttistic P vlue Men ±SD [95% CI] df Junior doctors n= ± (98) Senior doctors n= ±1.27 [-0.40,0.57] Confident doctors 5.24 ± (98) Unconfident doctors 5.42 ±1.13 [-0.67,0.31] Independent t-test Tble III: Comprison of confidence in ntibiotic prescribing between junior nd senior medicl doctors Vribles n Confident Unconfident X 2 sttistic P vlue n (%) n (%) df Junior doctors (60.6) 24 (39.4) 0.12 (1) Senior doctor (64.1) 14 (35.9) Frequent consulting with collegues on choice of ntibiotic 18 9 (50.0) 9 (50.0) 1.34 (1) Infrequent consulting (64.6) 29 (35.4) Chi-squre test for independence Tble IV: Awreness of Antibiotic Resistnce Antibiotic is problem Worldwide In Mlysi In my prctice Frequency, n (%) Frequency, n (%) Frequency, n (%) Strongly gree 56 (56.0) 27 (27.0) 9 (9.0) Agree 41 (41.0) 64 (64.0) 44 (44.0) Neutrl 3 (3.0) 8 (8.0) 40 (40.0) Disgree 0 (0) 1 (1.0) 6 (6.0) Strongly disgree 0 (0) 0 (0) 1 (1.0) Tble V: Fctors Contributing to Antibiotic Resistnce Fctor Yes, No Don t know Frequency, n (%) Frequency, n (%) Frequency, n (%) Tretment not completed 98 (98.0) 1 (1.0) 1 (1.0) Inccurte choice of ntibiotics 60 (60.0) 26 (26.0) 14 (14.0) Indequte dosge 79 (79.0) 18 (18.0) 3 (3.0) Poor qulity ntibiotic 79 (79.0) 18 (18.0) 3 (3.0) Over prescription nd overconsumption 90 (90.0) 7 (7.0) 3 (3.0) In-ptient trnsmission 85 (85.0) 6 (6.0) 9 (9.0) Self-mediction 92 (92.0) 3 (3.0) 5 (5.0) 310 Med J Mlysi Vol 70 No 5 October 2015

5 Knowledge, ttitude nd prctice of ntibiotics prescribing mong medicl officers of public helth cre fcilities Tble VI: Comprison of frequency in ntibiotic prescribing Vribles n Frequency of ntibiotic prescription X 2 sttistic P vlue Once dily 3 5 times 1 2 times df or more (%) per week (%) per week (%) Junior doctors (62.2) 11(18.1) 12 (19.7) 6.64 (1) Senior doctors (35.9) 12 (30.8) 13 (33.3) Doctors who greed on locl (67.9) 6 (11.3) 11(20.8) (2) ntibiotic resistnce Doctors who disgreed with locl (34.0) 17 (36.2) 14 (29.8) ntibiotic resistnce Chi-squre test for independence knowing the locl resistnce rte prior to prescribing ntibiotics (86.0%). In DR Congo, 89.7% of their respondents greed tht knowledge of locl ntibiotic resistnce pttern ws needed. 10 Ptients insistence for ntibiotics ws still extensively regrded s fctor in prescriber s decision in prescribing ntibiotic (83.0%) in this study. Kml et l. found tht 61.9% nd 34.3% of their respective respondents in community nd hospitl perceived tht ptient pressure contributed to overuse of ntibiotic in DR Congo. 10 Fctors influencing ntibiotic prescribing in Nice nd Dundee were previous experience 121/135, guideline 126/135 nd infectious diseses dvice 88/ In nutshell, there could be different fctors contributed to ntibiotic overprescribing in different countries. However, we hve to ber in mind tht most of the studies mentioned were conducted from helthcre providers point of view, thus, future studies my look into the possible fctors from other perspectives. When sked on sources of informtion pertining to ntibiotics, vst mjority of respondents use Internet followed by ntibiotics guidelines. Courses nd workshops on ntibiotics were climed s the lest importnt point of reference. On the other hnd, lectures ws the most used trining in Dundee nd Nice. 13 Proctive ction should be prompted to provide more courses nd workshops to prescribers. It would be interesting with the ide of providing courses nd workshops vi the net s wht hve been done in developed countries. This present study showed tht there is significnt difference in frequency of ntibiotic prescribing between junior nd senior medicl doctors. A study in Turkey lso reveled similr sitution whereby pproprite ntibiotic prescribing ws higher mong physicin in the ge group between 25- nd 29-yer-old s compred to older group of physicin. 15 This study hs few limittions. Firstly, there is possibility of bis in nswering the question s the questionnire ws distributed vi emil to every respondent. Thus, the respondent might discuss with their collegues while nswering the questions or refer to book while nswering the knowledge questions. Secondly, honesty in nswering some of the questions might lso cuse bis in our results. Thirdly, we did not include specilists nd house officers in this study where the two other min ctegories in medicl services will not be represented in this study. CONCLUSION In nutshell, knowledge score on ntibiotic is moderte mong our doctors while prescribing is frequent. Trining nd courses on ntibiotic prescribing re needed to strengthen their knowledge on ntibiotic in the future. On top of tht, we strongly recommend tht future study will include specilists nd house officers in their study s knowledge level on ntibiotic prescribing will be different in both ctegories. To reduce bis in nswering questionnire, questionnire cn be distributed in n enclosed environment such s in meeting, teching session, or gthering whereby referring to book nd discussing with others is prohibited. CONFLICT OF INTEREST There is no conflict of interest to declre for this study. REFERENCES 1. WHO. 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