“If it’s a broad spectrum, it can shoot better”: inappropriate antibiotic prescribing in Cambodia

Abstract

BackgroundCambodia is affected by antibiotic resistance but interventions to reduce the level of resistance require knowledge of the phenomena that lead to inappropriate prescribing. We interviewed physicians working in public hospitals to explore the drivers of inappropriate antibiotic prescribing.MethodsHospitals participating in a knowledge, attitudes and practices survey prior to this study were purposively selected and physicians were randomly recruited to participate in focus group discussions. Nvivo version 10 was used to inductively code the qualitative transcripts and manage thematic data analysis.ResultsInappropriate antibiotic prescribing was a common practice and driven by seven factors: prescribing habit, limited diagnostic capacity, lack of microbiology evidence, non-evidence-based clinical guidelines, perceived patient demand, poor hygiene and infection control, and perceived bacterial resistance to narrow spectrum antibiotics. “Every day, doctors are not performing appropriately. We have made lots of mistakes with our antibiotic prescribing.” When a patient’s clinical condition was not responsive to empiric treatment, physicians changed to a broader spectrum antibiotic and microbiology services were sought only after failure of a treatment with a broad-spectrum antibiotic. This habitual empirical prescribing was a common practice regardless of microbiology service accessibility. Poor hygiene and infection control practices were commonly described as reasons for ‘preventive’ prescribing with full course of antibiotics while perception of bacterial resistance to narrow-spectrum antibiotics due to unrestricted access in the community resulted in unnecessary prescribing of broad spectrum antibiotics in private practices.ConclusionsThe practice of prescribing antibiotics by Cambodian physicians is inappropriate and based on prescribing habit rather than microbiology evidence. Improvement in prescribing practice is unlikely to occur unless an education program for physicians focuses on the diagnostic capacity and usefulness of microbiology services. In parallel, hygiene and infection control in hospital must be improved, evidence-based antibiotic prescribing guidelines must be developed, and access to antibiotics in community must be restricted.

Melioidosis in lower provincial Cambodia: A case series from a prospective study of sepsis in Takeo Province

“…For example, at the time of this manuscript’s preparation, Takeo Provincial Referral Hospital’s annual allotment of formulary antimicrobials included enough ceftazidime to properly treat only 12–14 melioidosis patients. Additionally, a recent survey revealed that only 17% of Cambodian physicians have any experience treating melioidosis [ 56 ]. Although numbers are too small to draw significant statistical conclusions from our series, it is interesting to note that of the four patients who survived long enough to receive a course of ceftazidime or meropenem, three survived.…”

Meat and Fish as Sources of Extended-Spectrum β-Lactamase–Producing Escherichia coli, Cambodia

“…Nevertheless, our findings suggest that amphenicol resistance genes are circulating in the community, potentially because amphenicol use in food animals has selected for resistant bacteria that can spread to humans ( 12 ). This possibility is concerning because physicians in Cambodia are often unable to assess the resistance of infectious agents before prescribing antimicrobial drugs ( 4 ). …”

“…Few studies have been conducted in low- and middle-income countries, where colonization rates can exceed 60% ( 2 ). High ESBL colonization rates in low- and middle-income countries such as Cambodia are usually attributed to unrestricted consumer access to and hospital overuse of third-generation cephalosporins ( 3 , 4 ). However, antimicrobial drugs in classes critical for human health (e.g., β-lactams, macrolides, aminoglycosides, polymyxins) are increasingly being used in food animals ( 5 ).…”

Assessment of knowledge, attitude and practices on antibiotic resistance among undergraduate medical students in the school of medicine at the University of Zambia

“…7 Factors such as patients' demands, doctors' personal experiences and preferences, lack of culture and sensitivity results leading to uncertain diagnosis, sale of antibiotics without prescription are some of the most common contributors towards antibiotic resistance, poor knowledge and lack of knowledge on rational prescribing and AMR. 8,9 Knowledge and beliefs influence health-related behavior with regards to using antibiotics. 10 Inappropriate attitudes and lack of knowledge towards the use of antibiotics is a high-risk factor contributing to the rise of AMR cases.…”