Perceptions, views and practices regarding antibiotic prescribing and stewardship among hospital physicians in Jakarta, Indonesia: a questionnaire-based survey

Abstract

ObjectivesAntibiotic overuse is one of the main drivers of antimicrobial resistance (AMR), especially in low-income and middle-income countries. This study aimed to understand the perceptions and views towards AMR, antibiotic prescribing practice and antimicrobial stewardship (AMS) among hospital physicians in Jakarta, Indonesia.DesignCross-sectional, self-administered questionnaire-based survey, with descriptive statistics, exploratory factor analysis (EFA) to identify distinct underlying constructs in the dataset, and multivariable linear regression of factor scores to analyse physician subgroups.SettingSix public and private acute-care hospitals in Jakarta in 2019.Participants1007 of 1896 (53.1% response rate) antibiotic prescribing physicians.ResultsPhysicians acknowledged the significance of AMR and contributing factors, rational antibiotic prescribing, and purpose and usefulness of AMS. However, this conflicted with reported suboptimal local hospital practices, such as room cleaning, hand hygiene and staff education, and views regarding antibiotic decision making. These included insufficiently applying AMS principles and utilising microbiology, lack of confidence in prescribing decisions and defensive prescribing due to pervasive diagnostic uncertainty, fear of patient deterioration or because patients insisted. EFA identified six latent factors (overall Crohnbach’s α=0.85): awareness of AMS activities; awareness of AMS purpose; views regarding rational antibiotic prescribing; confidence in antibiotic prescribing decisions; perception of AMR as a significant problem; and immediate actions to contain AMR. Factor scores differed across hospitals, departments, work experience and medical hierarchy.ConclusionsAMS implementation in Indonesian hospitals is challenged by institutional, contextual and diagnostic vulnerabilities, resulting in externalising AMR instead of recognising it as a local problem. Appropriate recognition of the contextual determinants of antibiotic prescribing decision making will be critical to change physicians’ attitudes and develop context-specific AMS interventions.

Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: a scoping review

“…Five studies each cited the absence of approved national guidelines or educational programs [ 27 , 36 , 43 , 45 , 48 ], and time constraints for prescribers [ 28 , 30 , 36 , 41 , 48 ] as barriers. The ‘Others’ category included challenges like incomplete electronic medical records (EMR), long waiting times for tests, overcrowding in wards [ 30 , 46 ], the perception of AMR as an ‘external problem’ [ 49 ], frequent staff turnover, lack of specific ASP goals [ 36 ], stock shortage of antimicrobials [ 35 ], and suboptimal salary [ 36 ].…”

“…correct dose, diagnosis, and duration of antibiotic) [ 50 – 52 , 59 ]. In terms of attitude towards ASP implementation, the majority of prescribers showed positive attitudes, as they felt ASP is beneficial for both prescribers and patients [ 27 , 29 , 31 , 45 , 49 , 51 , 52 , 60 , 61 ], and were interested receive feedback on their antibiotic prescriptions [ 27 , 31 , 45 , 52 ]. However, some studies also revealed the physicians’ concern that implementation of ASP would limit their prescribing autonomy [ 47 , 50 , 52 ].…”

“…An inadequate fundamental understanding of ASP and AMR would lead to irrational and improper antimicrobial prescriptions [ 44 ]. Regarding perceptions toward ASP, studies reported positive perceptions toward ASP, as physicians felt that ASP made them think more carefully about their antibiotic choices, beneficial in terms of reducing AMR, decreasing patient length of stay, and reducing healthcare costs [ 27 , 31 , 49 – 52 , 58 ]. Our review revealed that prescribers were on board to receive regular monitoring and feedback on rational antibiotic use and recommended tailored ASP training [ 27 , 45 , 52 , 61 ].…”

The Clinimetric Profile of 11 Generic Quality Indicators for Appropriate Antibiotic Use in Hospitalized Patients in Indonesia

“…al . 35 reported these factors include insufficient application of antimicrobial stewardship principles and microbiology services, the lack of confidence in prescribing decisions, and defensive prescribing due to diagnostics uncertainties, fear of patient deterioration, or because the patient insisted. A wide variation exists between hospitals, departments, work experience and medical hierarchy.…”

Assessment of antimicrobial prescribing practice, knowledge, and culture in three teaching hospitals

“…(11,12) One study demonstrated that prescribers' confidence did not seem to be correlated with their knowledge of judicious antibiotic prescribing (12). Other studies demonstrated similar challenges regarding perception of AR and antimicrobial prescribing despite cultural and contextual differences (20,21) This study aimed to understand the culture of antimicrobial prescribing in order to optimize local strategies regarding antimicrobial stewardship at university hospitals in a Canadian context. The objectives were to assess knowledge, attitudes, and practices amongst antimicrobial prescribers.…”