Annals of Tropical Medicine and Public Health
Home About us Ahead Of Print Instructions Submission Subscribe Advertise Contact e-Alerts Editorial Board Login 
Users Online:2258
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size
 


 
Table of Contents   
ORIGINAL ARTICLE  
Year : 2018  |  Volume : 11  |  Issue : 1  |  Page : 23-31
Perception of health-care staff's knowledge, attitudes, and practices and of potential barriers toward containing antibiotic resistance in public health-care facilities of Tumkur district (South India)


1 Consultant Microbiologist, Central Laboratory, St. Martha's Hospital, Bangalore, Karnataka, India
2 Department of Clinical Sciences and Infectious Diseases, Institute of Tropical Medicine, Antwerpen, Belgium
3 Faculty, Department of Public Health, Institute of Public Health, Bangalore, Karnataka, India
4 Research Coordinator, Department of Public Health, Institute of Public Health, Bangalore, Karnataka, India
5 Research Scholar (Public Health), Institute of Tropical Medicine, Antwerpen, Belgium
6 Microbiologist, Laboratory Medicine, District Hospital, Tumkur, Karnataka, India

Click here for correspondence address and email

Date of Web Publication10-Dec-2019
 

   Abstract 


Background: India faces a major public health problem of antibiotic resistance. The rational prescription practices with behavioral change of health-care staff are one of the potential interventions for containment of antibiotic resistance at the health centers level. Yet, not much is known about the perceptions of health workers. Methodology: The present study evaluated the knowledge, attitude, practices, and barriers around antibiotic usage and resistance among the government health staff by a quantitative survey of 118 health-care providers (60 physicians and 58 pharmacists) across Tumkur district of Karnataka – 53 government health facilities from all levels – 1 district hospital (DH), 4 taluk hospitals, and 48 primary health centers. Results: Antibiotic resistance was perceived as an important problem globally, nationally, and locally by 81.3% (n = 96) and 83.8% (n = 99) and 54.2% (n = 64), respectively. About 86% (n = 52) of doctors were not aware of top three resistant organisms prevalent in their center. Only 38% (n = 23) sought microbiologist's input for antibiotic recommendations. Unavailability of antibiotics was quoted a major barrier to practice (78%, n = 47), followed by unregulated over-the-counter sale (OTC) (62%, n = 37) and high work-load (56.6%, n = 34). About 87% (n = 52) of the physicians and 98% (n = 57) of pharmacists expressed their interest for a potential educational program in antibiotics and resistance. Microbiology record (July–December 2013) from DH revealed only 22 isolates from 54 processed samples and resistance data were not recorded. Conclusions: While issues around antibiotics unavailability and OTC sales are being addressed at the center, the perceptions of the public health center's staff seem to have been overlooked. The laboratory support is grossly underutilized by the staff-culture seeking behavior of the practicing physicians needs to be enhanced, and laboratory strengthening at DH is imperative. The District seems ready for the implementation of Antibiotic stewardship programs, which may be introduced by the state as an educational intervention to address the gaps in knowledge, attitude, and practices of the staff.

Keywords: Antibiotic usage, health-care providers, India, resistance

How to cite this article:
Krishna S, Vlieghe E, Prashanth N S, Prakash B, Shahabuddin A, Rukmini V. Perception of health-care staff's knowledge, attitudes, and practices and of potential barriers toward containing antibiotic resistance in public health-care facilities of Tumkur district (South India). Ann Trop Med Public Health 2018;11:23-31

How to cite this URL:
Krishna S, Vlieghe E, Prashanth N S, Prakash B, Shahabuddin A, Rukmini V. Perception of health-care staff's knowledge, attitudes, and practices and of potential barriers toward containing antibiotic resistance in public health-care facilities of Tumkur district (South India). Ann Trop Med Public Health [serial online] 2018 [cited 2020 May 29];11:23-31. Available from: http://www.atmph.org/text.asp?2018/11/1/23/272539



   Introduction Top


Antibiotic resistance is a global problem. Typically, infections caused by multi-drug resistant organisms (MDRO) are often nosocomial or health-care associated and carries high mortality rates posing a therapeutic challenge to clinical practitioners. Over the past decade, MDROs have increasingly been isolated from community settings as well.[1] Poor sanitation and hygiene, crowding, increasing migration to cities, global trade of animals and goods, antibiotic use in food industry, and interspecies gene transmission have been identified as major drivers of antibiotic resistance.[2] The United States of America's Centers for Disease Control and Prevention (CDC) estimates that at least two million illnesses and 23,000 deaths a year in the USA are caused by antibiotic resistance.[3] Nosocomial infections by MDROs often results in a prolonged length of hospitalizations and additional burden of cost for the patients and health system.[4] The impending fear of resistance interferes with clinical decision-making in surgery, transplantation, and chemotherapy.[5]

In the absence of a robust national surveillance system for collecting antibiotic resistance data in India, the World Health Organization (WHO) Global Antimicrobial Surveillance Report (2014) throws light on the burgeoning problem of resistance in the Indian subcontinent.[6] Selected studies quote methicillin-resistant Staphylococcus aureus (MRSA) infection rates as high as, for example, 37% in bloodstream infections and 55%–63% in bone infections. Nasal carriage of MRSA in the community is reported to be as high as 4.2%–19%. Escherichia coli resistant to third-generation cephalosporins (extended-spectrum beta-lactamase (ESBL) producing) were described in 74.1% of isolates from lower respiratory tract infection (LRTI) in 60.5% of urinary tract infections (UTIs), 61% of bloodstream infections, and up to 95% from feces of healthy carriers. High rates of resistance were reported among Klebsiella spp. resistant to third-generation cephalosporins (ESBL producing); rates were as high as 100% for blood (62/62 isolates tested from 2006 to 2008), 45% in UTIs, 91.4% from ventilator-associated pneumonia (VAP), and 76.5% from LRTIs. Significant resistance to some of the highest order antibiotics such as carbapenem has been reported in Klebsiella spp. (52% of bloodstream isolates, 7.8% in LRTI, 55% in VAP, and 18.6% in UTI). Resistance to fluoroquinolones has also been described in an average of 44% Shigella spp. (intestinal pathogen) from pediatric diarrhea samples. The rising resistance of multidrug-resistant tuberculosis (TB) (estimated prevalence 20% in re-treatment and 3% new cases, RNTCP, 2013)[7] in the country is worsening the scenario.

Inappropriate use of antibiotics leads to the increased development of resistance, and the country is now developing a nation-wide surveillance to monitor the pattern of antibiotic usage. The US CDC estimates that over half of all antibiotic usage in the world could be inappropriate,[4] and the WHO surveillance data from New Delhi report 40% inappropriate use from the public care facilities alone.[8]

India is believed to be one of the countries with the highest use of antibiotics in the world.[9] Overprescribing, misuse of antibiotics and low adherence to treatment guidelines in both public and private settings[10],[11],[12],[13] along with other complex and interconnected factors such as over-the-counter sale, self-medication by people, poor quality of antibiotics, poor infection control practices further complicate the situation in rural India.[14],[15],[16] Poor access to medicines and the suboptimal availability of essential antibiotics at the public pharmacies limit and alter choices for prescription and thus prescription behavior among doctors.[17] A series of events in the last 5 years led to the recent launch of a national antibiotic policy[18],[19],[20],[21] with huge challenge in implementation. The policy calls for rational use of antibiotics calls through training of health workers on rational prescription, increasing pharmacists' involvement, regulating over-the-counter (OTC) sale of antibiotics, banning nontherapeutic usage in animals and farms, and drawing local antimicrobial policy in local health services at district and subdistrict levels. Several international and intergovernmental organizations including WHO, Society for healthcare epidemiology of America, Infectious diseases society of America, and the CDC advocate for the implementation of antibiotic stewardship programs (ASP).[22],[23],[24] The Indian Council of Medical Research (ICMR) has begun training programs on antibiotic stewardship[34] and National Center for Communicable Diseases (NCDC) has begun the data collection.[35]

The aim of this study was to prepare ground for the implementation of ASP as an intervention to decrease the antibiotic resistance in the public health centers which involves developing and implementing a district-wide tailored local antibiotic policy, guidelines, and procedure. The objectives were to assess the current perception, knowledge, and practices related to antibiotic usage and resistance (a situation analysis) in government health centers of Tumkur district in India and to identify the potential barriers for the implementation of good prescription practices in the local health system if any.


   Methodology Top


Study setting

Tumkur is one of the 30 districts of the Karnataka state in South India occupying an area of 10,598 km2. The district has 10 taluks. Health services delivery is both by public and private health-care facilities, most of them practicing modern medicine. The government health services are organized in three tiers. It has a network of 144 primary health centers (PHCs) that provide primary health care (source: DHIS-2). The secondary care is provided by 9 taluk hospitals in the district while tertiary care is provided at the district hospital (DH). Each PHC has a doctor who is in charge of the PHC as well as three to five subcenters, where an auxiliary nurse-midwife provides reproductive and child health services as well as implements several activities under disease control programs. Over 78% of Tumkur's, 2,678,980 people stay in rural areas (2011 census). The DH sees on an average about 2000 outpatients (OP) and over 400 inpatients (IP) in a day. The hospital is staffed with 18 specialists (surgery, obstetrics and gynecology, ophthalmology, orthopedics, otorhinolaryngology, pediatrician, dermatology, and physicians) and two duty doctors. Taluk hospitals being at the secondary care level cater to about 300 OP and 30–50 IP in a day. Each PHC attends to about 50–100 OP in a day with an average of up to 10 IP and covers a population of 20–30,000 people. The district (like most Indian districts) currently has no existing local antibiotic policy. In our study, we invited 53 government health facilities of all levels – one DH, four taluk hospitals, and 48 PHCs across the district. Survey coverage is shown in [Map 1].



Survey phase

We developed two survey questionnaires (one for pharmacists and one for doctors) containing about 40–45 items each. The questionnaires were based on previous Peruvian[26] and Brazilian study[25] questionnaires and adapted to the local context. The questions were narrowed down to knowledge about antibiotics (10–15 questions), practices on resistance prevention (10–12 questions), perceptions of antibiotic resistance (5 questions), prescription practices (8–10 questions), and the potential barriers for the implementation of an ASP (8–10 questions). The respondents were expected to answer in a five-point Likert's agreement scale, ranging from “strongly agree” to “strongly disagree”, four-point likelihood scale from “to a great extent” to “not at all,” and six-point frequency scale from “always” to “never.” Five research team members were trained in administering the questionnaire (oral consent and minimum briefing for filling the questionnaires). The survey was conducted from April 1st to April 24th, 2014. All doctors (both PHC doctors and specialists in medicine at higher hospitals) and pharmacists from the PHC, taluka hospital, and DH were invited to fill the questionnaire. The approval of participants to fill the questionnaire was considered as consent. The completed questionnaires were received coded from Tumkur in May 2014. Data were analyzed using EPINFO version 3.4.5 (CDC, Atlanta, USA) Descriptive statistics were computed using proportions for the outcome variables (as opinions, perceptions, knowledge, and practices). Categorical variables were expressed by proportions. Likert's items were dichotomized as- “not an important/less important” versus “quite an important/very important” for perception of problem, “strongly agree/somewhat agree” versus “strongly disagree/somewhat disagree” for the barriers”, “to a great extent/somewhat” versus “very little/not at all” for the knowledge preventing resistance, and “always/very often/occasional” versus “rarely/very rarely/never” for information seeking. The associations were studied by Chi-square tests or Fisher's tests wherever appropriate. P ≤ 0.05 was considered statistically significant.


   Results Top


Demographics and professional profile of study participants

A total of 118 health professionals were surveyed. Among them, 60 were doctors and 58 were pharmacists. The break-up of doctors by the location of their work was as follows: 51 from PHC, 2 from taluk Hospital, and 7 from DH, while for pharmacists, it was 47 from PHC, 8 from taluk Hospital, and 3 from DH [Table 1]. Fifty-five of the doctors were medical officers (MBBS qualified) while five were specialists (MS/MD qualified, working at DH). The specialists who participated included one each from orthopedics, pediatrics, ophthalmology, anesthesiology, and a district TB officer.
Table 1: Distribution of study participants from health centers sampled

Click here to view


Fifty percent (n = 30) had been practicing medicine and prescribing antibiotics for 6–10 years, 33.3% (n = 20) for 6 months – 5 years, and 16.7% (n = 10) for 10–19 years, mean age of experience being 7.5 years. Thirty-seven doctors (61.7%) and thirty-six pharmacists (62.1%) were of male gender. Nearly half of all doctors (48.3%, n = 29) answered that they had infection control practices at their health centers

Perception of the scope of antibiotic resistance and awareness of resistant organisms at their center

Eighty-seven percent (n = 52) of the physicians considered antibiotic resistance as an important problem globally, whereas 72.4% (n = 44) of the pharmacist regarded it so. Ninety-one percent (n = 55) of the physicians and 75.8% (n = 44) of the pharmacists perceived it as an important national problem, whereas 66% (n = 40) of the physicians and 41% (n = 24) of the pharmacists perceived it as an important problem in their health centers [Figure 1]. Fifty-two percent (n = 31) of the physicians and 38% (n = 22) of the pharmacists believed doctors these days write antibiotics more than necessary.
Figure 1: Perception of antibiotic resistance as a problem globally, nationally, and locally

Click here to view


Forty-seven physicians (78.3%) prescribed antibiotics every day, whereas 84.5% (n = 49) of pharmacists dispensed antibiotics every day. The top three antibiotics prescribed by doctors were of the penicillin group (amoxicillin, n = 26), fluoroquinolone (ciprofloxacin and ofloxacin, n = 17), and the cephalosporin group (n = 13, first-generation n = 4, second-generation n = 3, and third-generation n = 6). Most of the doctors were not aware of any three of resistant organisms prevalent in their center: (n = 34, 45, and 52 for each of the top three resistant organisms).

Knowledge on interventions to contain resistance

Physicians

Ninety-four percent of physicians believed that they could contribute in preventing resistance by having guidelines at their centers [n = 54, [Figure 2]. About 91.7% of physicians acknowledged that their activities such as using less antibiotics (n = 49), understanding the dosage requirements (n = 55), getting feedback about their prescriptions (n = 55), and guiding patients to complete the prescribed antibiotic course (n = 55) were important steps in decreasing resistance. About 80%–87% of the physicians agreed that by knowing the prevalent local bacteria (n = 50) and sending prompt samples to the microbiology laboratory (n = 48) also could help. Up to 50%–57% of the physicians agreed that by decreasing the frequency of administering low-end antibiotics such as ampicillin (n = 34) and by regular handwashing (n = 33). However, only 26.7% (n = 43) correctly objected against treating all the bacteria grown from patient's samples including colonizers as a measure to prevent antibiotic resistance
Figure 2: Knowledge of physicians on interventions to contain antibiotic resistance (n = 60)

Click here to view


Pharmacists

Up to 90% of the pharmacists agreed that their better understanding of the dosage durations (n = 52) would help prevent the resistance to a great extent. About 65%–75% thought that by maintaining prompt antibiotic stock and usage logs (n = 44), updating their knowledge on antibiotic resistance by attending workshops and conferences (n = 40) and having regular discussion with physicians (n = 39) would also contribute in reducing the resistance.

Knowledge-seeking behavior

Seventy-four percent of physicians sought information from either textbooks or manuals or colleagues either always (20%) or very often (32%) or occasionally (15.7%). Most consulted were the personal textbooks (35%), local manuals at health center (28%), and colleagues whom they regarded as knowledgeable (33%). An average of 58% of pharmacists (n = 34) sought information from either textbooks or manuals or from colleagues either always (16.6%), very often (21.2%) or occasionally (31.6%). About 21% (n = 12) of them very often sought information from textbooks, 38% (n = 22), from manuals (38%), and from their colleagues (36.2%) and were willing to seek information when in doubt. Eighty-one percent (n = 47) would ask the doctors when in doubt.

Knowledge on pathogen-drug combinations

Only 22% (n = 13) gave correct answer to the combination of MRSA and linezolid, 40% (n = 24) to the combination of Pseudomonas and piperacillin, 13.3% (n = 8) to Enterococcus and ampicillin, and 42% (n = 25) to Clostridium difficile combinations [Figure 3]. New practicing physicians with experience of < 5 years tended to give more correct answers for choice of treatment for MRSA infections (odds ratio [OR] 2.9, confidence interval [CI] 0.81–10.83, P = 0.09) and for Pseudomonal infections (OR 1.5, CI 0.49–5.02, P = 0.44) than with the more experienced physicians of over 5 years practice. Furthermore, there was no significant difference in choosing right or wrong answer for the four questions by the PHC physicians as compared to the second and tertiary level (P = 0.66, 0.21, 0.58, 0.27 by Fisher's, respectively). Only 64% (n = 37) of the pharmacists correctly selected penicillin as the answer for causing severe adverse reactions.
Figure 3: Assessment of Knowledge questions: pathogen-drug combination

Click here to view


Barriers preventing good prescription practices

Seventy-eight percent (n = 47) of the doctors agreed that required antibiotics were not available at their centers. Up to 61.6% (n = 37) of the physicians perceived patients taking antibiotics directly from the local medical shopkeeper also as a major barrier. Fifty-seven percent (n = 34) of the physicians agreed that they have too much of work with staff shortage and nearly half of them said that their patients ask them to give antibiotics [Figure 4]. Sixty-three percent (n = 37) of pharmacists agreed on long arrival delays of indented antibiotics in their health centers. 60% (n = 36) of pharmacists stated that they did not sufficiently see support from higher authorities.
Figure 4: Agreement with perceived barrier for good Antibiotic prescription practices by physicians (n = 60)

Click here to view


Physician's laboratory support seeking behavior

The bacterial culture rates, data on the sensitivity, and resistance rates was scarce as the samples received for processing was negligible. A majority of 81% (n = 49) of the physicians did not send cultures for infective cases (whenever appropriate). However, 52% (n = 31) of them said that they do not ask for culture and sensitivity for all patients with an infection but believed that it was required while 30% (n = 18) felt cultures were not required. Yet 43% (n = 26) of the doctors said that they ask for culture and sensitivity testing few days after starting the antibiotic when the patient does not improve. Physicians <5 years sought somewhat more cultures (not-significant) than those experienced over 5 years (OR 1.4, CI 0.40–4.86, P = 0.58). Microbiologist is available at DH. Still, 38% (n = 23) of physicians gave the opinion that they would seek microbiologist for antibiotic recommendations, whereas 30% (n = 18) did not respond to the question. However, another 28% (n = 17) said they did not seek advice but thought it was required. Younger physicians answered that they would tend to seek advice from microbiologist more frequently than those with over 5 years of practice (OR 2.0, CI 0.49–8.08, P = 0.32).

Physicians and pharmaceutical liaison

Forty-two percent (n = 25) of physicians stated that they met the pharmaceutical representatives for their prescriptions. On the whole, 60% (n = 36, procured additional responses) acknowledged that they never received gifts from marketing representatives, but 20% (n = 12) of them said they would accept gifts if given and as 33% (n = 20) did not respond to the gift-receiving question. A minimum 6.7% (n = 4) promptly declared they had received gifts. In addition, 63% (n = 38) doctors trusted their colleagues and declared that they did not know of anyone who received gifts. Among those who met the sales representatives, 19 of them (32%) acknowledged that they met <5 representatives/month. None of the pharmacists met the pharmaceutical representatives.

Perception of received training and interest around potential antibiotic interventions

On grouping, 80% (n = 48) of the physicians and 80% (n = 46) of the pharmacists perceived that their medical school and pharmacy school training was sufficient enough to confidently train them in antibiotic prescriptions and dispensing, respectively. On grouping, 87% (n = 52) of the physicians and 98% (n = 57) of pharmacists expressed their interest for a potential educational program in antibiotics and resistance.


   Discussion Top


The present study focuses on prescribing practices of physicians from all three tiers of government health services of Tumkur district. Knowledge, attitudes, and practices (KAP) surveys combined with data of local AB consumption, resistance data allow for possible design, and implementation of local interventions to combat rising problems of resistance. Such KAP-surveys about AB resistance and prescribing toward promoting rational prescriptions have been very few from rural India, [Table 2] list the surveys in low- and middle-income countries (LMIC) in recent years.
Table 2: Attitude and practices survey studies conducted in low- and middle-income countries in the recent years

Click here to view


Perception of the problem burden

The physicians acknowledged the global (87%) and national crisis (91%) of antibiotic resistance. However, the numbers fell when perceiving it as a problem in their health centers (67%) as in the Peruvian and Congolese study.[26],[29] This aligns well with the fact that the physicians were largely unaware of the MDROs at their centers as they never sought cultures for diagnosis due to unavailability or lack of habit. However, most of the physicians in this study were aware that they would contribute to bring the resistance rates down as in the Congolese study.

Knowledge on preventing resistance

Knowledge of prescribing less antibiotics (91.7%), getting feedback about their practices (91.7%), and understanding of dosages (91.7%) was thought to be a favorable environment for the ASP launch. However, we would have welcomed also a greater emphasis on the role of handwashing (40% were unaware), as well as on requesting bacterial cultures before the start of antibiotics. A high rates of incorrect answers for the pathogen-drug combination comparable to their West Indian counterparts[28] was noted but majority of physicians and pharmacists welcomed such educational programs on antibiotic prescribing highlighting their preparedness.[25],[26],[29] The remuneration and gifts influencing the antibiotic prescription practices which 20% of the practitioners were willing to receive from the pharmaceutical representatives, if provided, is a cause of concern, nevertheless.[41]

Educational training received by the service providers

Although majority (80%) perceived that they were sufficiently trained in the medical and pharmacy schools for good prescription practice, results however showed that the training gap existed and this was supported by their incorrect answers on knowledge questions. The lack of on-job training too was perceived as a major barrier in their practice by two-thirds of pharmacists. The potential role of university education on the topic is perceived as profound, and this is put forward by most of the KAP-surveys where the respondents are the medical students or residents in India and other LMIC.[26],[29],[30],[32]

Knowledge-seeking behavior

The assessed knowledge seeking behavior was quite satisfactory as 74% of physicians sought knowledge always or often by some means – either from textbook, manuals, or by talking to colleagues, unlike in Peru and Congo studies where they sought international guidelines and pharmaceutical companies, respectively, for their information.[26],[29] DHs are gradually getting connected by internet throughout the country, and the internet may help in updating current practices when compared to old textbooks; it may also be a source e-learning courses. The more experienced physicians tended to seek more inputs from combination of sources apparently being unaware that the textbooks came with the danger of outdated knowledge. The National Treatment Guidelines for Antimicrobial Use in Infectious Diseases have been brought out recently (2016) by the NCDC and ASP would help districts frame local guidelines.

Antibiotic availability and issues around it

The study results show that the selection of an antibiotic also depends on its availability at these public health centers; the majority of physicians agreed it to be a major practice barrier as in New Delhi study.[17] The Karnataka Drug and Logistics Warehouse Society has to gear up to ensure the availability and continuous supply of the antibiotics. The results, however, differ from the survey at Congo,[29] where more than two-thirds of the respondents agreed that choice was influenced by cause of infection. Such financial barriers limiting the availability to antibiotics with the delay in supply are drivers for informal dispensers compromising the quality of care[37] and levying out-of-pocket expenditures which is well supported by some of the recent Indian studies.[17] Unlike the Peruvian study,[26] less than half of our respondents agreed that the supplied antibiotics were of poor quality and also revealed people's mistrust in government supply.[36]

Strengthening of laboratory services

Lack of well-functioning and underutilization of microbiology facilities is a known problem in low-resource settings. Nonvertical program-based (not only for HIV, TB, Malaria but also for all prevalent infectious diseases) health system strengthening is imperative. The culture-seeking behavior from the physicians is expected to positively improve once the facilities including the point of care rapid diagnostic tests are readily available. Envisioning and strengthening the DH laboratories (as accomplished with HIV and TB) with automation are the maiden and the foremost steps. The microbiologist's advice was considered relevant only by few physicians (38%). The e-technology (such as mobile phones and telemedicine)[38],[39] could to be tapped effectively under the Digital India Scheme for timely and judicious antibiotic recommendations, faster report delivery and learning as well, in between centers. Geographical access, sample transportation and preserving the sample quality, side laboratory facilities, training the technician in basic reporting at Taluk Hospitals are the issues to be considered for the co-ordinated interaction between the tiers of local health system. Strengthening the infrastructure, integrated tiered referral networks, laboratory workforce development, regular participation at National External Quality Assurance System Tests, etc., to build sustainable laboratory capacities with in the country is imperative. The proposed consideration of Free Diagnostics initiative by the state of outsourcing laboratory services to the big private players may need to be reflected for a sustainable solution in the long run.

Human resources and a steward

Motivating a district health staff for leadership (usually a physician or a microbiologist) with adequate backup by the managerial team may be a key to the start. Health centers develop in both ASP and good IC practices simultaneously requiring the same staff. Focus may be on building up IC teams in the rest of the PHCs to prevent further transmission of MDROs. Many of the DHs have designated an Internal Quality Coordinator for National Quality Assurance Standards Implementation who may well play the role of a steward. Districts facing staff shortages require priority in hiring new staff[40] as rightly put forward that lack of qualified doctors to prescribe make the complete ban of OTC sale antibiotics throughout the country impractical (another parallel strategy to tackle resistance). Heavy workload is already perceived as a potential barrier for preventing resistance.

Limitations of the study

Over 10 specialists approached declined to fill the questionnaire due to time pressure in the busy duty hours; private practitioners were not covered under the study. Nine pharmacists required native translation. Qualitative data could have definitely strengthened the results and the study is underway. The multiple choice format could have elicited socially desirable answers from the respondents. Furthermore, the knowledge questions may not really reflect the practices and vice-versa. As the results now show the knowledge gap as an issue, follow-up study would need to include an assessment of their extent of knowledge translating into their practices, a review of the treatment charts would be a valuable data source.

Strengths of the study

This study provides an insight on the growing problem across the country. The study is based on the surveys conducted by the LMIC and with relevant public setting oriented questions, thus making it highly context-specific. Being one of the few studies from rural areas. This study has assessed the topics cited by the WHO[34] as influencing the AB prescription in addition to those being unique for the Indian context as barriers.


   Conclusions Top


This study has gathered important information about the knowledge, attitude, and practices of AB use among health-care professionals in Tumkur District which may be useful to tailor the interventions aimed to improve antibiotic use across the district's health-care settings. Having an antibiotic policy is now a standard requirement for accreditation of all hospitals across India, and Tumkur DH (government) has initiated the process of accreditation with the National Accreditation Board for Hospitals and Health Care Providers. The Government of India has also launched Swatchata (cleanliness) program in 2015 for all public health facilities which carries a check-point to have a local antibiotic policy besides infection control practices and others. Addressing the perceptions of the public health center's staff seem to have been overlooked and it is about time that the state initiates training on ASP for handholding across districts. Strengthening the DH with laboratory infrastructure, integrated tiered referral networks, laboratory workforce development, quality system improvement, etc., to build sustainable laboratory capacities with in the country is imperative.

Acknowledgment

This study was conducted as collaboration between Institute of Public Health, Bengaluru, Institute of Tropical Medicine, Belgium and DH, Tumkur. We thank Dr. Devadasan N, head, Institute of Public Health, Bengaluru, for facilitating the study and Prof Bart Criel, head, Health Systems Research, ITM, Belgium, for envisioning the study. We also thank District Surgeon, Tumkur DH and his team for the support extended for the study.

Financial support and sponsorship

The study was carried out by the corresponding author as a thesis requirement for the Master Degree in Public Health (supported by DGDC, Belgium) at the Institute of Tropical Medicine, Antwerpen, Belgium, in collaboration with Institute of Public Health, Bengaluru, and District Hospital, Tumkur.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Furuya EY, Lowy FD. Antimicrobial-resistant bacteria in the community setting. Nat Rev Microbiol 2006;4:36-45.  Back to cited text no. 1
    
2.
Laxminarayan R, Duse A, Wattal C, Zaidi AK, Wertheim HF, Sumpradit N, et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis 2013;13:1057-98.  Back to cited text no. 2
    
3.
Center for Disease Control and Prevention (CDC), US Department of Health and Human Services. Antibiotic Resistance Threats in the United States, 2013; April, 2013. Available from: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. [Last updated on 2014 May 07; Last accessed on 2014 May 29].  Back to cited text no. 3
    
4.
Roberts RR, Hota B, Ahmad I, Scott RD 2nd, Foster SD, Abbasi F, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: Implications for antibiotic stewardship. Clin Infect Dis 2009;49:1175-84.  Back to cited text no. 4
    
5.
Laxminarayan R, Malani A, Howard D, Smith DL. Extending the Cure: Policy Responses to the Growing Threat of Antibiotic Resistance. Washington DC: Resources for the Future; 2007. Available from: http://www.rff.org/rff/Documents/ETC_fullreport.pdf. [Last accessed on 2014 May 29].  Back to cited text no. 5
    
6.
World Health Organization. Antimicrobial Resistance. Global Report on Surveillance 2014. Geneva: World Health Organization; 2014. Available from: http://www.who.int/drugresistance/documents/surveillancereport/en/. [Last accessed on 2014 May 29].  Back to cited text no. 6
    
7.
TB India. Annual Status Report. Revised National TB Control Program India. Government of India; 2013. Available from: http://www.tbcindia. nic.in/pdfs/tb%20india%202013.pdf. [Last accessed on 2014 May 29].   Back to cited text no. 7
    
8.
Kotwani A, Holloway K. WHO Resource. Essential Medicine and Health Information Portal. Trends in Antibiotic Use among Outpatients in New Delhi, India; 2011.  Back to cited text no. 8
    
9.
Ganguly NK. Situation Analysis – Antibiotic Use and Resistance in India. New Delhi: Global Antibiotic Resistance Partnership (GARP) – India Working Group, PHFI; March 2011. Available from: http://www.cddep.org/sites/cddep.org/files/publication_files/India-report-web.pdf?issuusl=ignore. [Last accessed on 2014 May 29].  Back to cited text no. 9
    
10.
Pathak A, Mahadik K, Dhaneria SP, Sharma A, Eriksson B, Lundborg CS, et al. Antibiotic prescribing in outpatients: Hospital and seasonal variations in Ujjain, India. Scand J Infect Dis 2011;43:479-88.  Back to cited text no. 10
    
11.
Kotwani A, Holloway K. Trends in antibiotic use among outpatients in New Delhi, India. BMC Infect Dis 2011;11:99.  Back to cited text no. 11
    
12.
Kotwani A, Chaudhury RR, Holloway K. Antibiotic-prescribing practices of primary care prescribers for acute diarrhea in New Delhi, India. Value Health 2012;15:S116-9.  Back to cited text no. 12
    
13.
Pathak D, Pathak A, Marrone G, Diwan V, Lundborg CS. Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India – A cross-sectional prescription analysis. BMC Infect Dis 2011;11:32.  Back to cited text no. 13
    
14.
Bhartiy SS, Shinde M, Nandeshwar S, Tiwari SC. Pattern of prescribing practices in the Madhya Pradesh, India. Kathmandu Univ Med J 2008;6:55-9.  Back to cited text no. 14
    
15.
de Costa A, Bhartiya S, Eltayb A, Nandeswar S, Diwan VK. Patterns of drug use in the public sector primary health centers of Bhopal district. Pharm World Sci 2008;30:584-9.  Back to cited text no. 15
    
16.
Ganguly NK, Arora NK, Chandy SJ, Fairoze MN, Gill JP, Gupta U, et al. Rationalizing antibiotic use to limit antibiotic resistance in India. Indian J Med Res 2011;134:281-94.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Kotwani A, Holloway K. Access to antibiotics in New Delhi, India: Implications for antibiotic policy. J Pharm Policy Pract 2013;6:6.  Back to cited text no. 17
    
18.
Walsh TR, Weeks J, Livermore DM, Toleman MA. Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: An environmental point prevalence study. Lancet Infect Dis 2011;11:355-62.  Back to cited text no. 18
    
19.
World Health Organization Regional Office for Southeast Asia. Jaipur Declaration, World Health Organization South-East Asia Region. Southeast Asia: World Health Organization; 2011. Available from: http://www.searo.who.int/entity/world_health_day/media/2011/whd-11_amr_jaipur_declaration_.pdf. [Last accessed on 2014 May 29].  Back to cited text no. 19
    
20.
National Center for Disease Control. Government of India. National Policy for Containment of Antimicrobial Resistance (draft); 2011. Available from: http://www.nicd.nic.in/ab_policy.pdf. [Last accessed on 2014 May 29].  Back to cited text no. 20
    
21.
Chennai Declaration. Recommendations of “A Roadmap- to Tackle the Challenge of Antimicrobial Resistance”. Chennai: A Joint Meeting of Medical Societies of India; 2014. Available from: http://www.chennaideclaration.org/images/five%20year%20plan.pdf. [Last accessed on 2014 May 29].  Back to cited text no. 21
    
22.
World Health Organization. WHO Global Strategy for the Containment of Antimicrobial Resistance; 2001. Available from: http://www.who.int/drugresistance/WHO_Global_Strategy.htm/en/. [Last accessed on 2014 May 29].  Back to cited text no. 22
    
23.
Dellit TH, Owens RC, McGowan JE Jr., Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-77.  Back to cited text no. 23
    
24.
Centers for Disease Control and Prevention. Get Smart for Health Care- Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA; US Department of Health and Human Services, Centers for Disease Control and Prevention; 2014. Available from: http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf. [Last accessed on 2014 Jun 06].  Back to cited text no. 24
    
25.
Guerra CM, Pereira CA, Neves Neto AR, Cardo DM, Correa L. Physicians' perceptions, beliefs, attitudes, and knowledge concerning antimicrobial resistance in a Brazilian teaching hospital. Infect Control Hosp Epidemiol 2007;28:1411-4.  Back to cited text no. 25
    
26.
García C, Llamocca LP, García K, Jiménez A, Samalvides F, Gotuzzo E, et al. Knowledge, attitudes and practice survey about antimicrobial resistance and prescribing among physicians in a hospital setting in Lima, Peru. BMC Clin Pharmacol 2011;11:18.  Back to cited text no. 26
    
27.
Kheder SI. Physicians' knowledge and perception of antimicrobial resistance: A survey in Khartoum State hospital settings. Br J Pharm Res 2013;3:347-62.  Back to cited text no. 27
    
28.
Tennant I, Nicholson A, Gordon-Strachan GM, Thoms C, Chin V, Didier MA, et al. Asurvey of physicians' knowledge and attitudes regarding antimicrobial resistance and antibiotic prescribing practices at the University Hospital of the West Indies. West Indian Med J 2010;59:165-70.  Back to cited text no. 28
    
29.
Thriemer K, Katuala Y, Batoko B, Alworonga JP, Devlieger H, Van Geet C, et al. Antibiotic prescribing in DR Congo: A knowledge, attitude and practice survey among medical doctors and students. PLoS One 2013;8:e55495.  Back to cited text no. 29
    
30.
Khan A, Banu G, Reshma KK. Antibiotic resistance and usage-A survey on the knowledge, attitude, perceptions and practices among the medical students of a Southern Indian teaching hospital. J Clin Diagn Res 2013;7:1613-6.  Back to cited text no. 30
    
31.
Huang Y, Gu J, Zhang M, Ren Z, Yang W, Chen Y, et al. Knowledge, attitude and practice of antibiotics: A questionnaire study among 2500 Chinese students. BMC Med Educ 2013;13:163.  Back to cited text no. 31
    
32.
Aggarwal S, Mathew J, Singh H, Sharma V. Attitude and perception of junior resident doctors' regarding antibiotic resistance – A pilot study. J Acute Dis 2014;3:6-9.  Back to cited text no. 32
    
33.
Sivagnanam G, Thirumalaikolundusubramanian P, Mohanasundaram J, Raaj AA, Namasivayam K, Rajaram S, et al. Asurvey on current attitude of practicing physicians upon usage of antimicrobial agents in Southern part of India. MedGenMed 2004;6:1.  Back to cited text no. 33
    
34.
Leung E, Weil DE, Raviglione M, Nakatani H, World Health Organization World Health Day Antimicrobial Resistance Technical Working Group. The WHO policy package to combat antimicrobial resistance. Bull World Health Organ 2011;89:390-2.  Back to cited text no. 34
    
35.
Chandy SJ, Michael JS, Veeraraghavan B, Abraham OC, Bachhav SS, Kshirsagar NA, et al. ICMR programme on antibiotic stewardship, prevention of infection & control (ASPIC). Indian J Med Res 2014;139:226-30.  Back to cited text no. 35
[PUBMED]  [Full text]  
36.
Kotwani A, Wattal C, Katewa S, Joshi PC, Holloway K. Factors influencing primary care physicians to prescribe antibiotics in Delhi India. Fam Pract 2010;27:684-90.  Back to cited text no. 36
    
37.
Vlieghe E. The first global forum on bacterial infections calls for urgent action to contain antibiotic resistance. Expert Rev Anti Infect Ther 2012;10:145-8.  Back to cited text no. 37
    
38.
National Health Mission. Ministry of Health and Family Welfare. Government of India. Health System Strengthening: Telemedicine; 2013. Available from: http://www.nrhm.gov.in/images/pdf/Telemedicine/Telemedicine.pdf. [Last accessed on 2014 Jun 06].  Back to cited text no. 38
    
39.
Pardeshi G, Kakrani V. Challenges and options for the delivery of primary health care in disadvantaged urban area. Indian J Community Med 2006;31:132.  Back to cited text no. 39
  [Full text]  
40.
Hazarika I. Health workforce in India: Assessment of availability, production and distribution. WHO South East Asia J Public Health 2013;2:106-12.  Back to cited text no. 40
    
41.
Chandy SJ, Mathai E, Thomas K, Faruqui AR, Holloway K, Lundborg CS, et al. Antibiotic use and resistance: Perceptions and ethical challenges among doctors, pharmacists and the public in Vellore, South India. Indian J Med Ethics 2013;10:20-7.  Back to cited text no. 41
    

Top
Correspondence Address:
Dr. Sushma Krishna
Consultant Microbiologist, Central Laboratory, St. Martha's Hospital, Nrupatunga Road, Bangalore - 560 001
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_96_17

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *


    Abstract
   Introduction
   Methodology
   Results
   Discussion
   Conclusions
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed444    
    Printed11    
    Emailed0    
    PDF Downloaded0    
    Comments [Add]    

Recommend this journal