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 Table of Contents  
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 46-50

Attitude of prescribers about the rational use of antibiotics for common infections in a clinical setting as part of antibiotic stewardship program

1 Department of Pharmacology, JIPMER, Karaikal, India
2 Department of Anaesthesiology, Lakshmi Narayana Institute of Medical Sciences, Puducherry, India
3 Department of Microbiology, JIPMER, Karaikal, India

Date of Submission28-Nov-2020
Date of Decision15-Dec-2020
Date of Acceptance18-Dec-2020
Date of Web Publication19-Aug-2021

Correspondence Address:
Dr. Priyadharsini Raman Palanisamy
Department of Pharmacology, JIPMER, Karaikal, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jascp.jascp_9_20

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Background: The resistance of the bacteria toward the antibiotics is growing day by day, and it is a serious threat globally. The reasons are self-medication, unjustified prescription of antibiotics, high use of antibiotics in livestock, and nonadherence to antibiotic treatment guidelines by prescribers. The aim of the present study is to assess the knowledge and attitude of the prescribers toward the prescription of antibiotics and antibiotic resistance. Methodology: A descriptive cross-sectional study was conducted using a questionnaire which contains questions to assess the knowledge and attitude of the prescribers. The questionnaire had three parts: the first part was used to obtain the basic demographic characteristics from participants, the second part had questions regarding the antibiotic indication in common infections, and the third part assessed the knowledge questions about antibiotic resistance. The questionnaire was attempted by eighty prescribers. Results: More than 50% of the medical practitioners agreed that antibiotics had to be used for some common infections such as acute gastroenteritis, asymptomatic bacteriuria in nonpregnant patients, and burn wounds with no evidence of infection. The knowledge of the prescribers regarding antibiotic resistance is variable. Conclusion: A higher percentage of the prescribers responded in favor of the use of antibiotics for common infections. It requires an awareness program to sensitize the prescribers regarding the prescription of antibiotics for appropriate indications and the seriousness of antibiotic resistance.

Keywords: Antibiotic resistance, antibiotic stewardship program, attitude, knowledge, physician

How to cite this article:
Palanisamy PR, Natrajan N, Balaji VK. Attitude of prescribers about the rational use of antibiotics for common infections in a clinical setting as part of antibiotic stewardship program. J Appl Sci Clin Pract 2021;2:46-50

How to cite this URL:
Palanisamy PR, Natrajan N, Balaji VK. Attitude of prescribers about the rational use of antibiotics for common infections in a clinical setting as part of antibiotic stewardship program. J Appl Sci Clin Pract [serial online] 2021 [cited 2023 Mar 29];2:46-50. Available from: http://www.jascp.org/text.asp?2021/2/2/46/324119

  Introduction Top

Irrational use of antibiotics had led to a global problem, the antibiotic resistance which may result in postantibiotic era in the near future.[1] As per the WHO, the prescribing and dispensing of almost 50% of the drugs is not appropriate.[2] It is estimated that by 2050, there will be 4.7 million deaths in Asia due to antibiotic resistance. India has 12%–59% of beta-lactamase-producing Escherichia coli and 30% of carbapenemase-producing E. coli. India also consumed nearly 13 billion units of antibiotics in 2010 which is higher compared with other countries in the world. The percentage of people receiving antibiotics for common infections is on the higher side in both public and private hospitals in New Delhi, India.[3] The isolated stool samples from the patients who were not exposed to antibiotics for at least a month showed high antibiotic resistance among the population in New Delhi.[4] The various reasons for high antibiotic resistance are self-medication, irrational prescribing of the antibiotics by the physicians, and higher use of the antibiotics in poultry and livestock.[5],[6],[7],[8] The irrational prescription of antibiotics increases the risk of serious adverse events with the lack of clinical benefit in patients. The government aims to reduce the antibiotic resistance by implementing guidelines and promoting antibiotic stewardship program. The components of effective antibiotic stewardship program are rational antibiotic prescribing with effective infection control program to prevent the emergence of resistance. One of the strategies of antimicrobial stewardship is to improve the antibiotic prescribing behavior by creating awareness and administrative methods.[9] There is a continuous need to monitor the prescribing pattern of antibiotics by the physician and their awareness regarding antibiotic resistance. The aim of the present study is to assess the knowledge and attitude of the prescribers about the rational use of antibiotics for common infections in a clinical setting in southern India.

  Methodology Top

A cross-sectional descriptive study was conducted among the prescribers from January 2020 to June 2020 in Karaikal, Pondicherry, and various parts of South India. The location of the study was selected based on the proximity to institute of the investigator and convenience of data collection. The physicians who are currently involved in clinical practice are the eligible respondents. The study was approved by the scientific committee and institute ethics committee.

Inclusion criteria


  • Registered medical practitioners MBBS or MD degree who are currently engaged in clinical practice
  • Medical practitioners both in government and private practice.

Exclusion criteria

  • Doctors who practice other branches of medicine such as Ayurveda and Unani.

A survey was conducted using the questionnaire containing the questions to evaluate the rationality of prescription of antibiotics. The first step was the development of questionnaire based on the literature review, national guidelines, and previous studies. The questionnaire was developed based on the national treatment guidelines for the treatment of common infections 2019 issued by ICMR, India, and internally validated for the contents. The questionnaire had three parts with the information elicited on basic demographic characteristics, knowledge about the rational use of antibiotics, and the attitude toward the prescription of antibiotics in routine practice.

The information regarding the age, gender, and level of medical degree of the practicing prescriber is elicited in the basic demographic part. The knowledge section assessed the need for antibiotics in 13 clinical diagnostic infections. The attitude section had six framed statements about the antibiotic prescription. The prescribers were asked to answer the questions mentioned in the questionnaire. Out of the 95 prescribers approached, 80 consented and participated in the study. Informed consent was obtained from those who consented to participate. The questionnaire was circulated through online, and some prescribers answered the questionnaire in person.

  Results Top

The demographic characteristics of the prescriber population are shown in [Table 1]. Among the respondents, 60% were males and 40% were females. The prescribers who answered the questionaire belong to various specialities like obstetrics, paediatrics, ophthalmology, general medicine etc as shown in [Figure 1].
Table 1: Demographic characteristics of the population

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Figure 1: Distribution of various specialties of the prescribers who answered the questionnaire

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  Discussion Top

The present study shows that a higher percentage of prescribers (more than 50%) are of the opinion that the antibiotics should be prescribed to the common conditions such as acute gastroenteritis (70%) and food poisoning (60.5%) as shown in [Figure 2]. A moderate percentage of the doctors were in favour of prescription of antibiotics in asymptomatic bacteriuria in non pregnant patients, (32.5%), upper respiratory tract infection (11.3%), viral pharyngitis, viral bronchitis (22.5%), burn wounds with no evidence of clinical and microbiological infection (43.8%) [Table 2]. The clinical conditions mentioned are mostly very common infections that are encountered in day-to-day clinical practice with many infections not requiring antibiotics, and some infections require antibiotics only beyond a severity level. The results of our study are consistent with the results of another study reported by Palin et al. in which the antibiotic prescribing was high among respiratory tract infection, urinary tract infection, and ear-related infections. The update in the antibiotic prescribing guidelines did not have influence in prescribing behavior of physicians.[10] It is a well known fact that most of the acute gastroenteritis cases do not require antibiotics because they are viral in origin and usually self limiting. Antibiotic prescribing in these cases has no advantages like reducing symptoms, decreasing the length of hospital stay due to illness.[11]
Figure 2: Percentage of responses in favor of or the uses of antibiotics

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Table 2: Attitude questions addressed to the prescribers for the treatment of infections

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Asymptomatic bacteriuria is another common condition in diabetic patients, the elderly, and women where the antibiotics are prescribed irrationally. A Cochrane database systematic review by Zalmanovici Trestioreanu et al. identified that prescription of antibiotics does not have a significant effect compared to placebo or no treatment in patients with asymptomatic bacteriuria.[12] A study conducted in the UK by Rousham et al. reported that a percentage of urine dipstick test in elderly patients were on the higher side, and a high proportion of patients with asymptomatic bacteriuria received the antibiotics when it is not needed.[13] In our study, almost 32.5% of the prescribers had responded in favor of antibiotics for patients (excluding pregnancy) with asymptomatic bacteriuria and 10% are unsure about the antibiotic prescription in these patients. In India, a high percentage of antibiotics were prescribed in obstetrics and gynecology department with a value of 71% and 75% in teaching tertiary hospital and nonteaching tertiary hospital for the inpatients without any bacterial infection.[14] Similarly, 43.8% of the prescribers agreed to use antibiotics for minor burn wounds and 16.3% were totally unsure about the use of antibiotics. A study by Stewart et al. also reported that routine systemic antibiotic prophylaxis is not effective and recommended in burn injuries, whereas in our study, the physicians responded positively for the use of antibiotics.[15]

Antibiotics are ineffective in most of the viral infections when they are self-limiting. Many studies also reported overprescribing of antibiotics in viral infections.[16],[17] Around 11.3% and 22.5% of the medical practitioners responded that the antibiotics are required in the upper respiratory tract infections such as viral bronchitis and pharyngitis, respectively. A study by Ebell et al. identified that 49.4% of the patients with viral respiratory tract infection received the antibiotics, and antibiotics were also prescribed to 67.8% of the acute bronchitis cases.[18] The result of our study correlates with this study as the prescribers are more prone to prescribe antibiotics. This attitude of the prescribers may lead to increased prescription of inappropriate antibiotics. The reason for this prescribing behavior would be a high dependency on antibiotics for any infection and lack of awareness regarding severity of antibiotic resistance. The duration of antibiotic therapy also requires strict monitoring in rational indications. The duration of treatment for common infections exceeded the number of days mentioned in the recommended guidelines in a study reported by Pouwels et al.[19]

The results of knowledge of prescribers regarding the antibiotic prescribing and antibiotic resistance are variable, i.e., some responses indicated that they have good knowledge whereas some gave an opinion that some knowledge is lacking. The study results of the present study differ from the results reported by Alothman et al. in which the prescribers had good knowledge about the seriousness of antibiotic resistance.[20] Around 30% of the physicians agreed to use or unsure about the prescription of expensive antibiotics for infections [Table 3]. The efficacy of the antibiotics plays a major role in treatment more than the cost, and it is wondering to identify some responses in favor of expensive drugs. In our study, 71.3% of the patients were of the opinion to start empirical therapy with broad-spectrum antibiotics. Empirical antibiotic therapy is reserved for few infections in which initiating antibiotic at an early stage is proved to be beneficial (bacterial meningitis, sepsis, and septic shock), yet the drug dose and duration can be modified after a reassessment. It is concerning that almost 66.3% of the patients were not aware of postantibiotic era in which minor infections can kill patients in the near future due to antibiotic resistance. In our study, 46.3% of the prescribers think that broad-spectrum antibiotics are preferred in all infections. Almost 30% of the prescribers are unsure or feel that the prescription of two antibiotics will fetch a faster recovery to the patients.
Table 3: Knowledge questions addressed to the prescribers regarding antibiotic resistance

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The strengths of the present study are that the study population represented almost all the specialties, those working in both public and private sectors; the questions were directed toward the common infections which contribute to the maximum utilization of antibiotics. The limitation of the study is that the clinical scenarios can be still more accurate.

  Conclusion Top

A higher percentage and moderate percentage of doctors opted for the antibiotics for the conditions such as gastroenteritis and urinary tract infection, respectively. Few prescribers are also willing to use antibiotics for other common infections such as pharyngitis, URI, and bronchitis. The study also identified variable responses regarding the knowledge with many prescribers responding in favor of treatment with antibiotics for some common infections. Most of them had a moderate lack of knowledge regarding the seriousness of antibiotic resistance. Educational interventions such as CME programs on antibiotic resistance, implementation of local antibiotic policy, and routine prescription auditing can prevent the inappropriate prescription of antibiotics.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Zaman SB, Hussain MA, Nye R, Mehta V, Mamun KT, Hossain N. Review on antibiotic resistance: Alarm bells are ringing. Cureus 2017;9:e1403.  Back to cited text no. 1
WHO | Rational Use of Medicines. WHO. Available from: http://www.who.int/medicines/areas/rational_use/en/. [Last accessed on 2019 Aug 26].  Back to cited text no. 2
Kotwani A, Holloway K. Antibiotic prescribing practice for acute, uncomplicated respiratory tract infections in primary care settings in New Delhi, India. Trop Med Int Health 2014;19:761-8.  Back to cited text no. 3
Most Healthy Indians Resistant to Common Antibiotics: Study | India News - Times of India. Times India. Available from: https://timesofindia.indiatimes.com/india/most-healthy-indians-resistant-to-common-antibiotics-study/articleshow/69657111.cms. [Last accessed on 2020 Sep 29].  Back to cited text no. 4
Treatment Guidelines for Antimicrobial Use in Common Syndromes; 2019. Available from: https://main.icmr.nic.in/sites/default/files/guidelines/Treatment_Guidelines_2019_Final.pdf. [Last accessed on 2020 October 14].  Back to cited text no. 5
Laxminarayan R, Chaudhury RR. Antibiotic resistance in India: Drivers and opportunities for action. PLoS Med 2016;13:e1001974.  Back to cited text no. 6
Ventola CL. The antibiotic resistance crisis. Pharm Ther 2015;40:277-83.  Back to cited text no. 7
Priyadharsini RP. Antibiotic resistance: What is there in past, present and future? J Young Pharm 2019;11:333-6.  Back to cited text no. 8
Indian council of Medical Research. Antimicrobial Stewardship Program Guideline [Internet]. [India]: ICMR; 2017 [updated 2017 ; cited 2020 Oct 2020]. (Clinical guideline). Available from: https://iamrsn.icmr.org.in/images/pdf/AMSP_Guidelines_final.pdf.  Back to cited text no. 9
Palin V, Mölter A, Belmonte M, Ashcroft DM, White A, Welfare W, et al. Antibiotic prescribing for common infections in UK general practice: Variability and drivers. J Antimicrob Chemother 2019;74:2440-50.  Back to cited text no. 10
Homsi M, Singh B, Azawi M, Panchal A, Hauter N, Salafia C, et al. Antibiotic therapy in acute gastroenteritis: A single-center retrospective cohort study. Ann Gastroenterol 2019;32:565-9.  Back to cited text no. 11
Zalmanovici Trestioreanu A, Lador A, Sauerbrun-Cutler MT, Leibovici L. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev 2015;4:CD009534.  Back to cited text no. 12
Rousham E, Cooper M, Petherick E, Saukko P, Oppenheim B. Overprescribing antibiotics for asymptomatic bacteriuria in older adults: A case series review of admissions in two UK hospitals. Antimicrob Resist Infect Control 2019;8:1-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6498584/. [Last accessed on 2020 Sep 30].  Back to cited text no. 13
Machowska A, Landstedt K, Stålsby Lundborg C, Sharma M. Antibiotic prescribing to patients with infectious and non-infectious indications admitted to obstetrics and gynaecology departments in two tertiary care hospitals in central India. Antibiotics 2020;9:1-16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459830/. [Last accessed on 2020 Dec 17].  Back to cited text no. 14
Stewart BT, Gyedu A, Agbenorku P, Amankwa R, Kushner AL, Gibran N. Routine systemic antibiotic prophylaxis for burn injuries in developing countries: A best evidence topic (BET). Int J Surg Lond Engl 2015;21:168-72.  Back to cited text no. 15
Analysis of the Prescribing Patterns of Antibiotics in Respiratory Tract Infections at Department of Medicine at a Tertiary Care Hospital | International Journal of Pharmaceutical Sciences and Research. Available from: https://ijpsr.com/bft-article/analysis-of-the-prescribing-patterns-of-antibiotics-in-respiratory-tract-infections-at-department-of-medicine-at-a-tertiary-care-hospital/?view=fulltext. [Last accessed on 2020 Sep 30].  Back to cited text no. 16
Dekker AR, Verheij TJ, van der Velden AW. Inappropriate antibiotic prescription for respiratory tract indications: Most prominent in adult patients. Fam Pract 2015;32:401-7.  Back to cited text no. 17
Ebell MH, Radke T. Antibiotic use for viral acute respiratory tract infections remains common. Am J Manag Care. 2015;21:e567-75.  Back to cited text no. 18
Pouwels KB, Hopkins S, Llewelyn MJ, Walker AS, McNulty CA, Robotham JV. Duration of antibiotic treatment for common infections in English primary care: Cross sectional analysis and comparison with guidelines. BMJ 2019;364:l440.  Back to cited text no. 19
Alothman A, Algwizani A, Alsulaiman M, Alalwan A, Binsalih S, Bosaeed M. Knowledge and attitude of physicians toward prescribing antibiotics and the risk of resistance in two reference hospitals. Infect Dis 2016;9:33-8.  Back to cited text no. 20


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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