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infection control and hospital epidemiology

december 2007, vol. 28, no. 12

concise communication

Physicians Perceptions, Beliefs, Attitudes, and Knowledge Concerning Antimicrobial Resistance in a Brazilian Teaching Hospital
Carla Morales Guerra, MD; Carlos Alberto Pires Pereira, MD; Armando R. Neves Neto, MSc; Denise Mary Cardo, MD; Luci Correa, MD
This cross-sectional survey assessed physicians perceptions, knowledge and practices concerning antimicrobial resistance. Ninety-nine percent of participants reported that they perceived antimicrobial resistance as an important problem, and 86.7% agreed that antimicrobials are overprescribed, but only 2.9% rated practicing antimicrobial control as the most important strategy for preventing resistance. The results of this study warrant educational programs on antimicrobial resistance and the distribution of information regarding local antimicrobial susceptibility testing. Infect Control Hosp Epidemiol 2007; 28:1411-1414

Antimicrobial-resistant pathogens have become a threat to patients and have increased health care costs.1 Noncompliance with infection control precautions and the inappropriate use of antimicrobial agents have been identied as the main risk factors for the emergence of antimicrobial resistance.2-4 Interventions to prevent and control antimicrobial resistance usually include behavior changes, and the process of bringing about these changes is affected by the beliefs and motivations of target groups.3-5 Previous surveys have been conducted to assess both physicians knowledge and their attitudes concerning antimicrobial use and antimicrobial resistance.5-8 However, little is known about how physicians in Brazilian hospitals perceive the problem of antimicrobial resistance. The aim of this study was to assess the knowledge, beliefs, and practices of physicians in a Brazilian teaching hospital with respect to the use of antimicrobial drugs and antimicrobial resistance.

me th ods
We conducted a cross-sectional survey among physicians at the Federal University of Sao Paulo Hospital, a 700-bed ter tiary care teaching hospital. Eligible physicians included medical residents and their preceptors. We excluded psychiatrists, radiologists, and ophthalmologists because they prescribe antimicrobial agents less often than do other physicians; we also excluded family practitioners because, at our institution, they do not routinely work at the hospital. The Health Belief Model was used as a framework to create the study questionnaire because this model was helpful in

understanding the role of background factors, individual perceptions (such as benets and barriers), and cues to action that explain and predict a behavioral outcome.9 The self-administered questionnaire consisted of 40 questions covering the following topics: experience with antimicrobial use; perceptions about the scope of antimicrobial resistance, the causes of antimicrobial resistance, and the possible barriers to compliance with infection control precautions; strategies for antimicrobial resistance prevention; and sources for information about antimicrobials. Most questions used a 5-point Likert scale, which included answers that ranged from strongly disagree to strongly agree or answers that ranged from never to always (Table). To assess knowledge of the scope of antimicrobial resistance at the hospital, physicians were asked to evaluate the prevalence of antimicrobial resistance for 3 specic pathogen-drug combinations (ie, Pseudomonas aeruginosa and carbapenem, Acinetobacter species and carbapenem, and Enterococcus species and vancomycin). Possible answers were low, moderate, high, and I dont know (Figure). The suggestions for the prevention of antimicrobial resistance that were presented in the survey were extracted from the documentation of the Centers for Disease Control and Prevention Campaign to Prevent Antimicrobial Resistance in Health-Care Settings, which included important strategies to improve the use of antimicrobials and prevent the development of antimicrobial resistance.10 Data about the individuals level of training, specialization, and length of time in clinical practice were also collected. A focus group was conducted with 5 randomly recruited participants to assess the overall clarity and cultural relevance of the questionnaire. A moderator (L.C.) and a cognitive behavioral psychologist (A.R.N.N.) facilitated the discussion. Renements to the instrument were made on the basis of comments from these participants. The investigator (C.M.G.) distributed the questionnaire to participants as they went about their daily activities, during the period from July 1 to September 30, the time of year when most medical residents are actively working at the hospital. Participants were asked to respond immediately. There was no personal relationship between the investigator and the respondents. Participants were assured that their identities and answers would be kept condential. Data were entered into Excel 2000 (Microsoft) and analyzed with SPSS software, version 10.0 (SPSS). The x2 test, Fisher exact test, or Person correlation coefcient were calculated, as appropriate. A P value less than .05 was considered statistically signicant.

re s u l t s
A total of 310 physicians answered the questionnaire; 33 respondents were preceptors and 277 were medical residents

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table.

Questions Used to Assess Inuences on Physicians Perceptions of Antimicrobial Resistance in a Brazilian Teaching Hospital Measure 5-point scalea

Topic, question Experience with use of antimicrobial drugs How many times did you prescribe an antimicrobial agent last semester? Perceptions of the scope of antimicrobial resistance What do you think about antimicrobial resistance? Do you believe it is a worldwide problem? Do you believe it is a countrywide problem? Do you believe it is a problem in your daily practice? Do you believe that physicians prescribe antimicrobials more than necessary? Causes of antimicrobial resistance and possible barriers to compliance with infection control precautions Inappropriate antimicrobial therapyb Physicians lack of knowledge about antimicrobial resistance Physicians lack of knowledge about antimicrobial use High workload Noncompliance with infection control precautions Lack of routine hospital cleaning Lack of physical structure and equipment Suggestions for prevention of antimicrobial resistance Campaigns about prevention of antimicrobial resistance Healthcare personnel education about infection control practices Physician education about antimicrobial therapy Knowledge about pathogens and antimicrobial susceptibility test results Vaccination of inpatients and healthcare personnel Removing catheters when not essential Targeting antimicrobial therapy to likely pathogens and obtaining local antibiotic resistance proles Consulting with ID experts Practicing antimicrobial control Breaking the chain of contagion Treating infection, not contamination or colonization Sources for information about antimicrobials Personal digital assistant and/or pocket-sized book Colleagues suggestions Infectious diseases consultation Local guidelines International guidelines
a b

It isnt 5-point 5-point 5-point 5-point

a problem, it is a problem, or I dont know scale from strongly disagree to strongly agree scale from strongly disagree to strongly agree scale from strongly disagree to strongly agree scale from strongly disagree to strongly agree

5-point 5-point 5-point 5-point 5-point 5-point 5-point Rank Rank Rank Rank

scale scale scale scale scale scale scale

from from from from from from from

strongly strongly strongly strongly strongly strongly strongly

disagree disagree disagree disagree disagree disagree disagree

to to to to to to to

strongly strongly strongly strongly strongly strongly strongly

agree agree agree agree agree agree agree

importancec importancec importancec importancec

Rank importancec Rank importancec Rank importancec

Rank Rank Rank Rank

importancec importancec importancec importancec scale scale scale scale scale from from from from from never never never never never to to to to to always always always always always

5-point 5-point 5-point 5-point 5-point

Never, less than once per month, more than once per month, more than once per week, or every day. Inappropriate timing, dosage, route, and/or duration. c From this list of 11 strategies for preventing antimicrobial resistance, respondents were asked to choose the 2 strategies they believed to be most important and 1 strategy that they believed to be less important.

(accounting for 75.0% of 369 eligible medical residents). Sixty-four percent of respondents had less than 3 years of medical practice, and 63.5% were internists. Nearly half (52.0%) of respondents reported prescribing antimicrobials more than once per week during the past 6 months. Preceptors responses indicated that they prescribed antimicrobial agents more often than did internists (P ! .001), and internists prescribed antimicrobials more often than did surgeons (P ! .05). Most (86.7%) of the participants

agreed or strongly agreed that physicians prescribe antimicrobials more often than necessary. The accuracy of physicians estimates of the prevalence of antimicrobial resistance for 3 pathogen-drug combinations is depicted in the Figure. Nearly all physicians (99.0%) declared that they perceived antimicrobial resistance to be an important problem. When asked about the scope of the problem, 97.0% of respondents agreed or strongly agreed that antimicrobial resistance was a worldwide problem, 98.0% agreed

perceptions of antimicrobial resistance in brazil

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lines (45.9% of respondents); 36.7% reported that they seek input from colleagues, an answer that was signicantly more common among surgeons than among internists (P p .005).

discussion
Our survey demonstrated that most physicians (99.0%) in a Brazilian teaching hospital were aware of and concerned about antimicrobial resistance, and there were no signicant differences in their perceptions about antimicrobial resistance being a problem worldwide, countrywide, and in their own institution. These results differed from those of Wester et al.,7 in which 87% of respondents agreed that antimicrobial resistance was a countrywide problem, but only 55% believed that their own hospital faced the problem. A large number of participants in our study believed that physicians prescribe antimicrobials more often than necessary (86.7% of respondents agreed or strongly agreed with this statement), and they perceived the role of inappropriate antimicrobial use as an important cause of the emergence of antimicrobial resistance (97.7% of respondents agreed or strongly agreed that this was a cause), but only 2.9% of them chose practicing antimicrobial control as 1 of the 2 most important strategies for preventing the emergence of resistance. This nding shows a lack of understanding among physicians about the importance of our antimicrobial stewardship program, which is administered by a multidisciplinary team that has been working in the hospital since 1989. Our program is based on antimicrobial order forms combined with prior approval, education, and formulary restriction. The prescribing physician is asked to identify the indication, the dose, and the duration of administration, as well as the suspected pathogen and the site of infection. This program is part of the medical residence training. Most physicians underestimated the prevalence of antimicrobial resistance for 3 pathogen-drug combinations, and almost 20.2% of the respondents reported that they did not know about the prevalence of antimicrobial resistance for these 3 pathogen-drug combinations in the hospital (Figure). Perhaps this is the reason why 30.3% of respondents ranked knowing pathogens and antimicrobial susceptibility test results as 1 of the 2 most important strategies for preventing the development of antimicrobial resistance. The prevention strategy physician education about antimicrobial therapy was ranked as 1 of the 2 most important strategies by 44.2% of respondents. Srinivasan et al.6 found a similar result; in that study, 90% of respondents stated that they wanted more education on antimicrobials. This study suggests that, to prevent the development of antimicrobial resistance, we should further promote educational activities about antimicrobial therapy, create innovative strategies to attract physicians attention to campaigns about antimicrobial resistance prevention, and distribute guidelines in pocket book format. Furthermore, it showed the impor-

gure. Percentage of physicians in a Brazilian teaching hospital selecting an evaluation level for 3 pathogen-drug combinations (data on correct answers supplied by the infection control team at the Federal University of Sao Paulo Hospital from 2004 to 2005).

or strongly agreed that it was a countrywide problem, and 93.0% agreed or strongly agreed that it was a problem in their own practices. When asked about the important causes of antimicrobial resistance, 97.7% of respondents agreed or strongly agreed that inappropriate antimicrobial therapy was a cause, 90.0% agreed or strongly agreed that noncompliance with infection control precautions was a cause, and 86.1% agreed or strongly agreed that physicians lack of knowledge about antimicrobial use was a cause. Given a list of 11 possible strategies for preventing antimicrobial resistance, participants were asked to indicate what they believed to be the 2 most important strategies and to choose 1 strategy that they felt was less important. The strategy rated as 1 of the 2 most important by the largest percentage of respondents was physician education about antimicrobial therapy (selected by 44.2% of respondents), followed by knowing pathogens and antimicrobial susceptibility test results (30.3% of respondents). Practicing antimicrobial control was rated as 1 of the 2 most important strategies by 2.9% of participants. On the other hand, campaigns about antimicrobial resistance prevention was the strategy rated as less important by the largest percentage of respondents (73.9%). Physicians reported using a wide variety of resources for information about antimicrobials, including pocket books (reported by 73.0% of respondents) and international guide-

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tance of improving access to the results of local antimicrobial susceptibility tests and targeting this information at physicians, because there is currently no feedback to the staff about the local resistance trends at our institution. This study has some limitations. First, preceptorship is a volunteer job at our institution, and there is no ofcial registry of preceptors; therefore, questionnaires were distributed only to those whom the investigator encountered during their routine service hours at the hospital. As the total number of preceptors is not available, we cannot indicate the percentage of the total represented by those who responded to the survey. In addition, this study included only 1 institution and may not represent the opinions of Brazilian physicians overall. Our study highlights important information about the knowledge, attitudes, and beliefs of physicians with respect to antimicrobial resistance that may be used to tailor interventions that aim at improving antimicrobial use in hospitals.

2007 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2007/2812-0019$15.00. DOI: 10.1086/523278

re f e re n c e s
1. Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis 2006; 42(suppl 2):S82-S89. 2. Dellit TH, Owens RC, Mcgowan JE, 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; 44:159-177. 3. Kollef MH, Micek ST. Strategies to prevent antimicrobial resistance in the intensive care unit. Crit Care Med 2005; 33:1845-1853. 4. Ward MA, Diekema DJ, Yankey JW, et al. Implementation of strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in US hospitals. Infect Control Hosp Epidemiol 2005; 26:21-30. 5. Brinsley KJ, Sinkowitz-Cochran RL, Cardo DM, et al. Assessing motivation for physicians to prevent antimicrobial resistance in hospitalized children using the Health Belief Model as a framework. Am J Infect Control 2005; 33:175-181. 6. Srinivasan A, Song X, Richards A, Sinkowitz-Cochran RL, Cardo DM, Rand CA. A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med 2004; 164:1451-1456. 7. Wester CW, Durauraj L, Evans AT, Schwartz DN. Antibiotic resistance. Arch Intern Med 2002; 162:2210-2216. 8. Giblin TB, Sinkowitz-Cochran RL, Cardo DM, Jacobs S. Clinicians perceptions of the problem of antimicrobial resistance in health care facilities. Arch Intern Med 2004; 164:1662-1668. 9. Janz NK, Champion VL, Strecher VJ. The Health Belief Model. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research and Practice. 3rd ed. San Francisco: Jossey-Bass, 2002: 45-66. 10. Centers for Disease Control and Preventions campaign to prevent antimicrobial resistance in health-care settings. MMWR Morb Mortal Wkly Rep 2002; 51:343.

acknowledgments
Potential conicts of interest. All authors report no conicts of interest relevant to this article.

From the Federal University of Sao Paulo, Brazil (C.M.G., C.A.P.P., A.R.N.N., L.C.); and the Centers for Disease Control and Prevention, Atlanta, Georgia (D.M.C.). Address reprint requests to Carla Morales Guerra, MD, Division of Infectious Diseases, Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil, Rua Napoleao de Barros, 7157 andarVila Clementino, Sao Paulo SP 04024-002 Brazil (carla.ccih@gmail.com). Presented in part: 17th Annual Scientic Meeting of the Society for Healthcare Epidemiology of America; Baltimore, MD; April 14-17, 2007 (Abstract 276). Received May 18, 2007; accepted August 3, 2007; electronically published October 12, 2007.

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