Physicians’ Perceptions, Beliefs, Attitudes, and Knowledge Concerning AntimicrobialResistance in a Brazilian Teaching Hospital • Author(s): Carla Morales Guerra , MD; Carlos Alberto Pires Pereira , MD;Armando R. Neves Neto , MSc; Denise Mary Cardo , MD; Luci Correa , MDSource: Infection Control and Hospital Epidemiology, Vol. 28, No. 12 (December 2007), pp.1411-1414Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/523278 .

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infection control and hospital epidemiology december 2007, vol. 28, no. 12

c o n c i s e c o m m u n i c a t i o n

Physicians’ Perceptions, Beliefs,Attitudes, and Knowledge ConcerningAntimicrobial Resistance in a BrazilianTeaching 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, knowl-edge and practices concerning antimicrobial resistance. Ninety-ninepercent of participants reported that they perceived antimicrobialresistance as an important problem, and 86.7% agreed that anti-microbials are overprescribed, but only 2.9% rated “practicing an-timicrobial control” as the most important strategy for preventingresistance. The results of this study warrant educational programson antimicrobial resistance and the distribution of information re-garding local antimicrobial susceptibility testing.

Infect Control Hosp Epidemiol 2007; 28:1411-1414

Antimicrobial-resistant pathogens have become a threat topatients and have increased health care costs.1 Noncompli-ance with infection control precautions and the inappropriateuse of antimicrobial agents have been identified as the mainrisk factors for the emergence of antimicrobial resistance.2-4

Interventions to prevent and control antimicrobial resis-tance usually include behavior changes, and the process ofbringing about these changes is affected by the beliefs andmotivations of target groups.3-5 Previous surveys have beenconducted to assess both physicians’ knowledge and theirattitudes concerning antimicrobial use and antimicrobial re-sistance.5-8 However, little is known about how physicians inBrazilian hospitals perceive the problem of antimicrobial re-sistance. The aim of this study was to assess the knowledge,beliefs, and practices of physicians in a Brazilian teachinghospital with respect to the use of antimicrobial drugs andantimicrobial resistance.

methods

We conducted a cross-sectional survey among physicians atthe Federal University of Sao Paulo Hospital, a 700-bed ter-tiary care teaching hospital. Eligible physicians included med-ical residents and their preceptors. We excluded psychiatrists,radiologists, and ophthalmologists because they prescribe an-timicrobial agents less often than do other physicians; we alsoexcluded family practitioners because, at our institution, theydo not routinely work at the hospital.

The Health Belief Model was used as a framework to createthe study questionnaire because this model was helpful in

understanding the role of background factors, individual per-ceptions (such as benefits and barriers), and cues to actionthat explain and predict a behavioral outcome.9

The self-administered questionnaire consisted of 40 ques-tions covering the following topics: experience with antimi-crobial use; perceptions about the scope of antimicrobial re-sistance, the causes of antimicrobial resistance, and thepossible barriers to compliance with infection control pre-cautions; strategies for antimicrobial resistance prevention;and sources for information about antimicrobials. Most ques-tions used a 5-point Likert scale, which included answers thatranged from “strongly disagree” to “strongly agree” or an-swers that ranged from “never” to “always” (Table).

To assess knowledge of the scope of antimicrobial resistanceat the hospital, physicians were asked to evaluate the prev-alence of antimicrobial resistance for 3 specific pathogen-drugcombinations (ie, Pseudomonas aeruginosa and carbapenem,Acinetobacter species and carbapenem, and Enterococcus spe-cies and vancomycin). Possible answers were “low,” “mod-erate,” “high,” and “I don’t know” (Figure).

The suggestions for the prevention of antimicrobial resis-tance that were presented in the survey were extracted fromthe documentation of the Centers for Disease Control andPrevention Campaign to Prevent Antimicrobial Resistance inHealth-Care Settings, which included important strategies toimprove the use of antimicrobials and prevent the develop-ment of antimicrobial resistance.10 Data about the individual’slevel of training, specialization, and length of time in clinicalpractice were also collected.

A focus group was conducted with 5 randomly recruitedparticipants to assess the overall clarity and cultural relevanceof the questionnaire. A moderator (L.C.) and a cognitivebehavioral psychologist (A.R.N.N.) facilitated the discussion.Refinements to the instrument were made on the basis ofcomments from these participants.

The investigator (C.M.G.) distributed the questionnaire toparticipants as they went about their daily activities, duringthe period from July 1 to September 30, the time of yearwhen most medical residents are actively working at the hos-pital. Participants were asked to respond immediately. Therewas no personal relationship between the investigator and therespondents. Participants were assured that their identitiesand answers would be kept confidential.

Data were entered into Excel 2000 (Microsoft) and ana-lyzed with SPSS software, version 10.0 (SPSS). The x2 test,Fisher exact test, or Person correlation coefficient were cal-culated, as appropriate. A P value less than .05 was consideredstatistically significant.

results

A total of 310 physicians answered the questionnaire; 33 re-spondents were preceptors and 277 were medical residents

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1412 infection control and hospital epidemiology december 2007, vol. 28, no. 12

table. Questions Used to Assess Influences on Physicians’ Perceptions of Antimicrobial Resistance in a Brazilian Teaching Hospital

Topic, question Measure

Experience with use of antimicrobial drugsHow many times did you prescribe an antimicrobial agent

last semester?5-point scalea

Perceptions of the scope of antimicrobial resistanceWhat do you think about antimicrobial resistance? “It isn’t a problem,” “it is a problem,” or “I don’t know”Do you believe it is a worldwide problem? 5-point scale from “strongly disagree” to “strongly agree”Do you believe it is a countrywide problem? 5-point scale from “strongly disagree” to “strongly agree”Do you believe it is a problem in your daily practice? 5-point scale from “strongly disagree” to “strongly agree”Do you believe that physicians prescribe antimicrobials more

than necessary?5-point scale from “strongly disagree” to “strongly agree”

Causes of antimicrobial resistance and possible barriers tocompliance with infection control precautions

Inappropriate antimicrobial therapyb 5-point scale from “strongly disagree” to “strongly agree”Physician’s lack of knowledge about antimicrobial resistance 5-point scale from “strongly disagree” to “strongly agree”Physician’s lack of knowledge about antimicrobial use 5-point scale from “strongly disagree” to “strongly agree”High workload 5-point scale from “strongly disagree” to “strongly agree”Noncompliance with infection control precautions 5-point scale from “strongly disagree” to “strongly agree”Lack of routine hospital cleaning 5-point scale from “strongly disagree” to “strongly agree”Lack of physical structure and equipment 5-point scale from “strongly disagree” to “strongly agree”

Suggestions for prevention of antimicrobial resistanceCampaigns about prevention of antimicrobial resistance Rank importancec

Healthcare personnel education about infection control practices Rank importancec

Physician education about antimicrobial therapy Rank importancec

Knowledge about pathogens and antimicrobial susceptibilitytest results

Rank importancec

Vaccination of inpatients and healthcare personnel Rank importancec

Removing catheters when not essential Rank importancec

Targeting antimicrobial therapy to likely pathogens andobtaininglocal antibiotic resistance profiles

Rank importancec

Consulting with ID experts Rank importancec

Practicing antimicrobial control Rank importancec

Breaking the chain of contagion Rank importancec

Treating infection, not contamination or colonization Rank importancec

Sources for information about antimicrobialsPersonal digital assistant and/or pocket-sized book 5-point scale from “never” to “always”Colleagues’ suggestions 5-point scale from “never” to “always”Infectious diseases consultation 5-point scale from “never” to “always”Local guidelines 5-point scale from “never” to “always”International guidelines 5-point scale from “never” to “always”

a “Never,” “less than once per month,” “more than once per month,” “more than once per week,” or “every day.”b 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 importantand 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 ofmedical practice, and 63.5% were internists.

Nearly half (52.0%) of respondents reported prescribingantimicrobials more than once per week during the past 6months. Preceptors’ responses indicated that they prescribedantimicrobial agents more often than did internists (P !

), and internists prescribed antimicrobials more often.001than did surgeons ( ). Most (86.7%) of the participantsP ! .05

agreed or strongly agreed that physicians prescribe antimi-crobials more often than necessary.

The accuracy of physicians’ estimates of the prevalence ofantimicrobial resistance for 3 pathogen-drug combinations isdepicted in the Figure. Nearly all physicians (99.0%) declaredthat they perceived antimicrobial resistance to be an impor-tant problem. When asked about the scope of the problem,97.0% of respondents agreed or strongly agreed that anti-microbial resistance was a worldwide problem, 98.0% agreed

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perceptions of antimicrobial resistance in brazil 1413

figure. Percentage of physicians in a Brazilian teaching hospitalselecting an evaluation level for 3 pathogen-drug combinations (dataon correct answers supplied by the infection control team at theFederal University of Sao Paulo Hospital from 2004 to 2005).

or strongly agreed that it was a countrywide problem, and93.0% agreed or strongly agreed that it was a problem intheir own practices. When asked about the important causesof antimicrobial resistance, 97.7% of respondents agreed orstrongly agreed that inappropriate antimicrobial therapy wasa cause, 90.0% agreed or strongly agreed that noncompliancewith infection control precautions was a cause, and 86.1%agreed or strongly agreed that physicians’ lack of knowledgeabout antimicrobial use was a cause.

Given a list of 11 possible strategies for preventing anti-microbial resistance, participants were asked to indicate whatthey believed to be the 2 most important strategies and tochoose 1 strategy that they felt was less important. The strat-egy rated as 1 of the 2 most important by the largest per-centage of respondents was “physician education about an-timicrobial therapy” (selected by 44.2% of respondents),followed by “knowing pathogens and antimicrobial suscep-tibility test results” (30.3% of respondents). “Practicing an-timicrobial control” was rated as 1 of the 2 most importantstrategies by 2.9% of participants. On the other hand, “cam-paigns about antimicrobial resistance prevention” was thestrategy rated as less important by the largest percentage ofrespondents (73.9%).

Physicians reported using a wide variety of resources forinformation about antimicrobials, including pocket books(reported by 73.0% of respondents) and international guide-

lines (45.9% of respondents); 36.7% reported that they seekinput from colleagues, an answer that was significantly morecommon among surgeons than among internists ( ).P p .005

discussion

Our survey demonstrated that most physicians (99.0%) in aBrazilian teaching hospital were aware of and concernedabout antimicrobial resistance, and there were no significantdifferences in their perceptions about antimicrobial resistancebeing a problem worldwide, countrywide, and in their owninstitution. These results differed from those of Wester et al.,7

in which 87% of respondents agreed that antimicrobial re-sistance was a countrywide problem, but only 55% believedthat their own hospital faced the problem.

A large number of participants in our study believed thatphysicians prescribe antimicrobials more often than necessary(86.7% of respondents agreed or strongly agreed with thisstatement), and they perceived the role of inappropriate an-timicrobial use as an important cause of the emergence ofantimicrobial resistance (97.7% of respondents agreed orstrongly agreed that this was a cause), but only 2.9% of themchose “practicing antimicrobial control” as 1 of the 2 mostimportant strategies for preventing the emergence of resis-tance. This finding shows a lack of understanding amongphysicians about the importance of our antimicrobial ste-wardship program, which is administered by a multidisci-plinary team that has been working in the hospital since 1989.Our program is based on antimicrobial order forms combinedwith 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 thesuspected pathogen and the site of infection. This programis part of the medical residence training.

Most physicians underestimated the prevalence of anti-microbial resistance for 3 pathogen-drug combinations, andalmost 20.2% of the respondents reported that they did notknow about the prevalence of antimicrobial resistance forthese 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 re-sults” as 1 of the 2 most important strategies for preventingthe development of antimicrobial resistance.

The prevention strategy “physician education about anti-microbial therapy” was ranked as 1 of the 2 most importantstrategies by 44.2% of respondents. Srinivasan et al.6 founda similar result; in that study, 90% of respondents stated thatthey wanted more education on antimicrobials.

This study suggests that, to prevent the development ofantimicrobial resistance, we should further promote educa-tional activities about antimicrobial therapy, create innovativestrategies to attract physicians’ attention to campaigns aboutantimicrobial resistance prevention, and distribute guidelinesin pocket book format. Furthermore, it showed the impor-

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1414 infection control and hospital epidemiology december 2007, vol. 28, no. 12

tance of improving access to the results of local antimicrobialsusceptibility tests and targeting this information at physi-cians, because there is currently no feedback to the staff aboutthe local resistance trends at our institution.

This study has some limitations. First, preceptorship is avolunteer job at our institution, and there is no official reg-istry of preceptors; therefore, questionnaires were distributedonly to those whom the investigator encountered during theirroutine service hours at the hospital. As the total number ofpreceptors is not available, we cannot indicate the percentageof the total represented by those who responded to the survey.In addition, this study included only 1 institution and maynot represent the opinions of Brazilian physicians overall.

Our study highlights important information about theknowledge, attitudes, and beliefs of physicians with respectto antimicrobial resistance that may be used to tailor inter-ventions that aim at improving antimicrobial use in hospitals.

acknowledgments

Potential conflicts of interest. All authors report no conflicts of interest rel-evant 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 In-fectious Diseases, Department of Medicine, Federal University of Sao Paulo,Sao Paulo, Brazil, Rua Napoleao de Barros, 715—7 andar—Vila Clementino,Sao Paulo SP 04024-002 Brazil (carla.ccih@gmail.com).

Presented in part: 17th Annual Scientific Meeting of the Society for Health-care Epidemiology of America; Baltimore, MD; April 14-17, 2007 (Abstract276).

Received May 18, 2007; accepted August 3, 2007; electronically publishedOctober 12, 2007.

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

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