Are Clinicians Responsible for the Development of Antibiotic Resistance at a Tertiary Health Care Hospital? A Qualitative Study from Outlook of Doctors.

Dear Sir,

Emergence of antibiotic resistance (AR) is a complex natural biological phenomenon and it is caused by various factors, particularly the use and misuse of antimicrobials. In India, antibiotics are prescribed extensively in community as well as in hospital settings by primary care physicians and multiple publications have documented the irrational prescribing patterns in various settings.[1] To prevent the emergence and spread of antimicrobial resistance optimal utilization of antibiotics is required.[2] With no newer antibiotics coming in the last thirty years the doctors at tertiary health-care centers is facing an unprecedented challenge to save the patients. Limited literature is available regarding the antimicrobial resistance from clinician point of view from our country.

A qualitative study was conducted between December 2019 and March 2020 in the Urology department of a tertiary medical college in Eastern India to explore the clinician's perception, their role and the various factors responsible for AR and to find out the perceived solutions to this menace. In-depth face-to-face interviews[3] of 28 residents, including those from medical, surgical, gynecology, urology, pediatric surgery, critical care, and three three focused group discussions (FGDs) involving a total of 32 residents of different streams of the institute were conducted. All interviews were conducted in a free-flowing manner, mostly in English, with minimal intervention from the interviewer or moderator to identify. Maximum emerging themes until a saturation level was achieved. The data analysis was performed manually by deductive approach.[4] Descriptive “codes” of the text information were made. The consolidated criteria for reporting qualitative research guidelines were followed.[5]

Most admitted the overuse of antibiotics in their departments and lack of any standard institutional protocol. Most of the doctors follow Center for Disease Control and prevention Atlanta guideline and urologists follow American Urology Association/European Urology Association guidelines regarding the use of combination antibiotics. All doctors in this center used the antibiotics based on culture and sensitivity. While the surgeons usually gave antibiotics 01 day before and up to 05 days after surgery. Physicians always looked for clinical response to decide the duration of antibiotic use. Various factors identified for the AR were: easy availability and sale of over-the-counter drugs without any regulation or supervision in India, primary management of patients by unqualified practitioners due to shortage of doctors in rural areas, absence of standard institutional or country wise antibiotic protocol/policy, patient demand for quick recovery, poor compliance and nonadherence of the patients. Common Gram-positive and Gram-negative bacteria were resistant to most commonly prescribed antibiotics.

Following were suggested to tackle the problem of AR: immediate stoppage of over-the-counter sale of broad spectrum antibiotics, mass media, handouts, and posters to create awareness among people; good quality of culture, and sensitivity reports in the hospitals and promotion of institutional antibiotic protocols based on these; maintaining the electronic health records of all previously admitted patients in hospitals; training and raising awareness among the unqualified practitioners regarding detrimental effect of inappropriate antibiotic prescriptions. This is the one of the few Indian qualitative study of tertiary care clinicians' views about AR. It defines which factors doctors perceive as causative and their apparent solutions to this menace which include legislative action, funding, and public policy strategies. Contrary to the popular belief of Western health-care model in which the clinicians are made responsible for irrational use of antibiotics, here we get a different perspective regarding role of patients and unqualified practitioners contributing to this alarming situation in India which should definitely be kept in mind while forming the future regulations to solve this crisis.

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Conflicts of interest

There are no conflicts of interest.