Journal of Global Antimicrobial Resistance 4 (2016) 2127

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Journal of Global Antimicrobial Resistance

journal homepage: www.elsevier.com/locate/jgar

Administration of a survey to evaluate the attitudes of house staff

physicians towards antimicrobial resistance and the antimicrobial
stewardship programme at a community teaching hospital
Veena Venugopalan a,b,1, Nathan Trustman c,2, Nyla Manning b,d, Nehal Hashem b,e,
Leonard Berkowitz b,3, Levita Hidayat f,g,*
a
Scripps La Jolla, 9888 Genesee Avenue, La Jolla, CA 92037, USA
b
The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
c
Long Island University, 1 University Plaza, Brooklyn, NY 11201, USA
d
SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
e
Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
f
Touro College of Pharmacy, 230 West 125th Street, New York, NY 10027, USA
g
The Medicines Company, 8 Sylvan Way, Parsippany, NJ 07054, USA

A R T I C L E I N F O A B S T R A C T

Article history: Antimicrobial stewardship programmes (ASPs) are used in numerous institutions in an effort to promote
Received 15 October 2015 safe and effective antimicrobial use. The objectives of this study were to (i) assess physicians
Received in revised form 14 January 2016 perceptions, attitudes and knowledge about antimicrobial use, resistance and the ASP at The Brooklyn
Accepted 18 January 2016
Hospital Center (TBHC) and (ii) measure physicians beliefs and attitudes to the current system of prior
Available online 8 February 2016
authorisation of antimicrobials. A 75-item, anonymous, voluntary, traditional paper and pencil survey
was distributed to resident physicians at TBHC. Multiple-choice, 5-point Likert scale and knowledge-
Keywords:
based questions were utilised. Of the 261 residents, 129 (49%) completed the survey. The respondents
Survey
signicantly believed that antibiotics are overused more frequently nationally vs. locally [117/129 (91%)
Antimicrobial stewardship
Prior authorisation vs. 91/129 (71%); P = 0.0001]. Although 49% (63/129) felt that other providers overprescribe antibiotics,
Attitudes only 26% (34/129) agreed that they themselves were contributing to the current problem (P = 0.0003).
Perceptions Fifty-seven percent of respondents agreed that individual patient care is improved by having an
antibiotic approval programme; however, 45% of respondents reported that the antibiotic approval
programme limits their autonomy in choosing antibiotics. Compared with surgical residents, medical
residents were more likely (33% vs. 13%; P = 0.02) to feel that the antibiotic approval programme forced
them to choose an inappropriate antibiotic. On the antibiotic knowledge assessment segment of the
survey, there was no difference in score when stratied by specialty or years of postgraduate training.
Based on the survey results, house staff are supportive of antimicrobial stewardship and feel that the ASP
is valuable for patient care.
2016 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All
rights reserved.

1. Introduction

According to the US Centers for Disease Control and Prevention

(CDC), antimicrobial resistance has become increasingly problem-
* Corresponding author. Present address: The Medicines Company, 8 Sylvan Way,
Parsippany, NJ 07054, USA. Tel.: +1 626 841 9242.
atic and is on the rise [1]. Studies have noted that ca. 30% of days of
E-mail address: Lkhidayat@gmail.com (L. Hidayat). antimicrobial therapy may be deemed unnecessary [24]. Antimi-
1
Present address: Department of Pharmacy, Scripps Green Hospital, 10666 N. crobial stewardship programmes (ASPs) have been shown to
Torrey Road, La Jolla, CA 92037, USA. improve antimicrobial use and to reduce antimicrobial resistance,
2
Present address: Department of Pharmacy, Coney Island Hospital, 2601 Ocean
mortality, hospital length of stay and healthcare costs [5]. The
Pkwy, Brooklyn, NY 11235, USA.
3
Present address: Division of Infectious Diseases, Medical Director, PATH Center, Infectious Diseases Society of America (IDSA) and the Society for
Department of Internal Medicine, 121 DeKalb Avenue, Brooklyn, NY 11201, USA. Healthcare Epidemiology of America (SHEA) advocate the

http://dx.doi.org/10.1016/j.jgar.2016.01.004
2213-7165/ 2016 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All rights reserved.
22 V. Venugopalan et al. / Journal of Global Antimicrobial Resistance 4 (2016) 2127
implementation of ASPs and appropriate infection prevention and
control strategies in order to provide patients with safe and
effective therapy and limit the emergence of resistant pathogens
[6]. Institutions have implemented ASPs in an effort to promote the
judicious use of antimicrobial agents. The IDSA/SHEA guidelines
for developing an institutional programme to enhance antimicro-
bial stewardship outlined two core strategies for ASP practice,
namely (i) prospective review with intervention and feedback and
(ii) formulary restriction with prior authorisation (PA) [6]. Supple-
ments to these core ASP strategies include education, guidelines
and clinical pathways implementation, antimicrobial cycling,
antimicrobial order forms, combination therapy, streamlining
and de-escalation of therapy, dose optimisation, and parenteral-to-
oral conversion. Implementing multiple strategies has been shown
to be effective in the hospital setting in reducing antimicrobial
overuse and improving physicians antimicrobial knowledge
[7,8]. Peto et al. evaluated patients with bloodstream infections
and found that mean antimicrobial consumption was signicantly
reduced following a stewardship intervention [8]. The intervention
included formulary restriction and authorisation allowing only
intensive care unit consultants to prescribe antimicrobials.
Physicians perceptions of antimicrobial use and resistance
and ASPs have been shown to vary from institution to institution
[915]. Studies noted that while physicians agree that antimicro-
bials are overused on a national scale, they do not agree that
antimicrobials are overused at their own institution [9,14]. Simi-
larly, surveys taken by house staff physicians with regard to
antimicrobial resistance suggest that more physicians agree that
antimicrobial resistance is a national issue rather than a local one
[1012]. Overall, formal education of physicians on antimicrobials
in an effort to prevent antimicrobial resistance and overuse has
been well received [1114]. However, the varying degree of
antimicrobial knowledge among specialties presents a challenge in
identifying strategies to focus educational efforts [14].
Whilst a literature search revealed few studies that evaluated
physicians opinions of PA-based ASPs, these have all been
conducted in large academic institutions, therefore house staff
attitudes of stewardship practice and antimicrobial resistance in
smaller community-based facilities is unknown [15,16]. The
objectives of this study were (i) to assess the perceptions, attitudes
and knowledge of physicians about antimicrobial use, resistance
and the ASP at The Brooklyn Hospital Center (TBHC) (Brooklyn, NY)
and (ii) to measure the beliefs and attitudes of physicians regarding
the current system of PA of antimicrobials. Obtaining this
information will be critical in enhancing the effectiveness of the
ASP in training physicians on the appropriate use of antimicrobials.
2. Method
2.1. Survey instrument and administration
The study was conducted at TBHC from November 2012 through
July 2013. House staff employed by the institution (n = 261) were
allowed to participate. A 75-item, voluntary, anonymous, tradi-
tional paper and pencil survey was utilised. A survey instrument
based on two previously published studies on physicians
attitudes, beliefs and knowledge on antimicrobial use and
resistance was developed [9,16]. The rst survey was originally
developed by Abbo et al. and the Get Smart for Healthcare program
of the CDCs Division of Healthcare Quality Promotion [9] and the
second was created by Seemugal and Bruno [16]. Permission to use
these surveys was granted by the corresponding authors.
The survey consisted of four major sections: (i) demographics;
(ii) educational sources relating to antimicrobials; (iii) antimicro-
bial perceptions and attitudes; and (iv) attitudes towards the ASP.
Demographic information included an estimation of the number of
antimicrobial agents prescribed in the past 6 months, years since
graduating from medical school, year of residency/fellowship if
applicable, area of specialty and years since graduating from that
specialty. Questions regarding antimicrobial education sources
and antimicrobial perceptions and attitudes consisted of a
combination of standard multiple-choice questions and those
utilising a 5-point Likert scale with responses that ranged from
strongly agree to strongly disagree, always to never, or always
useful to never useful. The survey concluded with ten knowl-
edge-based questions that were obtained from a previously
conducted survey with permission from the author [9].
Following Institutional Review Board approval, the survey was
distributed at various physician conferences. Completion of the
survey served to indicate a participants consent to participate in
the study. An incentive in the form of a $5 gift card was provided
upon completion of the survey.
2.2. Setting and antimicrobial stewardship programme
TBHC is a 416-bed community teaching facility in Brooklyn, NY.
An ASP was established at TBHC in 2005 using a PA strategy that
required prescribers to obtain approval from a member of the
stewardship team before restricted antibiotics are dispensed. A
previously conducted audit of the programme revealed that the
most common antibiotic approvals were for vancomycin (72%),
piperacillin/tazobactam (27%) and cefepime (24%). The indications
for which antibiotics were most frequently requested for were skin
and soft-tissue infections (60%) and pneumonia (23%). In 49% of
patients, restricted antibiotics were initiated empirically without
an established source of infection. Forty-ve percent of interven-
tions performed by the ASP involved therapeutic dose monitoring
combined with renal dose adjustment. Also, recommendations for
ordering laboratory tests and cultures to assess response to
treatment were made in 23% of cases.
The ASP team is comprised of two infectious diseases-trained
clinical pharmacists, ve PGY-1 and one infectious diseases PGY-2
pharmacy residents, one infectious diseases physician and one
clinical microbiologist. The pharmacy residents at TBHC partici-
pate in stewardship activities through a 24-h in-house on-call
programme.
Prescriber education and training performed by the ASP at TBHC
was developed based on the educational strategies described by
Pulcini et al. and include activities such as antimicrobial
stewardship-focused lectures, development of clinical pathways,
restrictive formulary with PA, and prospective audits with active
intervention on restricted antimicrobials [12].
2.3. Data analysis
Following distribution and collection of the survey from all
participants, data were organised and compiled. Demographic and
practice pattern data were recorded. Interns and upper-year
residents were compared based on the factors that inuenced their
antibiotic selection, their perceptions about antimicrobial use and
resistance, and their attitudes towards the ASP and the antimicro-
bial PA process at TBHC. Interspecialty perceptions were compared
based on their perceptions about antimicrobial use and resistance
and their attitudes towards the ASP and the antimicrobial PA
process at TBHC. Performance on the knowledge-based section
was compared between interns and upper-year residents and
between specialties (i.e. emergency medicine, internal medicine,
paediatrics, surgery, etc.).
The study objectives were analysed through univariate and
bivariate analyses. A x2 or Fishers exact test was performed for all
categorical variables and a Students t-test was performed for all
continuous variables. A P-value of 0.05 was considered to
 V. Venugopalan et al. / Journal of Global Antimicrobial Resistance 4 (2016) 2127 23

indicate signicance. Statistical analyses were performed using
GraphPad Prism v.6.0 (GraphPad Software Inc., San Diego, CA).
3. Results
3.1. Demographics
Of the 261 residents, 129 (49%) completed the survey. The
response was highest among rst-year interns with 45 (35%),
compared with 33 (26%) second-year, 27 (21%) in their third-year
and 24 (19%) in their fourth year or higher (Table 1). The two most
common specialties among the respondents were internal medi-
cine (54/129; 42%) and surgery (40/129; 31%).
3.2. Antimicrobial use and education
The majority of respondents (123/129; 95%) noted that they had
been involved in antibiotic prescribing in the past 6 months
and most of their clinical time was spent in the inpatient setting
(96/129; 74%). When asked about empirical antibiotic selection, the
majority of respondents preferred to start with broad-spectrum
therapy and tailor antibiotic regimens based upon culture results
(81/129; 63%). However, only 25 (19%) based their decision on the
hospital antibiogram and almost one-third (37/129; 29%) based
their decision on antibiotic resources such as The Sanford Guide to
Antimicrobial Therapy and UpToDate (Table 1).
The utility of various sources of antimicrobial continuing
education and information is summarised in Table 2. Overall,
infectious diseases colleagues and UpToDate were rated as the
most useful [105/129 (81%) and 104/129 (81%), respectively], and
pharmaceutical-sponsored off-campus lectures as the least useful
(30/129; 23%). Other resources used and found to be always or
often useful include the Sanford guide (68/129; 53%), grand rounds
(71/129; 55%), case conference (73/129; 57%) and ward rotations
(84/129; 65%).
Almost all respondents agreed that strong knowledge of
antibiotics is critical for their medical career (121/129; 94%)
(Table 3). In addition, the majority of respondents were in
agreement that they would like more education on antibiotics
and would like feedback on their antibiotic selections [107/129
(83%) and 104/129 (81%), respectively] (Table 3).
3.3. Attitudes about resistance and antimicrobial use

Table 1 Factors inuencing respondents antibiotic prescribing are

Demographics and characteristics of respondents (N = 129). summarised in Table 4. Factors that most providers felt always
or often inuenced their antibiotic selection were the risk of
Characteristic Respondents
[n (%)]
missing an infection and if the patient is critically ill or
immunocompromised [93/129 (72%) and 107/129 (83%), respec-
Year of postgraduate training
tively] (Table 4). These two factors were also signicantly more
First 45 (35)
Second 33 (26) important in inuencing antibiotic selection for upper-year
Third 27 (21) residents compared with rst-year interns (P = 0.05). Cost savings
Fourth or higher 24 (19) for the hospital and for patients as well as the risk of developing
Area of specialtya Clostridium difcile colitis were not signicant inuencing factors
Anaesthesiology 2 (2) for antibiotic selection.
Critical care 3 (2) The perceptions of respondents about antibiotic use and
Emergency medicine 19 (15)
resistance are summarised in Table 3. Most respondents agreed
Hospitalist 2 (2)
Infectious diseases 2 (2) that antibiotics are overused, however the respondents signi-
Internal medicine 54 (42) cantly believed that antibiotics are more frequently overused
Paediatrics 9 (7) nationally vs. locally [117/129 (91%) vs. 91/129 (71%); P = 0.0001,
Surgery 40 (31) data not shown]. Upper-year residents were more signicantly in
Years of post-specialty trainingb agreement that antibiotics are overused both nationally and at
One 3 (2) TBHC compared with interns (P = 0.02 and P = 0.05, respectively).
Two There was no difference between upper-year residents and interns
Three 1 (1)
Four or higher 16 (12)
Not applicable/resident/fellow 103 (80)
Table 2
No. of involvements in antibiotic prescribing in the past 6 monthsb Utility of various antimicrobial continuing education sources (N = 129).a
0
16 4 (3) Educational source Not familiar Sometimes Often or
712 8 (6) or never [n (%)] always
1324 13 (10) useful or useful
>24 98 (76) rarely [n (%)]
[n (%)]
Clinical time is spent caring for:b
Inpatients 96 (74) Ward rotations 12 (9) 28 (22) 84 (65)
Outpatients 6 (5) Grand rounds 17 (13) 33 (26) 71 (55)
Approximately equal time between both 23 (18) Case/noon conference 16 (12) 29 (22) 73 (57)
Infectious diseases 5 (4) 16 (12) 105 (81)
Empirical antibiotic selection colleagues
I start with broad-spectrum and tailor upon culture results 81 (63) Pharmaceutical 27 (21) 33 (26) 63 (49)
I base my decision on the hospital antibiogram 25 (19) representatives
I base my decision on the antibiotic 37 (29) Off-campus lectures 48 (37) 32 (25) 30 (23)
resources (i.e. Sanford Guide, UpToDate) sponsored by
I ask my resident 12 (9) pharmaceutical
I ask my attending 16 (12) companies
I use the same one or two antibiotics 5 (4) CME online or live lectures 28 (22) 39 (30) 47 (36)
Otherc 5 (4) Medical journals 9 (7) 34 (26) 78 (60)
a Sanford guide 13 (10) 30 (23) 68 (53)
Multiple specialties for one respondent.
b UpToDate 4 (3) 15 (12) 104 (81)
Some respondents left this section blank.
c a
Others include based on history and physical (H&P), pharmacokinetic (PK) Percentage may not total 100 because of rounding and/or some respondents did
consult and infectious diseases consult. not complete the questionnaires.
24 V. Venugopalan et al. / Journal of Global Antimicrobial Resistance 4 (2016) 2127

Table 3
Agreement of respondents with statements regarding perceptions about antimicrobial use and resistance.

Perception All respondents Interns Upper-year P-value

(N = 129) [n (%)] (N = 45) [n (%)] residents
(N = 84) [n (%)]

Antibiotics are overused nationally 117 (91) 37 (82) 80 (95) 0.02

Antibiotics are overused at TBHC 91 (71) 27 (60) 64 (76) 0.05
Antibiotic resistance is not a signicant problem nationally 19 (15) 11 (24) 8 (10) 0.02
Antibiotic resistance is not a signicant problem at TBHC 12 (9) 6 (13) 6 (7) 0.2
Better use of antibiotics will reduce problems with antibiotic-resistant 114 (88) 37 (82) 77 (92) 0.14
organisms
Strong knowledge of antibiotics is important in my medical career 121 (94) 40 (89) 81 (96) 0.09
I am condent that I use antibiotics optimally outside the ICU 66 (51) 20 (44) 46 (55) 0.26
I am condent that I use antibiotics optimally in the ICU 67 (52) 18 (40) 49 (58) 0.04
I overprescribe antibiotics 34 (26) 15 (33) 19 (23) 0.19
Other doctors overprescribe antibiotics 63 (49) 20 (44) 43 (51) 0.46
I would like more feedback on my antibiotic selections 104 (81) 33 (73) 71 (85) 0.12
I would like more education on antibiotics 107 (83) 37 (82) 70 (83) 0.87
Interactions with pharmaceutical representatives do not inuence 66 (51) 19 (42) 47 (56) 0.14
my antibiotic selections
Locally developed guidelines for antibiotic treatment would be more 87 (67) 22 (49) 65 (77) 0.001
useful to me than national guidelines
I am concerned about antibiotic resistance in the community when 106 (82) 31 (69) 75 (89) 0.004
I prescribe antibiotics
I am concerned about antibiotic resistance in my hospital when 107 (83) 34 (76) 73 (87) 0.1
I prescribe antibiotics
New antibiotics will be developed in the future that will keep up 50 (39) 23 (51) 27 (32) 0.04
with the problem of resistance
Prescribing broad-spectrum antibiotics when there are equally 92 (71) 31 (69) 61 (73) 0.65
effective narrower-spectrum antibiotics increases antibiotic
resistance
Poor infection control practices by healthcare professionals causes 79 (61) 25 (56) 54 (64) 0.94
antibiotic resistance
Inappropriate use of antibiotics can harm patients 115 (89) 39 (87) 76 (90) 0.51
Inappropriate use of antibiotics is professionally unethical 90 (70) 31 (69) 59 (70) 0.9

TBHC, The Brooklyn Hospital Center; ICU, intensive care unit.

Table 4 when asked whether better use of antibiotics will reduce problems
Frequency distribution of respondents and factors inuencing their antibiotic
with antibiotic-resistant organisms [77/84 (92%) vs. 37/45 (82%);
selection (N = 129).
P = 0.14). When further stratied by specialty, surgical residents
Factor Never or Sometimes Often or P-value felt more strongly than internal medicine residents that resistance
rarely [n (%)] always
could be reduced with more appropriate antibiotic usage [38/40
[n (%)] [n (%)]
(95%) vs. 44/54 (81%); P = 0.05, data not shown].
Cost savings for patients 0.45 Overall, 49% (63/129) agreed that other providers overprescribe
Intern 12 (9) 20 (16) 13 (10)
antibiotics, however only 26% (34/129) felt that they themselves
Upper-year residents 17 (13) 37 (29) 29 (22)
overprescribe antibiotics (P = 0.0003). When further stratied by
Cost savings for the hospital 0.54 specialty, there was a trend for surgical residents to indicate that
Intern 16 (12) 17 (13) 12 (9)
Upper-year residents 41 (32) 25 (19) 18 (14)
other doctors overprescribe antibiotics compared with internal
medicine residents [21/40 (53%) vs. 19/54 (35%); P = 0.09, data not
Risk of missing an infection 0.05 shown]. Upper-year residents were signicantly more concerned
Intern 1 (1) 9 (7) 34 (26)
Upper-year residents 6 (5) 16 (12) 59 (46)
with antibiotic resistance in the community when they prescribed
antibiotics compared with interns [75/84 (89%) vs. 31/45 (69%);
Patient demands and expectations for antibiotics 0.13
P = 0.004]. A majority of the respondents agreed that locally
Intern 28 (22) 11 (9) 6 (5)
Upper-year residents 59 (46) 11 (9) 14 (11)
developed guidelines for antibiotic treatment would be more
useful to them than national guidelines (87/129; 67%). Upper-year
Patient is critically ill and/or immunocompromised 0.05
residents were more in favour of locally developed guidelines
Intern 2 (2) 6 (5) 37 (29)
Upper-year residents 3 (2) 9 (7) 70 (54) compared with interns [65/84 (77%) vs. 22/45 (49%); P = 0.001].
Whilst the majority of respondents agreed that inappropriate
Reassurance when using an antibiotic even if it might be the wrong 0.17
use of antibiotics could harm patients (115/129; 89%), when
one
Intern 26 (20) 7 (5) 10 (8) stratied based on specialty, surgical residents were overwhelm-
Upper-year residents 65 (50) 16 (12) 3 (2) ingly more in agreement with this statement compared with
internal medicine residents [39/40 (98%) vs. 40/54 (74%); P = 0.002,
Unexplained fever or leukocytosis even if culture results 0.46
Intern 12 (9) 18 (14) 14 (11) data not shown].
Upper-year residents 19 (15) 42 (33) 23 (18)

Treat colonisation to prevent infections 0.29 3.4. Attitudes towards the antimicrobial stewardship programme
Intern 21 (16) 10 (8) 14 (11)
Upper-year residents 48 (37) 19 (15) 16 (12) Perceptions of respondents towards the ASP and the antimi-
Risk of developing Clostridium difcile colitis 0.62 crobial PA (dened earlier) process at TBHC are summarised in
Intern 12 (9) 12 (9) 21 (16) Table 5. Fifty-eight percent (75/129) of respondents felt that a
Upper-year residents 19 (15) 34 (26) 31 (24) reduction in antimicrobial resistance was the ASPs major
 V. Venugopalan et al. / Journal of Global Antimicrobial Resistance 4 (2016) 2127 25

Table 5
Perceptions of respondents towards the antimicrobial stewardship programme (ASP) and the antimicrobial prior authorisation process.

Perception All respondents Interns Upper-year residents P-value

(N = 129) [n (%)] (N = 45) [n (%)] (N = 84) [n (%)]

Individual patient care is improved by having an antibiotic approval 74 (57) 27 (60) 47 (56) 0.95
programme
Having to call for approval makes the team think more carefully about 66 (51) 24 (53) 42 (50) 0.93
choosing an antibiotic
The antibiotic approval programme limits clinicians autonomy in choosing 58 (45) 22 (49) 36 (43) 0.75
antibiotics
I nd the antibiotic approval process educational 56 (43) 20 (44) 36 (43) 0.83
The recommendations I get from the antibiotic approval programme are 65 (50) 27 (60) 38 (45) 0.16
consistent
Because of the antibiotic approval programme I am forced to choose 25 (19) 9 (20) 16 (19) 0.93
antibiotics I feel are inappropriate
If there was no antibiotic approval programme our team would likely 57 (44) 23 (51) 34 (40) 0.38
consult ID more frequently
The primary purpose of the antibiotic approval programme is to decrease 75 (58) 25 (56) 50 (60) 0.24
antibiotic resistance in the hospital
The primary purpose of the antibiotic approval programme is to reduce the 47 (36) 17 (38) 30 (36) 0.92
amount of money the hospital spends on antibiotics
Having an antibiotic approval programme helps me provide better care for 68 (53) 23 (51) 45 (54) 0.4
my patients
I nd the antibiotic approval programme helpful in assisting me in dosing 67 (52) 26 (58) 41 (49) 0.52
antibiotics appropriately
Having an antibiotic approval system helps to prevent the development of 71 (55) 27 (60) 44 (52) 0.65
antibiotic resistance in the hospital
I nd having to call for antibiotic approval frustrating 35 (27) 10 (22) 25 (30) 0.22
The clinician who is seeing the patient is in a more appropriate position to 48 (37) 20 (44) 28 (33) 0.31
pick the correct antibiotic than someone on the phone who has never seen
the patient

ID, infectious diseases.

objective, whilst 36% (47/129) perceived cost savings to the
hospital as the primary purpose.
Eighty-one percent (104/129) of respondents stated that they
would like more feedback on their antibiotic selections and 83%
(107/129) would like more education on antibiotics. Whilst more
than one-half of the respondents (74/129; 57%) agreed that
individual patient care is improved by having an antibiotic
approval programme, 45% (58/129) reported that the antibiotic
approval programme limits their autonomy in choosing anti-
biotics. There were no difference in perceptions of these two
factors between upper-year residents and interns. One-half of the
respondents (65/129; 50%) agreed that the recommendations from
the antibiotic approval programme are consistent; however, 19%
(25/129) felt that the antibiotic approval programme forced them
to choose an antibiotic that they considered inappropriate. There
were no difference in perceptions of these two factors between
upper-year residents and interns. However, when stratied by
specialty, internal medicine residents were more in agreement
that recommendations from members of the ASP are consistent
compared with surgical residents [39/54 (72%) vs. 20/40 (50%);
P = 0.03, data not shown]. In addition, internal medicine residents
felt more strongly than surgical residents that the ASP forced them
to choose an antibiotic that they felt was inappropriate [18/54
(33%) vs. 5/40 (13%); P = 0.02, data not shown].
3.5. Antibiotic knowledge score
The overall median score for all respondents was 70 [inter-
quartile range (IQR) 6080]. Overall, 76% (98/129) of respondents
were able to identify correct rst-line treatment for patients with
meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia
compared with only 33% (42/129) who were able to identify
correct treatment of extended-spectrum b-lactamase (ESBL)-
positive Escherichia coli. The vast majority were able to identify
specic antibiotics that can potentially increase the risk
of developing C. difcile and the appropriate management of
indwelling catheters [97/129 (75%) and 115/129 (89%), respec-
tively, data not shown]. There was no difference in antibiotic
knowledge score when stratied by specialty or years of
postgraduate training.
4. Discussion
To the best of our knowledge, this is the rst study assessing a
PA-based ASP in a community teaching hospital [1317]. Overall,
the results demonstrated that house staff are aware of antimicro-
bial resistance and overuse problems both at a national and local
level, with no signicant interspecialty differences. Based on the
survey responses, upper-year residents were signicantly more in
an agreement with the problem of national and local antimicrobial
resistance and overuse compared with interns. In addition, similar
to results from previous studies, 91% of the respondents
signicantly felt that antibiotics are overused nationally, whilst
71% felt that antibiotics are overused at TBHC [9,14,17].
The strict PA process for broad-spectrum antibiotics at TBHC
may contribute to the perceived differences in overuse of
antibiotics nationally vs. locally among medical staff.
Most respondents also signicantly agreed that while other
practitioners overprescribe antibiotics, they did not feel that their
own prescribing practice was a problem. This nding is consistent
with those in prior studies performed at large academic institu-
tions and highlights the commonality of such preconceptions
regardless of size of institution or practice site [9,14].
The PA strategy, requiring prescribers to obtain approval from a
member of the ASP team before restricted antibiotics are
dispensed, is frequently employed as an ASP strategy
[6,15,16]. PA ASPs may be perceived negatively as it is time
consuming and infringing on the prescribers autonomy. Lack of
prescribers buy-in to the ASP may prevent it from being
maximally effective [16]. We are only aware of a few studies that
assessed the attitudes of house staff on PA-based ASPs [15,16]. A
study by Seemungal and Bruno noted that one-half of their
26 V. Venugopalan et al. / Journal of Global Antimicrobial Resistance 4 (2016) 2127
respondents nd calling for antibiotic approval frustrating [16]. In
contrast, less than one-third of the respondents in the current
study found having to call for antibiotic approval frustrating and
one-half of respondents believed that they received consistent
recommendations. The difference in ndings from the previous
study may be due to the ASP team providing around-the-clock
services, whilst the prior study had only an 8 am to 10 pm ASP
approval service [16]. As noted in previous studies, the current
study also found that most physicians agreed that knowledge of
antibiotics is important, that they would like more education and
feedback on their antibiotic selections, that they are less likely to
prescribe restricted agents requiring pre-approval, and that locally
developed guidelines for antimicrobial treatment are more useful
than national guidelines [1315,18]. Conversely, in the current
study upper-year residents were more likely to be in agreement
with the usefulness of locally developed guidelines compared with
interns. The difference in this result may largely due to better
understanding of antimicrobial use and resistance by upper-year
residents compared with interns.
The results of this survey are noteworthy and reveal that house
staff at TBHC nd the ASP services valuable. Less than one-half of
the respondents perceive cost savings to the hospital as the
primary purpose of the ASP, whilst more than one-half of
respondents felt that reduction of antimicrobial resistance was
the major objective and the ASP helps them provide better care for
their patients. This nding highlights the need to present the ASP at
our institution as a best practice rather than a cost cutting
initiative. The majority of respondents reported that they would
like more education on antibiotics and feedback on their antibiotic
selections. This information will be vital in the development of
guidelines and educational programmes to promote appropriate
antimicrobial use.
Similar to other survey results, the respondents agreed that
other physicians overprescribe antibiotics compared with their
own prescribing patterns. Internal medicine residents in particular
were more likely than surgical residents to feel that others
overprescribe.
These results are also consistent with the results of prior
surveys [9,14]. The current ndings are in agreement with those of
Srinivasan et al. that the interspecialty variations on several items
suggest that the answers on the survey were a true reection of
practice [14]. Internal medicine residents were more likely to feel
that the ASP forced them to choose an antibiotic that they felt was
inappropriate compared with surgical residents. No differences
were found when stratied between interns vs. upper-year
residents. This study also found that surgical residents were more
in agreement than internal medicine residents with the statement
that recommendations from members of the ASP are consistent.
These survey ndings will assist us in targeted interventions such
as tailoring antimicrobial education to specic specialties.
The overall median score of the antibiotic knowledge test in this
study was higher compared with a previous study [14]. In the
current study, the respondents median score was 70 (IQR 6080)
and no difference in antibiotic knowledge score was found when
stratied by specialty or years of postgraduate training. However,
only 33% of respondents were able to identify correct treatment of
ESBL-positive E. coli. These results demonstrate the need for
continued educational efforts with particular focus on topics such
as antimicrobial resistance mechanisms.
A limitation of this study is that house staff who chose not to
participate may have opinions signicantly different from those of
responders, potentially introducing unmeasured bias. However,
we believe the results of this survey are encouraging and
demonstrate the widespread support for PA-based ASPs and ASPs
in hospitals. The survey ndings have also revealed areas of
improvement for our ASP, such as focused educational efforts
aimed at informing prescribers about resistance, antimicrobial
usage patterns within the institution, and prescribing patterns
among house staff. Education is an essential element of any
programme designed to inuence prescribing behaviour and can
provide a foundation of knowledge that will enhance and increase
the acceptance of stewardship strategies [6]. We believe the results
from the current study will be valuable in guiding educational
efforts in order for ASPs to be successful and well received by
clinicians in their respective institutions.
Funding
This study was funded through the senior authors intramural
funding during her tenure at Touro College of Pharmacy (New York,
NY).
Competing interests
None declared.
Ethical approval
This study was approved by the Institutional Review Board of
The Brooklyn Hospital Center (Brooklyn, NY).
Acknowledgments
The authors would like to thank Drs Lilian Abbo (University of
Miami Miller School of Medicine, Miami, FL) and Christopher
Bruno (Drexel University College of Medicine, Philadelphia, PA) for
permission to use their survey questionnaires.
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