6

Ana Clemmer
IR 2/10-GT
4 June 2019

Antimicrobial Resistance: Gaps Between Knowledge and Practice

INTRODUCTION:

After years of college, medical school, and practice, healthcare professionals are well

educated and trained, and expected to perform faultlessly in each scenario they face in their

professional roles. But, when it comes to challenges that are still emerging and there is new

research continuing to be developed, such as antimicrobial resistance, do healthcare

professionals still follow the best practices? Doctors are trained in appropriate prescription of

antimicrobials, but do they always follow those precepts? There are standard practices for

cleanliness within healthcare settings, but still microbes spread diseases within these facilities,

with antimicrobial resistance developing as one of the consequences. Handwashing and other

forms of hand hygiene are both well-known and widespread methods of preventing the spread of

disease. However, hand hygiene is not always implemented correctly by healthcare professionals

to prevent the spread of disease and the potential for the spread of antimicrobial resistance

persists. What about when it comes to the general public? Most people are not experts, and have

various levels of knowledge about antimicrobial resistance, some of it possibly being false. How

do their knowledge, attitudes and practices align with the correct ones, and what do they witness

of healthcare professionals’ practices? ​Practices of healthcare professionals concerning

antimicrobial resistance do not match knowledge, leading to an increase in antimicrobial

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resistance, the main areas of concern being in appropriate prescribing of antimicrobials,

cleanliness of healthcare facilities and equipment, and appropriate hand hygiene.

Additionally, the level of knowledge of the general population regarding antimicrobial

resistance is very low, with attitudes not holding much concern, and a result of risky

practices for the spread of antimicrobial resistance.

BACKGROUND:

Though antimicrobial resistance has been known for decades, it is still a growing

problem. Antimicrobial resistance (AMR) was identified within 20 years after the development

of antimicrobial drugs (Ventola, 2015a). Yet AMR is a growing problem worldwide in

hospital-acquired infection (Labricciosa, 2018). AMR increases mortality, medical costs, and

length of hospital stays (World Health Organization [WHO], 2018). Over 23,000 people die

annually as a direct result of antibiotic resistant infections (“The End of Antibiotics?” 2018).

Antimicrobial resistance develops through the effect of the antimicrobial being neutralized, and

thus the microbes avoid the lethal effect of the antimicrobial drug. The exposure to antibiotics

can create selective pressure, killing susceptible bacteria and allowing antibiotic resistant

bacteria to survive and multiply. Also, bacteria can mutate and transfer antimicrobial resistance

genes, contributing to the antimicrobial resistance gene pool (“Antibiotic resistance: questions

and answers”).

Incorrect prescription of antimicrobials is one the driving factors behind the emergence of

antimicrobial resistance, so adhering to appropriate prescription of antimicrobials is a highly

effective approach to decrease the emergence of antibiotic resistance (ABR) which is one for of
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antimicrobial resistance (Ventola, 2015b). Inappropriate prescription of antibiotics includes

prescribing incorrect antibiotics or prescribing an antibiotic for the incorrect period of time. So,

reducing inappropriate prescription of antibiotics is one key step to prevent antimicrobial

resistance from developing (Pokrywka, 2016). Healthcare professionals are educated in the

appropriate prescription of antimicrobial drugs, but their actual practice of prescription of

antimicrobials does not always align with their training. Patients can have a significant effect

upon healthcare professionals’ decisions regarding antimicrobial prescriptions, and sometimes

this can be quite detrimental as patients know the antibiotics which they want prescribed, and

often the patients will react negatively or even not return to a doctor if they do not receive the

drug prescriptions which they think they need (Sanchez, et al., 2014). Patients and healthcare

professionals disagree on the best process for antimicrobial selection and prescription in other

ways as well. Some patients believe a larger group of healthcare professionals should be

involved in antimicrobial selection, whereas healthcare professionals recognize how unrealistic

and inefficient this process would be in the prescription of antimicrobials (Holland, et al., 2016).

The majority of doctors responding to a research questionnaire in Lima, Peru agree that the

demand by patients for certain antibiotics contributes to the overuse of antibiotics in hospitals

(García, et al., 2011). Often, patients are not aware of the severe consequences of misusing

antimicrobials, including leading to the development of antimicrobial resistant strains of

pathogens, and how antimicrobial resistance could affect them personally. Those patients who do

know about antimicrobial resistance may not care, assuming that new antimicrobial drugs will be

formulated, and thus combating the dire effects of antimicrobial resistance through innovation

(Sanchez, et al., 2014). Also, the attitudes of healthcare professionals toward antimicrobials
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affect their practice. A dominant categorical gist for both patients and doctors is “why not take a

risk” (Broniatowski, et al., 2018). Clinicians who follow the “why not take a risk” approach

assume antimicrobial therapy is “essentially harmless” (Klein, et al., 2017). In fact, antimicrobial

therapy is not harmless, since reckless use can lead to antimicrobial resistance. Additionally,

physicians tend to be rigid and habits are hard to change (Sanchez, et al., 2014). Because medical

education related to the prescription of antimicrobials mainly revolves around what to prescribe

versus what not to prescribe, this sets a faulty foundation for practice and a tendency towards

rigidness of habits can be a barrier to correction of practice over time (Janet Robinson, personal

communication, 2019). In summary, though healthcare professionals are educated in the field of

antimicrobial resistance, the continuation of inappropriate prescription of antimicrobials

indicates that their practice does not always reflect their knowledge.

Healthcare workers are aware of the necessity of cleanliness and general sanitation to

prevent the spread of infections, including those which are antimicrobial resistant. Both

disinfection and cleanliness are vital in the hospital, disinfection referring to reducing the number

of bacteria present, which in most cases means decreasing the presence of soils. Cleaning must

take place prior to disinfection, since it allows for disinfection to be optimized. Proper cleaning

is cost-effective and should be more of a major part of reducing the increase of antibiotic

resistance (Malavaud, 2016). However, it is one of the topics with the lowest levels of

consultations between patients and healthcare professionals (Smith, et al., 2017). It is almost like

a second thought, indicating its lack of priority for this precaution. Cleanliness can include

cleansing operating room garb, as well as various surfaces throughout the hospital setting.

Operating room nurses have a high amount of bacterial growth and recolonization on their glove
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cuffs, which is often overlooked (Wistrand, et al., 2018). This lack of attention toward such areas

may lead to cross-infection. Cross infection is defined as the transfer of infection, which can

include antimicrobial resistant diseases. There are numerous areas which could contribute to the

spread of disease, and require proper cleaning. Areas such as surfaces near patients are often

properly cleaned, however there are more causes for concern in other areas that are not

prioritized for proper cleaning, such as in showers, sinks, toilets, and with the management of

human waste (Malavaud, 2016). In short, good cleanliness and sanitation help to prevent the

spread of disease, and thus prevent the spread of antimicrobial resistant disease. And, any

lacking in cleanliness and sanitation can contribute to the spread of antimicrobial resistance.

Hand hygiene prevents the spread of infections, thus preventing the spread of ABR

infections. Proper hand hygiene reduces disease transmission and healthcare-associated

infections (HCAIs). Consistent with the timing of a program which successfully improved hand

hygiene (HH), the HCAI rate decreased by half in a hospital in Saudi Arabia (Al Kuwaiti, 2017).

Though the methods to prevent antimicrobial resistance are known, antimicrobial is still a

growing problem due to practices not always coming up to the stringent best practices needed in

healthcare settings. People, including healthcare workers and the general public, are aware that

they should wash their hands, however they do not implement this in their everyday life, as they

do not wash their hands appropriately. Handwashing has been proven to be a strong but

underused preventative measure of disease, including disease which may be antimicrobial

resistant (Pokrywka, 2016). In a Nigerian study conducted on healthcare workers in intensive

care units of a tertiary hospital, 86% of respondents were knowledgeable about the relation

between dirty hands and infection. However, only 28% practice correct handwashing techniques
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(Adegboye, et al., 2018). This indicates that only approximately one third of knowledgeable

respondents practiced correctly. Additionally, healthcare workers may need a program to aid in

the adoption of hand hygiene guidelines, suggesting that they are not being followed

appropriately prior to said program (Creedon, 2005). There are numerous negative attitudes

toward handwashing such as carelessness​. This contributes to the incomplete removal of

contamination. Users of practices, such as the use of alcohol-based handrubs (ABHR), may have

low acceptability and tolerance. This was shown in a study on the hand hygiene of nurses, where

25% of the respondents had poor acceptability and tolerance. Due attention is not paid to

handwashing due to carelessness, and entire areas of the hand are often neglected during

sanitation. Namely, areas on the back of the fingers and on fingers are most often missed during

handwashing (Ataee, R., et al., 2017). Though respondent attitudes towards handwashing are

primarily positive in an Irish study conducted in 2007 and 2015, a large number of respondents

did not use proper hand washing techniques (Kingston, et al., 2017). ​Hand hygiene is

well-known to be critical in preventing the spread of disease, including in a healthcare setting,

and the lack of appropriate hand hygiene practice shows that knowledge and practices are

disconnected. This is one of the practices used to combat antimicrobial resistance, and the

disconnection between knowledge and practice is detrimental to the overall decrease of

emergence of antimicrobial resistance genes.

People, including healthcare workers and the general public, are aware that they should

wash their hands, however they do not practice proper handwashing at all of the critical times

consistently in their everyday life. Handwashing has been proven to be a strong but underused

preventative measure of disease, including diseases which may be antimicrobial resistant

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(Pokrywka, 2016). In a Nigerian study conducted on healthcare workers in intensive care units of

a tertiary hospital, 86% of respondents were knowledgeable about the relation between dirty

hands and infection. However, only 28% practice correct handwashing techniques (Adegboye, et

al., 2018). This indicates that only a third of the respondents with the knowledge of the need for

good hand hygiene actually practiced this infection prevention measure. Healthcare workers may

need a promotion program to facilitate the adoption of hand hygiene guidelines (Creedon, 2005).

There are numerous attitudes, such as carelessness, which have a negative consequence in

handwashing practice​ and the resultant incomplete removal of the contamination source from

hands. Use of other hand hygiene practices such as the use of alcohol-based handrubs, also face

acceptability and tolerance challenges. This was shown in a study on the hand hygiene of nurses,

where 25% of the respondents reported a lack of acceptability and tolerance of ABHR. Due

attention is not paid to handwashing due to carelessness, and entire areas of the hand are often

neglected during sanitation. Namely, areas on the back of the fingers and on fingers are most

often missed during handwashing (Ataee, R., et al., 2017). Though respondent attitudes towards

handwashing are primarily positive in an Irish study conducted in 2007 and 2015, a large number

of respondents did not use proper hand washing techniques (Kingston, et al., 2017). ​Hand

hygiene is well-known to be critical in preventing the spread of disease, including in a healthcare

setting, and a persistent lack of appropriate hand hygiene practice shows that knowledge and

practices are disconnected. Proper hand washing is one of the practices used to combat

antimicrobial resistance, and the disconnection between knowledge and practice is detrimental to

the fight against the emergence of antimicrobial resistance genes.

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METHODS:

Survey 1: KAP survey of U.S. healthcare professionals

Survey 2: KAP survey of the general population of Maryland (observing Maryland physicians).

In this questionnaire, ‘antimicrobial resistance’ was referred to as ‘antibiotic resistance,’ and will

be referred to as such in the results and discussion to ensure accuracy and consistency.

Question type Question and answer options

and number
(K=Knowledge,
A=Attitudes,
P=Practices)

K1 How much do you know about antibiotic resistance?

Scale of 1-5, 1=My knowledge is minimal, 5=I know a lot

K2 Antibiotic resistance occurs when a person becomes resistant to antibiotics.

True or False

K3 Antibiotic resistance occurs when bacteria become resistant to antibiotics.

True or False

A1 Antibiotic resistance is a large problem worldwide.

Scale of 1-5, 1=Strongly disagree, 5=Strongly agree

A2 Antibiotic resistance is a large problem in the United States.

Scale of 1-5, 1=Strongly disagree, 5=Strongly agree

P1 Do you ever request an antibiotic prescription when your doctor is not

offering to write one for you?
Scale of 1-5, 1=Never, 5=Often

P2 Does your doctor ever write an antibiotic prescription for you when they
seem unsure you need it?
Scale of 1-5, 1=Never, 5=Often

P3 During a visit to the doctor when you're sick, does your doctor address
hand-washing practices or use of a hand sanitizer?
Scale of 1-5, 1=Never, 5=Often

P4 If a doctor does not prescribe an antibiotic when you are sick, does your
doctor address why an antibiotic is not being given?
Scale of 1-5, 1=Never, 5=Often
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P5 When your doctor prescribes an antibiotic to you, does your doctor instruct
you on proper use of the antibiotic?
Scale of 1-5, 1=Never, 5=Often

P6 Do you see the doctor washing their hands during your visit?
Scale of 1-5, 1=Never, 5=Often

P7 When you visit the doctor, do you ever have concerns about antibiotic
resistance and ask about it?
Scale of 1-5, 1=Never, 5=Often

RESULTS:

In the first Knowledge, Attitudes, and Practices survey conducted on healthcare

professionals in the United States, all 7 respondents answered correctly for knowledge questions,

and strongly agreed that AMR is a problem in the United States and in Maryland. Additionally,

none of the respondents receive reports on local AMR data. However, this survey is not

statistically significant due to its low number of respondents.

In the second Knowledge, Attitudes, and Practices survey, this one conducted on the

general population of Maryland, the majority of the 190 respondents, 69.5% answered correctly

(False) to the first and more tricky knowledge question: “Antibiotic resistance occurs when a

person becomes resistant to antibiotics. True or False?” For the next true or false question,

“Antibiotic resistance occurs when bacteria become resistant to antibiotics. True or False?,”

96.8% of respondents answered correctly (True). Granted, these questions were not very

difficult, but they did show that the general population of Maryland is knowledgeable about

antimicrobial resistance at least at a minimal level. However, the respondents’ opinion of their

own knowledge indicated 41.8% of respondents answered on the lower side (1-2) of the 1-5 scale

for the first question, “How much do you know about antibiotic resistance?” Answer 1
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represented minimal knowledge, with 5 representing “I know a lot.” On the other hand, 29% of

respondents think their knowledge is on the upper side (4-5) of the scale, with 29.5% answering

number 3 in the middle of the scale. This indicates that the general population of Maryland

thinks that they have at least a relatively good understanding of antimicrobial resistance.

Regarding attitudes of Marylanders, only 1.6% of respondents strongly disagreed that

antimicrobial resistance is a large problem worldwide, with 0% strongly disagreeing that

antimicrobial resistance is a large problem in the United States. 28.4% of respondents agree that

antimicrobial resistance is a large problem worldwide, with 32.6% strongly agreeing, resulting in

a majority 61% respondents agreeing that antimicrobial resistance is a large problem worldwide.

35.3% of respondents agree that antimicrobial resistance is a large problem in the United States,

with 37.4% strongly agreeing, resulting in a majority of 72.7% respondents agreeing that

antibiotic resistance is a large problem in the United States. This indicates that Marylanders tend

to think that antimicrobial resistance is more of a problem in the United States more than it is

worldwide.

The practices of Maryland physicians observed by the Maryland general public were

quite revealing. Only 43.6% of respondents often see their doctor wash their hands during their

visit. At less than half, this is a scarily low percentage of doctors to be performing one of the

most basic tasks in the prevention of both the spread of disease and antimicrobial resistance.

Similarly, only 48.9% of respondents reported their doctors often instructing them on proper use

of the antibiotic prescribed. This can be especially detrimental, especially for patients who are

less knowledgeable. Furthermore, 45.8% respondents reported their doctors never or almost

never address hand hygiene while counseling them during a visit. But, 35.8% of respondents said
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that their doctors did address hand hygiene with them. For antibiotic counseling, 53.1%

respondents reported their doctors address why an antibiotic is not being prescribed when the

patient is sick. Doing this can help educate patients about antibiotics, thus preventing the patients

from taking actions that may encourage the spread and emergence of antimicrobial resistance or

actions that encourage a healthcare professional to incorrectly prescribe an antibiotic. While

64.2% of Marylander respondents never or almost never observe their doctors prescribing

antibiotics when the doctor seems unsure if it is needed or not, only 15.3% of respondents said

that their doctors often or occasionally prescribe antibiotics when the doctor seems unsure if they

(the patient) need it.

DISCUSSION:

Though the amount of respondents was not statistically significant in the first KAP

survey, 100% of the U.S. healthcare professionals answered all of the knowledge questions

correctly, whereas in international studies, a smaller percentage of the respondents answered the

knowledge questions correctly. The U.S. healthcare professional respondents know more about

antimicrobial resistance than the general population of Maryland (as measured in the second

KAP survey, with 100% accuracy in healthcare professionals versus lower accuracy in the

general population. Also, U.S. healthcare professionals and the general population differ in their

attitudes towards antimicrobial resistance, with a majority of 85.7% (6 out of 7 responses) of

healthcare professionals strongly agreeing that antimicrobial resistance is a large problem

worldwide, and only 32.6% of Maryland’s general population strongly agreeing that

antimicrobial resistance is a large problem worldwide. This is also the case in attitudes towards
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antimicrobial resistance within the United States, with only 37.4% of Maryland’s general

population strongly agreeing that antimicrobial resistance is a large problem in the United States,

while the U.S. healthcare professionals unanimously strongly agree.

An overwhelming majority of 84.7% of Marylanders said they never or almost never

request an antibiotic prescription when it is not being offered. No respondents said they often

request an antibiotic prescription when it is not being offered, and only 5.3% do so occasionally.

Thus, the report by the general population is that they have a good practice towards antibiotic

prescriptions. However, the general population tends to not be very concerned about antibiotic

resistance, since 72.1% of respondents never or almost never have concerns about antibiotic

resistance and ask the doctor about it. Only 8.4% of respondents occasionally or often ask their

doctor about antibiotic resistance, indicating an overall lack of concern.

So how do Marylanders compare to the general public in other countries? While

Marylanders overwhelmingly do not request an antimicrobial when it is not being given, whereas

in a Peruvian study, doctors claim that one of the major reasons for overuse of antimicrobials in

hospitals is due to patients’ demand for antimicrobials (García, et al., 2011). This would indicate

that patient requests for antimicrobials are less of a reason for antimicrobial resistance in

Maryland than Peru, though it should be noted that the Peru results are doctor reports of patients

while the Maryland results are patient reports of themselves, each with their own bias.

Local Maryland physicians differ from international physicians in practices, especially

from a similar Canadian study. Primarily, 87.5% of Canadian physicians report addressing

hand-washing practices and 75% report addressing hand sanitizer during a consultation. In

contrast, only 14.2% of Maryland physicians address either of these things often, with 33.1%
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addressing it occasionally, and 26.3% sometimes (as reported by patients). Overall, only 73.6%

of Maryland physicians are reported to address hand hygiene with patients at least semi

regularly, 13.9% less than Canadian physicians. Furthermore, 99% of Canadian physicians report

that they instruct patients in antibiotic use, while only 48.9% of Maryland patients report that

physicians often instruct them in the use of antibiotics being prescribed while the number is 91%

of Maryland physicians are reported to instruct antibiotic use ever, which is still low for another

key element of patient interaction. Moreover, 99% of Canadian physicians address why an

antibiotic is not being given, while only 53.1% of Maryland physicians often or occasionally do

this. This may lead to lack of patient trust in the doctor, and the patient seeking other ways to

receive an antibiotic, thus misusing antibiotics. Again, in the Maryland study, results are from

reported observations by the general population, who may not remember everything they

observed. In the Canadian study, responses are self reported by physicians, and there is likely

some bias towards reporting correct practices of oneself when answering these questions as a

healthcare professional.

CONCLUSION:

Data collected has proven that some practices of Maryland healthcare professionals

concerning antimicrobial resistance do not match knowledge, thus leading to the risk of an

increase in antimicrobial resistance. The difference between the practices of international and

Maryland healthcare professionals is variable. Maryland healthcare professionals do not exercise

their knowledge as properly as Canadian healthcare professionals, in practices including

counseling patients in handwashing and explaining why an antibiotic is not being prescribed.
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However, Peru physicians reported being more affected by patients in writing prescription than

what was observed of Maryland physicians. The general population of Maryland seems to have a

relatively good knowledge of antimicrobial resistance, for lay people, and practice appropriate

behaviors for some of the practices which could prevent the risk of antimicrobial resistance.
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