# I. Introduction ntimicrobial resistance (AMR) a global problem is particularly pressing in developing countries where the Health care associated infection (HCAI) burden is high and cost constrains the replacement of older antibiotics with newer, more expensive ones. Several studies (1)(2)(3)(4) have identified the inappropriate use of antimicrobials and noncompliance with infection control precautions as the main risk factors associated with an increased probability of colonization with resistant pathogens and there by Antimicrobial resistance. Hence management of common and lethal Anaesthetists, Pre & para clinical doctors who were general bacterial infections has been critically compromised by the rapid appearance & spread of these antibioticresistant bacteria (5) . The pipeline of antibiotic research and development is nearly dry, especially when it comes to antibiotics active against Gram-negative bacteria (6) . The bacterial disease burden in India is among the highest in the world ; consequently, antibiotics play a critical role in limiting morbidity and mortality in the country. This has led to increasing use of newer antibiotics and ultimately ended up with increased prevalence rates of Multi drug resistant bacteria. Though we all know that Abuse, overuse & Misuse of antibiotics have exacerbated Antibiotic resistance, resistance development is a natural unstoppable process. Hence our challenge is to slow the rate at which resistance develops & spreads. Combating Antimicrobial resistance calls for a concerted approach from individuals to global levels involving various organisations like CDC , WHO, Health ministry of India and other organisations [6,7] . These organizations recommends all the health care facilities to have their own Antibiotic policy based on Local Cumulative antibiogram (8) and to implement antibiotic stewardship programme (9) accordingly to combat the most prevalent MDR pathogens at their own hospital settings. # II. Background Many strategies have been proposed for the rational use of antibiotics, like a formulary replacement or restriction, health care provider education, feedback activities, approval requirement from an infectious disease specialist for the drug prescription [9] . Various studies which were done in India and other developed countries have highlighted the importance of rational drug therapy through educational interventions, strict antibiotic policy and Stewardship (9,10,11). knowledge about the driving forces behind antibiotics prescription followed by educational intervention plays a very important role. The assessment is usually done by Knowledge, perception & attitude survey based on LIKERTs scale. Studies on clinicians' attitude towards Knowledge, perception of Antimicrobial resistance have been published in both Community and Hospital settings [12][13][14][15][16][17][18][19][20][21][22] . Some of these studies have shown poor correlation between knowledge and practice. Hence the purpose of this study is to conduct a survey to assess and explore Knowledge, attitude & Perception of clinicians' towards antimicrobial resistance at three tertiary care centre. # III. Material & Methods This study is a cross sectional survey from three tertiary care teaching hospitals during 2014.All the three are located in suburban areas with 530, 900 & 300 beds respectively. Clinicians of above mentioned three tertiary care centres belonging to following specialities like General medicine, Surgery, Obstetrics Gynaecology, Paediatrics, Orthopaedics and super specialities like Nephrology, Urology, Paediatric surgery and Resident doctors working in all the above mentioned speciality participated. Anaesthesia &Para clinical doctors who were general practitioners also participated in the survey. The Study instrument: The survey was carried out with a structured, validated, anonymous questionnaire encompassing sessions to assess Knowledge & perception of Clinicians towards Antibiotic Resistance. The Questionnaire was reviewed by Institutional Ethical Committee team to assess the relevance & Wordings of questions. The willing participants were approached individually and were requested to fill in the questionnaire anonymously. The Questionnaire was distributed onsite during working hours. No incentives for subjects to participate and no reminders were given. The response to questionnaire was assessed in FIVE point Likert scale ranging from strongly agrees to strongly disagree. Briefly the questionnaire consisted of ? Professional profile of area of speciality, staff position, experience in that speciality. ? Section-1-Question pertaining to knowledge about Antimicrobial resistance like awareness at Global, national level and community level. # IV. Results A total of 737 doctors filled in the questionnaire. An overview of the professional profile of the 737 participantsare given in Fiure-1. The staff position and years of experience in that particular field shown in Table -1 # V. Discussion One of the emerging public health problems is AMR and no effective first line drugs exist for resistant pathogens. Inappropriate Antibiotics use & Infection control noncompliance has been primary attributes for dramatic raise in antimicrobial resistance. The present study describes the results of a KAP-survey among 737 medical doctors (From all the specialities) practicing in three tertiary care teaching hospitals .Our study was done to assess the knowledge, attitude and the perception among the practitioners at a hospital setting towards a rational use of antibiotics. The awareness of AMR problem worldwide, national & Institutional level and in their practice by clinicians at three centres varied .In our study significant percentage of clinicians (90%) perceived that Antibiotic resistance is a problem Worldwide& national level and less percentage (75%) in their institutional level as shown in Fig- 2. In contrast to our study, a high perception that AMR as an institutional problem was shown in studies by Arjun Srinivasan (18) etal, and Maha et al (21) .Our data is similar to a study by Wester etal (21) where in 87% respondents agreed that Antibiotic resistance is a national problem and 55% perceived it to be a problem in their institution. In a study by Giblin etal (16) 89% respondent's choice was national problem and 73% in their own institution and 65% in their practice. regarding the problem. Therefore, until the clinician's perception changes towards the fact that even in their personal practice their patients are also susceptible to AMR they will not have any motivation to change their practice behaviour particularly with respect to antibiotics use. Regarding our clinician's response to practices contributing to AMR, 93% agreed that patient's failure to adhere to treatment an important contributor of AMR as shown in TABLE-3.In contrast, a study by Maha etal (16) showed only 68% agreed that patient's failure to adhere to treatment an important contributor of AMR. Our study also showed only 80% of respondents agreed that poor adherence to infection control practices like isolation precaution & Hand hygiene contributes to antibiotic resistance. In a study by Shah etal (20) only 31% respondents agreed that hygiene is significant in reducing antibiotic resistance. 54% of respondents agreed that patients demand for antibiotics a contributing factor to Antibiotic resistance. A similar data was shown by Sivagnanam (12) etal and Garcia et al (14) where in 55% of respondents agreed patients demands for antibiotics a contributing factor . Among the data's on clinicians antibiotics prescribing practice (Table -3)79% agreed that they refer to susceptibility pattern while treating for infections at their respective institution &82% agreed that Micro lab results are efficiently communicated to treating physicians. In a study by Sivagnanametal (12) only 42% of practitioners agreed that they refer sensitivity reports. The necessity of De-escalation to oral antibiotics from IV is needed was agreed by 86% of clinicians. As shown in Table-5, 74% of respondents disagreed for pharmacist's recommendation for Antibiotics. A similar data was shown in a study by Shah etal (20) wherein 73% respondents gave less importance for Pharmacists Recommendations. Our institution organised a CME which emphasised problems of AMR, and how to combat Resistance by Basic infection control measures like Hand Hygiene, Antibiotic policy &Antibiotic stewardship .A post CME questionnaire survey was done to assess the transfer of knowledge which revealed that almost 100% agreed that basic infection control measures will reduce HCAI & there by Antibiotic resistance as shown in TABLE: 5. 100% of respondents agreed that they will be benefited by CME which will update them in AMR knowledge & Infection control practices. In a study by shah etal 70% agreed that CME will help in updating knowledge. To our knowledge this is the first time Pre &Para clinical faculties were included in a KAP survey on Antibiotic resistance. This inclusion was done because many of the pre and Para clinical staffs are into General practise and also the necessity of AMR knowledge is essential while treating friends & families. # VI. Conclusion Antimicrobial resistance accounts for numerous social & economic costs including mortality &morbidity. AMR continues to be a growing problem for all clinicians nationally & at institutional level. A multifaceted problem caused by AMR requires a multifaceted solution. At the institutional level, the assessment of clinician's knowledge on awareness about AMR and to educate them becomes a priority before initiating other strategies. To summarise, our KAP study on Antibiotic resistance showed that though 95% of clinicians viewed this as a national problem, only 75%agreed that it's a problem in their institution. Also only 81% agreed that poor infection control measures & poor isolation precautions contributes to AMR and 79% refer to susceptibility pattern given by Micro lab. De-escalation of IV antibiotics to Oral antibiotics is a necessity was agreed by 86.5% of respondents. Finally what have we learnt and understood was that the knowledge& attitude of clinician is crucial to reduce AMR at institutional level. Also as AMR problem is not limited by specialities, a better understanding of practices by all specialities included. Overall, most of our clinicians had better understanding and surprisingly Pre & Para clinical doctors also have enough knowledge regarding Antibiotics practice. Education by workshops & CME play a major role in updating knowledge. Following the study we have framed Antibiotics Policy and stewardship based on our institutional Antibiogram which addressed the susceptibility pattern of the most prevalent drug resistant pathogens. # VII. Acknowledgement ![Section-II-Question pertaining to practices known to contribute to Antimicrobial Resistance. ? Section-III-Questions pertaining to factors involved in antibiotic prescribing practices. ? Section-1V-Questionnaires were Drivers of choice in decision making to prescribe antibiotics. Following the Questionnaire survey and based on the feedback, a CME on Antimicrobial resistance, Basic infection control practices, Antibiotic policy and Stewardship was organised. Again a Post CME survey in a questionnaire format to assess the Knowledge transfer was given to the Clinicians which consisted of Questionnaire on Necessity for Role of hand hygiene, Isolation precautions, Antibiotic policy & Stewardship programme for reducing Antimicrobial Resistance](image-2.png "?") 1Staff positionNumber %Years ofexperienceProf/Associate prof17023%18-25 yeasAssistant prof12517%6-10 yearsSenior and Junior36149%1-8 yearsResidentsConsultants8111%10-15 years 2SpecialityTotalPercentageAnaesthesia304.1%General medicine10314.1%General surgery9412.5%OBG8812%Paediatrics7610.5%Orthopaedics638.5%Ophthalmology253.4%ENT212.8%Dermatology233.1%Chest/TB152%ICU8111%Surgical super101.4%specialityMedical Super152%specialityPre/Para clinical9312.6%TOTAL737100%Professional profile-1343Physicians73793301Surgeons Pre/paraFigure 1 : Overall Demographic profile© 2015 Global Journals Inc. (US) 3Strongly DisagreeDisagreeNeitherAgreeStrongly AgreeFailure to properly diagnose2.5%16%9.2%48.3%24patients infective conditionsPrescribing antimicrobials when4.1%5.5%8.4%3745they are not neededLimited use of laboratory services2.5%7.1%8.4%56%26%for infection diagnosisPoor Adherence to isolation and1%8.4%9.6%58.4%22.6%contact precautionsPoor hand hygiene & Poor infection1.2%10.5%8%40.3%40controlPatients demand for Antibiotics3.5%20.5%22%40%14%Patients failing to adhere to04.2%3.3%45%47.5%treatment 4Strongly DisagreeDisagreeNeitherAgreeStrongly AgreeMicrobiology lab results are2.9%8.4%5.5%41.1%42.1%efficiently communicated tothe treating physician.I regularly refer to the2.1%6.3%12.6%53%26%susceptibility/sensitivitypatterns at this institution(e.g., an antibiogram) whenprescribing antibioticsIf medically appropriate IV3.3%4.6%5.6%58.4%28.1%antibiotics should bestepped down to an oralalternativeA majority of patients1.2%5.8%21.8%52.5%18.7%admitted to this institutionwill be prescribed at leastone antibiotic during theirhospital stayMany of my patients receive4.2%9.6%13.4%51.2%21.6%5 or more days of antibioticsduring their stay at thisinstitution.Only Few of my patients are2.5%9.2%19.5%56.5%12.5%discharged from thisinstitution on antibiotics. 5Assessment of Clinician's Knowledge and Perception on Antimicrobial Resistance a Primary Strategy forAntimicrobial Resistance ControlYear 2 01511Volume XV Issue IV Version I( C )Medical ResearchGlobal Journal ofStrongly Disagree Disagree NeitherAgreeStrongly AgreeSeverity of infection1.2%2.1%2.9%50.8%43%Likely infecting organisms00.4%3.7%63%32.9%Lab results0.7%2.9%8.4%58.4%29.6%Effectiveness of antibiotics for1.2%3.3%12.6%62.1%20.85patients typically seenRecommendations' by the27.7%48.3%10.5%3.5%10%pharmacists© 2015 Global Journals Inc. (US) 6Strongly DisagreeDisagree Neither AgreeStrongly AgreeEssential Infection control practices like Hand00037%63%Hygiene reduceHealth care AssociatedInfectionsIsolation Precautions will significantly reduce0015%43%42%Health care Associated InfectionsDo you think Antibiotic policy will help to07%11%58%24%reduce Antimicrobial resistance in thisInstitutionDo you think Antimicrobial stewardship003%81%16%programs can improve patient care?According to you will Antimicrobial stewardship0015%69%16%programs reduce the problem of antimicrobialresistance?In your opinion will you be able to benefit or00062%38%update your knowledge by this CME organisedby the institution pertaining to Infection ControlProgramme? Year 2 01512Volume XV Issue IV Version I44.50%55.30% 47%23.50% 43.00% 26.80%( C )39.00%52.00%Medical ResearchSDD0%N37.00% 20% A SA40%60%56.00% 80%100%Global Journal ofThisdisparityamongclinician'sperceptiondemonstrates a lack of awareness & understanding© 2015 Global Journals Inc. (US) The authors acknowledge all the clinicians & Pre and Para medical doctors who participated in this survey. * Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals: a challenge to leadership DAGoldmann RAWeinstein RPWenzel JAMA 275 1996 * Preventing the emergence of multidrugresistant microorganisms through antimicrobial use controls: the complexity of the problem WRJarvis Infect Control Hosp Epidemiol 17 1996 * Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals DMShlaes DNGerding JFJohn Infect Control Hosp Epidemiol 18 1997 * Implementation of strategies to control antimicrobial resistance RMurthy Chest 119 2001 suppl * Editorial --antimicrobial resistance: a global threat World Health Organization 28 2000 Essent Drugs Monit * The Chennai declaration" Recommendations of "A roadmap-to tackle the challenge of antimicrobial resistance" -A joint meeting of medical societies of India Ghafur Indian Journal of Cancer 4 2012 * Step Approach for Development and Implementation of Hospital Antibiotic Policy and Standard Treatment Guidelines * Hospital antibiogram: A Necessity Indian J Med Microbial 28 4 2010 Oct-Dec * 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 44 2 2007 * India needs an implementable antibiotic policy AKapil Indian J Med Microbial 31 2 2013 * A Survey on Current Attitude of Practicing Physicians upon Usage of Antimicrobial Agents in Southern Part of India GSivagnanametal MedGenMed 6 2 1 2004 * The Knowledge, Attitude and the Perception of Prescribers on the Rational Use of Antibiotics and the Need for an Antibiotic Policy-A Cross Sectional Survey in a Tertiary Care Hospital AAmbili Remesh RohitGayathri KGSingh Retnavally Journal of Clinical and Diagnostic Research 2013 * April 7 * Knowledge, attitudes and practice survey about antimicrobial resistance and prescribing among physicians in a hospital setting in Lima García BMC Clinical Pharmacology 11 18 2011 * Junior doctors' knowledge and perceptions of antibiotic resistance and prescribing: a survey in France and Scotland Pulcini Clin Microbiol Infect 17 2011 * Clinicians' Perceptions of the Problem of Antimicrobial Resistance in Health Care Facilities Giblin Arch Intern Med 164 2004 * Antibiotic Stewardship and Occupational Health Resources in Irish Acute Hospitals SARI Hospital Survey Survey of Infection Control 2003. November 2004 Draft Report * Physicians from Various specialities concerning Antimicrobial use and resistance. Arch Int medicine 2004 164 * A point prevalence survey of antibiotic prescriptions: benchmarking and patterns of use Mamoonetal 71:2 / 293-296 / 293 Br J Clin Pharmacol * Emerging Antibiotic Resistance: A Reflection of Actual Practice among Doctors at Tertiary Care Hospitals M SalmanShah1 AneesAhmad1 RiyazAhmad S NajamKhalique MAnsari1 Int.J.Curr. Microbiol.App.Sci 1 2015 * Assessment of knowledge perception of resident doctors regarding antibiotic resistance and prescription practice at zigzag university hospital SMaha GhadaMEltwansy Salem International journal of Basic and Applied sciences 3 4 2013 * Antibiotic Resistance: A Survey of Physician Perceptions CWilliamWester Md; LakshmiDurairaj TMd; Arthur MDEvans NMph; David Md; ShahidSchwartz Md; EnriqueHusain MDMartinez Arch Intern Med 162 19 2002