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Antibiotic Resistance
A Survey of Physician Perceptions
C. William Wester, MD;
Lakshmi Durairaj, MD;
Arthur T. Evans, MD, MPH;
David N. Schwartz, MD;
Shahid Husain, MD;
Enrique Martinez, MD
Arch Intern Med. 2002;162:2210-2216.
ABSTRACT
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Background Antibiotic resistance is caused partly by excessive antibiotic prescribing,
yet little is known about prescribers' views on this problem.
Methods We surveyed 490 internal medicine physicians at 4 Chicago-area hospitals
to assess their attitudes about the importance of antibiotic resistance, knowledge
of its prevalence, self-reported experience with antibiotic resistance, beliefs
about its causes, and attitudes about interventions designed to address the
problem.
Results The response rate was 87% (424 of 490 physicians). Antibiotic resistance
was perceived as a very important national problem by 87% of the respondents,
but only 55% rated the problem as very important at their own hospitals. Nearly
all physicians (97%) believed that widespread and inappropriate antibiotic
use were important causes of resistance. Yet, only 60% favored restricting
use of broad-spectrum antibiotics, although this percentage varied by hospital
and physician group.
Conclusions Although most physicians view antibiotic resistance as a serious national
problem, perceptions about its local importance, its causes, and possible
solutions vary more widely. Disparities in physician knowledge, beliefs, and
attitudes may compromise efforts to improve antibiotic prescribing and infection
control practices.
INTRODUCTION
THE RECOGNITION that antibiotic resistance is caused in part by excessive
antibiotic prescribing has prompted calls for reform,1-4 yet
the optimal methods for addressing this problem remain obscure. Because such
reform is likely to require fundamental changes in physicians' behavior,5-8 a better
understanding of physicians' perceptions of antibiotic resistance is essential.
In general, physicians are likely to alter their practice patterns only when
their knowledge, beliefs, attitudes, and skills are aligned with the ends
(a reduction in antibiotic resistance) and the means to achieve them.5
Most surveys regarding antibiotic resistance have focused on patients'9-12 and
physicians'11-13 perceptions
of antibiotic prescribing for respiratory tract infections in the outpatient
setting, with an emphasis on patient demands and expectations. Little is known,
however, about how physicians perceive the problem of antibiotic resistance—and
efforts to control it—in the inpatient setting.14
We surveyed internal medicine physicians at 4 hospitals to measure their
knowledge, beliefs, and attitudes regarding antibiotic resistance, with the
goal of using the information to design and implement more effective antibiotic
control interventions.
PARTICIPANTS AND METHODS
We conducted a cross-sectional survey of all eligible physicians at
4 Chicago-area hospitals during April and May 1999 using a self-administered
questionnaire. The 4 hospitals were selected because they were geographically
local and shared professional affiliations, yet varied greatly in mission,
level of care, and prevalence of antibiotic resistance. The 4 hospitals included
the following: (1) a large, urban, public teaching hospital with a relatively
low prevalence of antibiotic resistance (Cook County Hospital); (2) a large,
private, university-based teaching hospital with an intermediate prevalence
of antibiotic resistance (Rush–Presbyterian–St Luke's Medical
Center); (3) a small, public, community hospital with a low prevalence of
antibiotic resistance (Provident Hospital); and (4) a large, public, long-term
care hospital with a high prevalence of antibiotic resistance (Oak Forest
Hospital).
Physicians eligible for the survey included all internal medicine residents
and all internal medicine attending physicians at the 4 institutions (excluding
cardiologists and neurologists) who cared for a minimum of 60 inpatients during
the preceding calendar year. We did not survey cardiologists and neurologists
because we believed they prescribe antibiotics much less often.
The survey defined antibiotic resistance as being present if the bacterial
pathogen in question demonstrated in vitro resistance to the first-line antibiotic
of choice as recommended by current textbooks or guides.15-16 Antibiograms,
when mentioned, refer to pocket-sized cards listing in table format the most
recent hospital-specific antibiotic resistance rates for important bug-drug
combinations.
SURVEY INSTRUMENT
The 94-item self-administered questionnaire collected information on
physicians' perceived importance of the problem of antibiotic resistance,
their knowledge of the local hospital prevalence of antibiotic resistance,
their self-reported experience with antibiotic resistance and its complications,
their beliefs about the causes of antibiotic resistance, and their attitudes
on current and potential interventions designed to address the problem. Data
were also collected on hospital affiliation, level of training, subspecialty,
and duration of clinical practice. Copies of the survey instrument are available
from one of us (A.T.E.).
Most questions about beliefs and attitudes used 5- to 7-point Likert-style
response options, from strongly disagree to strongly agree, or other graded
response options, such as a 7-point scale from unimportant to extremely important.
To assess knowledge of the prevalence of antibiotic resistance, physicians
were asked to estimate the prevalence of resistance at their hospital—from
0% to 100%—for 7 specific bug-drug combinations. Recent rates of resistance
were obtained from antibiograms published internally by each hospital's antibiotic
and infection control committee. Based on a review of the literature and on
local focus groups, we amassed a list of 19 possible causes of antibiotic
resistance and 15 possible interventions for respondents to evaluate. Each
possible intervention was rated on a 5-point scale for effectiveness, from
definitely ineffective to definitely effective, and on a 5-point scale for
desirability, from definitely more harm than good to definitely more good
than harm. Because the results of the 2 scales (effectiveness and desirability)
are nearly identical, only the results for effectiveness are reported. Physicians
were also given the opportunity to identify and rate other causes and interventions
that were not among the options listed.
SURVEY ADMINISTRATION
After the institutional review boards at each institution had approved
the study, we distributed the questionnaires during a 2-month period in 1999
using a unique identifying number linking the questionnaire to individual
respondents. Questionnaires not returned within 2 weeks triggered telephone
call reminders and the delivery of up to 2 additional questionnaires. Before
data entry, we physically removed the identifying numbers on questionnaires
and destroyed the roster linking numbers to physician names. Therefore, although
the data were not collected anonymously, we guaranteed complete confidentiality
to each respondent.
STATISTICAL METHODS
Our goal was an 80% response rate, which would require 392 respondents
among the 490 eligible physicians. To simplify reporting results, we collapsed
most 5- to 7-point response options into 3, such as agree/uncertain/disagree,
unimportant/neutral/important, and ineffective/unsure/effective. There were
no important differences when the analyses were conducted using the full response
scales and the collapsed scales.
Descriptive univariate analyses included means and SDs for normally
distributed continuous data, percentages for categorical data, and quartiles
for ordinal or nonnormal continuous data. We tested for differences among
the 4 hospitals and among 4 physician groups (residents, general internal
medicine attending physicians, infectious disease attending physicians, and
other internal medicine subspecialty attending physicians) using an analysis
of variance if the data were normally distributed and if the data met the
assumption of equal variances (Levene test). Otherwise, we used the equivalent
nonparametric test, such as the Mann-Whitney test, the Kruskal-Wallis test,
or logistic regression. For examining the relationships among knowledge, beliefs,
and attitudes, we used Pearson product moment or Spearman rank correlation
coefficients and multivariable linear and logistic regression. We analyzed
all data using Statistical Product and Service Solutions software, versions
8 and 9 (SPSS Inc, Chicago). All reported P values
are 2-tailed. We made no adjustments for multiple comparisons, but we considered P .01 as statistically significant.
RESULTS
Among the 490 eligible physicians, 429 returned questionnaires, of which
424 (87%) were complete and evaluable. The sample included 243 internal medicine
residents, 114 general internal medicine attending physicians, 21 infectious
disease subspecialists, and 46 other internal medicine subspecialists (Table 1).
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Table 1. Characteristics of Participating Physicians and Hospitals*
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IMPORTANCE OF THE PROBLEM OF ANTIBIOTIC RESISTANCE
Most respondents (87%) perceived antibiotic resistance to be a very
important national problem. Even more (91%) thought it would be a very important
national problem 10 years from now. These attitudes did not differ across
hospitals, specialty, or level of training.
However, there was significant variability among physicians' attitudes
regarding the problem of antibiotic resistance in their own clinical practices
(Figure 1). The proportion of physicians
who rated the local problem of antibiotic resistance as very important ranged
from 49% at the county hospital to 94% at the long-term care hospital (P = .01). Nearly all infectious disease attending physicians
(90%) ranked the local problem of antibiotic resistance as very important,
compared with only 53% of non–infectious disease respondents (P = .004). There were no differences between residents
and attending physicians (Figure 1).
In a multivariable linear model, physicians' attitudes about the local problem
of antibiotic resistance were best predicted by their previous experiences
with resistance (r = 0.25; P<.001),
whereas all other variables in the model were insignificant (training status,
subspecialty, hospital, and knowledge of local resistance).
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Figure 1. Physicians' perceptions of the
importance of the problem of antibiotic resistance in their clinical practices.
Physicians' responses are collapsed into 3 groups: extremely important or
very important (very important), moderately important or somewhat important
(moderately important), and minimally important or unimportant (unimportant).
Responses differed by hospital (Kruskal-Wallis test, P =
.001) and physician group (Kruskal-Wallis test, P =
.004). Numbers in parentheses indicate the number of physicians; ID attendings,
infectious disease subspecialists; and non–ID attendings, general internal
medicine attending physicians and internal medicine physicians who specialize
in areas other than IDs.
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KNOWLEDGE OF THE PREVALENCE OF ANTIBIOTIC RESISTANCE
The prevalence of antibiotic resistance for 7 bug-drug combinations
is shown for each hospital in Table 1.
The accuracy of physicians' estimates of these prevalences is depicted in Figure 2.
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Figure 2. Box plots of the differences between
physician estimates of antibiotic resistance and true hospital prevalence
for 7 bug-drug combinations (surveillance year, 1999). The boxes represent
physicians between the 25th and 75th percentiles; white lines within the boxes,
medians. Whiskers extend a length of 1.5 times the interquartile range or
to the most extreme value, whichever is shortest. The 3 physician groups differed
significantly for some of the bug-drug combinations (multivariate analysis
of variance, Wilks  = 0.77, P<.001), in
particular, for Escherichia coli and the combination
of ampicillin and sulbactam and for Streptococcus pneumoniae and penicillin (P<.001 for both). For Klebsiella pneumoniae and ceftazidime, the median estimate
was an underestimate of the true prevalence by 9 percentage points, whereas
the middle half of physicians (represented by the box) ranged from an underestimate
of 12 percentage points to an overestimate of 4 percentage points. However,
there were some physicians who underestimated the problem by nearly 30 percentage
points. Non–ID subspecialists indicates internal medicine physicians
who specialize in areas other than infectious diseases; ID subspecialists,
those who specialize in IDs; and MIC, minimum inhibitory concentration.
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Most physicians tended to underestimate the prevalence of antibiotic
resistance at their own institution, except for those bug-drug combinations
for which only overestimation was possible—vancomycin-resistant Staphylococcus aureus and high-level (minimum inhibitory
concentration, >2.0 µg/mL) penicillin-resistant Streptococcus
pneumoniae, which had actual rates of 0, with one exception (Figure 2). As expected, infectious disease
physicians estimated antibiotic resistance rates more accurately and with
much less variation.
EXPERIENCE WITH ANTIBIOTIC RESISTANCE AND ITS COMPLICATIONS
Infectious disease physicians reported that, on average, 32% of the
infected inpatients they cared for had antibiotic-resistant infections, similar
to the mean percentage reported by critical care physicians (34%), but twice
the rate reported by general internal medicine physicians (16%) (P<.001). There were significant differences in physicians' experiences
with antibiotic-resistant infections that paralleled the true variation in
the prevalence of antibiotic resistance across hospitals (Spearman  =
0.55, P<.001).
Although the reported prevalence of in vitro resistance to the standard,
recommended, first-line antibiotic of choice (our definition of "antibiotic
resistance") ranged from 11% to 44% across the 4 hospitals, the reported resistance
to the initial antibiotics actually prescribed was lower (10%) and nearly
the same for all physician groups and hospitals.
CAUSES OF ANTIBIOTIC RESISTANCE
Nearly all physicians (97%) believed that widespread and inappropriate
use of antibiotics were important general causes of antibiotic resistance,
while use of antibiotics for self-limited nonbacterial infections and use
of antibiotics with a broader-than-necessary spectrum were most often considered
very important specific causes (Table 2). Poor hand washing was identified as a very important cause by
only 45% of respondents, although with greater frequency at the 2 nonteaching
hospitals (71% and 82%) than at the 2 teaching hospitals (38% and 45%) (P = .006).
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Table 2. Physician Ratings of the Importance of Possible Causes of
Antibiotic Resistance*
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The factors most frequently identified as unimportant or minimally important
were lack of antibiotic restrictions, poor access to prescribing guidelines,
drug company promotions, excessive antibiotic use in livestock, and antibiotic
use for an inappropriately long duration.
INTERVENTIONS
Although most physicians cited widespread antibiotic use as a very important
cause of antibiotic resistance, reducing use of antibiotics was considered
an effective remedy by only 66% (Table 3). However, almost all infectious disease physicians (20 of 21 physicians)
supported the effectiveness of this general approach (P = .02).
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Table 3. Physician Ratings of the Effectiveness of Potential Interventions
for Antibiotic Resistance*
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The most favored interventions were those that provided information
and did not restrict physicians' behavior, such as providing current antibiograms
and institution-specific antibiotic prescribing guidelines and conducting
grand rounds on antibiotic prescribing and antibiotic resistance (Figure 3).
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Figure 3. Physicians' beliefs about the
effectiveness of informational interventions. Among the 5 response options,
we collapsed definitely effective and probably effective (effective) and definitely
ineffective and probably ineffective (ineffective). There was 1 physician
from the public hospital and 1 from the university hospital (1 resident and
1 non–ID physician, respectively) who believed informational interventions
would be ineffective. Responses differed among the 3 physician groups (Kruskal-Wallis
test, P<.001), but did not differ significantly
among the 4 hospitals (Kruskal-Wallis test, P = .40).
Numbers in parentheses indicate the number of physicians; ID attendings, infectious
disease subspecialists; and non–ID attendings, general internal medicine
attending physicians and internal medicine physicians who specialize in areas
other than infectious diseases.
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At the 2 hospitals with established restrictions on antibiotic use (county
and community hospitals), only 11% of residents, 29% of community hospital
attending physicians, and 39% of public hospital attending physicians favored
increasing the scope of restrictions. In contrast, increasing restrictions
was favored by more than 50% of the physicians at the other 2 hospitals, where
there are few restrictions (Figure 4).
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Figure 4. Physicians' beliefs about the
effectiveness of restricting more antibiotics. Among the 5 response options,
we collapsed definitely effective and probably effective (effective) and definitely
ineffective and probably ineffective (ineffective). Responses differed among
the 4 hospitals and among the 3 physician groups (Kruskal-Wallis test, P<.001 for both). Numbers in parentheses indicate the
number of physicians; ID attendings, infectious disease subspecialists; and
non–ID attendings, general internal medicine attending physicians and
internal medicine physicians who specialize in areas other than infectious
diseases.
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COMMENT
Our survey demonstrates that internal medicine physicians are aware
of and concerned about antibiotic resistance in the inpatient setting. However,
their perceptions about its importance, its causes, and potential solutions
are often contradictory and at variance with available medical evidence.
Although 87% of our sample viewed resistance as a very important national
problem—demonstrating awareness of an ecologic problem that poses risks
to patients—only 55% believed that antibiotic resistance was a very
important problem in their own hospitals, suggesting that many respondents
see the risks as more theoretical than concrete, possibly weakening the impetus
for behavior change. These findings are consistent with those of Paluck and
colleagues,13 who found that only 77% of British
Columbian family practitioners agreed that widespread antibiotic use was a
notable factor in their own communities.
There was also wide variation in physicians' knowledge of the prevalence
of antimicrobial resistance at their own hospitals, despite the availability
of antibiograms at each. Perceived prevalence, however, was only weakly correlated
with physicians' perceived importance of resistance in their own hospitals.
This suggests that educational interventions or antibiograms that correct
physicians' underestimates of the prevalence of resistance may not translate
into a heightened concern for the problem. Because personal experience with
antibiotic resistance was a stronger predictor of perceptions about importance,
it raises the possibility that case vignettes illustrating the harmful effects
of antibiotic resistance may improve the effectiveness of interventions.
Another apparent contradiction in our survey results is the perceived
role of antibiotic use as a cause of resistance and as a target for interventions.
Widespread antibiotic use and inappropriate use were believed to be important
general causes of resistance by 97% of the respondents, yet reducing antibiotic
use was believed effective in ameliorating resistance by only 66%. This discrepancy
may be due to a lack of awareness of the effectiveness of this strategy in
inpatient17-20 and
outpatient21-22 settings or to
skepticism about the feasibility of reducing antibiotic use in actual practice.
The tepid endorsement of poor hand hygiene as a contributor to antibiotic
resistance may reflect a similar lack of awareness of the effectiveness of
this simple, yet underused, practice.23-26 Dispelling
such misconceptions is a prerequisite for effectively combating resistance.
Agreement with a general strategy of reducing inappropriate antibiotic
use does not guarantee acceptance of the specific means of accomplishing the
goal. Consistent with the findings of Murray et al,14 the
internists we surveyed preferred interventions that promote voluntary changes
in prescribing behavior, such as dissemination of guidelines, antibiograms,
and educational conferences. Guidelines, in particular, have the additional
advantage of offering prescribing support to those physicians who are insecure
about optimal antibiotic use.27
Although physician education has a generally poor track record in changing
physician behavior,28 a multifaceted approach
can be successful.29 The likelihood of success
is further enhanced if the educational message is delivered at the time of
prescribing,30 which is easiest to implement
in the context of computerized physician order entry.31-32 Because
sophisticated informational interventions such as these conform more closely
to physicians' preferences, they may meet with greater acceptance and, possibly,
more sustained effectiveness.
There was much less support in our survey for interventions that compel
compliance by requiring prior approval for antibiotic use or limiting formulary
antibiotic choices, perhaps because they restrict physician autonomy and complicate
antibiotic ordering. Indeed, although prior approval programs can effectively
reduce use of targeted antibiotics,18-20 they
may promote a shift in antibiotic use rather than a reduction33 and,
thereby, have little effect on antibiotic resistance, while causing resentment
among prescribing physicians.34
Previous surveys11-13 about
antibiotic use and resistance have focused on the outpatient setting because
of the greater volume of antibiotic use and the greater discretion in empirical
antibiotic prescribing. Therefore, our study of physicians' attitudes about
antibiotic resistance in the inpatient setting provides complementary information.14 Our overall response rate was high (87%), but we
surveyed physicians in only 4 hospitals and did not include all relevant specialties
(surgery, pediatrics, family practice, and emergency medicine). And, as with
most surveys, it is possible that respondents gave socially desirable answers.
To minimize this potential bias, we introduced our survey in a neutral manner,
emphasized the dearth of prior research and the appropriateness of disparate
views, and assured complete respondent confidentiality. Finally, questions
about personal experience are subject to recall bias. Several findings, however,
support the questionnaire's validity: the spectrum of physicians' reported
experiences with antibiotics varied appropriately (twice as common among infectious
disease specialists) and physicians' perceived experiences with antibiotic
resistance correlated with objectively measured levels of antibiotic resistance
at each hospital.
In summary, the physicians we surveyed were aware of antibiotic resistance
as a national problem and recognized the causal role of excessive antibiotic
use. At the same time, however, there was substantial ambivalence about the
importance of antibiotic resistance in the physicians' own hospitals, the
effectiveness of reducing antibiotic consumption in combating resistance,
and the importance of poor hand hygiene as a contributor to resistance. These
contradictory perspectives present challenges that must be overcome if we
are to successfully address the mounting problem of antibiotic resistance.
AUTHOR INFORMATION
Accepted for publication April 3, 2002.
This study was supported by the Collaborative Research Unit of the Department
of Medicine, Cook County Hospital, and by the Chicago Antimicrobial Resistance
Project, funded by grants U50/CCU15853-01 and U50/CCU515853-02 from the Centers
for Disease Control and Prevention, Atlanta, Ga (Robert A. Weinstein, MD,
principal investigator for the 2 grants).
We thank Brendan M. Reilly, MD, and Dr Weinstein for their critical
reviews and contributions to the manuscript; and the surveyed physicians for
their participation.
The contents of this study are solely the responsibility of the authors
and do not necessarily represent the official views of the Centers for Disease
Control and Prevention.
Corresponding author and reprints: Arthur T. Evans, MD, MPH, Collaborative
Research Unit, Department of Medicine, Cook County Hospital, Room 1600, Administration
Building, 1900 W Polk St, Chicago, IL 60612 (e-mail: aevans{at}cchil.org).
From the Department of Medicine, Cook County Hospital and Rush Medical
College, Chicago, Ill.
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