Research

Web exclusive

Canadian physicians’ knowledge andcounseling practices related to antibiotic
use and antimicrobial resistanceTwo-cycle national survey
Courtney R. Smith MPH Lisa Pogany MSc Simon Foley MA Jun Wu PhD
Karen Timmerman MSc Margaret Gale-Rowe MD Alain Demers PhD

Abstract
Objective To establish a baseline for physicians’ knowledge of and counseling practices on the use of antibiotics andantimicrobial resistance (AMR), and to determine potential changes in these measures after the implementation of anational AMR awareness campaign.
Design Cross-sectional design.
Setting Canada.
Participants A total of 1600 physicians.
Main outcome measures Physicians’ knowledge of and counselingpractices on antibiotic use and AMR at baseline and after implementationof the AMR awareness campaign.
Results A total of 336 physicians responded to the first-cycle survey(before the campaign), and 351 physicians responded to the second-cycle
survey (after the campaign). Overall, physicians’ knowledge of appropriate
antibiotic use and AMR was high and their counseling practices in relation
to antibiotics were appropriate in both surveys. Counseling levels about
topics related to infection prevention and control (eg, food handling,household hygiene) were slightly lower. Counseling levels were also lower
for certain antibiotic-use practices (eg, proper disposal of antibiotics). In
addition, physicians with less than 10 years of practice experience hadsignificantly lower odds of counseling their patients on topics related topreventing antibiotic resistance and infection prevention than those with
15 or more years of practice experience (adjusted odds ratio = 0.27, 95% CI
0.10 to 0.74). Significantly more physicians from the second-cycle survey
counseled patients on the appropriate disposal of antibiotics (P = .03), as
well as on some of the infection prevention topics (eg, using antibacterial
hand soap [P = .02] and cleaning supplies [P = .01]). Most respondents inboth surveys reported feeling confident with respect to counseling theirpatients on the appropriate use of antibiotics and AMR.
Conclusion Physicians’ knowledge of and levels of counseling on theuse of antibiotics and AMR were high and fairly stable in both survey
results. This shows that Canadian physicians are demonstrating behaviour
patterns of AMR stewardship. Existing gaps in counseling practices
might be a result of physicians believing that pharmacists or nurses are
addressing these issues with patients. Future national surveys conductedamong pharmacists and nurses would contribute to the evidence base for
AMR stewardship activities.

e526 Canadian Family Physician Le Médecin de famille canadien | VOL 63: DECEMBER • DÉCEMBRE 2017•

EDITOR’S KEY POINTS• To address antimicrobial resistance(AMR) in Canada, a national
antibiotics awareness campaign
was implemented. Surveys wereadministered to physicians before
and after the campaign to establish
a baseline of their knowledge of andcounseling on antibiotics and AMR.
• This study found that physicians’
knowledge of antibiotic use and AMR
was very high. The overall results suggestthat physicians are we ll informed about
the spread of resistance.
• Topics least likely to be counseled
on included food handling, householdhygiene, proper coughing and handwashing practices, and using handsanitizer and antibacterial supplies(eg, dish soap); this might be because
physicians do not believe these topics
are important and might expect that
other health care professionals will
discuss these topics with patients.
While counseling on correct antibiotic
use was quite high overall, thecounseling levels were lowest forcautioning patients about sharing
antibiotics and advising on how toproperly dispose of them.
This article has been peer reviewed.
Can Fam Physician 2017;63:e526-35

Recherche

Exclusivement sur le web

Les connaissances et les pratiques de consultation
des médecins canadiens relativement à l’utilisation
des antibiotiques et à la résistance aux antibiotiques
Une enquête nationale en 2 étapes
Courtney R. Smith MPH Lisa Pogany MSc Simon Foley MA Jun Wu PhD
Karen Timmerman MSc Margaret Gale-Rowe MD Alain Demers PhD

Résumé

Objectif Déterminer ce que les médecins savent de l’utilisation des antibiotiques et du développement de la résistance aux
antibiotiques (RAB), et ce, avant et après l’instauration d’une campagne nationale sur ce problème.
Type d’étude Une enquête transversale.
Contexte Le Canada.
Participants Un total de 1600 médecins.
Principaux paramètres à l’étude Les connaissances et les pratiques de consultation des médecins relativement àl’utilisation des antibiotiques et à la résistance aux antibiotiques, au point de départ et après la mise en œuvre d’une
campagne de sensibilisation à la RAM.
Résultats Au total, 336 médecins ont répondu au premier cycle du sondage (avant la campagne) et 351 au deuxième cycle
du sondage (après la campagne). Dans les deux sondages, les répondants ont démontré qu’ils connaissaient bien la façon
correcte d’utiliser les antibiotiques et la RAB, et leurs pratiques de consultation relatives aux antibiotiques étaient appropriées.
Toutefois, pour des sujets comme la prévention et le contrôledes infections (p. ex. la manipulation des aliments et l’hygiène
POINTS DE REPÈRE DU RÉDACTEUR
domestique), le counseling était un peu plus faible. Et c’était aussi le• Une campagne nationale de sensibilisation aux
cas pour certaines pratiques d’utilisation des antibiotiques (p. ex. la
antibiotiques a été mise sur pied au Canada pourfaçon d’en disposer). De plus, par rapport aux médecins qui avaients’attaquer à l’accroissement de la résistance aux
15 années ou plus de pratique, ceux qui en avaient moins de 10
antibiotiques (RAB). On a tenu des sondages auprès derécoltaient des cotes moins élevées pour leur façon de conseiller
médecins avant et après cette campagne afin d’établir une
les patients sur des sujets liés à la prévention de la résistancebase de leurs connaissances et des conseils qu’ils donnent
bactérienne aux antibiotiques et à la prévention des infections
relativement aux antibiotiques et sur la RAB.
(rapport de cotes ajustée = 0.27, IC à 95 % 0,10 à 0,74). Un nombre• Cette étude a montré que les médecins ont une trèssignificativement plus élevé de répondants au deuxième cycle
bonne connaissance de l’utilisation des antibiotiques et de la
du sondage conseillaient leurs patients sur la façon correcte de
RAB. Dans l’ensemble, les résultats donnent à croire que lesdisposer des antibiotiques (P = .03), mais aussi sur certains sujets
médecins sont bien informés de l’augmentation de la RAB.
concernant la prévention des infections (p. ex. l’utilisation de• Les sujets le moins susceptibles de faire l’objet desavons antibactériens pour les mains [P = 0,2] et le nettoyage desconseils sont la manipulation des aliments, l’hygiène
instruments [P = ,01]). La plupart des répondants aux deux sondages
domestique, la bonne façon de tousser et de se laver les
se disaient confiants pour ce qui est de conseiller leurs patients sur
mains ainsi que l’utilisation de produits désinfectants etla façon appropriée d’utiliser les antibiotiques et sur la RAB.
antibactériens (p. ex. le savon à vaisselle); cela pourraitêtre dû au fait que les médecins ne croient pas que ces
sujets sont importants et qu’ils s’attendent à ce qued’autres professionnels de la santé les abordent avec
les patients. Les conseils sur l’utilisation correcte desantibiotiques étaient généralement très bien prodigués,mais ceux concernant le partage d’antibiotiques et lafaçon correcte d’en disposer l’étaient beaucoup moins.

Cet article a fait l’objet d’une révision par des pairs.
Can Fam Physician 2017;63:e526-35

Conclusion Les deux sondages ont montré que les médecins avaient
une bonne connaissance de l’utilisation des antibiotiques et de la
RAB, et que les conseils qu’ils donnaient à leurs patients étaientappropriés. Cela montre que les médecins canadiens font preuved’un comportement adéquat quant à la gestion de la RAB. Certaines
failles dans leurs pratiques de consultation pourraient résulter du fait
qu’ils croient que les pharmaciens ou les infirmières abordent cesquestions avec les patients. De futurs sondages nationaux auprèsde pharmaciens et d’infirmières pourraient contribuer à la base deconnaissances relative aux activités de gestion de la RAB.

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Research | Knowledge and counseling practices related to antibiotic use and AMR

Antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi, and parasites change in sucha way that the medications used to eliminate
these organisms become less effective.1-3 Antimicrobial
resistance presents a serious public health concern, as
it threatens our ability to effectively treat infectious diseases. To address this concern, studies conducted in
the United Kingdom,4 Sweden,5 Ethiopia,6 Peru,7 Spain,8Korea,9 Brazil,10 and the United States11 have gathereddata on physician knowledge of, beliefs about, and practice patterns for the use of antibiotics and AMR.
Despite this wealth of international literature, there
is a lack of concrete data about Canadian physicians’
knowledge of and counseling practices regarding antibiotics and AMR. While related studies on antibiotic overprescribing have been done at the provincial level,12,13
no surveys related to these topics have been conducted
about physicians at the national level. This paucity ofdata is a considerable limitation in conducting effective
knowledge translation activities and developing guidance related to AMR.
To address AMR in Canada, the Government of
Canada dedicated funds to pilot an antibiotics awareness campaign through the Public Health Agency ofCanada. The objectives of the campaign were to
improve physicians’ knowledge of the potential risks
associated with the inappropriate use of antibiotics, andto improve the capacity and confidence of physicians to
discuss AMR with their patients. Multiple media platforms were used to promote campaign messages over
several months, starting in November 2014.14 A suite ofresources and knowledge products, such as webinars,
campaign posters, and Government of Canada Web
content was developed and provided to health care professionals. These newly developed resources were promoted in a variety of ways, ranging from social media,
news outlets (eg, online, radio, and print), Web bannerads on select sites targeted to health care professionals,
and search engine marketing.
In order to establish a baseline of physicians’ antibiotic knowledge and counseling practices, and later
assess the effect of the campaign, an evaluation wasplanned to collect first-cycle (before the campaign) andsecond-cycle (after the campaign) data. The first-cycle
survey was conducted in February to March of 2014,
while the second-cycle survey was administered in
March to April of 2015, 4 months after the launch of thecampaign. The objective of the surveys was 2-fold: toestablish a baseline for Canadian physicians’ knowledge
and counseling practices in relation to use of antibiotics
and AMR, and to determine potential changes in thesemeasures after implementation of the national AMR
awareness campaign.

METHODS
Approval for the research protocol was granted byHealth Canada’s Research Ethics Board and the appropriate provincial, territorial, and regional boards.

First-cycle survey
A panel of approximately 1600 physicians living andpractising in Canada was invited to participate. The contractor for this survey, TNS Canada Ltd, provided thepanel of 1600 physicians, who were all Canadian, werefrom a variety of medical specialties, and were on thepanel because of an expressed interest in participatingin research. Physicians had to counsel on or prescribe
antibiotics in their practice in order to be eligible for the
study. All physicians on the panel were contacted by
TNS Canada Ltd using e-mail invitations, and respondents were those who met the eligibility criteria andagreed to participate. Respondents were required to provide informed consent before being directed to the survey. There was a nominal remuneration of $40 for theparticipating physicians.
The survey was available between February 18, 2014,
and March 10, 2014, and administered online in English
or French. The survey was divided into 4 sections: demographic characteristics, practice and patient interaction,knowledge about AMR, and antibiotic counseling intentions and confidence. The survey was developed internally at the Public Health Agency of Canada by a team ofpolicy analysts, epidemiologists, knowledge translation
experts, and communication and marketing experts. The
survey was also pilot-tested internally and was reviewed
by the Health Canada Research Ethics Board.

Second-cycle survey
The same survey and methodology was used for thesecond-cycle survey. The survey was administered
between March 28, 2015, and April 9, 2015, 4 months
after the launch of the campaign. The same panel ofapproximately 1600 physicians living and practising in
Canada was invited to participate. All physicians were
eligible to complete the survey, regardless of whether
they had completed the first-cycle survey. As a result of
this methodology, the 2 samples were neither matched,
nor completely independent.

Analyses
The first- and second-cycle surveys were designed to
be able to detect a 10% improvement in knowledge andpractice. To compare responses between the first- andsecond-cycle surveys, χ2 tests were used, and significant differences were set at an α level of .05. When theassumptions for the χ2 test were violated, a Fisher exact
test was performed. Select multivariate analyses werealso conducted on the second-cycle survey results.

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Knowledge and counseling practices related to antibiotic use and AMR | Research
RESULTS

Demographic characteristics
A total of 359 physicians (22% response rate) participatedin the first-cycle survey and 354 (22% response rate) participated in the second-cycle survey. Because there was asmall number of non–family physician specialists who participated in each survey (n = 23 in the first cycle; n = 3 in thesecond cycle), and owing to the diversity of their specialties, non–family physician specialists were removed fromthe analysis and only family physicians were included.
Thus, the final sample size for the first- and secondcycle surveys was 336 and 351, respectively (Table 1).
Respondents were predominantly men (71% in the firstcycle and 76% in the second cycle), practising in areas witha population of 100 000 or more residents (64% and 69%,
respectively), and practising for 15 years or more (70% and77%, respectively). There were no significant differences
between the first- and the second-cycle surveys in sex distribution (P = .14), practice setting (P = .34), or years of practice (P = .06). However, region of practice was statisticallydifferent between the 2 cycles (P = .04), with slightly greater
representation from the Prairies (Alberta, Saskatchewan,
and Manitoba), British Columbia, and Ontario in thesecond-cycle survey compared with the first. All further
analyses will be pooled over regions and multivariate
analyses will be adjusted for region.

first-cycle survey and 9% of respondents in the secondcycle survey either didn’t know the answer, or responded
incorrectly as to whether AMR can increase as a result of
patients not taking their full course of antibiotics (indeed,
AMR can increase as a result of this). This question was
also the only question that showed a statistically significant
difference in responses between cycles (P = .04). Between
the first and second cycles, there was a 2% increase in correct responses, a 4% decrease in incorrect responses, anda small corresponding increase in “don’t know” responses.

Counseling: topics and physician confidenceCounseling on topics related to preventing antibiotic
resistance and infection prevention. Respondents in both

Table 1. Demographic characteristics of the participantsin the first-cycle and second-cycle surveys: There were
336 participants in first cycle and 351 participants inthe second cycle.
FIRST-CYCLESURVEY,N (%)

SECOND-CYCLESURVEY,N (%)• Male240 (71)268 (76)• Female96 (29)83 (24)27 (8)

21 (6)

VARIABLE

Sex.14

Region.04*• Atlantic†

Prescribing practices and knowledge• Quebec

77 (23)52 (15)

Physicians’ reasons for prescribing antibiotics. In thefirst-cycle survey, 92% of respondents indicated that theyfrequently prescribed antibiotics for respiratory infections, followed by urinary tract infections (69%), skininfections (54%), sexually transmitted infections (33%),
prophylaxis (17%), and digestive tract infections (12%).
In the second-cycle survey, these results changed very
little (Figure 1). There were no significant differences
between the first- and the second-cycle survey resultsin the percentage of respondents who reported that theyfrequently prescribed antibiotics for each condition.

• Ontario

123 (37)141 (40)• Prairies‡

59 (18)71 (20)• British Columbia

50 (15)66 (19)• <5 y17 (5)

15 (4)• 5-9 y32 (10)32 (9)

Physicians’ knowledge about issues relating to antibiotic
resistance. To assess their knowledge of AMR, respondents were asked true-false questions regarding the development and spread of resistance (Table 2). Of the 10questions that were asked, respondents answered atleast 9 of them correctly 87% of the time in the first-cycle
survey and 91% of the time in the second-cycle survey.
Despite these overall positive results, 14% of respondents
in the first-cycle survey and 16% in the second-cycle survey falsely believed that AMR occurs when people become
resistant to antibiotics; however, it is the bacteria and invasive organisms that develop resistance, not humans (7%and 4% responded “don’t know” in the first and second
cycles, respectively). In addition, 11% of respondents in the

P VALUE

Years of practice.06• 10-14 y

52 (15)35 (10)• ≥ 15 y

235 (70)269 (77)

Practice setting(population).34• Large urban centre(≥ 100 000)216 (64)243 (69)• Medium centre(30 000-99 999)

57 (17)55 (16)• Small urban orsuburban centre(1000-29 999)

50 (15)46 (13)• Rural area (< 1000)

12 (4)

7 (2)• Geographicallyisolated or remote

1 (0)

0 (0)

*Significant at the .05 α level.
†
Atlantic provinces comprise Nova Scotia, Prince Edward Island, and
New Brunswick.
‡
Prairie provinces comprise Manitoba, Saskatchewan, and Alberta.

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Research | Knowledge and counseling practices related to antibiotic use and AMR
Figure 1. Percentage of respondents who reported frequently prescribing antibiotics, by condition
100
90

92 91

80
70

71

RESPONDENTS, %

69
60

54

50

52

40
33 32

30

First–
cycle survey

20

Second–cycle survey

17
10

12

12

9

io

n

xi
s

ct

la

fe

hy
st
ge
Di

Se

xu

ive

al

ly

tra

ct

in

Pr
op

tra
n
in sm
fe itt
ct ed
io
n

n
io
ct
fe
in
n
sk
i
or

W
ou

nd

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ar
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sp
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ra
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ct

ct

io

io

n

n

0

CONDITION

survey cycles were asked about how often they counseled patients on topics related to preventing antibiotic
resistance and infection prevention. Respondents were
presented with a list of 10 topics, ranging from influenza
vaccination and hand hygiene, to safe sex and food handling. Respondents had 4 answers to choose from: “often,”“sometimes,” “almost never,” and “don’t remember.”Overall, 99% of respondents in both the first- and secondcycle surveys reported often or sometimes discussing
the annual influenza vaccination program with patients.
A high percentage of respondents in both surveys also
reported having discussions with patients about safe sex,
coughing practices, and hand-washing practices. Food
handling, household hygiene, and the use of hand sanitizer were topics that were less frequently addressed byphysicians. The topics discussed the least were the use ofantibacterial dish soap, antibacterial hand soap, and antibacterial cleaning supplies (Figure 2).
In 8 out of the 10 topics, there were no significant differences in responses between the first- and secondcycle surveys. However, significantly more respondents
reported often or sometimes counseling patients on using

antibacterial hand soap (P = .02) and antibacterial cleaning supplies (P = .01) in the second-cycle survey comparedwith the first cycle. In addition, logistic regression analyses
revealed that physicians with less than 10 years of practice experience had significantly lower odds of counseling patients on all 10 topics (versus 9 or fewer) comparedwith those with 15 or more years of practice experience(adjusted odds ratio = 0.27, 95% CI 0.10 to 0.74).
Counseling on correct antibiotic use. Respondents inboth cycles were asked about how often they counseled
patients about correct antibiotic use and were presented
with a list of 5 topics. Respondents had 4 answers tochoose from: “often,” “sometimes,” “almost never,” and“don’t remember.”
Ninety-nine percent of respondents in both the first- andsecond-cycle surveys reported that they often or sometimes
counsel their patients about the correct daily dose andlength of the prescription of antibiotics, or why an antibiotic
is not being prescribed (ie, that antibiotics are only effective
for the treatment of bacterial infections). Respondents fromboth cycles also reported high levels of counseling theire530 Canadian Family Physician Le Médecin de famille canadien | VOL 63: DECEMBER • DÉCEMBRE 2017•

Knowledge and counseling practices related to antibiotic use and AMR | Research
Table 2. Percentage of respondents correctly answering true-false questions related to antimicrobial resistanceRESPONDENTS
WHO ANSWEREDCORRECTLY, %TRUE-FALSE QUESTIONSCORRECTANSWER

FIRST-CYCLESURVEYSECOND-CYCLESURVEYP VALUE(ALL CATEGORIESOF RESPONSE*)

True
True
True
True
False
True
True
False
False
False

97
89
98
98
79
99
96
95
96
87

98
91
95
99
80
98
98
97
98
90

.76
.04†
.21
.08
.35
> .99
.35
.24
.51
.31

Use of antibiotics is associated with disturbance of the normal microbial flora
The following factor increases AMR: patients not taking their full course of antibiotics
The following factor increases AMR: bacteria adapting rapidly to new conditions
The following factor increases AMR: patients taking antibiotics when not necessary
Antibiotic resistance occurs when people become resistant to antibiotics
Antibiotic resistance occurs when bacteria become resistant to antibiotics
Proper hand-washing technique prevents spread of organisms that are on the hands
When one gets a cold, antibiotics will help one get better more quickly
If someone you know is not feeling well, it is safe to share antibiotics with them
If someone in a household is sick, taking antibiotics will prevent otherhousehold members from getting sick

AMR—antimicrobial resistance.
*Analyses were conducted by comparing all response categories between the first- and second-cycle surveys (ie, correct, incorrect, “don’t know”), notjust the correct responses.
†
Significant at the .05 α level.

Figure 2. Percentage of respondents who indicated that they “often” or “sometimes” address topics related topreventing antibiotic resistance with their patients during a consultation
100

99 99

97

95

90

91 90

88 87

80

73

78

73
69

72

68

60

61

50

50

49

40

41

37

30

31

20

First–
cycle
surveySecond–cycle
survey

10

so
ap
ish

ria

ld

lc
su lean
pp in
lie g
s

ria

te
ac
tib
An

tib
An

An

tib

ac

ac

te

te

ria

nd

lh

an

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sa
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so

iti
z

ap

er

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us
e
Ho

Ha

ho
ld

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od
Fo

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es
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pr
ac
ng

wa
nd
Ha

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ug
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Sa

pr
ac

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tic

se

es

x

0

sh G
ot ettev ing
er a
y fl
ye u
ar

RESPONDENTS, %70

TOPICS RELATED TO PREVENTING ANTIBIOTIC RESISTANCE*Significant at thelevel of .05.

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Research | Knowledge and counseling practices related to antibiotic use and AMR
patients not to use antibiotics that belong to others and not
to share antibiotics. How to dispose of leftover antibiotics
was discussed least often in both cycles (Figure 3).
Significantly more respondents reported often or sometimes counseling patients on how to dispose of leftover
antibiotics in the second-cycle survey compared with thefirst-cycle survey (P = .03). Logistic regression analyses
revealed that all physicians, regardless of demographic
characteristics (eg, sex, years of practice, practice setting),
were equally likely to counsel their patients on all 5 topics
that related to antibiotic use (versus 4 or fewer).

influenza immunization program (70% of respond-ents
in the first cycle; 71% in the second cycle). Hand-washingpractices were discussed by 59% of respondents in thefirst-cycle survey and 55% in the second. Last, correct
coughing practices were addressed by approximately
60% of respondents, with similar levels among the firstand second-cycle survey respondents (61% and 56%
in the first and second cycle, respectively). There wereno significant differences between the first and second
cycle in any of the topics discussed. In addition, logistic regression revealed that all physicians, regardless ofdemographic characteristics (eg, sex, years of practice,practice setting), were equally likely to counsel theirpatients on all 4 topics (versus 3 or fewer) during theirlast consultation for a viral respiratory infection.

Topics discussed during the last consultation for a viral
respiratory infection. Respondents were then asked tothink back to their last consultation for a suspected viral
respiratory tract infection and to report whether they had
discussed certain topics related to infection prevention
and the appropriate use of antibiotics. Available responses
were “yes,” “no,” “unsure,” and “not applicable to visit.”
Ninety-four percent of first-cycle survey respondents and 95% of second-cycle survey respondents reported that they addressed the fact that
antibiotics are only effective in treating bacterial infections. The second most frequently discussed topic shownin both survey results was participation in an annual

Physicians’ confidence about specific counseling topics.
Respondents were asked to rate their confidence withrespect to counseling patients about topics related tothe appropriate use of antibiotics and the prevention of
AMR. Available answers were “very confident,” “somewhat confident,” “neutral,” “somewhat not confident,”“not confident at all,” and “don’t know.”
When the categories “somewhat confident” and “veryconfident” were combined, at least 95% of physicians

Figure 3. Percentage of respondents who indicated that they “often” or “sometimes” address topics related to
antibiotic use with their patients during a consultation
100
99

99

99

99

90
85

80

87
79

79

RESPONDENTS, %

70

*

60

60

50

51

First–
cycle
surveySecond–cycle
survey

40
30
20
10
0

Correct daily
dose andduration

Why anantibiotic is
not being given

Not to use
others’antibiotics

Not to shareantibiotics withsomeone else

TOPICS RELATED TO ANTIBIOTIC USE*Significant at thelevel of .05.

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How to disposeof antibiotics

Knowledge and counseling practices related to antibiotic use and AMR | Research
responded that they were confident in discussing thefact that antibiotics are for bacterial infections (99% in
the first cycle, 98% in the second cycle); providing astrong rationale for not prescribing antibiotics (99% and98%, respectively); discussing the annual influenza vaccination program (98% and 99%, respectively); discussing proper antibiotic use and prevention of AMR (97%in both cycles); refusing to give an unnecessary prescription for antibiotics (96% and 95%, respectively); andcounseling their patients on safer sex (95% and 97%,
respectively). At least 91% of respondents in both cycles
were confident in providing counseling on hand hygieneand coughing practices, but respondents in both cycles
were less confident about counseling on household
infection control (77% in both cycles) and food handling(72% and 69%, respectively). There were no significant
differences between the first and second cycle in physicians’ confidence related to the 10 specific counseling
topics discussed above.

DISCUSSION
Knowledge and behaviour among physicians remained relatively stable across survey cycles. Based on the impressive
results of the first-cycle survey, it was not realistic to observea large difference in the second-cycle survey. The stability
across cycles does provide confidence in results, and fulfils
the surveys’ primary intention, which was to establish baseline data for Canadian physicians’ knowledge of and counseling practices on the use of antibiotics and AMR.
The response rate for both survey cycles was
22%. This is comparable to other surveys using similar methods and similar samples. 15 However, this
response rate might be artificially low, as the online
survey was taken offline as soon as the desired sample size (ie, N = 350) was reached. The samples fromboth survey cycles were predominantly men, werefrom urban centres, and had 15 or more years of practice experience. This distribution is fairly representative of the Canadian physician population.16 The highrepresentation of physicians from urban centres andwith 15 or more years of practice experience is ofnote, however, as some literature indicates that thosewith more time in practice and higher patient volumes
are more likely to prescribe antibiotics inappropriately.17,18 However, the results of this survey suggestthat Canadian physicians are demonstrating behaviour
patterns of AMR stewardship (eg, patient counseling,refusal to give inappropriate antibiotics). The discrepancy between the research literature and the results ofthis survey might indicate the presence of social desirability bias in the survey responses. Alternatively, thediscrepancy might indicate that physician behaviour
and attitudes toward antibiotics has changed since

the noted publications (ie, 2007 and 2012). This would
not be unrealistic, considering the increased focus on
AMR and antibiotic use in recent years.
In general, physicians’ knowledge of antibiotics and
AMR was very high; however, a small group of respondents
falsely believed that AMR occurs when people become
resistant to antibiotics (rather than the bacterium or organism becoming resistant). This might have occurred becauseof the way the question was worded, an assumption supported by the high rate of correct answers to other questions. Overall, the results suggest that physicians are wellinformed on the development and spread of resistance.
As expected, the conditions for which physicians
frequently prescribe antibiotics remained consistent
between surveys. These results also align with Canadiansurveillance data on physician prescribing patterns, providing confidence in our survey results.19
Topics with the lowest levels of consultations
included food handling, household hygiene, the use ofhand sanitizer, proper coughing practices, proper handwashing practices, and the use of antibacterial dishsoap, antibacterial hand soap, and antibacterial cleaning supplies. Counseling on these topics might be lower
in relation to other topics because physicians do not
feel as though these topics are important. Alternatively,
physicians might expect that nurses will discuss theseprevention and education topics with patients. A survey
on nurses’ knowledge of and behaviour patterns regarding AMR-related prevention and education counselingmight be useful to provide insight in this area.
While specific counseling on correct antibiotic
use was quite high overall, the levels were lowest
for cautioning patients about sharing antibiotics andproviding advice regarding the proper disposal of antibiotics. Significantly more respondents reported counseling patients on proper disposal of antibiotics in thesecond-cycle survey compared with the first cycle(P = .03); however, the percentage of physicians whoreported counseling on this topic still remained relatively low. A patient might have leftover antibiotics if
he or she experiences an adverse reaction to a medication or if test results require a change in prescription. It is possible that physicians are not discussingthese topics because they consider them counterintuitive to the messaging about using all of the prescribed
medication. Physicians might also expect that pharmacists will discuss these topics at the point of sale.
A survey on pharmacist knowledge and behaviour
related to antibiotic use and counseling might provide helpful insight in this area. In addition, creatinga checklist of appropriate counseling topics for family
physicians might be helpful to ensure fulsome counseling occurs in the office setting.

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Research | Knowledge and counseling practices related to antibiotic use and AMR
Limitations
Online surveys are associated with limitations. Physicians
who agree to participate in research panels could
be more aware of and interested in public healthsubjects than the average physician, resulting inselection bias. However, relevant work on physicianbased survey research suggests that no systematic bias
manifests from the use of panel samples.20 Other potential limitations of the study include social or professionaldesirability bias, recall bias, varying interpretations ofquestions, unintentional ambiguity in question phrasing, and the use of closed-ended questions. In addition,
the results rely on self-reported responses and selfassessments; actual physician behaviour might differ.
Finally, there are several limitations in interpreting
the results of the first-cycle and second-cycle surveys.
The 2 samples were neither matched nor completely
independent. While much of the second-cycle sample islikely unique from the first, there might be some overlap if physicians agreed to answer both survey requests.
The degree of overlap could not be definitively determined owing to the confidential nature of the responses.
Because the samples were not independent, multivariate analyses were not pooled over survey cycles.
Thus, all multivariate analyses were conducted with thesecond-cycle sample as its data source. Without pooling, the sample size for the multivariate analyses was
reduced by half, and thus some statistical power was
lost. Because the samples were not matched, differences
between the first- and second-cycle surveys could haveresulted from various factors, including both random
and systematic differences in the physicians selected forthe first-cycle sample and second-cycle sample. Insteadof a traditional “pre” and “post” longitudinal design,these surveys should instead be considered 2 crosssectional surveys at 2 different time points.

Conclusion
Although the study is subject to limitations, the relative
stability in results across both the first- and second-cycle
surveys provides confidence that the study met its primary objective (ie, establishing a baseline for the knowledge and counseling practices of Canadian physicians
related to the use of antibiotics and AMR). According
to the results of the survey, Canadian physicians wereknowledgeable about the appropriate use of antibiotics
and AMR, and were confident in discussing these topics with their patients. Existing gaps in physician counseling on select AMR-related topics might be a resultof the belief that pharmacists or nurses are addressingthese issues with patients. Obtaining information on theknowledge and behaviour patterns of these groups ofhealth care professionals might be advantageous.
This study serves as the first national survey of its
kind, contributing much-needed exploratory research

into the knowledge and counseling practices ofCanadian physicians as it relates to antibiotics and AMR.
These results can serve to inform policy makers in theirdevelopment of AMR campaigns and guidelines in both
the Canadian context and beyond.
Ms Smith is an epidemiologist at the Centre for Food-borne, Environmental
and Zoonotic Infectious Diseases at the Public Health Agency of Canada
in Guelph, Ont. Ms Pogany is Senior Policy Analyst at the Centre forCommunicable Diseases and Infection Control at the Public Health Agency
of Canada in Ottawa, Ont. Mr Foley is an advisor at the Treasury Board of
Canada in Ottawa. Dr Wu is Acting Manager, Ms Timmerman is Senior
Epidemiologist, and Dr Gale-Rowe is Acting Director, all at the Centre forCommunicable Diseases and Infection Control at the Public Health Agency
of Canada in Ottawa. Dr Demers is Senior Epidemiologist at the Centre for
Chronic Disease Prevention at the Public Health Agency of Canada in Ottawa.
Contributors
Ms Smith contributed to data analysis and interpretation, as well as drafting of
the manuscript. Ms Pogany, Mr Foley, Dr Wu, Ms Timmerman, and
Dr Gale-Rowe contributed to data acquisition and interpretation, as well as
critical revisions to the manuscript. Dr Demers contributed to the study conception and design, data acquisition, and critical revisions to the manuscript. All
authors approved the final version for publication.
Competing interests
None declared
Correspondence
Ms Courtney R. Smith; e-mail courtneyrady.smith@mail.utoronto.ca
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