Perceptions, views and practices regarding antibiotic prescribing and stewardship among hospital physicians in Jakarta, Indonesia
Authors: Limato Ralalicia , Nelwan Erni J. , Mudia Manzilina , Alamanda Monik , Manurung Elfrida R. , Mauleti Ifael Y. , Mayasari Maria , Firmansyah Iman , Djafar Roswin , Huong Vu Thi Lan , van Doorn H. Rogier , Broom Alex , Hamers Raph L. 
Published: September 2021

Objectives

Antibiotic overuse is one of the main drivers of antimicrobial resistance (AMR), especially in low and middle-income countries. This study aimed to gain an understanding of perceptions, views, and practices regarding AMR, antibiotic prescribing, and stewardship (AMS) among hospital physicians in Jakarta, Indonesia.

Design

cross-sectional, self-administered questionnaire-based survey, with descriptive statistics, exploratory factor analysis (EFA) to identify distinct underlying constructs in the dataset, and multivariable linear regression of factor scores to analyse physician subgroups.

Setting

Six public and private general hospitals in Jakarta in 2019.

Participants

1007 of 1896 (53.1% response rate) antibiotic prescribing physicians.

Results

EFA identified six latent factors (overall Crohnbach’s α=0.85): awareness of AMS activities; awareness of AMS purpose; views regarding rational antibiotic prescribing; confidence in antibiotic prescribing decisions; perception of AMR as a significant problem; and immediate actions to contain AMR. Physicians acknowledged the significance of AMR and contributing factors, rational antibiotic prescribing, and purpose and usefulness of AMS. However, this conflicted with reported suboptimal local hospital practices, such as room cleaning, hand hygiene and staff education, and views regarding antibiotic decision-making. These included insufficiently applying AMS principles and utilising microbiology, lack of confidence in prescribing decisions, and defensive prescribing due to pervasive diagnostic uncertainty, fear of patient deterioration or because patients insisted. Physicians’ factor scores differed across hospitals, departments, work experience and medical hierarchy.

Conclusions

AMS implementation in Indonesian hospitals is challenged by institutional, contextual and diagnostic vulnerabilities, resulting in externalising AMR instead of recognising it as a local problem. Appropriate recognition of the contextual determinants of antibiotic prescribing decision-making will be critical to change physicians’ attitudes and develop context-specific AMS interventions.

Strengths and limitations of this study

The self-developed questionnaire in this study identified a relevant set of attributes through a factor analysis optimization process, with adequate content, face and construct validity and internal reliability. This study adds important value in the absence of adequately validated instruments regarding antimicrobial resistance and stewardship, with particular applicability for LMIC.

This study had a large, varied respondent sample and high response rate among physicians at six public and private hospitals in Jakarta, Indonesia, and identified differences between physicians across hospitals, departments, work experience and medical hierarchy, which can guide priority-setting and tailoring of stewardship interventions.

However, non-participation and the convenient hospital sample could have introduced selection bias, and the data are not necessarily representative for Jakarta or Indonesia.

Factor analysis is based on using a “heuristic”, which leaves room to more than one interpretation of the same data and cannot identify causality.