The healthcare professionals’ perspectives on antimicrobial re- sistance (AMR) associated factors and their consequences: A cross sectional study in Eastern province of Saudi Arabia

(1) Background: Factors reported in literature associated with inappropriate prescribing of antimicrobials, such as physicians with less experience, uncertain diagnosis, and patient caregiver influences on physicians' decisions. Monitoring antimicrobial resistance is critical for identifying emerging resistance patterns, developing, and assessing the effectiveness of mitigation strategies. Improvement in prescribing `antimicrobials would minimize the risk of resistance and, consequently, improve patients' clinical and health outcomes. The purpose of the study is to delineate factors associated with antimicrobial resistance, describe the factors influencing prescriber’s choice during prescribing of antimicrobial, and examine factors related to consequences of inappropriate prescribing of antimicrobial. (2) Methods: Cross-sectional study conducted among healthcare providers (190) in six tertiary hospitals in the Eastern province of Saudi Arabia. The research panel has developed validated and piloted survey specific with closed-ended questions. A value of P <0.05 was considered for statistical significance. All data analysis was performed using Statistical Package for Social Sciences (IBM SPSS version 23.0). (3) Results: 72.7% of the respondents have agreed that poor skills and knowledge are key factors that contribute to the inappropriate prescribing of antimicrobials. All the respondents acknowledged effectiveness and previous experience with the antimicrobial, and reading scientific materials (such as books, articles, and the internet) were key factors influencing physicians’ choice during antimicrobial prescribing. (4) Conclusion: The current study has identified comprehensive education and training needs for healthcare providers about antimicrobial resistance. Using antimicrobials unnecessarily, insufficient duration of antimicrobial use, and using broad spectrum antimicrobials, were reported to be common practices. Further, poor skills and knowledge were a key factor that contributed to the inappropriate use and overuse of antimicrobials and using antimicrobials without physician prescription (self-medication) were the Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 2 June 2021 doi:10.20944/preprints202106.0061.v1 © 2021 by the author(s). Distributed under a Creative Commons CC BY license.

Abstract: (1) Background: Factors reported in literature associated with inappropriate prescribing of antimicrobials, such as physicians with less experience, uncertain diagnosis, and patient caregiver influences on physicians' decisions. Monitoring antimicrobial resistance is critical for identifying emerging resistance patterns, developing, and assessing the effectiveness of mitigation strategies. Improvement in prescribing `antimicrobials would minimize the risk of resistance and, consequently, improve patients' clinical and health outcomes. The purpose of the study is to delineate factors associated with antimicrobial resistance, describe the factors influencing prescriber's choice during prescribing of antimicrobial, and examine factors related to consequences of inappropriate prescribing of antimicrobial. (2) Methods: Cross-sectional study conducted among healthcare providers (190) in six tertiary hospitals in the Eastern province of Saudi Arabia. The research panel has developed validated and piloted survey specific with closed-ended questions. A value of P <0.05 was considered for statistical significance. All data analysis was performed using Statistical Package for Social Sciences (IBM SPSS version 23.0). (3) Results: 72.7% of the respondents have agreed that poor skills and knowledge are key factors that contribute to the inappropriate prescribing of antimicrobials. All the respondents acknowledged effectiveness and previous experience with the antimicrobial, and reading scientific materials (such as books, articles, and the internet) were key factors influencing physicians' choice during antimicrobial prescribing. (4) Conclusion: The current study has identified comprehensive education and training needs for healthcare providers about antimicrobial resistance. Using antimicrobials unnecessarily, insufficient duration of antimicrobial use, and using broad spectrum antimicrobials, were reported to be common practices. Further, poor skills and knowledge were a key factor that contributed to the inappropriate use and overuse of antimicrobials and using antimicrobials without physician prescription (self-medication) were the

Introduction
Infectious diseases are caused by the microorganism's penetration into the epidermis, dermis, soft tissues of the skin, and other body tissues, leading to infectious diseases and comorbidities that can ultimately lead to sepsis and death. Antimicrobial agents have the advantage of treating infectious diseases, and they have the potential not only to retain the quality of life of the patient but have also proved to be lifesaving in a variety of severe infectious conditions [1]. Improper use of antimicrobials has led to the development of antimicrobial resistant (AMR), which has been associated with failure in managing infections, increased in length of hospital stay, increased mortality, morbidity [2,3] , and health costs [4,5 ]. Several factors have been described in the literature to be correlated with inappropriate prescribing of antimicrobials, such as physicians with less experience, level of knowledge, uncertain diagnosis, and patient caregiver influences on physician's decision [6]. Over two million infections and 23,000 deaths annually in the United States were due to AMR [7]. Studies from diverse settings estimate that between 25% and 50% of antibiotic use in hospitals was suboptimal or unnecessary [8,9]. Gulf Cooperation Council countries face challenges of emerging AMR with no clear, regional guidelines for antimicrobial use or specific policies for restricting and monitoring antimicrobial prescribing [10]. Monitoring AMR is critical for identifying emerging resistance and developing, monitoring, and evaluating the effectiveness of mitigation strategies [11]. Improvement in antimicrobial prescribing would minimize the risk of AMR, reduce healthcare costs, and improve patient clinical outcomes. In attempt from world health organization (WHO) to reduce AMR, several initiatives and programs; have been established to educate healthcare providers about appropriate antimicrobial prescribing for evidence-based indications [12][13]. A study conducted in Saudi Arabia has revealed that medications most commonly used were antibiotics [14]. In another study, it has been confirmed that certain types of medications, such as chemotherapeutic agents and antipsychotics, are exclusively prescribed by the specialists involved, while antibiotics are vigorously prescribed by all physicians, as well as by allied health practitioners, irrespective of their knowledge or experience about antibiotics prescribed [15]. According to, general practitioners are the most common prescribers of antibiotics in Saudi Arabia relative to specialists and residents. The objectives of the recent study were to delineate the factors associated with antimicrobial resistant, describe the factors influencing prescriber's choice during prescribing of antimicrobial, and examine the factors related to consequences of inappropriate prescribing of antimicrobial.

Results
A total of 184 healthcare providers have responded to the survey with 96.8% response rate. Results have demonstrated that more than half of the respondents (53.8%) were pharmacists, (35.8%) were physicians, and (10.9%) were nurses (56% were males).
Nearly 56% of respondents' age was less than 30 years; around one-third (30.4%) were in the age strata 31 to 40 years, and only 13.6% were aged ≥ 41 years. Regarding years of practice, 37% of the respondents had less than 3 years of clinical experience, whereas only 16% reported that their experience exceeded ten years. The majority (72.8%) have worked more than 8 hours per day. Regarding the average of continuous professional development (CPD), (71%) of the respondents had more than 20 CPD hours per year;   Table 2. Concerning the causes of AMR, the highest number of respondents (80.4%) has concurred that using antimicrobial when they were not necessary, whereas not completing the full course of antimicrobial (59.8%), using antimicrobials without physician prescription as self-medication (66.3%) were reported as the key factors which contribute to AMR; Table 4.  considered as a source of information for antimicrobials Table 7. Similar to healthcare professionals from other parts of the world, 72.7% of the respondents agreed that poor skills and knowledge were a key factor that contributes to the inappropriate use of antimicrobials [1,18]. However, most of the respondents have agreed that unrestricted availability of antimicrobials, overworked/busy health care providers and lack of physicians' interest in the subject of antimicrobial prescribing and infection management were not causes of inappropriate prescribing of antimicrobials.
Many healthcare providers in our study have agreed that using antimicrobials when they were not necessary, not completing the full course of antimicrobial, and using broad spectrum antimicrobial, were common practices. Further, using antimicrobials without physician prescription (self-medication) were the key factors which contribute to AMR [16,19]. Our findings lend support to previously published studies [1,14,18]. In response to this and based on the current study results, this can be controlled via increasing the sessions of CPD for healthcare providers on appropriate antimicrobial treatment, providing local antimicrobial guidelines and consulting with experts on infectious diseases. The majority of healthcare professionals have believed that AMR was a consequence of antimicrobial overuse. Whereas they have denied that the waste of resources and recurrence of infections can be the consequences of antimicrobials overuse. We highly encourage each hospital to generate their internal policy or guidelines to guide and restrict antimicrobials' overuse. In response to this and based on healthcare professionals' responses here, this can be rectified via CPD awareness programs and education on appropriate antimicrobial therapy, providing local antimicrobial guidelines, consulting with infectious diseases experts, and above all implementing antimicrobial stewardship program. Yusef ,D. et al.
concluded that antimicrobial stewardship programs (ASPs) helped to reduce the use of antifungals in hospitalized patients and highlighted the importance of promoting antifungal stewardship among antibiotic stewardship [20]. Also, Rodolfo E. Quirós et al. showed significant improvement in antimicrobial utilization after multiple and intensive ASPs [3] . Interestingly, targeting antimicrobial therapy to likely pathogens was not mostly considered a factor that may help control AMR. This may be due to the poor of knowledge in our respondents on the importance of targeting pathogens. Some recent studies conducted in Saudi Arabia by Al-Harthi and colleague were in line with our results, where they identified the importance of healthcare professional education on appropriate antimicrobial therapy, providing local antimicrobial guidelines and consulting with infectious diseases experts as crucial factors that can control AMR and its consequence. [5] In fact, further studies are needed to target the reasons behind the gap in knowledge, experience, and skills on antimicrobials, as revealed by the current study respondents.
This will help in controlling AMR and its consequences in our region.
Limitations of the study: There are some limitations to be considered when interpreting the study findings.
First, although the research was conducted at six hospitals in the Eastern province that were well-resourced, the findings of the study may not be generalizable to other regions in the Kingdom. Second, participants were selected randomly and the characteristics of those who did not participate in the survey are unknown. Further, purposive sampling was used to target doctors, nurses, and pharmacists from departments with high antibiotic use; therefore, there are departments such as psychiatry for example that are underrepresented. Therefore, it is possible that the sampling approach and recruitment limit the generalizability of the study results to other departments or hospitals. Finally, the sample included in the study was small, with a moderate response rate. We believe the results from the current study will be valuable in guiding educational efforts in order to prevent antimicrobial resistance and well received by clinicians in their respective institutions. However, our study strength is that, for the best of our knowledge, it is the first study that investigates factors affecting healthcare providers' perceptions regarding AMR consequences.

Materials and Methods
The study was a cross-sectional study among health care providers (190) in six tertiary hospitals (4 governmental and 2 private hospitals with more than 500 beds) in the Eastern province of Saudi Arabia.

Sample size
A published statistical formula was used to calculate the sample size for the unknown nature of population size. Finally, the sample was adjusted for potential missing or non-response error using the formula: Where, n = required sample size; Z1-β = Z value at power 1-β (at power 90% this value is 1.24); p = preferred population proportion (0.5); d = margin of error (ideal value is 0.05. And. = /(1 − ) Where 'n' is the required sample size as per formula, 'n1' is adjusted sample size and 'd' is the potential missing or non-response rate. A minimum number of 190 samples was required to achieve 90% power when considering a 5% margin of error and a 10% missing/non-response error rate.

Survey development
The has resolved both improvements in terminology and ease of use. However, the data collected from the pilot study were not involved in the final analysis. In terms of reliability, a variety of factors have been taken into account when planning this analysis to reduce the risk to the reliability. This has included: the data collection process was clearly documented, and research procedures were followed as per the data collection protocol during the research process. Further, the results were obtained on one occasion to simplify the capture of answers from participants, and to help mitigate any unintended bias in the analysis of responses, closed-ended questions were purposely selected for this survey design.

Administration of the survey
A standard set of the pre-tested validated survey was used to collect data among health care providers (physicians, pharmacists, and nurses) by self-administrative procedure. In addition, questions for online surveys (QuestionPro) have been distributed to the hospital administration, pharmacy directors, and nursing supervisors via e-mails and related social media accounts to boost data collection. The data collection procedure was administrated by the investigators via several necessary visits, reminders by phone calls as well as emails.

Statistical Analysis
The online survey (QuestionPro) has enabled the view of some missing cases among the data set. Therefore, we have used the 'last-observation-carried-forward method', some of these cases were treated, and the rest were cleaned from the final analysis. Additionally, informal technique was used to check and cleaned the whole data set. Variables were coded and recoded as per the requirements of study objectives. Descriptive statistics were utilized for data analysis. Frequencies and their corresponding percentages were reported to describe the factors and their respective items. A value of p<0.05 was considered for statistical significance. The whole data analysis was conducted using Statistical Package for Social Sciences (IBM SPSS version 23.0).

Conclusions
The current study has identified comprehensive education and training needs for healthcare providers about the AMR and how to prevent such problem. Using antimicrobials unnecessarily, insufficient duration of antimicrobial use, and using broad spectrum antimicrobials, were reported to be common practices. Further, poor skills and knowledge were a key factor that contributed to the inappropriate use and overuse of antimicrobials and using antimicrobials without physician prescription (self-medication) were the key factors which contribute to AMR from participants' perspectives. This problem can be controlled via increasing the sessions of CPD for healthcare providers on appropriate antimicrobial treatment, providing local antimicrobial guidelines and consulting with experts on infectious diseases. More studies about local AMR patterns are deemed, and more efforts are warranted to educate clinicians about antimicrobial resistance.We highly encourage each hospital to generate their internal policy or guidelines to guide and restrict antimicrobials' overuse to combat AMR.