Background: Antimicrobial resistance is one of the most serious and growing threats to public health. Healthcare professionals have important role against antibiotic resistance.
Purpose: This study aim to identify and compare knowledge, attitude, and practice (KAP) among different healthcare professionals (HCPs) toward antimicrobial stewardship (AMS), and to determine factors associated with KAP.
Method: A cross-sectional design was conducted at a tertiary teaching hospital Manado, Indonesia. Social-demography and KAP of HCPs were measured using a 48-items questionnaire Indonesian version with satisfactory validity and reliability score. Stratified random sampling with proportional allocation was applied. Data were collected from September to November, 2018. Chi-squared test applied in comparing KAP, and binary logistic regression applied in determining factors associated.
Results: Of the 168 HCPs participating in this study, pharmacists had lower basic knowledge of inappropriate antibiotic use (p= 0.005), but they were significantly more familiar with terms DDD and DOT (p<0.001). Doctors were more familiar with term AMR (p<0.001). For attitudes, doctors had higher positive attitude in prescribing antibiotics (p= 0.001). Overall, HCPs had poor practices of AMS (p= 0.001). Pharmacists were significantly lower using normal heart rate (p= 0.002), as well as midwives in using full recovery (p= 0.002) for parameters to switch from parenteral to oral antibiotics. For the use of prophylactic antibiotics in contaminated surgical procedures, nurses significantly had greater adherence (p= 0.001). Meanwhile, for empirical antibiotics used based on microbial pattern, doctors have significantly greater adherence (p= 0.001). HCPs had a significant different comparison regarding better practices (p<0.001). For microbial patterns and sensitivities renewed annually; doctors were significantly higher compared to pharmacists (p= 0.001).
Conclusions: The study found a differences in knowledge, attitudes, and practice among HCPs. Majority of HCPs showed good knowledge and positive attitude toward AMS. However, most of them have poorer practice. Nurses had the highest proportion of good knowledge, while doctors had the highest proportion in both positive attitudes and better practices. Female was associated with positive attitude, as well as good knowledge were associated with better practice. Meanwhile, nurses, midwives, and pharmacists were inversely associated with better practice.

Abbo, L., Sinkowitz-Cochran, R., Smith, L., Ariza-Heredia, E., Gomez-Marin, O., Srinivasan, A., & Hooton, T. M. (2011). Faculty and Resident Physicians' Attitudes, Perceptions, and Knowledge about Antimicrobial Use and Resistance. Infection Control and Hospital Epidemiology, 32(7), 714-718. doi:10.1086/660761
Abera, B., Kibret, M., & Mulu, W. (2014). Knowledge and beliefs on antimicrobial resistance among physicians and nurses in hospitals in Amhara Region, Ethiopia. Bmc Pharmacology & Toxicology, 15. doi:Artn 2610.1186/2050-6511-15-26
Al-Harthi, S. E., Khan, L. M., Osman, A. M. M., Alim, M. A., Saadah, O. I., Almohammadi, A. A., . . . Kamel, F. O. (2015). Perceptions and knowledge regarding antimicrobial stewardship among clinicians in Jeddah, Saudi Arabia. Saudi Medical Journal, 36(7), 813-820.
Albrecht, S. L., Defleur, M. L., & Warner, L. G. (1972). Attitude-Behavior Relationships - Reexamination of Postulate of Contingent Consistency. Pacific Sociological Review, 15(2), 149-168.
Andrews, K. H., & Kandel, D. B. (1979). Attitude and Behavior - Specification of the Contingent Consistency Hypothesis. American Sociological Review, 44(2), 298-310. doi:Doi 10.2307/2094512
Aschenbrenner, D. S., & Venable, S. J. (2009). Drug therapy in nursing: Lippincott Williams & Wilkins.
Badran, I. G. (1995). Knowledge, attitude and practice the three pillars of excellent and wisdom: a place in the medical profession. Eastern Mediterranean Health Journal, 1(1), 8-16.
Beardsley, J. R., Williamson, J. C., Johnson, J. W., Luther, V. P., Wrenn, R. H., & Ohl, C. C. (2012). Show me the money: long-term financial impact of an antimicrobial stewardship program. Infect Control Hosp Epidemiol, 33(4), 398-400. doi:10.1086/664922
Broom, A., Broom, J., Kirby, E., Plage, S., & Adams, J. (2015). What role do pharmacists play in mediating antibiotic use in hospitals? A qualitative study. BMJ Open, 5(11). doi:ARTN e008326 10.1136/bmjopen-2015-008326
Buckel, W. R., Hersh, A. L., Pavia, A. T., Jones, P. S., Owen-Smith, A., & Stenehjem, E. (2016). Antimicrobial stewardship knowledge, attitudes, and practices among health care professionals at small community hospitals. Hosp Pharm, 51(2), 149-157. doi:10.1310/hpj5102-149
Camins, B. C., King, M. D., Wells, J. B., Googe, H. L., Patel, M., Kourbatova, E. V., & Blumberg, H. M. (2009). Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial. Infect Control Hosp Epidemiol, 30(10), 931-938. doi:10.1086/605924
CDC. (2014). Core Elements of Hospital Antibiotic Stewardship Programs. Retrieved from https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html
CDC. (2017). Antibiotic resistance the global threat. In C. f. D. C. a. Prevention (Ed.).
CDC. (2018). Antibiotic/antimicrobial resistance. Retrieved from https://www.cdc.gov/drugresistance/
Cialdini, R. B., Petty, R. E., & Cacioppo, J. T. (1981). Attitude and Attitude-Change. Annual Review of Psychology, 32, 357-404. doi:DOI 10.1146/annurev.ps.32.020181.002041
Collier, R. (2012). Professionalism: assessing physician behaviour. CMAJ, 184(12), 1349-1350. doi:10.1503/cmaj.109-4240
Costelloe, C., Metcalfe, C., Lovering, A., Mant, D., & Hay, A. D. (2010). Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ, 340, c2096. doi:10.1136/bmj.c2096
Cotta, M. O., Roberts, J. A., Tabah, A., Lipman, J., Vogelaers, D., & Blot, S. (2014). Antimicrobial stewardship of beta-lactams in intensive care units. Expert Review of Anti-Infective Therapy, 12(5), 581-595. doi:10.1586/14787210.2014.902308
Cunningham, J. B., & McCrum-Gardner, E. (2007). Power, effect and sample size using GPoower: practical issues for researchers and members of research ethics committees. Evidence Based Midwifery, 5(4), 132-136.
Dancer, S. J., Kirkpatrick, P., Corcoran, D. S., Christison, F., Farmer, D., & Robertson, C. (2013). Approaching zero: temporal effects of a restrictive antibiotic policy on hospital-acquired Clostridium difficile, extended-spectrum beta-lactamase-producing coliforms and meticillin-resistant Staphylococcus aureus. Int J Antimicrob Agents, 41(2), 137-142. doi:10.1016/j.ijantimicag.2012.10.013
Davey, P., Brown, E., Charani, E., Fenelon, L., Gould, I. M., Holmes, A., . . . Wilcox, M. (2013). Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev(4), CD003543. doi:10.1002/14651858.CD003543.pub3
Davey, P., & Garner, S. (2007). Professional education on antimicrobial prescribing: a report from the Specialist Advisory Committee on Antimicrobial Resistance (SACAR) Professional Education Subgroup. Journal of Antimicrobial Chemotherapy, 60, I27-I32. doi:10.1093/jac/dkm154
Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., . . . Surviving Sepsis Campaign Guidelines Committee including the Pediatric, S. (2013). Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med, 41(2), 580-637. doi:10.1097/CCM.0b013e31827e83af
Dellit, T. H., Owens, R. C., McGowan, J. E., Gerding, D. N., Weinstein, R. A., Burke, J. P., . . . Hooton, T. M. (2007). Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clinical Infectious Diseases, 44(2), 159-177. doi:10.1086/510393
DiazGranados, C. A., & Abd, T. T. (2011). Participation of clinical pharmacists without specialized infectious diseases training in antimicrobial stewardship. Am J Health Syst Pharm, 68(18), 1691-1692. doi:10.2146/ajhp100482
Dik, J. W., Hendrix, R., Poelman, R., Niesters, H. G., Postma, M. J., Sinha, B., & Friedrich, A. W. (2016). Measuring the impact of antimicrobial stewardship programs. Expert Rev Anti Infect Ther, 14(6), 569-575. doi:10.1080/14787210.2016.1178064
Doron, S., Nadkarni, L., Lyn Price, L., Kenneth Lawrence, P., Davidson, L. E., Evans, J., . . . Snydman, D. R. (2013). A nationwide survey of antimicrobial stewardship practices. Clin Ther, 35(6), 758-765 e720. doi:10.1016/j.clinthera.2013.05.013
Eagly, A. H., Mladinic, A., & Otto, S. J. P. o. W. Q. (1991). Are women evaluated more favorably than men?: An analysis of attitudes, beliefs, and emotions. 15(2), 203-216.
ECDC/EMEA. (2009). The bacterial challenge: time to react. Retrieved from Stockholm: https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf
Edwards, R., Drumright, L., Kiernan, M., & Holmes, A. (2011). Covering more Territory to Fight Resistance: Considering Nurses' Role in Antimicrobial Stewardship. J Infect Prev, 12(1), 6-10. doi:10.1177/1757177410389627
Elligsen, M., Walker, S. A., Pinto, R., Simor, A., Mubareka, S., Rachlis, A., . . . Daneman, N. (2012). Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol, 33(4), 354-361. doi:10.1086/664757
Erku, D. A. (2016). Complementary and Alternative Medicine Use and Its Association with Quality of Life among Cancer Patients Receiving Chemotherapy in Ethiopia: A Cross-Sectional Study. Evidence-Based Complementary and Alternative Medicine. doi:Artn 2809875 10.1155/2016/2809875
Ferdoush, J., Ata, M., Parveen, K., Reza, F. H., & Rahman, M. S. (2016). Knowledge, perception and preparedness of future prescribers about antimicrobial stewardship. Bangladesh Journal of Pharmacology, 11(4), 928-934. doi:10.3329/bjp.v11i4.29507
Francis, J., & Abraham, S. (2014). Clinical pharmacists: Bridging the gap between patients and physicians. Saudi Pharmaceutical Journal, 22(6), 600-602. doi:10.1016/j.jsps.2014.02.011
Fridkin, S. K., & Srinivasan, A. (2014). Implementing a strategy for monitoring inpatient antimicrobial use among hospitals in the United States. Clin Infect Dis, 58(3), 401-406. doi:10.1093/cid/cit710
Garcia, C., Llamocca, L. P., García, K., Jiménez, A., Samalvides, F., Gotuzzo, E., & Jacobs, J. (2011). Knowledge, attitudes and practice survey about antimicrobial resistance and prescribing among physicians in a hospital setting in Lima, Peru. BMC clinical pharmacology, 11(8), 18-26.
Hadi, U., Duerink, D. O., Lestari, E. S., Nagelkerke, N. J., Werter, S., & Keuter, M. (2008). Antimicrobial Resistance in Indonesia ‘Prevalence and Prevention’ study group. Survey of antibiotic use of individuals visiting public healthcare facilities in Indonesia. Int J Infect, 12, 622-629.
Handayani, R. S., Siahaan, S., & Herman, M. J. (2017). Resistensi Antimikroba dan Penerapan Kebijakan Pengendalian di Rumah Sakit di Indonesia. Jurnal Penelitian dan Pengembangan Pelayanan Kesehatan, 1(2).
Hensgens, M. P., Goorhuis, A., Dekkers, O. M., & Kuijper, E. J. (2012). Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother, 67(3), 742-748. doi:10.1093/jac/dkr508
Howard, P., Pulcini, C., Hara, G. L., West, R. M., Gould, I. M., Harbarth, S., . . . Stewardship, I. S. C. G. A. (2015). An international cross-sectional survey of antimicrobial stewardship programmes in hospitals. Journal of Antimicrobial Chemotherapy, 70(4), 1245-1255. doi:10.1093/jac/dku497
Huang, D. T., & Yealy, D. M. (2013). Antibiotic stewardship-what should I do tomorrow? Ann Emerg Med, 62(1), 78-79. doi:10.1016/j.annemergmed.2013.02.019
Ibrahim, O. M., & Polk, R. E. (2012). Benchmarking antimicrobial drug use in hospitals. Expert Rev Anti Infect Ther, 10(4), 445-457. doi:10.1586/eri.12.18
Indonesia, R. (2009). Undang-undang Republik Indonesia nomor 36 tahun 2009 tentang Kesehatan. Jakarta: Republik Indonesia.
Khan, M. U., Hassali, M. A., Ahmad, A., Elkalmi, R. M., Zaidi, S. T., & Dhingra, S. (2016). Perceptions and Practices of Community Pharmacists towards Antimicrobial Stewardship in the State of Selangor, Malaysia. PLoS One, 11(2), e0149623. doi:10.1371/journal.pone.0149623
Launiala, A. (2009). How much can a KAP survey tell us about people's knowledge, attitudes and practices? Some observations from medical anthropology research on malaria in pregnancy in Malawi. Anthropology Matters Journal, 11(1), 1-13.
Louh, I. K., Greendyke, W. G., Hermann, E. A., Davidson, K. W., Falzon, L., Vawdrey, D. K., . . . Ting, H. H. (2017). Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention. Infect Control Hosp Epidemiol, 38(4), 476-482. doi:10.1017/ice.2016.324
Malani, A. N., Richards, P. G., Kapila, S., Otto, M. H., Czerwinski, J., & Singal, B. (2013). Clinical and economic outcomes from a community hospital's antimicrobial stewardship program. Am J Infect Control, 41(2), 145-148. doi:10.1016/j.ajic.2012.02.021
Manning, M. L., Pfeiffer, J., & Larson, E. L. (2016). Combating antibiotic resistance: The role of nursing in antibiotic stewardship. Am J Infect Control, 44(12), 1454-1457. doi:10.1016/j.ajic.2016.06.023
Menkes, R. (2015). Permenkes RI No. 8 Tahun 2015 tentang Program Pengendalian Resistensi Antimikroba di Rumah Sakit. Hukor Depkes RI, 23-24.
Messina, A. P., van den Bergh, D., & Goff, D. A. (2015). Antimicrobial Stewardship with Pharmacist Intervention Improves Timeliness of Antimicrobials Across Thirty-three Hospitals in South Africa. Infectious Diseases and Therapy, 4, 5-14. doi:10.1007/s40121-015-0082-x
Moody, J., Cosgrove, S. E., Olmsted, R., Septimus, E., Aureden, K., Oriola, S., . . . Trivedi, K. K. (2012). Antimicrobial Stewardship: A Collaborative Partnership between Infection Preventionists and Healthcare Epidemiologists. Infection Control and Hospital Epidemiology, 33(4), 328-330. doi:10.1086/665037
Nowak, M. A., Nelson, R. E., Breidenbach, J. L., Thompson, P. A., & Carson, P. J. (2012). Clinical and economic outcomes of a prospective antimicrobial stewardship program. American Journal of Health-System Pharmacy, 69(17), 1500-1508. doi:10.2146/ajhp110603
Olans, R. N., Olans, R. D., & DeMaria, A., Jr. (2016). The Critical Role of the Staff Nurse in Antimicrobial Stewardship--Unrecognized, but Already There. Clin Infect Dis, 62(1), 84-89. doi:10.1093/cid/civ697
Pakyz, A. L., MacDougall, C., Oinonen, M., & Polk, R. E. (2008). Trends in antibacterial use in US academic health centers: 2002 to 2006. Arch Intern Med, 168(20), 2254-2260. doi:10.1001/archinte.168.20.2254
Parathon, H., Kuntaman, K., Widiastoety, T. H., Muliawan, B. T., Karuniawati, A., Qibtiyah, M., . . . Thamlikitkul, V. (2017). Analysis Antimicrobial Resistance in South East Asia Progress towards antimicrobial resistance containment and control in Indonesia. BMJ, 358(j3808), 31-35. doi: 10.1136/bmj.j3808
Parker, H. M., & Mattick, K. (2016). The determinants of antimicrobial prescribing among hospital doctors in England: a framework to inform tailored stewardship interventions. Br J Clin Pharmacol, 82(2), 431-440. doi:10.1111/bcp.12953
Patel, S. J., Saiman, L., Duchon, J. M., Evans, D., Ferng, Y. H., & Larson, E. (2012). Development of an antimicrobial stewardship intervention using a model of actionable feedback. Interdiscip Perspect Infect Dis, 2012, 150367. doi:10.1155/2012/150367
Pogorzelska-Maziarz, M., Herzig, C. T., Larson, E. L., Furuya, E. Y., Perencevich, E. N., & Stone, P. W. (2015). Implementation of antimicrobial stewardship policies in U.S. hospitals: findings from a national survey. Infect Control Hosp Epidemiol, 36(3), 261-264. doi:10.1017/ice.2014.50
Polit, D., & Beck, C. (2017). Nursing Research: Generating and assessing evidence for nursing practice (10 ed. Vol. 10): Wolters Kluwer.
Polk, R. E., Fox, C., Mahoney, A., Letcavage, J., & MacDougall, C. (2007). Measurement of adult antibacterial drug use in 130 US hospitals: comparison of defined daily dose and days of therapy. Clin Infect Dis, 44(5), 664-670. doi:10.1086/511640
Pollack, L. A., & Srinivasan, A. (2014). Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis, 59 Suppl 3, S97-100. doi:10.1093/cid/ciu542
Pulcini, C., & Gyssens, I. C. (2013). How to educate prescribers in antimicrobial stewardship practices. Virulence, 4(2), 192-202. doi:10.4161/viru.23706
Rav-Marathe, K., Wan, T. T. H., & Marathe, S. (2016). The Effect of Health Education on Clinical and Self-Reported Outcomes of Diabetes in a Medical Practice. Journal of Integrated Design & Process Science, 20(1), 45-63. doi:10.3233/jid-2016-0010
Pedoman umum penggunaan antibiotik, (2011).
Rohde, J. M., Jacobsen, D., & Rosenberg, D. J. (2013). Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther, 35(6), 751-757. doi:10.1016/j.clinthera.2013.05.005
Rosdiana, D., Anggraini, D., Balmas, M., Effendi, D., & Bet, A. (2017). Peningkatan rasionalitas penggunaan antibiotik pasca implementasi kebijakan penggunaan antimikroba di RSUD Arifin Achmad Pekanbaru. Jurnal Kedokteran Brawijaya, 30(1), 36-40.
Sarwar, M. R., Saqib, A., Iftikhar, S., & Sadiq, T. (2018). Knowledge of community pharmacists about antibiotics, and their perceptions and practices regarding antimicrobial stewardship: a cross-sectional study in Punjab, Pakistan. Infection and Drug Resistance, 11, 133-145. doi:10.2147/Idr.S148102
Setiawan, E., Poedjibudojo, J. K., & Tondok, M. S. (2017). The health-care needs among older persons in an Indonesian urban setting. Asian Journal of Pharmaceutical and Clinical Research, 10(7), 233-238. doi:10.22159/ajpcr.2017.v10i7.18300
Shaikh, S., Fatima, J., Shakil, S., Rizvi, S. M., & Kamal, M. A. (2015). Antibiotic resistance and extended spectrum beta-lactamases: Types, epidemiology and treatment. Saudi J Biol Sci, 22(1), 90-101. doi:10.1016/j.sjbs.2014.08.002
Shallcross, L. J., & Davies, S. C. (2014). The World Health Assembly resolution on antimicrobial resistance. Journal of Antimicrobial Chemotherapy, 69(11), 2883-2885. doi:10.1093/jac/dku346
Sick, A. C., Lehmann, C. U., Tamma, P. D., Lee, C. K. K., & Agwu, A. L. (2013). Sustained Savings from a Longitudinal Cost Analysis of an Internet-Based Preapproval Antimicrobial Stewardship Program. Infection Control and Hospital Epidemiology, 34(6), 573-580. doi:10.1086/670625
Singh, M., & Singh, A. K. (2017). Knowledge, attitude, practice study on awareness of antibiotic stewardship among healthcare professionals in a tertiary care hospital in Delhi. Int.J.Curr.Microbiol.App.Sci, 6(7), 238-245.
Srinivasan, A. (2011). Engaging Hospitalists in Antimicrobial Stewardship: The CDC Perspective. Journal of Hospital Medicine, 6, S31-S33. doi:10.1002/jhm.863
Stach, L. M., Hedican, E. B., Herigon, J. C., Jackson, M. A., & Newland, J. G. (2012). Clinicians' Attitudes Towards an Antimicrobial Stewardship Program at a Children's Hospital. J Pediatric Infect Dis Soc, 1(3), 190-197. doi:10.1093/jpids/pis045
Standiford, H. C., Chan, S., Tripoli, M., Weekes, E., & Forrest, G. N. (2012). Antimicrobial Stewardship at a Large Tertiary Care Academic Medical Center: Cost Analysis Before, During, and After a 7-Year Program. Infection Control and Hospital Epidemiology, 33(4), 338-345. doi:10.1086/664909
Sutthiruk, N., Considine, J., Hutchinson, A., Driscoll, A., Malathum, K., & Botti, M. (2018). Thai clinicians' attitudes toward antimicrobial stewardship programs. Am J Infect Control, 46(4), 425-430. doi:10.1016/j.ajic.2017.09.022
Tegagn, G. T., Yadesa, T. M., & Ahamed, Y. (2017). Knowledge, attitudes and practices of healthcare professionals towards antimicrobial stewardship and their predictors in Fitche Hospital. J Bioanal Biomed, 9(2), 091-097. doi:10.4172/1948-593X.1000159
Tonna, A. P., Gould, I. M., & Stewart, D. (2014). A cross-sectional survey of antimicrobial stewardship strategies in UK hospitals. J Clin Pharm Ther, 39(5), 516-520. doi:10.1111/jcpt.12181
Trautner, B. W., Greene, M. T., Krein, S. L., Wald, H. L., Saint, S., Rolle, A. J., . . . Mody, L. (2017). Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel. Infect Control Hosp Epidemiol, 38(1), 83-88. doi:10.1017/ice.2016.228
Ventola, C. L. (2015). The antibiotic resistance crisis: part 1: causes and threats. Pharmacy therapeutics, 40(4), 277.
Weier, N., Thursky, K., & Zaidi, S. T. R. (2017). Antimicrobial knowledge and confidence amongst final year medical students in Australia. PLoS One, 12(8). doi:ARTN e018246010.1371/journal.pone.0182460
Global action plan on antimicrobial stewardship. World Health Organization 2015., (2015a).
WHO. (2015b) Global plan action on antimicrobial resistance. In. Geneva Switzerland: World Health Organization.
WHO. (2015c). Worldwide country situation analysis: response to antimicrobial resistance. Retrieved from World Health Organization, Geneva, Switzerland: http://apps.who.int/iris/bitstream/10665/163473/1/WHO_HSE_PED_AIP_2015.1_eng.pdf?ua=1&ua=1
WHO. (2018a). Antimicrobial Resistance. Retrieved from http://www.who.int/en/news-room/fact-sheets/detail/antimicrobial-resistance
WHO. (2018b). Process of translation and adaptation of instruments. Retrieved from http://www.who.int/substance_abuse/research_tools/translation/en