Demographics and professional profile
A total of 260/317 physicians filled in the questionnaire (response rate 82%). Four were excluded since they did not specify which department they were affiliated to. The vast majority of participants (97%) agreed that knowledge about AMs and their adequate use are important in their daily work and 49% declared to prescribe AMs more than once a day. Table gives an overview of the professional profile of the 256 participants; the profiles were similar within the two hospitals except for the proportion of surgeons. Unless otherwise stated, there were no significant differences between the participants belonging to different professional categories and levels, departments or hospitals for the results presented below.
Professional profile of the participants in the two hospitals of Lima, Peru
Knowledge on AM use and AMR rates
The average score to the questions regarding knowledge of AMs was 6 out of 7(SD ± 1.3). For the case-based questions about acute diarrhoea and upper respiratory tract infection, the vast majority of participants agreed that there was no need to start an AM (238, 93% and 194, 76%, respectively). The knowledge about the need to reduce the dose of AM in a patient with severe renal impairment was assessed by presenting a sepsis case where ceftriaxone and gentamicin were prescribed. About three quarters (n = 194, 76%) correctly identified that AMs would need to be reduced in this case. Furthermore, nearly all participants (n = 250, 99%) correctly replied that metronidazole has activity against anaerobes and 213 (83%) participants correctly answered that methicillin resistant Staphylococcus aureus (MRSA) is not susceptible to cephalosporins, the remaining participants (n = 41, 16%) incorrectly responded that it is susceptible to cefalotine, cefuroxime or ceftriaxone. The majority (n = 237, 93%) of participants agreed that amoxicillin is safe during the first three-month period of pregnancy whereas 17 (7%) incorrectly answered that ciprofloxacin or gentamicin are safe. A total of 180 (70%) participants correctly answered that ceftriaxone is the most effective drug crossing the blood-brain barrier where as 62 (24%) and 10 (4%) of participants incorrectly chose vancomycin and clindamycin above ceftriaxone. With regard to the estimate about local AMR rates, it was striking that only 51 (20%) of participants correctly estimated that > 50% of K. pneumoniae isolates are resistant to cephalosporins, whilst half, 129 (50%) answered that the resistance rate was 20%-50% and 47 (18%) answered 'don't know'. In response to the question about resistance rates of P. aeruginosa to ciprofloxacin, 82 (32%) of participants gave correct estimates (i.e. 20-50%), 118 (46%) answered that the rate was higher than 50% and 39 (15%) answered 'don't know'.
Awareness about the current scope of AMR
Almost all participants considered that AMR is a problem (98%). There were fewer residents than attending physicians who strongly agreed that AMR is a worldwide problem (58% versus 81%, p < 0.001). A similar scenario was observed in relation to the perception of AMR at the national level as 54% of residents strongly agreed that AMR was a problem compared to 78% of attending physicians (p < 0.001). However, whilst a mere 22% strongly agreed AMR is a problem in their own practice (Figure ), Further, there was agreement upon the perception of overuse of AMs in both the Peruvian community and hospitals (96% and 90% combined "strongly agree" and "agree" answers for both settings respectively).
Awareness of the scope of AMR among 256 participants (data in the graphs represent percentages). AM: Antimicrobial, AMR: Antimicrobial resistance
Confidence and seeking of inputs
Nearly half (63/135, 47%) of residents revealed they were very confident about the optimal use of antimicrobials compared to 99/121 (82%) of attending physicians (p < 0.001). A total of 78 (31%) participants agreed that it is difficult for them to select the correct AM, this was recorded for 36% participants from the medical departments versus 20% from the surgical departments (p = 0.014). Moreover, it should be noted that almost a quarter of participants (n = 58, 23%), strongly agreed and agreed that prescribing AMs when they are not required does not cause any harm. With regard to seeking inputs, when participants were asked about the frequency of reviewing their decision to prescribe AMs with a senior colleague, 15% replied 'never' and 57% 'sometimes'; only 6% answered 'always'. More than half (74/135, 55%) of residents declared that they never or only sometimes reviewed their decision with a senior colleague compared to 89% (108/121) of attending physicians (p < 0.001). This was seen more frequently among participants from surgical departments compared to those from medical departments (80% versus 67%, p = 0.03). Among the 219 participants who declared to review their decision to prescribe AMs with a senior colleague at least sometimes, nearly three quarters (161, 74%) reported that senior colleagues sometimes recommended a different AM.
Sources of information and continuing education about AMs
Overall, 88 (34%) participants declared that there had been no lectures about AM use as part of academic activities within their departments during the previous year, although there was a slight difference between the medical and surgical departments (29% versus 45%; p = 0.015). Likewise, 37% (95/256) of participants had not participated in a course on AM use during the previous year; the rate was 65% among residents versus 35% among attending physicians (p = 0.003). Regarding sources of information, two-thirds (173, 68%) of participants reported having readily available sources of information on AMs. The "Sanford Guide on Antimicrobial Therapy" was considered as a very useful source (n = 129, 50%), although preferentially among residents (n = 78, 58%) compared to attending physicians (n = 51, 42%, p = 0.013). Internet sources were considered as very useful or useful by nearly two-thirds (159, 62%) of participants. Thirty six (14%) participants did not consider the national guidelines useful and a quarter (65, 25%) noted that they were not familiar with these guidelines. Advice from colleagues of higher rank or same rank were considered useful or very useful in 98 (38%) and 71 (28%) of participants respectively.
Factors influencing decisions around AM prescription
Nearly three quarters (183/256, 72%) of participants strongly agreed or agreed that patients' demand for AMs contributes to their overuse in the community, but only half (n = 128, 50%) did so for the hospital setting (Figure ). Almost 40% (n = 102) of participants declared that they were unaware of the AMs available in their hospital because of continuously changing formulations. Surprisingly, more than half (146, 57%) agreed with the statement that the AMs available in their hospitals are of poor quality and are not effective.
Perception of factors influencing the decision on AM prescription. Data represent percentages among 256 participants. AM: Antimicrobial
Acceptability and appropriateness of potential interventions
The vast majority of participants strongly agreed and agreed with the development of AM prescribing educational programs (n = 247, 97%) and confirmed that a local AM guideline would be more useful than an international one (n = 235, 92%). Moreover, 224 (88%) participants strongly agreed and agreed that knowledge about local AMR rates should be considered when prescribing AMs. Ninety-six participants (38%) strongly agreed and agreed that the need to apply for approval to prescribe restricted AMs caused them to seek an alternative AM (Figure ). More participants from Arzobispo Loayza hospital (88%) strongly disagreed or disagreed with the statement that AM guidelines and AM committees are an obstacle to patient care compared to participants from Cayetano Heredia hospital (45%) (p < 0.001).
Figure 3 Acceptability and appropriateness of potential interventions on AM prescribing as surveyed among 256 participants. Data represent percentages. AM: antimicrobial, AMR: Antimicrobial resistance, *38% answered 'There is no a restrictive policy in my hospital' (more ...)