Baseline Data: Coverage, Response Rate, Professional Profile
Eighty-nine of the estimated 185 medical doctors in Kisangani were addressed, as well 106 of the 131 medical students at UH Kisangani (coverage rates of 48.1% and 80.9% respectively). Of the total of 195 questionnaires, 11 (5.6%) were either not returned or incompletely filled in (all from medical doctors), leaving 184 eligible surveys (response rate 94.4%). Medical doctors and students accounted for 78 (42.3%) and 106 (57.6%) of respondents respectively.
Among the medical doctors, 11.5% (n
9) had less than one year work experience, 38.5% (n
30) had between 1 and 3 year work experience, 23.1% (n
18) between 4 to 6 years work experience and the remaining 26.9% (n
21) had more than 10 years of work record. Unless otherwise stated, the results are presented for all respondents (medical students and medical doctors regardless of work experience) combined, except when there were differences between these groups.
All respondents prescribed AB to in- as well as outpatients. More than half (100/183, 54.4% - one respondent did not reply to this question) reported to prescribe AB more than once a day, 15.2% (n
28) and 17.4% (n
32) reported 1 to 2 times and 3 to 5 times per week respectively. As expected, medical students prescribed less frequently compared to medical doctors (≥1 prescription/day: 42.5% versus 85.7% and <1 prescription/day: 57.5% versus 14.3%; p<.0001).
On a score of 8, the mean (± S.D.) and median (range) scores were 4.9 (±0.09) and 5 (2–8) respectively. A total of 1 (0.5%) and 20 (10.9%) of respondents scored 8 and 7 points respectively; scores of 6 and 5 were achieved by 36 (19.6%) and 55 (29.9%) respondents respectively. The remaining respondents (n
72, 39.1%) had a score of 4 or less. There was no significant difference in the mean score according to years of experience (p
.19), frequency of consulting colleagues before deciding about AB prescribing (p
.21) or previous training about AB prescribing (p
As to the individual questions (), the results were as follows: although the majority (89.7%) of respondents correctly answered to install no AB treatment in case of non-febrile diarrhea, less than one third (27.9%) replied so to the question about upper respiratory tract infection (URTI). Further, less than 20% of respondents correctly replied to questions about dose reduction in case of renal failure and less than 40% about cross-resistance of methicillin resistant Staphylococcus aureus (MRSA) to beta-lactam AB. Compared to medical doctors, medical students answered three questions significantly more frequently incorrect: they more frequently advised AB in case of URTI, were less aware of the cross-resistance of MRSA and were more unsure about safe antibiotics in pregnancy.
Knowledge questions and results.
Less than half and fewer than 10% of respondents correctly estimated the local resistance rate of, Salmonella
Typhi to trimethoprim-sulphamethoxazole (cotrimoxazole, TMP/SMX) and of Klebsiella
spp. to ceftriaxone respectively 
. The other respondents invariably underestimated the resistance rates of both pathogens.
The majority of respondents agreed or strongly agreed that ABR is an important problem, though significantly (p<.0001) less in their own practice as compared to the national or worldwide scope (). Likewise, most (87.5%) respondents agreed that AB are overused in the country. Factors recognized by respondents as thriving ABR in DRC are listed in self-treatment by patients, and non-completing AB treatment were scored by approximately 90% of respondents, but only 69.0% and 71.2% respectively agreed with over-prescription and low quality of AB and less than two-thirds (64.1%) with in-hospital transmission of AB resistant bacteria as thriving factors.
Perception of Antibiotic resistance as a problem.
Factors contributing to antibiotic resistance in DRC.
Confidence and Seeking Input
Nearly 90% of the respondents declared to feel very confident (n
21, 11.4%) or confident (n
142, 77.2%) about their knowledge on AB. Medical students tended to have lower self-confidence in AB prescribing than medical doctors (85.7% versus 94.8%), although this difference did not reach statistical difference (p
.053).There was no significant correlation between confidence and mean knowledge score (p
.1622). Despite this confidence, more than half (55.4%) of respondents agreed with the statement that the selection of the correct AB is difficult. However, when asked about the frequency of consulting a colleague when prescribing AB, most respondents replied sometimes (79.4%) and never (1.1%) versus 3.3%, 11.4% and 4.0% replying half of the times, mostly and always respectively. In line with the lower self confidence among student they also reported to consult significantly more often a colleague compared to medical doctors (25.4% versus 11.6%; p
Source of Information
For medical doctors and students combined, the sources of information about AB used during the month prior to the survey were, in rank of decreasing frequency: pharmaceutical companies (consulted by 73.9% of respondents), antibiotic guidelines (66.3%), university courses (63.6%) and information retrieved from the internet (45.7%). Only 26.6% of respondents declared to have used WHO guidelines. gives the details for medical doctors versus students: university courses had been used significantly more by students and there were more medical doctors who had consulted internet sources, although this difference did not reach statistical significance. With regard to appreciation of usefulness, all sources were appreciated as useful or very useful by more than 85% of respondents, except for the information provided by pharmaceutical companies (75.5%).
Sources of information about AB and AB prescribing used in the month prior to the survey, categorized for last year medical students versus medical doctors.
Factors Influencing Prescription
Patient pressure was perceived as a factor contributing to overuse of AB in the community by nearly two-thirds (61.9%) of respondents, whereas only one third (34.3%) did so for the hospital setting (p<.001). The majority of respondents (n
165; 89.7%) agreed that knowledge of local AB resistance patterns was needed for good prescribing. About two-thirds (63.8%) of respondents did not agree with the statement that choice of prescribed AB was more influenced by availability than by the cause of infection. A total of 72.3% of respondents disagreed with the statement that ABs if not needed do not cause harm to the patient; however, 6.0% were neutral and about one fifth (21.7%) subscribed this statement.
Only 16.3% (n
30) of respondents agreed that ABs available at the local pharmacies were in most cases of good quality (39.7% mentioned they did not have an opinion about it). One third (30.4%) believed that AB coming through the national central procurement office were of good quality (i.e. significantly higher than those available at the pharmacies; p<.001), whereas 22.8% considered them to be of poor quality and nearly half (44.6%) of respondents did not indicate an opinion.
Acceptability of Potential Interventions
Nearly three quarters (73.4%) of respondents agreed with the statement that local AB guidelines were more useful than international guidelines. AB committees were only seen by 9.8% of respondents as obstacles rather than as a help, although 42.9% of respondents declared not to have an opinion about this topic. Nearly all (98.8%) respondents expressed their wish for additional training on AB prescribing.