Increased antibiotics consumption and antimicrobial resistance are still significant problems in low socioeconomic countries (11). In our country, Turkey, the efforts have been made to reduce higher antibiotic consumption rates, to increase antimicrobial resistance awareness levels of physicians with training before and after graduation though raising the issue in writing/visual media, increasing the public awareness with public spots, and to prevent the non-prescribed sales of antibiotics in pharmacies since 2014.
One of the studies that was reported by Mahmood et al. (12) showed that the irrational antimicrobial use resulted in reduced quality of care, increased morbidity and mortality, and increased cases of adverse drug reactions and medication errors. Andrajati et al. (13) conducted a study though analyzing 788 oral prescriptions, which were prescribed by 28 doctors for acute pharyngitis and nonspecific respiratory infections at primary healthcare services, and 392 of them were evaluated for rationality according to local guidelines issued by Indonesian Ministry of Health. They found that 220 prescriptions for selecting the right antibiotic did not meet the rational antibiotic prescribing criteria. Besides, they concluded that training for rational antibiotic use and physician experience were the factors associated with the rationality of antibiotic prescriptions. Since viral agents play roles in the etiology of the common cold, antibiotics have no usage in its treatment; and resting and supportive treatments are adequate (14). We found that both groups had a sufficient level of awareness of this issue.
Practitioners sometimes cannot deal with their health problems in a detailed way because of their busy work schedules and they want to solve the problems in the most practical way (15). It may be argued that group 1 started antibiotics for simpler reasons. It was also possible to argue that the self-confidence of group 2 was higher than group 1 in making this decision, and group 1 was more cautious in this respect. These different approaches might be associated with the lack of self-confidence in the professional experience of the physicians or lack of adequate time rather than the presence of a healthcare employee in the place of residence and family. Given that the group 2 decided not to start antibiotics treatment, although it would necessarily cause more worries for themselves, and that the concerns of the group 2 being less might be explained by having more professional experience. The differences in knowledge, attitudes, and behaviors of physicians who prescribe antibiotics in primary healthcare facilities on deciding to start treatment and the necessity of treatment may also cause the rates of increase antibiotic prescription (16). The quality of a candidate physicians’ pre-graduation training and the ability to apply this theoretical training in the master-apprentice or individual practice may significantly affect the attitude and behavior when starting antibiotics. Many factors may influence doctors’ decisions, leading them to breach the principles of good clinical practice (17). For example, the fear of possible future complications in their patients or a desire to fulfill patients’ expectations. Many physicians fear that they may miss out on the infection in the presence of leukocytosis, and often prefer to prescribe antibiotics to feel safe (18). In our study, the group 2 had more professional experience generally about antibiotics prescription in the presence of leukocytosis and argued the most important condition that forced primary healthcare physicians to write antibiotics is the lack of knowledge of these physicians. The physicians who had less experience believed that the presence of fever was more important, and the suspicion of infection that is not evidenced was the most important factor driving primary healthcare physicians to write antibiotics (19). Today, unfortunately, physicians can allocate less than optimal time to the patients for diagnosis because of an overcrowded patient for primary health care services and are often under pressure to prescribe antibiotics by patients and/or their relatives (20).
Among the most common causes of irrational antibiotic use, there is the expectation of the patient to prescribe an antibiotic from the physician considering “being a good doctor” equivalent to writing a prescription, insufficient examination facilities, and the need for the physician for feel safe by prescribing antibiotics by fearing that they might overlook an infection (21). The expectation of a patient to prescribe an antibiotic from the physician, keeping the equivalent of writing good medicine prescriptions, insufficient examination facilities, and the need for the physician to feel safe by prescribing antibiotics with the fear of distracting a possible infection are among the most common causes of irrational antibiotic use. (22). Another finding is that physicians forget their theoretical knowledge in time after they start active duty; they do not improve themselves, and follow update literature and developments because of their intensive work schedule (23). Group 1 thought that these reasons were more prominent in primary healthcare. Chemoprophylaxis is an optional procedure that is aimed to keep an infection with a high probability of development (24). The correct definition in this respect was made by group 1. Although there are guidelines released on surgical prophylaxis, we have witnessed misconduct in many clinics. The level of knowledge on surgical prophylaxis was low in both of our groups, and the possible cause of this might have been that they did not use it too much. Thus, the theoretical knowledge could be forgotten in time.
Antimicrobial resistance can be defined as the inefficiency of antibiotics in time due to the irrational/excessive use of antibiotics (25). The correct definition is made by group 1 at higher rates may be explained by that their theoretical knowledge is more recent. The most common reason for penicillin resistance in Staphylococci is the synthesis of a new PBP (Penicillin-Binding Protein) (26). Although nearly half of group 1 was thought in this way, more than half of group 2 believed that beta-lactamase was secreted, which was wrong. This finding may suggest that both groups are inadequate or do not update their knowledge of antimicrobial resistance mechanisms.
The presence of comorbid conditions and diseases must be considered in a patient who is scheduled to receive antibiotics. If an antibiotic drug that is initiated for the treatment of an infection is administered without considering comorbid diseases, it will inevitably lead to undesirable outcomes (27). The ability to answer the questions on comorbid conditions and diseases (e.g., pregnancy and renal failure) and the percentages of accurate answers were higher at a significant level in group 1. This may make us consider that group 2 forgets the theoretical knowledge in time and they are more likely to make mistakes. This subject shows the importance of transforming the antibiotic awareness in the basic pharmacology courses to the students in the early stages of school into knowledge that may also be used in the future (28). In this study, the most probable factors for the three most common primary healthcare groups were asked. The findings showed that the percentages of the rates of answering to questions and providing correct answers were low. Another interesting detail was that some of them in group 2 answered this question by writing the name antibiotics instead of the name of the agent by mistake and trying to answer the question more carelessly.
The opinions and suggestions of the participants in the awareness of antimicrobial resistance were also of interest when planning the questionnaire. Among the suggestions that were included in our questionnaire, group 1 defended the idea that periodic training before and after graduation, developing strict usage policies and applying penal sanctions would be more effective; and the group 2 defended that the issue should be brought to the agenda in written and visual media more frequently, using public spots emphasizing antimicrobial resistance, and preparing brochures and posters would be more effective. A new generation of messages that encourage the first-choice use of narrow-spectrum antibiotics is needed, reflecting international efforts to preserve broad-spectrum antibiotic classes (29).
We have demonstrated the following conclusions: The levels of theoretical antibiotic knowledge are better in the pre-graduation period. After graduation, doctors ' theoretical knowledge of antibiotics is forgotten over time, and they are more likely to make mistakes. This situation has once again revealed the importance of education after graduation. The penal sanctions could be more effective by developing strict use policies to raise awareness of antimicrobial resistance. It could be said that they could not update their knowledge in this period due to the intensity in working life, and they forgot their theoretical knowledge of antibiotics over time. Especially training after graduation is crucial in reducing the excessive rates of antibiotic usage. This study could draw attention to increased antimicrobial resistance by highlighting the slogan which was put forward by Unal S et al. for the first time in 2014 at Hacettepe University in Ankara “Either awareness or resistance develops for antibiotics”. This slogan may be useful for raising awareness against increased antimicrobial resistance. These results once again highlighted the need for immediate action of training and corrective actions.
The survey model used in this study was adapted from several similar studies that have been carried out before. It was applied to medical school senior students and family physicians to determine the differences between before and after graduation. If there were more participants, perhaps more accurate results could have been obtained, and more accurate analyses might have been performed.