International Journal of Clinical Pharmacy

, Volume 41, Issue 5, pp 1348–1358 | Cite as

Antimicrobial prescribing and determinants of antimicrobial resistance: a qualitative study among physicians in Pakistan

  • Zikria SaleemEmail author
  • Mohamed Azmi Hassali
  • Brian Godman
  • Furqan Khurshid Hashmi
  • Fahad Saleem
Research Article


Background Understanding physicians’ perception about antimicrobial use and resistance is essential to ensure that the objectives of the Pakistan national action plan on antimicrobial resistance are met. Little is currently known about physicians’ perceptions in Pakistan. Objective Assess physicians’ perception surrounding antibiotic use and resistance, factors influencing antibiotic prescribing and potential interventions to improve future antibiotic prescribing. Settings The study was conducted in Lahore, the capital of the province of Punjab, which is the second largest and most populous city of Pakistan. Method Qualitative study was conducted with a semi-structured interview guide involving in-depth face-to-face interviews with purposively selected physicians. Audiorecorded interviews were transcribed verbatim and transcripts analyzed by thematic content analysis. Main outcome measures Themes surrounding the perspectives of physicians on issues of antimicrobial use and resistance. Results Five major themes emerged: (1) knowledge and perception of physicians about antimicrobials, (2) antimicrobial prescribing behaviors of physicians, (3) factors influencing prescribing, (4) determinants of antimicrobial resistance, (5) and potential interventions to reduce antimicrobial resistance. The main challenges and issues associated with antibiotic prescribing were the improvement of knowledge, implementation of hygienic measures, access to and clarity of treatment recommendations and minimizing external factors influencing prescribing including pharmaceutical company activities. Suggestions for the future included stricter regulations for prescribing, improved diagnosis, availability of local guidelines and monitoring of prescribing and resistance patterns. Conclusion Identification of concerns regarding inappropriate antimicrobial prescribing will enable specific initiatives and approaches to improve future antimicrobial use and reduce antimicrobial resistance in Pakistan.


Antimicrobial resistance Pakistan Physicians Prescribing Qualitative study 



Authors acknowledge the support of all the interviewees who participated in the study.


There was no external funding for this project, with the study funded by the co-authors.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Supplementary material

11096_2019_875_MOESM1_ESM.docx (18 kb)
Supplementary material 1 (DOCX 17 kb)


  1. 1.
    Gandra S, Barter D, Laxminarayan R. Economic burden of antibiotic resistance: how much do we really know? Clin Microbiol Infect. 2014;20(10):973–9.CrossRefGoogle Scholar
  2. 2.
    Jinks T, Lee N, Sharland M, Rex J, Gertler N, Diver M, et al. A time for action: antimicrobial resistance needs global response. Bull World Health Organ. 2016;94(8):558-A.CrossRefGoogle Scholar
  3. 3.
    Saleem Z, Hassali MA. Travellers take heed: outbreak of extensively drug resistant (XDR) typhoid fever in Pakistan and a warning from the US CDC. Travel Med Infect Dis. 2019;27:127.CrossRefGoogle Scholar
  4. 4.
    Saleem Z, Hassali MA, Hashmi FK. Pakistan’s national action plan for antimicrobial resistance: translating ideas into reality. Lancet Infect Dis. 2018;18(10):1066–7.CrossRefGoogle Scholar
  5. 5.
    Okeke IN. Poverty and root causes of resistance in developing countries. In: Sosa A, Byarugaba D, Amábile-Cuevas C, Hsueh PR, Kariuki S, Okeke I, editors. Antimicrobial resistance in developing countries. Springer; 2010. p. 27–35.Google Scholar
  6. 6.
    Ceyhan M, Yildirim I, Ecevit C, Aydogan A, Ornek A, Salman N, et al. Inappropriate antimicrobial use in Turkish pediatric hospitals: a multicenter point prevalence survey. Int J Infect Dis. 2010;14(1):e55–61.CrossRefGoogle Scholar
  7. 7.
    Md Rezal RS, Hassali MA, Alrasheedy AA, Saleem F, Md Yusof FA, Godman B. Physicians’ knowledge, perceptions and behaviour towards antibiotic prescribing: a systematic review of the literature. Expert Rev Anti-infect Ther. 2015;13(5):665–80.CrossRefGoogle Scholar
  8. 8.
    Pakyz AL, Moczygemba LR, VanderWielen LM, Edmond MB, Stevens MP, Kuzel AJ. Facilitators and barriers to implementing antimicrobial stewardship strategies: results from a qualitative study. Am J Infect Control. 2014;42(10):S257–63.CrossRefGoogle Scholar
  9. 9.
    Pulcini C, Williams F, Molinari N, Davey P, Nathwani D. Junior doctors’ knowledge and perceptions of antibiotic resistance and prescribing: a survey in France and Scotland. Clin Microbiol Infect. 2011;17(1):80–7.CrossRefGoogle Scholar
  10. 10.
    Brink AJ, Messina AP, Feldman C, Richards GA, Becker PJ, Goff DA, et al. Antimicrobial stewardship across 47 South African hospitals: an implementation study. Lancet Infect Dis. 2016;16(9):1017–25.CrossRefGoogle Scholar
  11. 11.
    Ashiru-Oredope D, Sharland M, Charani E, McNulty C, Cooke J. Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: start smart—then focus. J Antimicrob Chemother. 2012;67(suppl_1):i51–63.CrossRefGoogle Scholar
  12. 12.
    Bannan A, Buono E, McLaws ML, Gottlieb T. A survey of medical staff attitudes to an antibiotic approval and stewardship programme. Intern Med J. 2009;39(10):662–8.CrossRefGoogle Scholar
  13. 13.
    Srinivasan A, Song X, Richards A, Sinkowitz-Cochran R, Cardo D, Rand C. A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med. 2004;164(13):1451–6.CrossRefGoogle Scholar
  14. 14.
    Wester CW, Durairaj L, Evans AT, Schwartz DN, Husain S, Martinez E. Antibiotic resistance: a survey of physician perceptions. Arch Intern Med. 2002;162(19):2210–6.CrossRefGoogle Scholar
  15. 15.
    Kaae S, Malaj A, Hoxha I. Antibiotic knowledge, attitudes and behaviours of Albanian health care professionals and patients–a qualitative interview study. J Pharm Policy Pract. 2017;10(1):13.CrossRefGoogle Scholar
  16. 16.
    Reynolds L, McKee M. Factors influencing antibiotic prescribing in China: an exploratory analysis. Health Policy. 2009;90(1):32–6. Scholar
  17. 17.
    Velasco E, Ziegelmann A, Eckmanns T, Krause G. Eliciting views on antibiotic prescribing and resistance among hospital and outpatient care physicians in Berlin, Germany: results of a qualitative study. BMJ Open. 2012;2(1):e000398.CrossRefGoogle Scholar
  18. 18.
    Abbo L, Sinkowitz-Cochran R, Smith L, Ariza-Heredia E, Gómez-Marín O, Srinivasan A, et al. Faculty and resident physicians’ attitudes, perceptions, and knowledge about antimicrobial use and resistance. Infect Control Hosp Epidemiol. 2011;32(7):714–8.CrossRefGoogle Scholar
  19. 19.
    Nakwatumbah S, Kibuule D, Godman B, Haakuria V, Kalemeera F, Baker A, et al. Compliance to guidelines for the prescribing of antibiotics in acute infections at Namibia’s national referral hospital: a pilot study and the implications. Expert Rev Anti-infect Therapy. 2017;15(7):713–21.CrossRefGoogle Scholar
  20. 20.
    Babar A, Khan B, Godman B, Hussain S, Mahmood S, Aqeel T. Assessment of active pharmaceutical ingredients in drug registration procedures in Pakistan: implications for the future. Generics Biosimilars Initiat J. 2016;5(4):156–63.CrossRefGoogle Scholar
  21. 21.
    Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.CrossRefGoogle Scholar
  22. 22.
    Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud P-AC, et al. Why don’t physicians follow clinical practice guidelines?: A framework for improvement. JAMA. 1999;282(15):1458–65.CrossRefGoogle Scholar
  23. 23.
    Fadare JO, Oshikoya KA, Ogunleye OO, Desalu OO, Ferrario A, Enwere OO, et al. Drug promotional activities in Nigeria: impact on the prescribing patterns and practices of medical practitioners and the implications. Hosp Pract. 2018;46(2):77–87.CrossRefGoogle Scholar
  24. 24.
    Organization WH. WHO competency framework for health workers’ education and training on antimicrobial resistance. Geneva: World Health Organization; 2018.Google Scholar
  25. 25.
    Riaz H, Godman B, Hussain S, Malik F, Mahmood S, Shami A, et al. Prescribing of bisphosphonates and antibiotics in Pakistan: challenges and opportunities for the future. J Pharm Health Serv Res. 2015;6(2):111–21.CrossRefGoogle Scholar
  26. 26.
    Guerra CM, Pereira CAP, Neto ARN, Cardo DM, Correa L. Physicians’ perceptions, beliefs, attitudes, and knowledge concerning antimicrobial resistance in a Brazilian teaching hospital. Infect Control Hosp Epidemiol. 2007;28(12):1411–4.CrossRefGoogle Scholar
  27. 27.
    Giblin TB, Sinkowitz-Cochran RL, Harris PL, Jacobs S, Liberatore K, Palfreyman MA, et al. Clinicians’ perceptions of the problem of antimicrobial resistance in health care facilities. Arch Intern Med. 2004;164(15):1662–8.CrossRefGoogle Scholar
  28. 28.
    García C, Llamocca LP, García K, Jiménez A, Samalvides F, Gotuzzo E, et al. Knowledge, attitudes and practice survey about antimicrobial resistance and prescribing among physicians in a hospital setting in Lima, Peru. BMC Clin Pharmacol. 2011;11(1):18.CrossRefGoogle Scholar
  29. 29.
    Haque A, Hussain K, Ibrahim R, Abbas Q, Ahmed SA, Jurair H, et al. Impact of pharmacist-led antibiotic stewardship program in a PICU of low/middle-income country. BMJ Open Qual. 2018;7(1):e000180.CrossRefGoogle Scholar
  30. 30.
    Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003;163(12):1409–16.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Zikria Saleem
    • 1
    • 2
    Email author
  • Mohamed Azmi Hassali
    • 1
  • Brian Godman
    • 1
    • 4
    • 5
    • 6
  • Furqan Khurshid Hashmi
    • 3
  • Fahad Saleem
    • 7
  1. 1.School of Pharmaceutical SciencesUniversiti Sains MalaysiaPenangMalaysia
  2. 2.Rashid Latif College of PharmacyLahorePakistan
  3. 3.University College of PharmacyUniversity of the PunjabLahorePakistan
  4. 4.Department of Clinical PharmacologyKarolinska InstituteStockholmSweden
  5. 5.Strathclyde Institute of Pharmacy and Biomedical SciencesStrathclyde UniversityGlasgowUK
  6. 6.Health Economics CentreUniversity of Liverpool Management SchoolLiverpoolUK
  7. 7.Faculty of Pharmacy and Health SciencesUniversity of BalochistanQuettaPakistan

Personalised recommendations