Barriers for Antimicrobial Stewardship Among Junior Doctors

Barriers for Antimicrobial Stewardship Among Junior Doctors 1
BARRIERS FOR ANTIMICROBIAL STEWARDSHIP AMONG JUNIOR DOCTORS
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Barriers for Antimicrobial Stewardship Among Junior Doctors 2
1.1 Background
Antibiotics are among the most common antimicrobial prescribed medicines. However,
there is an alarming increase of bacterial resistance amidst the plethoric availability of
antimicrobial agents. The arising antimicrobial resistance (AMR) has gained global attention for
common bacterial infections such as Staphylococcus aureus that was once treatable are now
incurable (Papoutsi et al., 2018, p.1).
An AMR research commissioned by the UK government depicts an estimate of 10
million deaths in one year by the year 2050 due to drug resistance (de Kraker, Stewardson, and
Harbarth, 2016, p.1002184). In addition to this mortality and morbidity burden, antimicrobial
resistance has affected other therapeutic procedures such as the surgical procedures where the
antibiotics are used prophylactically with the intention of curbing infections. Even
chemotherapeutical cancer treatment is affected by the AMR burden (Laxminarayan et al., 2013,
pp.1057-1098).
Also, there is a significant financial burden as a result of the increased high second line
and third line medicines, extended hospitalization and certain complications resulting from failed
therapies. The world economy is likely to suffer losses of about US$ 100T due to reduced
production as a result of AMR by the 2050 (de Kraker, Stewardson, and Harbarth, 2016,
p.1002184). There is an urgent need to reinforce the already available set of strategies aimed at
preventing the occurrence and spread of AMR. There is a positive relationship between
antimicrobial usage and AMR (Sun, Klein and Laxminarayan, 2012, pp.687-694). Studies have
shown that there is an everyday inappropriate use of the antibiotics in acute care facilities
(Stuurman, van Keulen and Kluytmans, 2013, pp.3729-3731). The new resistance of various

Barriers for Antimicrobial Stewardship Among Junior Doctors 3
bacterial strains majorly results from the prolonged and inappropriate use of the antibiotics.
Multiple factors contribute to the inappropriate prescription of these antimicrobials among
healthcare professionals. For example, the lack of accessing the local antibiograms and poor
choice of the antibiotics during therapy. These challenges have led to the establishment of the
antimicrobial stewardship programs (AMS) in healthcare settings throughout the world to limit
the emergence and spread of AMR as well as improve patient outcomes upon treatment (Carlet
et al., 2012, p.11).
Mostly, prescription of the antibiotics is done by recognized expertise, however, in real
situations, the decisions regarding the medicine are often made by the junior staff such as junior
doctors. These junior staff may or may not receive guidance from their seniors which leaves
themselves entirely to depend on for decision making (Charan et al., 2013, pp.188-196). This
paper seeks to evaluate the barriers to effective implementation of the AMS strategies among the
junior doctors. However, it is necessary to first understand the classes of antimicrobial and
resistant to the antimicrobials.
1.2 Antimicrobial classification
An antimicrobial agent is any natural, semisynthetic or synthetic substance which kills or
inhibits the growth of microorganism without killing the host. Primarily, antimicrobials are
derived from fungi, bacteria or can be manufactured synthetically or semi-synthetically. Fungal
derivatives are majorly obtained from Penicillium spp and the Streptomyces spp. Bacillus spp is
the source of many bacterial derived antimicrobials. Semisynthetic are as a result of chemical
alterations of the naturally existing antimicrobials while the synthetic ones such as sulfonamides
are purely derived from chemicals. Antimicrobials have been in place and commonly used for

Barriers for Antimicrobial Stewardship Among Junior Doctors 4
about 2000 years. In the ancient times, the Greeks and Egyptians treated certain infections
utilizing some plant extracts as well as specific molds (Alharbi et al., 2015, pp.600-603).
Remarkably in the 19th-century scientists, Louis Pasteur and Jules Francois realized antagonism
between bacteria and discussed its applicability in medicine to control bacterial infections
(Punitha et al., 2013, pp.2746-2750). Later in 1928, a natural antimicrobial antifungal was
discovered by Alexander Fleming who was referred to as Penicillium rubens and then called
penicillin. This antimicrobial successfully treated Streptococcus infection when it was widely
used in 1942 (Derderian, 2007, pp.1-5). Another antimicrobial that naturally occurs in
Streptomyces fungi called Streptomycin, an aminoglycoside, was discovered in 1944 by
Waksman. This was a timely discovery for the antibiotic was effective against most gram-
negative bacteria that had penicillin resistance. Other significant developments are those of
broad-spectrum Chloramphenicol and chlortetracycline that were discovered in 1947 and 1948
respectively (Zaffiri, Gardner and Toledo-Pereyra, 2012, pp.67-77).
The antimicrobials are categorized regarding the microorganisms they affect. For
example, antibiotics act against bacteria, antifungals are effective against fungi, antiviral act
against viral infections and antiparasitic act against parasites. Antibiotics are the most widely
studied antimicrobial agents in most cases the term is interchangeably used to refer to
antimicrobials. Also, the antimicrobial agent can be classified by their function. For example, the
antimicrobials that destroy the microorganism are termed as microbicides such as bactericidal
antibiotics which include cephalosporins, aminoglycosides, fluoroquinolones, vancomycin,
daptomycin, and metronidazole. Those that limit microbial growth are referred to as biostatic
such as bacteriostatic drugs for instance macrolides, tetracyclines, trimethoprim and
sulfonamides (Bahar and Ren, 2013, pp.1543-1575). Mainly, there are three types of