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\def\RunningAuthor{Abdulrahman Hadi Almutiri}
\firstPage{5665}
\articleType{Original Article}
\receivedDate{28 May 2020}
\acceptedDate{21 Jul 2020}
\revisedDate{25 Jun 2020}
\journalVolume{2020, 11}
\journalIssue{4}
\journalDoi{ijrps.v11i4.3208}
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\title{\textbf{Antimicrobial-stewardship Knowledge, attitude, and practice among professional physicians in Saudi hospitals}}
\author{Abdulrahman~Hadi~Almutiri\textsuperscript{*},  
            Abdul~Bari~Mohd, 
            Tahani~Mohammad~Al~Rahbeni~\\[5pt]{Department of Pharmaceutics, College of Pharmacy, Riyadh Elm University, Kingdom of Saudi Arabia }}

\begin{abstract}
Antimicrobial stewardship (AMS) is of vital significance to tackle the antibiotic resistance. Insights of physicians is important for implementation of AMS. Therefore, present study was conducted to assess the knowledge, attitude and practices regarding antibiotic stewardship programme among professional physicians in Riyadh, Saudi Arabia. A cross-sectional questionnaire-based survey was conducted among professional physicians between January 2020 to April 2020 in clusters of Saudi hospitals. The self-administered and closed ended questionnaire encompassed of informed consent, demographics information and questionnaire which included 7 items for knowledge, 10 for attitude and 8 for practices. Chi-square test and Fisher's exact test was performed to assess the relationship of knowledge, attitude and practices with gender and medical specialty of the study participants along with descriptive statistics. A p value below (p{\textless}0.05) was considered significant for all the statistical purposes. A total of 413 medical practitioners participated in this study. Most of the participants were male 280 (67.8\%), aged 31-40 years 163 (39.4\%). The term antimicrobial stewardship was known to 55.9\% of participants and 65\% of participants knew the difference between bacteriostatic and bactericidal antimicrobial agents (AMAs). 71.9\% participants opined that superinfections can be prevented by using specific AMAs. 89\% of participants do not prescribe AMAs on demand of patients. Health professionals should be adequately trained regarding usage of antimicrobials and their consequences to curb the menace of quickly developing AMA resistance. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Awareness,\newline Drug resistance,\newline Antimicrobial-stewardship
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Abdulrahman~Hadi~Almutiri~\\ Phone:\ 00966553228474~\\  Email:\ abrhp2006@hotmail.com
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\section{Introduction}
Inapt prescribing practices by clinicians have been regarded as a principal causal aspect for antibiotic resistance, which is now are cognized menace to world health\unskip~\citep{834996:19856208}. Insufficient training and lack of admiration of the degree and repercussion of ABR might be a basis for such inappropriate prescription. Thus, it becomes crucial to endow clini\-cians with the essential confidence and proficiency from the initial period in their professional life on apposite antibiotic prescribing,\unskip~\citep{834996:19856217} and alteration of insights and persistent behaviour change through execution of inter\-ventions focusing on appreciation of the causes resulting in antimicrobial resistance\unskip~\citep{834996:19856208},\unskip~\citep{834996:19856216}. Even though lectures of phar\-macology and microbiology are incorporated in medical education formally, failure to convert this into clinical prescribing pattern has been noticed \$. Previous surveys revealed that 


\begin{table*}[!htbp]
\caption{\boldmath {Characteristics of the study participants (n=413)} }
\label{tw-29ac68e29985}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.26330000000000002\linewidth-2\tabcolsep}p{\dimexpr.23669999999999998\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{2}{p{\dimexpr(.50\linewidth-2\tabcolsep)}}{Characteristics } & \textbf{n}\%\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.26330000000000002\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{Age (Years)}} &
  21-30 &
  88 &
  21.3\%\\
 &
  31-40 &
  163 &
  39.4\%\\
 &
  41-50 &
  120 &
  29.1\%\\
 &
  \ensuremath{\geq }51  &
  42 &
  10.2\%\\
\multicolumn{1}{p{\dimexpr(.26330000000000002\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Gender}} &
  Male &
  280 &
  67.8\%\\
 &
  Female &
  133 &
  32.2\%\\
\multicolumn{1}{p{\dimexpr(.26330000000000002\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{Experience years}} &
  0-10 &
  204 &
  49.4\%\\
 &
  11-20 &
  131 &
  31.8\%\\
 &
  21-30 &
  39 &
  9.4\%\\
 &
  31-40 &
  39 &
  9.4\%\\
\multicolumn{1}{p{\dimexpr(.26330000000000002\linewidth-2\tabcolsep)}}{\multirow{5}{\linewidth}{Work region}} &
  Central &
  180 &
  43.6\%\\
 &
  Western &
  102 &
  24.7\%\\
 &
  Northern &
  42 &
  10.2\%\\
 &
  Eastern &
  48 &
  11.6\%\\
 &
  Southern &
  41 &
  9.9\%\\
\multicolumn{1}{p{\dimexpr(.26330000000000002\linewidth-2\tabcolsep)}}{\multirow{8}{\linewidth}{Medical specialty}} &
  Other  &
  39 &
  9.4\%\\
 &
  Gynecology &
  12 &
  2.9\%\\
 &
  Pediatrics &
  58 &
  14.0\%\\
 &
  Dermatology &
  17 &
  4.1\%\\
 &
  Ophthalmology &
  12 &
  2.9\%\\
 &
  Orthopedics &
  17 &
  4.1\%\\
 &
  Medicine &
  190 &
  46.0\%\\
 &
  Surgery &
  68 &
  16.6\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
medical students in-spite of being acquainted with the significance of anti\-biotic prescribing awareness, consider themselves efficiently primed and want additional educa\-tion on choosing antibiotic\unskip~\citep{834996:19856214},\unskip~\citep{834996:19856210}.

Antimicrobial stewardship (AMS) is of vital significance to lessen hospital-acquired infection and deal with the crisis of multi-resistant bacteria. It intervenes for improving prescribing patterns at personal and institutional levels\unskip~\citep{834996:19856208}. To tackle antimicrobial resistance, every country ought to execute a comprehensive strategy for AMS \unskip~\citep{834996:19856215}. The utilization of the most appropriate antibiotic for the presenting clinical situation and the particular patient is promoted by AMS\unskip~\citep{834996:19856211}. It is an integrated approach which ensures appropriate antimicrobial agents (AMAs)usage by advocating the selection of drug regime with proper dose and duration along with a suitable route of administration. Through these measures, the possibility of toxicity is diminished, the cost-effectiveness of treatment is enhanced, and the option for antimicrobial-resistant strains is limited \unskip~\citep{834996:19856204},\unskip~\citep{834996:19856212}.


\begin{table*}[!htbp]
\caption{\boldmath {Knowledge of study participants towards Antimicrobial agents} }
\label{tw-cb0cc0fead77}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
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\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Items & \cAlignHack Knowledge & \cAlignHack Responses & \cAlignHack n & \cAlignHack \% & \cAlignHack Gender \mbox{}\protect\newline (p value) & \cAlignHack Medical specialty \mbox{}\protect\newline (p value)\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.05380000000000001\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{K1}} &
  The difference between bacteriostatic  &
  Yes &
  264 &
  65.0\% &
  \multicolumn{1}{p{\dimexpr(.14\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.439}} &
  \multicolumn{1}{p{\dimexpr(.16\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{000}}\\
 &
  and bactericidal Antimicrobial agents  &
  No &
  142 &
  35.0\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.05380000000000001\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{K2}} &
  The difference between broad  &
  Yes &
  401 &
  98.8\% &
  \multicolumn{1}{p{\dimexpr(.14\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.562}} &
  \multicolumn{1}{p{\dimexpr(.16\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.332}}\\
 &
  spectrum and narrow spectrum antimicrobials? &
  No &
  5 &
  1.2\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.05380000000000001\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{K3}} &
  Do you know the term antimicrobial  &
  Yes &
  227 &
  55.9\% &
  \multicolumn{1}{p{\dimexpr(.14\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{.002}} &
  \multicolumn{1}{p{\dimexpr(.16\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{{\textless}0.001}}\\
 &
  stewardship? &
  No &
  179 &
  44.1\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.05380000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{K4}} &
  Mechanisms are for  \mbox{}\protect\newline  &
  Increased entry of antibiotic into pathogen  &
  82 &
  19.9\% &
  .001 &
  .460\\
 &
  drug resistance &
  Decreased export by efflux pumps  &
  114 &
  27.6\% &
  0.439 &
  {\textless}0.001\\
 &
   &
  Alteration of target proteins &
  239 &
  57.9\% &
  0.134 &
  {\textless}0.001\\
 &
   &
  Release of microbial enzymes that destroy the antibiotic &
  157 &
  38.0\% &
  0.596 &
  .007\\
\multicolumn{1}{p{\dimexpr(.05380000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{K5}} &
  \multicolumn{1}{p{\dimexpr(.20330000000000002\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{Factors responsible for emergence of consequences for drug resistance.}} &
  Drug-resistant pathogen &
  328 &
  79.4\% &
  0.380 &
  .049\\
 &
   &
  Toxicity to the patient &
  61 &
  14.8\% &
  .049 &
  .003\\
 &
   &
  Requirement of higher AMA &
  40 &
  9.7\% &
  0.966 &
  .038\\
 &
   &
  Fetal damage &
  69 &
  16.7\% &
  0.730 &
  .142\\
\multicolumn{1}{p{\dimexpr(.05380000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{K6}} &
  \multicolumn{1}{p{\dimexpr(.20330000000000002\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{Drugs used to treat gram negative anaerobes.}} &
  Metronidazole &
  236 &
  57.1\% &
  0.831 &
  {\textless}0.001\\
 &
   &
  Fluoroquinolones &
  157 &
  38.0\% &
  0.735 &
  {\textless}0.001\\
 &
   &
  Imipenem &
  229 &
  55.4\% &
  0.266 &
  .001\\
 &
   &
  Cotrimoxazole &
  20 &
  4.8\% &
  0.784 &
  .445\\
\multicolumn{1}{p{\dimexpr(.05380000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{K7}} &
  \multicolumn{1}{p{\dimexpr(.20330000000000002\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{Regarding storage of AMAs, which is/are correct}} &
  Short expiry medicines should be kept at back &
  53 &
  13.2\% &
  \multicolumn{1}{p{\dimexpr(.14\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{0.053}} &
  \multicolumn{1}{p{\dimexpr(.16\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.008}}\\
 &
   &
  Cool storage means refrigeration &
  177 &
  43.9\% &
   &
  \\
 &
   &
  Most antibiotics need temperature of 15-20\ensuremath{^\circ}C  &
  113 &
  28.0\% &
   &
  \\
 &
   &
  Storage should be according to brand name &
  60 &
  14.9\% &
   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{For items K4, K5 and K6 only `` YES'' responses displayed}
\end{tablenotes}
\end{threeparttable}

\end{table*}
 In Saudi Arabia, the national AMS program set in motion in 2014, is a component of the pharmacy strategic plan of the Ministry of Health, and its complete execution has been achieved in 2018\unskip~\citep{834996:19856202},\unskip~\citep{834996:19856209}. Relatively few studies of knowledge, attitude, and practice are published about antimicrobial-stewardship concerning microbial resistance in Saudi Arabia\unskip~\citep{834996:19856213},\unskip~\citep{834996:19856203}. It was therefore found appropriate to assess the knowledge, attitude and practices regarding antibiotic stewardship programme among professional physicians in Riyadh, Saudi Arabia.
    
\section{\textbf{Materials and Methods}}
A cross-sectional questionnaire-based survey was conducted among professional physicians to evaluate their knowledge, attitude and practice towards Antimicrobial stewardship program in Saudi hospitals. The study was conducted between January 2020 to April 2020 in clusters of Saudi hospitals. The ethical committee obtained approval before proceeding with the research, and informed consent 


\begin{ThreePartTable}

\centering 
\begingroup
\makeatletter\if@twocolumn\@ifundefined{theposttbl}{\gdef\TwoColDocument{true}\onecolumn\onecolumn}{}\fi\makeatother 
\begin{TableNotes}\footnotesize 
    
\item{   For items A2, A3, A5, A7 and A8 only `` YES'' responses displayed    }
\end{TableNotes}\setlength\LTcapwidth{\textwidth}
\begin{longtable}{p{\dimexpr.1128\linewidth-2\tabcolsep}p{\dimexpr.15629999999999999\linewidth-2\tabcolsep}p{\dimexpr.22409999999999997\linewidth-2\tabcolsep}p{\dimexpr.13010000000000002\linewidth-2\tabcolsep}p{\dimexpr.13340000000000003\linewidth-2\tabcolsep}p{\dimexpr.1182\linewidth-2\tabcolsep}p{\dimexpr.1251\linewidth-2\tabcolsep}}
\caption{\boldmath {Attitude of study participants towards Antimicrobial agents} }
\label{tw-e31a07aa2aa6}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} 
\tbltoprule \rowcolor{kwdboxcolor}Items & Attitude domain items & Responses & N & \% & Gender \mbox{}\protect\newline (p value) & Medical specialty \mbox{}\protect\newline (p value)\\
\tblmidrule \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \insertTableNotes \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}Items & Attitude domain items & Responses & N & \% & Gender \mbox{}\protect\newline (p value) & Medical specialty \mbox{}\protect\newline (p value)\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{A1}} &
  \multicolumn{1}{p{\dimexpr(.15629999999999999\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{What precautions do you take to prevent AMA resistance?}} &
  Use of AMAs when necessary after AST &
  342 &
  85.3 &
  \multicolumn{1}{p{\dimexpr(.1182\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{0.232}} &
  \multicolumn{1}{p{\dimexpr(.1251\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{0.051}}\\
 &
   &
  Using {\textgreater} 1 AMAs at a time &
  10 &
  2.5 &
   &
  \\
 &
   &
  Using newer AMAs for long duration &
  7 &
  1.7 &
   &
  \\
 &
   &
  Use of broad spectrum AMAs for mild short-term illness &
  42 &
  10.5 &
   &
  \\
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{A2}} &
  \multicolumn{1}{p{\dimexpr(.15629999999999999\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{Which criteria do you use for selection of AMAs?}} &
  Clinical judgement &
  120 &
  29.1 &
  .008 &
  .008\\
 &
   &
  Empirical therapy &
  140 &
  33.9 &
  {\textless}0.001 &
  0.36\\
 &
   &
  Clinical and experimental evidence &
  264 &
  63.9 &
  0.37 &
  .050\\
 &
   &
  Lucrative practices &
  4 &
  1.0 &
  .444 &
  .917\\
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{A3}} &
  \multicolumn{1}{p{\dimexpr(.15629999999999999\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{What is/are the basis of choosing a proper dosing schedule?}} &
  As per Pharmacokinetic variability &
  309 &
  74.8 &
  0.114 &
  .329a\\
 &
   &
  Integrating microbial PK-PD studies &
  101 &
  24.5 &
  0.113 &
  0.026\\
 &
   &
  As per minimum inhibitory concentration of pathogen &
  53 &
  12.8 &
  .026 &
  0.282\\
 &
   &
  According to post-antibiotic effect &
  19 &
  4.6 &
  0.287 &
  0.06\\
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{A4}} &
  How frequently you follow the ontrol  &
  Always &
  216 &
  53.9 &
  \multicolumn{1}{p{\dimexpr(.1182\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.018}} &
  \multicolumn{1}{p{\dimexpr(.1251\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{{\textless}0.001}}\\
 &
  suggestions given by Hospital Infection  &
  Often &
  132 &
  32.9 &
   &
  \\
 &
  Committee (HICC) or antimicrobial  &
  Sometimes &
  52 &
  13.0 &
   &
  \\
 &
  tewardship team? &
  Seldom or never &
  1 &
  0.2 &
   &
  \\
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{8}{\linewidth}{A5}} &
  \multicolumn{1}{p{\dimexpr(.15629999999999999\linewidth-2\tabcolsep)}}{\multirow{8}{\linewidth}{When do you use empirical therapy?}} &
  Life-threatening infection &
  310 &
  75.1 &
  {\textless}0.001 &
  {\textless}0.001\\
 &
   &
  Recurrent local wound infection &
  30 &
  7.3 &
  0.891 &
  .012\\
 &
   &
  Community acquired infections &
  48 &
  11.6 &
  .005 &
  {\textless}0.001\\
 &
   &
  Failure to respond to initial therapy &
  78 &
  18.9 &
  .006 &
  .002\\
 &
   &
  To accelerate rapidity of microbial activity &
  243 &
  58.8 &
  0.097 &
  {\textless}0.001\\
 &
   &
  To enhance therapeutic efficacy &
  248 &
  60.0 &
  0.853 &
  0.120\\
 &
   &
  To prevent resistance to monotherapy &
  100 &
  24.2 &
  {\textless}0.001 &
  {\textless}0.001\\
 &
   &
  To reduce severity or incidence of ADR &
  9 &
  2.2 &
  0.891 &
  .012\\
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{A6}} &
  Does risk of ADR increase with post-treatment  &
  Yes &
  309 &
  77.1 &
  \multicolumn{1}{p{\dimexpr(.1182\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.355}} &
  \multicolumn{1}{p{\dimexpr(.1251\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{{\textless}0.001}}\\
 &
  suppressive therapy (secondary prophylaxis)? &
  No &
  92 &
  22.9 &
   &
  \\
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{A7}} &
  When do you prescribe a secondary antimicrobial  &
  For all surgical patients &
  178 &
  43.1 &
  .009 &
  {\textless}0.001\\
 &
  (excluding No option from each responses) \mbox{}\protect\newline prophylaxis? &
  For all AIDS patients &
  279 &
  67.6 &
  .012 &
  {\textless}0.001\\
 &
  \multicolumn{1}{p{\dimexpr(.15629999999999999\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{}} &
  For all post-transplant patients &
  232 &
  56.2 &
  .009 &
  {\textless}0.001\\
 &
   &
  For all patients with major disease &
  72 &
  17.4 &
  0.107 &
  0.356\\
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{A8}} &
  \multicolumn{1}{p{\dimexpr(.15629999999999999\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{How do you prevent super-infections?}} &
  Use of specific AMAs &
  297 &
  71.9 &
  0.307 &
  .759\\
 &
   &
  Use of AMAs to treat self-limiting illness &
  28 &
  6.8 &
  0.092 &
  .270\\
 &
   &
  Use of narrow spectrum AMAs &
  199 &
  48.2 &
  0.088 &
  .001\\
 &
   &
  Use of AMAs for prolong period &
  35 &
  8.5 &
  {\textless}0.001 &
  .063\\
\multicolumn{1}{p{\dimexpr(.1128\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{A9}} &
  \multicolumn{1}{p{\dimexpr(.15629999999999999\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{Most common reason for misuse of AMAs}} &
  Conflicting advertising claims of superiority to newer AMAs &
  63 &
  15.8 &
  \multicolumn{1}{p{\dimexpr(.1182\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{{\textless}0.001}} &
  \multicolumn{1}{p{\dimexpr(.1251\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{{\textless}0.001}}\\
 &
   &
  Prescribing AMAs without prior antibiotic sensitivity test (AST) &
  198 &
  49.5 &
   &
  \\
 &
   &
  Strong clinical suspicion of an infection &
  113 &
  28.3 &
   &
  \\
 &
   &
  According to availability of AMAs and following opinion of senior doctors. &
  26 &
  6.5 &
   &
  \\
\tblbottomrule 
\end{longtable}
\endgroup
\end{ThreePartTable}

\makeatletter\@ifundefined{TwoColDocument}{}{\twocolumn}\makeatother 
 was taken from each participant.

An online sample size calculator (Qualtrics) was used to calculate the ideal sample size of the participants from the 30,000 physicians as per the 1439 H health Indicator.

The calculated ideal sample size was 380 participants at a 95\% confidence level and 5\% margin of error.  All physicians who are in close contact with patients' medications and were present during that visit were explained about the purpose of the study and those who willingly provided informed consent participated in the study. Physicians who have no direct responsibilities on prescribing medications or following a patient's drug administration, including administration, radiation and laboratory staff were excluded from the study. A single investigator approached all the doctors working in hospitals. 


\bgroup
\fixFloatSize{images/e765f8e1-ad14-4d94-b805-5b2199bcf4aa-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/e765f8e1-ad14-4d94-b805-5b2199bcf4aa-upicture1.png}{\includegraphics{images/e765f8e1-ad14-4d94-b805-5b2199bcf4aa-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Preferred way of updating the knowledge among study participants}}
\label{f-55402bf85049}
\end{figure}
\egroup

\begin{table*}[!htbp]
\caption{\boldmath {Practice of study participants towards Antimicrobial agents} }
\label{tw-9b33b86d351c}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.0866\linewidth-2\tabcolsep}p{\dimexpr.21950000000000003\linewidth-2\tabcolsep}p{\dimexpr.3353\linewidth-2\tabcolsep}p{\dimexpr.07019999999999998\linewidth-2\tabcolsep}p{\dimexpr.092\linewidth-2\tabcolsep}p{\dimexpr.1127\linewidth-2\tabcolsep}p{\dimexpr.08370000000000001\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Items & Practice items & Responses & n & \% & Gender \mbox{}\protect\newline (p value) & Medical specialty \mbox{}\protect\newline (p value)\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.0866\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{P1}} &
  Do you prescribe AMAs on demand of  &
  Yes &
  44 &
  11.1\% &
  \multicolumn{1}{p{\dimexpr(.1127\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{.002}} &
  \multicolumn{1}{p{\dimexpr(.08370000000000001\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{.201}}\\
 &
  patients? &
  No &
  353  &
  88.9\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.0866\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{P2}} &
  Do you explain the patient about use  &
  Yes &
  171 &
  43.1\% &
  \multicolumn{1}{p{\dimexpr(.1127\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{{\textless}0.001}} &
  \multicolumn{1}{p{\dimexpr(.08370000000000001\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{{\textless}0.001}}\\
 &
  and ADRs of AMAs? &
  No &
  226 &
  56.9\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.0866\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{P3}} &
  Do you advice simple rapid lab  &
  Always &
  96 &
  24.2\% &
  \multicolumn{1}{p{\dimexpr(.1127\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.002*}} &
  \multicolumn{1}{p{\dimexpr(.08370000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.424}}\\
 &
  tests before starting AMA therapy? &
  Often &
  210 &
  52.9\% &
   &
  \\
 &
  \multicolumn{1}{p{\dimexpr(.21950000000000003\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{}} &
  Sometimes &
  84 &
  21.2\% &
   &
  \\
 &
   &
  Seldom or Never &
  7 &
  1.8\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.0866\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{P4}} &
  Do you advice culture-sensitivity in  &
  Always &
  237 &
  59.7\% &
  \multicolumn{1}{p{\dimexpr(.1127\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.953}} &
  \multicolumn{1}{p{\dimexpr(.08370000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.419}}\\
 &
  all severe cases if not responding to AMA? &
  Often &
  116 &
  29.2\% &
   &
  \\
 &
  \multicolumn{1}{p{\dimexpr(.21950000000000003\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{}} &
  Sometimes &
  41 &
  10.3\% &
   &
  \\
 &
   &
  Seldom or Never &
  3 &
  0.8\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.0866\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{P5}} &
  \multicolumn{1}{p{\dimexpr(.21950000000000003\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{When do you switch from I/V to oral AMAs?}} &
  Tachycardia {\textgreater}12 hours or febrile {\textgreater} 24 hours &
  74 &
  18.6\% &
  \multicolumn{1}{p{\dimexpr(.1127\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{{\textless}0.001}} &
  \multicolumn{1}{p{\dimexpr(.08370000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{{\textless}0.001}}\\
 &
   &
  Clinical improvement &
  269 &
  67.8\% &
   &
  \\
 &
   &
  No ongoing problems with absorption &
  15 &
  3.8\% &
   &
  \\
 &
   &
  Suitable oral AMA available &
  39 &
  9.8\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.0866\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{P6}} &
  Average duration of AMA treatment that  &
  3-5 days &
  110 &
  27.7\% &
  \multicolumn{1}{p{\dimexpr(.1127\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.605}} &
  \multicolumn{1}{p{\dimexpr(.08370000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.219}}\\
 &
  you prescribe for  &
  7-14 days &
  279 &
  70.3\% &
   &
  \\
 &
  community-acquired pneumonia is &
  24-28 days &
  6 &
  1.5\% &
   &
  \\
 &
   &
  more than 28 days &
  2 &
  0.5\% &
   &
  \\
\multicolumn{1}{p{\dimexpr(.0866\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{P7}} &
  Ideal duration of surgical prophylaxis  &
  1 hour before incision &
  259 &
  65.2\% &
  \multicolumn{1}{p{\dimexpr(.1127\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{.002}} &
  \multicolumn{1}{p{\dimexpr(.08370000000000001\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{{\textless}0.001}}\\
 &
  (pre, during, post-surgical) that you suggest- &
  {\textgreater} 24 hours after surgery for clean wounds &
  124 &
  31.2\% &
   &
  \\
 &
  \multicolumn{1}{p{\dimexpr(.21950000000000003\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{}} &
  At the time of ocular surgeries (intra-operational) &
  9 &
  2.3\% &
   &
  \\
 &
   &
  12 hours after traumatic wound &
  5 &
  1.3\% &
   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
 The self-administered and closed-ended questionnaire encompassed of informed consent, demographics information and questionnaire which included 7 items for knowledge, 10 for attitude and 8 for practices. For the item generation of questionnaire expert opinion and previous research carried out by Badar et al. was utilized\unskip~\citep{834996:19856212}. 


\bgroup
\fixFloatSize{images/f61bf0ea-1861-413b-9064-905086e54954-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/f61bf0ea-1861-413b-9064-905086e54954-upicture2.png}{\includegraphics{images/f61bf0ea-1861-413b-9064-905086e54954-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Insist on Combination therapy}}
\label{f-1ee250a985e6}
\end{figure}
\egroup
Items of knowledge focused on the difference between bacteriostatic and bactericidal AMAs, the difference between narrow and broad-spectrum AMAs etc. The attitude was assessed by topics such as precautions do you take to prevent AMA resistance?, Which criteria do you use for selection of AMAs,? How frequently you follow the suggestions given by the Hospital Infection Control Committee (HICC) or antimicrobial stewardship team? Practice evaluation items were like. Do you explain to the patient about the use and adverse drug reactions (ADRs) of AMAs? Do you advice simple, rapid lab tests before starting AMA therapy? Ideal duration of surgical prophylaxis (pre, during, post-surgical) that you suggest. All participants responses and answers are presented as Yes/no and multiple-choice questions (MCQs). 

The questionnaire was subjected to a pilot study to test for its validity on 20 participants before being distributed to actual participants. The ensuing amendments were done to the questions for the superior understanding of participants. The results and participants of the pilot study were not integrated into the actual survey. The final most version of the questionnaire had Cronbach's alpha and split-half reliability values of 0.83 and 0.79 for knowledge; 0.86 and 0.81 for attitude; and 0.78 and 0.82 for behaviour, respectively. 

\textbf{Statistical analysis}

All the responses obtained from the questionnaires were coded and entered into the statistical package for social sciences SPSS (IBM-SPSS version 25, Armonk, NY) and analysis was performed. A descriptive statistics of frequency distribution and percentages were calculated for the characteristics, knowledge, attitude and practices of the study participants. Further, the chi-square test and Fisher's exact test was performed to assess the relationship of knowledge, attitude and practices with gender and medical speciality of the study participants. A p-value below (p{\textless}0.05) was considered significant for all the statistical purposes.
    
\section{Results and Discussion}
The personal characteristics of the study participants are displayed in Tables~\ref{tw-29ac68e29985}, \ref{tw-cb0cc0fead77}, \ref{tw-e31a07aa2aa6} and~\ref{tw-9b33b86d351c}. A total of n=413 medical practitioners participated in this study. Most of the participants were male 280 (67.8\%), aged 31-40 years 163(39.4\%). Nearly half 204(49.4\%) of them having an experience of 0-10 years. Majority of the 180 (43.6\%) participants were from the central region and practising medicine speciality 190 (46\%).One of the chief factors in the suppression of AMR is by the decline of inconsistent antimicrobial employment and alteration of prescribing behaviour of the clinicians may perhaps bring about this to a considerable extent\unskip~\citep{834996:19856203}. Unless and until perceptions and attitudes of health care providers' regarding AM are understood, every learning intercession on AMR and AMS programs will be a failure\unskip~\citep{834996:19856213}. Thus the present study was conducted to explore the KAP regarding antibiotic stewardship program in physicians at Riyadh. 

Most of the participants in the present study were male and had an experience of up to 10 years. This was in accord with the findings of the Indian study\unskip~\citep{834996:19856212} as well as another Saudi study\unskip~\citep{834996:19856213}.

Our findings reveal that 44\% of participants were unaware of the term 'Antimicrobial stewardship'. These findings were better than survey on Indian physicians were 56\% of participants did not know the term \unskip~\citep{834996:19856212}. The nation-wide implementation of AMS program in Saudi Arabia might be the reason for this difference. However, these Figure~\ref{f-55402bf85049} are still not very pleasing and point out the dearth of implementation approaches and edification about stewardship program across the country. 

Our participants opted most preferred way of updating knowledge were internet and journal followed by CME's and workshop. At the same time, the most preferred way in India was chosen as CME's and workshop (10) and in China as standard textbook\unskip~\citep{834996:19856205}. The preferences might vary based on demographics as well as the socio-economic profile of the country, and it just an essential factor to be remembered while various policy formulation. 

Attitude analysis showed that 74.8\% physician used pharmacokinetic variability for the basis of choosing a proper dosing schedule. This was in contrast to the previous research were only 58\% physician used pharmacokinetic variability for dosing schedule\unskip~\citep{834996:19856212}. 53.9\% participant always and 13\% sometimes followed the suggestions given by Hospital Infection Control Committee (HICC) or antimicrobial stewardship team. Their results show disappointing Figure~\ref{f-1ee250a985e6} and necessitate urgent internal policy check with-in the hospitals. 

The poor practice of not explaining the patient about use and ADRs of AMAs was seen in 56.9\% of physicians. Elucidating patient regarding undesirable effects and inappropriate use of antimicrobials is an essential measure to avoid corollary of antimicrobial misuse. Maximum participants responded that they advise simple, rapid lab test before starting AMA therapy. These findings were coinciding with the results of the study conducted in the eastern province of Saudi Arabia \unskip~\citep{834996:19856213}. 

More education should be given to doctors during the UG teaching allied to AMA resistance and suitable prescribing. The 4 `R's Right diagnosis, Right dose, Right drug, Right duration determines the clinical effectiveness of antibiotics\unskip~\citep{834996:19856207}. 

Few limitations do exist in this research which must be considered while viewing the results. Firstly it was a cross-sectional study and thus presented with integral limitations of such study designs. These studies single-handedly cannot be used for policy formulation. The data collection tool was a questionnaire which again may or may not depict the actual KAP of the participants. It was conducted only in physicians of the Riyadh city thus limiting generalizability.
    
\section{Conclusions}
To curb the menace of quickly developing AMA resistance, understanding of its gravity and connotation is important. There should be monitored regular audits of the prescription and gathering of data from prescribers and mass users of antibiotics. Health professionals should be adequately trained regarding the usage of antimicrobials and their consequences. The judicious use of AMA should be promoted by incorporating in the curriculum about proper prescribing, supplying and usage of AMA. 

\textbf{Source of Funding }

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest }

The authors declare that they have no conflict of interest for this study.
    

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\end{document}
