Carbapenem and piperacillin-tazobactam prescribing in a hospital setting in Kingdom of Saudi Arabia : a mixed methodology study

  • Nada Abdullah M Alsaleh

Student thesis: Doctoral Thesis


Background: Antimicrobial resistance (AMR) is spreading rapidly and is considered tobe one of the greatest public threats worldwide. The inappropriate use of broadspectrum antimicrobials has contributed to the emergence of AMR. The WHO hasdeveloped Access, Watch, Reserve (AWaRe) classification to support hospitals andcountries in promoting the appropriate utilisation of antimicrobials. Studying broadspectrum antimicrobial utilisation and the determinants of broad-spectrumantimicrobial prescribing can assist in developing strategies and policies to improvethe local prescribing practice for these agents.Aim: To evaluate the practices of broad-spectrum antimicrobial prescribing toprovide potentially effective and feasible recommendations and interventions thatwill result in improvements in broad-spectrum antimicrobial prescribing practices ina hospital setting in the Kingdom of Saudi Arabia (KSA).Methods: An explanatory sequential mixed methods approach was adopted. First, aquantitative, observational, retrospective, cross-sectional, drug utilisation study,which included adult patient data on carbapenems (imipenem/cilastatin ormeropenem) and piperacillin/tazobactam use retrieved from a hospital database forthe period from 1 January 2016 to 31 December 2017, was conducted followed by aqualitative study of physicians' views and perceptions of broad-spectrumantimicrobial prescribing. The qualitative study employed semi-structured interviewswith 16 physicians to identify and explore the determinants of broad-spectrumantimicrobial prescribing practices, recommendations to improve practice andpossible barriers. This study was carried out in a single tertiary care institution in theKSA.Results: A total of 2,871 patients received 5,250 courses of antimicrobial treatmentwith at least one of the studied broad-spectrum antimicrobials across 3,671 patientadmissions over a two-year period. It was shown that 4,106 (82%) of broadspectrum antimicrobials were prescribed for empiric indications. Of the assessedprescriptions, only 2,787 (56.5%) were prescribed appropriately, with 2,142 (43.5%)deemed inappropriate. The three most common reasons for inappropriate empiricperceptions were: spectrum of activity was too broad 1029 (40%), antimicrobial usedwithout a culture request 929 (36.2%), and failure of suitable antimicrobial deescalation 570 (22.2%). Interview findings identified key determinants of broadspectrum antimicrobial prescribing practices, including patient co-morbidities andclinical presentations, the unavailability of local guidelines, physicians’ perceptionsand attitudes toward broad-spectrum antimicrobials prescribing and severalinstitutional constraints. Suggestions prioritised by physicians for improvements tothe practice of prescribing broad-spectrum antimicrobials included education andtraining, monitoring and feedback, improved logistics of care and antimicrobialstewardship.Conclusion: This research adds to our knowledge on broad-spectrum antimicrobialprescribing practices and recommended intervention and strategies for improvingthe appropriateness of broad-spectrum antimicrobials prescribing in a hospitalsetting in the KSA. Implementing a multifaceted intervention can possibly improveantimicrobials prescribing practices. Educating physicians about the importance ofantimicrobial stewardship practices could be considered. Moreover, introducingantimicrobial prescribing guidelines should be significant part of the intervention toimprove the appropriate prescribing of broad-spectrum antimicrobials. Botheducation and guidelines should consider the factors that influence physiciansprescribing and involve physicians to impact effectively and positively on theirinappropriate prescribing practices and reduce the risk of AMR.
Date of Award20 Dec 2021
Original languageEnglish
Awarding Institution
  • University Of Strathclyde
SupervisorAlexander Mullen (Supervisor) & Marion Bennie (Supervisor)

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