BACKGROUND microorganisms develop the ability to resist the

BACKGROUND OF THE STUDYAntimicrobial resistance (AMR) occurs when microorganisms develop the ability to resist the effects of antimicrobials, such as drugs, chemicals, or other agents they are exposed to. It is a natural process, being rapidly increased by the overuse of antimicrobials. Thus, reducing the misuse of antimicrobials can reverse this phenomenon. AMR causes about 700, 000 deaths per year worldwide. Up to 9.5 million people may die yearly if the current resistance rates increase by 40%. 1Different factors contribute to the growing trend of antimicrobial resistance. The first and major factor is the inappropriate use of antibiotics. Based from a study 2, one of the mostly prescribed drugs in the field of medicine is antibiotics. However, resistance increases due to high volume and inappropriate use of antibiotics. Another factor is that antibiotic usage in human and animals causes development of resistance in microbes that contaminate food. Lastly, transmission of the resistant strains of bacteria from person to person, or from the non-human sources in the environment, leads to the rise in AMR.Antimicrobial resistance is becoming a global concern because of the serious problems that it can bring to the public. AMR hinders treatment of common infectious diseases, leading to prolonged disease, which may also result to death. In addition to that, it increases the cost of healthcare due to longer admission in hospitals and more intensive care is needed by patients. Furthermore, medical procedures become risky for patients without effective antimicrobial agents. 3To monitor drug resistance, different efforts are being done such as the generation of an antibiogram. As noted from a study 4, antibiograms are tables that demonstrate the susceptibility level of a series of organisms to different antimicrobial agents as tested inroutine clinical microbiology practice. It is important to construct an antibiogram annually as it can be a source of information on which antimicrobial drugs are more or less effective for different microbes, allowing proper prescription of drugs. Over the years, collection of antibiogram can also be used to track changes in resistance patterns of microorganisms.RESEARCH QUESTIONWhat is the knowledge, perception and utilization of University of Perpetual Help DALTA Medical Center consultants on the antibiogram in a cross-sectional survey?STATEMENT OF THE PROBLEMNowadays, the rise of antimicrobial resistance is becoming alarming because of the threats that it can bring to public health. To slow down the emergence and spread of antimicrobial resistance, drug resistance must be monitored; hence antibiogram usage was proposed. Different studies have then associated the emerging antibiotic resistance to antibiogram availability. With the aforementioned statements, a cross-sectional survey will be conducted mainly to determine the knowledge, perception and utilization of University of Perpetual Help DALTA Medical Center consultants on the antibiogram. Ideally, the consultants must be updated with current microbial resistance patterns in University of Perpetual Help DALTA Medical Center in order for antibiotic prescription to be effective.OBJECTIVESThe objective of the study is to determine the knowledge, perception and utilization of the antibiogram by the consultants of the University of Perpetual Help DALTA Medical Center in Las Piñas City.SIGNIFICANCE OF THE STUDYThe findings in the study will be beneficial to the consultants of the University of Perpetual Help DALTA Medical Center, for them to know and utilize the antibiogram for an updated list of current resistant microorganisms and its antibiotic of choice for patient management.The study will also be of great help to the Infection Prevention and Control Unit of the hospital, to evaluate whether the antibiogram is known and utilized by the consultants in prescribing antibiotics to patients with infection from a resistant microorganism and determine the efficiency of the antibiogram implementation in the hospital.Moreover, the study may serve as a reference for future researchers if they want to further investigate on the antibiogram. The findings of the study may also stimulate research efforts in raising the awareness on the antibiogram to be able to monitor antimicrobial resistance.SCOPE AND LIMITATIONS OF THE STUDYThe knowledge, perception and utilization of antibiogram among consultants from all departments of University of Perpetual Help DALTA Medical Center will be determined. Only the consultants affiliated with the hospital and who are conducting clinics at the Medical Arts Building will be considered in the study. In addition to that, consultants from the Department of Radiology, Department of Pathology, Department of Nutrition and Dietetics, Department of Sports Medicine, Department of Medico-Legal Medicine and Department of Rehabilitation Medicine will not be included as they do not prescribe antibiotics. The outcome of proper antibiogram implementation in the hospital to the consultant’s knowledge, perception and utilization of the antibiogram is not of particular interest in the study.ASSUMPTIONS OF THE STUDYIn conducting the study, the following assumptions are made. It is assumed that:1. The consultants of the University of Perpetual Help DALTA Medical Center are aware of the antibiogram provided by the hospital and know its importance, as well as its contents.2. The consultants of the University of Perpetual Help DALTA Medical Center have a positive perception of the importance and relevance of the antibiogram in their practice.3. The antibiogram is available and accessible to the consultants of the University of Perpetual Help DALTA Medical Center and is being utilized by them when prescribing antibiotics and for other medical activities.DEFINITION OF KEY TERMS AND CONCEPTS The following terms are defined for a better understanding of the research study.Antibiogram ? A collection of data usually in the form of a table summarizing the percent of individual bacterial pathogensKnowledge ? Acts, information, and skills acquired by a person through experience or education; the theoretical or practical understanding of a subject.Perception ? A way of regarding, understanding, or interpreting something; a mental impression.Utilization ? The state of being useful, profitable, or beneficial.REVIEW OF RELATED LITERATUREAntimicrobial resistanceAntimicrobial resistant or drug resistant is the term used when microorganisms are no longer prevented by antimicrobials to which they are previously sensitized. It is encoded by resistance genes in the DNA of the microbe that can be mutated spontaneously or by evolution due to usage of antimicrobials. 5The discovery and use of antimicrobial agents to treat certain infections greatly increased the survivability and improved quality of life of the affected communities. However, with the breakthrough in treating infectious diseases, the development of antimicrobial resistance (AMR) follows. The occurrence of resistance infectious microorganisms against antimicrobial agents needs to be monitored with the use of laboratory-based surveillance. 6 Hence, the implementation of antibiogram was established.Over the years, AMR increases rapidly due to incorrect use of antimicrobials. Some factors that contributed are patient failure to complete their course of antimicrobial therapy, heavy use of antimicrobials in hospitals and over-the-counter access to antimicrobials such as that of found in small pharmacies. In consequence to this increasing phenomenon, infections caused by antimicrobial resistant microbes often fail to respond to standard drug therapy leading to prolonged infectivity and hospitalization. They also compromise the success of cancer chemotherapy, major surgery and organ transplantation.In lieu with this, the World Health Organization (WHO) came up with ways on how to combat antimicrobial resistance which is becoming a global scare due to international travel and trade. The organization recommended a six-point policy package for governments, namely, lack of research, no commitment, weak surveillance, poor drug quality, irrational drug use and no infection control. 7In a study conducted in 2015 8, nearly 93% of the research participants strongly agreed/agreed that AMR is a global concern and 75% believed that it is a problem in their institute. About 85% of the respondents answered that inappropriate use of antibiotics was a main contributor to AMR while 81% rated that poor infection control measures & poor isolation precautions were important causes of resistance. Findings of another survey also showed that educational intervention is of importance in controlling antimicrobial resistance.AMR, if left unrecognized, may cause infections and diseases untreatable. To reduce this phenomenon, there should be a strict and efficient surveillance system within institutions that combats the occurrence of AMR’s. In order to do this, the WHO Regional Office in South-East Asia developed a plan which includes regulations regarding antimicrobial drugs utility in all healthcare institutes, by establishing Antimicrobial Resistance Surveillance Program. This was implemented in the member states and in the Philippines, the laboratory-based surveillance was focused mostly on aerobic bacteria that exhibit unusual susceptibility patterns and these are studied to find out its mechanisms of resistance. The surveillance data for AMR is made with the use of the WHONET software, and surveillance reports are produced every year. 9 Routineantimicrobial surveillance is imperative to be able to obtain accurate data and be able to serve its purpose of assisting in prescribing the proper antimicrobial treatment. 10Antimicrobial stewardship (AMS) is a strategy used by different healthcare institutions to optimize antimicrobial usage. In line with national policies, hospitals employ this program to decrease inappropriate antibiotic utility, improve results of antibiotic prescription to patients, lessen healthcare costs and counter the fast rising levels of antimicrobial resistance. This approach is deemed necessary to be certain that available antibiotic agents are still effective. 11, 12 In the Philippines, the first AMS program was implemented in 2016 by the Department of Health in partnership with the WHO to reduce AMR and AMR-related death cases. 13As antibiotic resistance is a result of inappropriate antibiotic use, the local measures of antimicrobial drug utilization is associated with local measures of antimicrobial resistance. In accordance to this, the antibiogram can be used to measure resistance rates. 14Antibiogram An antibiogram is a tabular summary of susceptibility and resistance patterns of microorganisms to certain antimicrobial agents. It serves as a guide to physicians in choosing the appropriate antibiotic for treating infections. Each antibiogram differs per institution and is used for specific units, such as Intensive Care Units (ICU), High Risk Nurseries, and Burn Units, in the hospital as well as specific specimens, including blood, urine and stool, for identification of susceptibility to commonly used antimicrobials. 15 With that, the antibiogram can aid in comparing susceptibility rates and detect changes inresistance trends from one institute to another. 16 It may also assist in choosing the most effective therapy after a microbial organism has undergone identification but not susceptibility tests or as an alternative to information on Culture and Sensitivity (C&S) while results are unavailable or if no organism grows although an infection is highly suspected. 15, 17 Reports from C&S tests done in laboratories are used to prepare antibiograms. These provide the percentage of samples for an organism which is sensitive to specific antibiotic agents. However, information from the antibiogram does not include sensitivity of an organism to an antibiotic based on site of infection and location in hospital (ICU vs non-ICU), average minimum inhibitory concentration, antibiotic killing at different dosages and trend data. 17 Instead of the standard antibiogram, a combination antibiogram is used for severe infections caused by a specific microorganism. Combination antibiograms can guide physicians in choosing the combination antimicrobial therapy that will give the best results. This type of antibiogram is shown in a form of a matrix which contains percentage of microorganisms susceptible to individual antibiotics and combinations of agents. The benefit of using a combination antibiogram over the standard antibiogram is that cross-resistance between certain antibiotic agents can be determined. Through this, physicians will be able to evaluate the advantages and disadvantages of using a two-drug antibiotic treatment. 18 As mentioned, antibiograms are used for selecting the most beneficial antibiotic agent and tracking resistance trends. For the antibiogram to be able to serve its functions, it must be prepared using standardized procedures to be able to facilitate comparisonwithin and between hospitals. 19 Results of a study in the United States which analyzed degree of compliance of antibiogram to a guideline set by National Committee for Clinical Laboratory Standards (NCCLS) found out that there were inconsistent susceptibility reports. To resolve this issue, it was proposed that infectious disease specialists, clinical microbiologists and infection control personnel should be involved in reviewing the antibiograms before their dissemination. 20 NCCLS, now called Clinical and Laboratory Standards Institute (CLSI), has provided guidelines, composed of correct presentation of susceptibility reports, proper dissemination of the antibiogram to doctors and other healthcare providers, and organized presentation of information in a manner that enables comparison across institutions, for the construction of the antibiogram. 21 A study with the use of an online survey also made an analysis of whether antibiograms generated by University HealthSystem Consortium hospitals followed the recommended standards published by the CLSI. Among those that were surveyed, 49 hospitals responded. Of those that made a response, 36 hospitals stated that they complied with all or most of the guidelines set by CLSI. New strategies were employed by 19 hospitals while changes in hospital formulary were made by 16 hospitals as a result of the information from the antibiogram to decrease resistance rates. Results of the study also showed that pharmacists aided in antibiogram review in 30 hospitals. 22Availability, Perception and Utilization of the Antibiogram Different studies have linked the problem of antibiotic resistance to the availability of antibiogram. In a cross-sectional survey conducted in Khartoum state teaching hospitals, 47.4% of the physicians identified inaccessibility of local antibiogramas one of the major causes of antibiotic resistance. In a list consisting of 7 interventions made by the researchers, 35.2% answered accessibility to an updated antibiogram as the intervention that will be of great use in solving the problem regarding AMR. 23 Another study also made use of a cross sectional self-administered questionnaire and among the clinicians, including specialists from medical and surgical branches and junior doctors surveyed, 96% indicated lack of access to local antibiogram as a factor that contributes to antibiotic resistance. The study also highlighted the unavailability of the local antibiogram as only 46% of the clinicians had access and used local antibiogram in antibiotic prescription. 24 Aside from conducting a study regarding the generation of antibiogram and its compliance to the recommendations provided by CLSI, the study on University HealthSystem Consortium (UHC) hospitals also contains data on availability of the antibiogram. Among the 49 responding hospitals that responded, 48 of them stated that they routinely constructed antibiograms while only 1 hospital do not. Results showed that 26% made the antibiograms available through the intranet, 4% distributed printed copies, and 62% provided antibiograms through both the intranet and hard copies. 22 A different study also investigated the availability of the antibiogram among Illinois pediatricians through an electronic survey. It was found out that 58% of the respondents reported that the antibiogram was accessible. Among those with access to antibiogram, 78% said that an electronic antibiogram could be accessed. Ninety-nine (99%) percent of them had their antibiogram provided by a hospital while the remaining 1% percent had their antibiogram provided by a nonhospital institution. In addition, thestudy among Illinois pediatricians determined the perception of the respondents on the antibiogram. Among those with access to antibiogram, 87% and 83% answered that it is of great help in understanding antibiotic resistance trends and giving antibiotic prescription, respectively. On the other hand, among those who said that the antibiogram was inaccessible, 88% and 83% agreed that an antibiogram would possibly assist in understanding antibiotic resistance trends and giving antibiotic prescription, respectively. Another finding of the study is that 91% of respondents used smartphones/tablets. With that, the reseachers mentioned that an antibiogram which is electronically accessible could improve the clinician’s antibiogram utility. 25 A study conducted in Dallas County, Texas also evaluated the perception in terms of usefulness of community antibiogram among doctors and infection preventionists in different institutes with the use of a questionnaire. Results of the study indicated that 100% of the participants agreed that the antibiogram is helpful in monitoring antimicrobial resistance trends on a community level. 26 Meanwhile, in a cross-sectional study, the utility of antibiogram was assessed through a state-wide survey among healthcare providers at acute care hospitals in Michigan. Findings of the study showed that 97% of the personnels answered that antibiogram is present in their hospital. The researchers concluded that the prevalence of antibiogram use was high. Despite the high prevalence, it was noted that there were gaps in use of the antibiogram in some geographically remote areas, thus the need for programs to improve utility of the antibiogram on these regions. Part of the study also included the perception of the research participants on the antibiogram in which it was found out that administrative personnel less likely believed that the antibiogram is helpfulin development of hospital formulary. Another finding is that teaching hospitals morelikely utilize an electronic copy than a printed copy of the antibiogram while communityhospitals more likely utilize a printed copy than an electronic copy of the antibiogram. 27