Abstract
Background
Antimicrobial resistance (AMR) is a critical global health issue, with inconsistent adherence to antimicrobial stewardship contributing to its worsening. This study aims to assess physicians’ awareness and attitudes towards AMR and appropriate antimicrobial use across different medical specialties in Japan.
Methods
An online cross-sectional survey was conducted from January 31 to February 5, 2024, among 280 physicians from three specialties (internal medicine, pediatrics, and otorhinolaryngology) who were working in outpatient clinics in Japan. Participants were asked about their familiarity with the National Action Plan (NAP) on AMR and the manuals of Ministry of Health and Labor Welfare (MHLW) on prudent antimicrobial use. Their opinions on AMR facts and antibiotic use were also surveyed using five-point Likert scales. Data were analyzed using descriptive statistics, multilevel mixed-effects ordered logistic regression and generalized linear models to examine factors influencing NAP/manuals adherence.
Results
Most respondents were male (85%) and predominantly aged 50 and above (73.9%), Familiarity with the AMR Action Plan varied, with 36.4% of respondents reported understanding its content, while 37.5% only knew its name. Similarly, 27.1% of respondents used the MHLW manuals, whereas 48.6% were aware of them but did not use them. Internal medicine physicians showed the highest adherence to antimicrobial stewardship and most concern about AMR facts, while pediatricians demonstrated the highest adherence to MHLW manuals (AOR = 2.4, p = 0.000 compared to internal medicine doctors). Otorhinolaryngologists reported higher awareness of NAP (AOR = 2.6, p = 0.006 compared to internal medicine doctors) but had the lowest adherence to NAP and MHLW manuals. Younger physicians (< 50 years) were more proactive in addressing AMR and adhering to antimicrobial stewardship than older physicians. Messages emphasizing the prevention of drug resistance and societal impacts of AMR were most associated with positive attitudes from physicians in outpatient clinics.
Conclusions
This study highlights significant variability in AMR awareness and adherence across specialties and age groups. Internal medicine physicians showed the highest adherence, while pediatricians were the most familiar with AMR manuals. Otorhinolaryngologists demonstrated strong awareness but lower adherence. Targeted educational interventions, particularly focusing on older physicians and specific specialties, are needed to improve antimicrobial use and combat the growing threat of resistance.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12879-025-11583-1.
Keywords: Antimicrobial resistance (AMR), Antimicrobial stewardship, Health education, Infectious disease control, Physician awareness
Background
Antimicrobial resistance (AMR) represents a critical global health challenge that could make continuing modern healthcare difficult [1]. The World Health Organization (WHO) has identified AMR as one of the top global public health threats, calling for urgent, coordinated action to mitigate its impact [2]. Antimicrobial stewardship programs (ASPs) are one of the most effective strategies to combat AMR by promoting the appropriate use of antibiotics, reducing the spread of resistant infections, and improving patient outcomes [3].
Some successful interventions in ASPs were introduced including the dissemination of up-to-date prescribing guidelines [4], antimicrobial restriction policies, prospective audits with feedback [5, 6], and the use of technological tools such as electronic prescription systems and rapid diagnostic tests [7–9]. Additionally, multidisciplinary teams, including behavioral experts, are integral to addressing the human factors influencing prescribing behaviors [10, 11]. By fostering a culture of accountability, ASPs have demonstrated their potential to enhance adherence to standard treatment and improve prescribing practices [4, 12]. While these strategies have demonstrated success, the generalizability and sustainability of these interventions require ongoing evaluation and adaptation to ensure long-term impact [8].
During the interventions of the ASPs, significant gaps persist in awareness and adherence to antibiotic stewardship among healthcare providers worldwide [4, 12]. Variations in antibiotic prescribing practices across medical specialties further exacerbate these challenges. For instance, pediatricians and internal medicine physicians have been shown to prescribe antibiotics less frequently for respiratory tract infections than general practitioners or emergency department physicians [12, 13]. These differences reflect varying levels of training, practice environments, perceptions of patient demand, and awareness of guidelines [12, 14, 15]. Bridging these gaps is essential for fostering a unified approach to stewardship [4].
In Japan, inappropriate antibiotic use in outpatient care remains a significant concern, driven by unnecessary prescriptions, suboptimal drug choices, and inadequate treatment durations [16]. Ministry of Health Labour and Welfare (MHLW) published the National Action Plan on AMR in 2016 and 2023, along with Manuals of Antimicrobial Stewardship in 2017, 2019 and 2023, to reduce antimicrobial use through targeted educational interventions and dissemination of stewardship resources [17–20]. However, physicians continued to prescribe antibiotics inappropriately, with usage trends varying by medical specialty [13, 21, 22].
Tailored educational programs that address specific specialties and age groups, combined with behavioral insights like “nudge” techniques, offer promising solutions [23]. Based on the theory developed by Thaler and Sunstein, nudging subtly guides individuals toward better choices without limiting their freedom [24]. By leveraging cognitive biases and heuristics, nudges such as default options, reminders, or framing information to emphasize benefits can influence behavior [25, 26]. For example, awareness messages highlighting the importance of appropriate antimicrobial use have shown potential for modifying prescribing habits [27, 28]. However, it remains unknown about the effectiveness of such messages in improving the clinicians’ prescribing behavior in Japan, and their variation across medical specialty.
Given these disparities, our study aimed to assess the awareness and attitudes towards AMR and antimicrobial stewardship across different medical specialties. Specifically, we examined the association between demographic factors and physicians’ attitudes toward AMR and their likelihood to prescribe antibiotics. Additionally, we also tried to identify key messages that could effectively change prescription behaviors. By addressing these objectives, we hope to contribute to the development of more effective strategies for promoting antibiotic stewardship and mitigating the global impact of AMR.
Methods
Study setting and participants
This cross-sectional online study was conducted from January 31, 2024, to February 5, 2024, across Japan via the Nikkei Medical Online Panel platform administered by Nikkei Research Co., Ltd [29]. As of December 2024, the panel comprised more than 510,000 healthcare professionals in eight regions of Japan, including 186,171 working physicians from various specialties and departments [29]. Several studies were conducted using this platform [30, 31]. In this survey, we targeted physicians specializing in internal medicine, pediatrics, or otorhinolaryngology working in outpatient clinics. Eligible participating doctors were those who worked in outpatient clinics and reported seeing 10 or more patients with acute respiratory tract infections (ARTIs) in the last three months. These doctors were verified through a pre-screening questionnaire distributed via the panel’s secure online platform. A sample of 280 doctors was targeted in this study, including 100 internal medicine doctors, 100 pediatricians, and 80 otorhinolaryngologists, with regional distribution proportional to Japan’s physician workforce. The survey was completed once these targets were met.
Data collection
The self-administered, web-based survey was designed to capture detailed information on the respondents’ awareness, attitudes, and practices related to AMR and antimicrobial stewardship. It included questions on demographic characteristics, familiarity with the National Action Plan (NAP) on AMR [17], the MHLW manuals on antimicrobial use [18–20] and facts about AMR and appropriate antimicrobial use. The survey also assessed self-perceived understanding of AMR and the application of antimicrobial stewardship in clinical practice. The list of questions was described in Supplementary Table 1.
The questionnaire was structured into three main sections. The first one, Demographics session (S01-S02, F02-F04), gathered information on respondents’ medical specialty (Internal medicine/Pediatrics/Otorhinolaryngology/Other), workplace type (Clinics/Others), gender (Male/Female), age group (≤ 49/50–59/≥60), and the location of their primary medical institution (by eight regions of Japan). The second one, Knowledge and Familiarity session (Q01-Q02), evaluated respondents’ awareness of Japan’s NAP for AMR (Can explain/Understand/Only know the name/Don’t know) and the MHLW’s manuals for appropriate antimicrobial use (Use manuals/Know but no use manuals/Don’t know manuals). The third one, Attitudes and Intentions session (Q03-Q04), explored participants’ intentions to review their antibiotic use and perceptions of the importance of AMR measures with 11 statements in each group.
In the Attitudes and Intentions section, responses were captured using five-point Likert scales and categorical variables to provide detailed insights into participants’ knowledge and practices. For the Q03 statements, responses ranged from 1 (no intention to review antibiotic use) to 5 (strong intention to review antibiotic use). For the Q04 statements, participants rated their perceived importance of AMR measures, with responses ranging from 1 (do not feel AMR measures are important at all – or totally no perceived importance) to 5 (strongly feel AMR measures are important – or strongly perceived importance). The internal consistency of these scales was evaluated using Cronbach’s alpha, with values of 0.96 for both the Q03 and Q04 groups.
Data analysis
Descriptive statistics included frequencies for categorical variables and means with 95% confidence intervals for ordinal variables. The results of calculations for each component in the questionnaires can be seen at Supplementary Tables 2, 3, 4 and 5. Multilevel mixed-effects ordered logistic regression (“meologit”) models were employed to identify factors associated with the awareness of AMR and appropriate antimicrobial use. These models were adjusted for age, gender, specialty (fixed effects), and region (random effects). Physicians aged ≤ 49 years and those specialized in internal medicine served as the reference categories. Pearson pairwise correlation coefficients were calculated for Q03 statements on the AMR facts (11 items) and Q04 statements on the antimicrobial use attitudes (11 items), the results can be retrieved in Supplementary Tables 2 and 3.
A multilevel Poisson regression model using mix-effects generalized linear (“meglm”) modeling was applied to examine the association between awareness/attitudes of AMR and the use MHLW manuals, accounting for hierarchical data structure. Region was included as a random intercept, while fixed effects comprised survey responses, age group, gender, and specialty. A Poisson distribution was specified to model count data, and robust standard errors were applied to account for potential heteroskedasticity. The answers of “Do not agree & Neutral” and “Totally no perceived importance & Moderately” were treated as Reference groups in the analysis of Groups 03 and 04 statements, respectively. Results were reported as Incidence Rate Ratios (IRRs) with 95% confidence intervals. Data analysis was performed using Stata version 18 with the “meologit” and “meglm” packages [32].
Ethical considerations
The study protocol was reviewed and approved by the Research Ethics Committee of the Institute of Science Tokyo (C2023-047). All participants provided informed consent before participating in the survey. The data were anonymized to ensure confidentiality and privacy of the respondents. The study adhered to ethical standards for research involving human subjects, ensuring that the participants’ rights and well-being were protected throughout the research process.
Results
Characteristics of survey respondents
Table 1 describes the characteristics and attitudes of physicians towards antimicrobial resistance (AMR) and the MHLW manuals. Most respondents were male (85%) and predominantly aged 50 and above (73.9%), with the highest representation from the Kanto region (31.1%). Familiarity with the AMR Action Plan varied: 36.4% of respondents reported understanding its contents, while 37.5% were only familiar with its name. Similarly, 27.1% of respondents used the MHLW manuals, whereas 48.6% were aware of them but did not use them.
Table 1.
Characteristics of survey respondents
| Total (n = 280) |
Internal Medicine (n = 100) | Pediatrics (n = 100) | Otorhinolaryngology (n = 80) | |||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| Gender | ||||||||
| Male | 238 | 85.0 | 87 | 87.0 | 84 | 84.0 | 67 | 83.8 |
| Age group | ||||||||
| <=49 | 73 | 26.1 | 25 | 25.0 | 29 | 29.0 | 19 | 23.8 |
| 50–59 | 83 | 29.6 | 35 | 35.0 | 26 | 26.0 | 22 | 27.5 |
| ≥ 60 | 124 | 44.3 | 40 | 40.0 | 45 | 45.0 | 39 | 48.8 |
| Region | ||||||||
| Hokkaido | 14 | 5.0 | 6 | 6.0 | 2 | 2.0 | 6 | 7.5 |
| Tohoku | 14 | 5.0 | 5 | 5.0 | 6 | 6.0 | 3 | 3.8 |
| Kanto | 87 | 31.1 | 30 | 30.0 | 34 | 34.0 | 23 | 28.8 |
| Chubu | 49 | 17.5 | 19 | 19.0 | 18 | 18.0 | 12 | 15.0 |
| Kansai | 58 | 20.7 | 20 | 20.0 | 17 | 17.0 | 21 | 26.3 |
| Chugoku | 19 | 6.8 | 8 | 8.0 | 8 | 8.0 | 3 | 3.8 |
| Shikoku | 13 | 4.6 | 3 | 3.0 | 6 | 6.0 | 4 | 5.0 |
| Kyushu & Okinawa | 26 | 9.3 | 9 | 9.0 | 9 | 9.0 | 8 | 10.0 |
| Familiarity to AMR Action Plan | ||||||||
| Can explain | 30 | 10.7 | 9 | 9.0 | 13 | 13.0 | 8 | 10.0 |
| Understand | 102 | 36.4 | 29 | 29.0 | 33 | 33.0 | 40 | 50.0 |
| Only know the name | 105 | 37.5 | 45 | 45.0 | 38 | 38.0 | 22 | 27.5 |
| Don’t know | 43 | 15.4 | 17 | 17.0 | 16 | 16.0 | 10 | 12.5 |
| Familiarity to MHLW Manuals of Antimicrobial Stewardship | ||||||||
| Use manuals | 76 | 27.1 | 18 | 18.0 | 35 | 35.0 | 23 | 28.8 |
| Know but no use manuals | 136 | 48.6 | 54 | 54.0 | 44 | 44.0 | 38 | 47.5 |
| Don’t know manuals | 68 | 24.3 | 28 | 28.0 | 21 | 21.0 | 19 | 23.8 |
Specialty-based differences in awareness and attitudes toward AMR
Figure 1 illustrates the agreement rates with AMR facts across specialties. Internal medicine physicians demonstrated the highest agreement with most statements, particularly emphasizing the consequences of AMR like future drug resistance (Q03_03, Q03_04), drug-resistant bacterial infections (Q03_05), side effects of unnecessary antibiotic prescriptions such as allergies and enteritis (Q03_10), improve treatment outcomes (Q03_06), and reduce antibiotic prescriptions without compromising satisfaction by providing appropriate patient explanations (Q03_08).
Fig. 1.
Mean and 95% CI of the responses by specialty for physicians’ intentions to review their antibiotic use. CI: Confidence Interval Q03_01: WHO recommends prioritizing the use of basic Access group (note) antibiotics, and promotes the appropriate use of antibiotics. (Note: These are antibiotics that are used as the first or second choice for common infections and have little risk of developing resistance) Q03_02: The Japanese government aims to reduce antibiotic usage by 15% by 2027 (compared to 2020 levels) by promoting the appropriate use of antibiotics Q03_03: Infectious disease experts stress the importance of appropriate use of antibiotics to prevent drug resistance Q03_04: You can prevent future drug resistance by prescribing antibiotics appropriately in your daily practice Q03_05: Appropriate use of antibiotics reduces the chances that not only the patient but also those around them will develop drug-resistant bacterial infections Q03_06: Appropriate use of antibiotics reduces side effects and complications and improves treatment outcomes Q03_07: Many doctors are reviewing how they use antibiotics in outpatient care, and the amount of antibiotics used has decreased Q03_08: By providing appropriate explanations to patients, antibiotic prescriptions can be reduced without reducing patient satisfaction Q03_09: Patients who visit the doctor with symptoms such as fever or cough just want to get better quickly, and do not necessarily want to be prescribed antibiotics Q03_10: Prescribing antibiotics in situations where they are not medically necessary can cause unexpected side effects such as allergies and enteritis Q03_11: For the treatment of acute pharyngitis, it is recommended that antibiotics be administered only when it is caused by group A streptococcus
Figure 2 displays the perceived importance of different attitudes of AMR, and internal medicine physicians still obtained the highest rates on most statements, particularly about impact of AMRs on antibiotic effectiveness with other treatments (Q04_10), the number of deaths associated with AMR (Q04_05), and the recommendation of WHO on using basic Access group antibiotics and appropriate antibiotic use (Q04_01). Meanwhile, pediatricians showed the strongest perceived importance on four issues, including the number of deaths due to AMR in Japan (Q04_06), peer review of other doctors in daily medical practices (Q04_07), the spread of AMR to healthy people (Q04_09), and taking action against AMR to reduce impact of infectious diseases (Q04_08). Conversely, otorhinolaryngologists exhibited the lowest rates of concerns on AMR fact as well as the perceived importance of AMR issues in both figures. More details of the difference of responses by specialty can be seen in Supplementary Figs. 1 and 2.
Fig. 2.
Mean and 95% CI of the responses by specialty for physicians’ perceptions of the importance of AMR measures. CI: Confidence Interval Q04_01: The WHO has positioned antimicrobial resistance (AMR) countermeasures as a major public health issue and is calling on countries around the world to take action Q04_02: The Japanese government has formulated an action plan to combat antimicrobial resistance (AMR) and is working on various measures Q04_03: Infectious disease experts are calling for the immediate implementation of measures against antimicrobial resistance (AMR) Q04_04: It is important that you take the first step in combating antimicrobial resistance (AMR). There are things that every doctor can do Q04_05: It is estimated that by 2050, antimicrobial resistance (AMR) could cause 10 million deaths per year worldwide Q04_06: In Japan, the number of deaths directly related to antimicrobial resistance (AMR) is estimated to be approximately 23,000 per year (2019) Q04_07: Many doctors responded that they are conscious of antimicrobial resistance (AMR) measures in their daily medical practice Q04_08: By taking action against antimicrobial resistance (AMR), we can reduce the impact of infectious diseases in the future Q04_09: Antimicrobial resistance (AMR) is not just a problem in hospitals: it is already spreading to healthy people and the environment Q04_10: If antimicrobial resistance (AMR) continues to spread, antibiotics will lose their effectiveness, and surgery and anticancer drug treatments may become more difficult Q04_11: In some regions, medical associations are taking the lead in taking measures against antimicrobial resistance (AMR)
Table 2 shows the significance of physician specialty’s influences on familiarity of NAP of AMR and MHLW’s manuals of antimicrobial use. Otorhinolaryngologists reported higher odds of understanding the NAP of AMR (AOR = 2.6, p = 0.006) compared to internal medicine specialists. Pediatricians were the most using MHLW manuals among all specialties (AOR = 2.4, p = 0.000).
Table 2.
Association between the personal factors with the physicians’ familiarities with National action plan of AMR and the manuals of antimicrobial stewardship from MHLW
| Familiarity of National Action Plan of AMR Reported understanding NAP vs. Not understanding NAP (n = 280) |
Familiarity of MHLW manuals Use manuals vs. Don’t use manuals (n = 280) |
|||
|---|---|---|---|---|
| AOR. | p | AOR | p | |
| Physician specialty | ||||
| Internal Medicine | 1 [Ref.]. | 1 [Ref.] | ||
| Pediatrics | 1.422 | (0.308) | 2.406* | (0.000) |
| Otorhinolaryngology | 2.603** | (0.006) | 1.857 | (0.133) |
| Age group | ||||
| <=49 | 1 [Ref.]. | 1 [Ref.] | ||
| 50–59 | 0.800 | (0.480) | 0.404 | (0.060) |
| ≥ 60 | 0.735 | (0.257) | 0.559 | (0.065) |
| Male | ||||
| No | 1 [Ref.]. | 1 [Ref.] | ||
| Yes | 1.753 | (0.257) | 1.374 | (0.482) |
The multilevel mixed-effects ordered logistic regression model was applied with adjustment of the regional difference;
AOR: Adjusted Odd Ratios; Ref.: Reference;
AMR: Antimicrobial Resistance
NAP: National Action Plan on Antimicrobial Resistance
MHLW: Ministry of Health, Labour and Welfare
p-values in parentheses
* p < 0.05, ** p < 0.01, *** p < 0.001
Tables 3 and 4 highlighted the significant differences among different physicians’ specialties. Compared to internal medicine doctors and pediatricians, otorhinolaryngologists were less likely to agree and have perception of importance with all statements on facts and attitudes about antibiotic use and AMR impacts. Particularly, in statement Q03_08 saying that providing appropriate patient explanations could reduce antibiotic prescriptions without compromising satisfaction, they showed the significant lower agreement than internal medicine doctors (AOR = 0.38, p = 0.037). Pediatricians reported lower agreement than internal medicine physicians for statements such as WHO’s recommendation on using basic Access group antibiotics (Q03_01) (AOR = 0.74, p = 0.008) and the side effects of unnecessary antibiotic prescriptions, such as allergies and enteritis (Q03_10) (AOR = 0.54, p = 0.030) in Table 3.
Table 3.
Associations between the age/specialty and the answers to the individual items in statements on physicians’ intentions to review their antibiotic use
| Age group ≤ 49 as Reference [1] (n = 280) |
Specialty Internal Medicine as Reference [1] (n = 280) |
|||||||
|---|---|---|---|---|---|---|---|---|
| 50–59 | ≥ 60 | Pediatrics | Otorhinolaryngologists | |||||
| AOR | p | AOR | p | AOR | p | AOR | p | |
| Q03_01: WHO recommends prioritizing the use of basic Access group (note) antibiotics and promotes the appropriate use of antibiotics. (Note: These are antibiotics that are used as the first or second choice for common infections and have little risk of developing resistance.) | 0.80 | (0.489) | 0.94 | (0.834) | 0.74** | (0.008) | 0.62 | (0.339) |
| Q03_02: The Japanese government aims to reduce antibiotic usage by 15% by 2027 (compared to 2020 levels) by promoting the appropriate use of antibiotics. | 0.91 | (0.653) | 0.65 | (0.069) | 0.94 | (0.765) | 0.84 | (0.276) |
| Q03_03: Infectious disease experts stress the importance of appropriate use of antibiotics to prevent drug resistance | 0.57 | (0.076) | 0.64 | (0.052) | 0.64 | (0.064) | 0.61 | (0.289) |
| Q03_04: You can prevent future drug resistance by prescribing antibiotics appropriately in your daily practice | 0.78 | (0.218) | 0.77 | (0.170) | 0.72 | (0.160) | 0.48 | (0.218) |
| Q03_05: Appropriate use of antibiotics reduces the chances that not only the patient but also those around them will develop drug-resistant bacterial infections | 0.78 | (0.300) | 0.92 | (0.729) | 0.58 | (0.078) | 0.61 | (0.460) |
| Q03_06: Appropriate use of antibiotics reduces side effects and complications and improves treatment outcomes. | 0.56 | (0.066) | 0.57 | (0.099) | 0.76 | (0.234) | 0.60 | (0.393) |
| Q03_07: Many doctors are reviewing how they use antibiotics in outpatient care, and the amount of antibiotics used has decreased. | 0.73 | (0.109) | 0.94 | (0.841) | 0.90 | (0.655) | 0.82 | (0.631) |
| Q03_08: By providing appropriate explanations to patients, antibiotic prescriptions can be reduced without reducing patient satisfaction | 0.67 | (0.152) | 0.71 | (0.368) | 0.60 | (0.071) | 0.38* | (0.037) |
| Q03_09: Patients who visit the doctor with symptoms such as fever or cough just want to get better quickly, and do not necessarily want to be prescribed antibiotics. | 0.76 | (0.147) | 0.75 | (0.262) | 0.72 | (0.204) | 0.66 | (0.335) |
| Q03_10: Prescribing antibiotics in situations where they are not medically necessary can cause unexpected side effects such as allergies and enteritis. | 0.74 | (0.472) | 0.82 | (0.593) | 0.54* | (0.030) | 0.45 | (0.129) |
| Q03_11: For the treatment of acute pharyngitis, it is recommended that antibiotics be administered only when it is caused by group A streptococcus | 0.84 | (0.417) | 0.86 | (0.636) | 0.85 | (0.486) | 0.48 | (0.225) |
The multilevel mixed-effects ordered logistic regression models were applied with adjustment of sex and regions. The answers for each question were divided into three groups (disagree, neutral, agree)
AOR: Adjusted Odd Ratios
p-values in parentheses
* p < 0.05, ** p < 0.01, *** p < 0.001
Table 4.
Associations between the age/specialty and the answers to the individual items in the statements on physicians’ perceptions of the importance of AMR measures
| Age group ≤ 49 as Reference [1] (n = 280) |
Specialty Internal Medicine as Reference [1] (n = 280) |
|||||||
|---|---|---|---|---|---|---|---|---|
| 50–59 | ≥ 60 | Pediatrics | Otorhinolaryngologists | |||||
| AOR. | p | AOR. | p | AOR. | p | AOR. | p | |
| Q04_01: The WHO has positioned antimicrobial resistance (AMR) countermeasures as a major public health issue and is calling on countries around the world to take action. | 1.56 | (0.116) | 1.46 | (0.087) | 1.00 | (0.994) | 0.55 | (0.154) |
| Q04_02: The Japanese government has formulated an action plan to combat antimicrobial resistance (AMR) and is working on various measures. | 1.09 | (0.719) | 0.97 | (0.911) | 0.79 | (0.391) | 0.68 | (0.500) |
| Q04_03: Infectious disease experts are calling for the immediate implementation of measures against antimicrobial resistance (AMR). | 1.24 * | (0.028) | 1.41 | (0.200) | 0.98 | (0.945) | 0.84 | (0.693) |
| Q04_04: It is important that you take the first step in combating antimicrobial resistance (AMR). There are things that every doctor can do. | 1.21 | (0.202) | 1.84 *** | (0.000) | 0.95 | (0.858) | 0.64 | (0.281) |
| Q04_05: It is estimated that by 2050, antimicrobial resistance (AMR) could cause 10 million deaths per year worldwide. | 0.47 ** | (0.002) | 0.49 ** | (0.006) | 0.85 | (0.608) | 0.74 | (0.554) |
| Q04_06: In Japan, the number of deaths directly related to antimicrobial resistance (AMR) is estimated to be approximately 23,000 per year (2019). | 0.53 ** | (0.009) | 0.75 | (0.189) | 0.93 | (0.847) | 0.78 | (0.686) |
| Q04_07: Many doctors responded that they are conscious of antimicrobial resistance (AMR) measures in their daily medical practice. | 1.00 | (0.998) | 0.79 | (0.467) | 1.20 | (0.476) | 0.78 | (0.540) |
| Q04_08: By taking action against antimicrobial resistance (AMR), we can reduce the impact of infectious diseases in the future. | 1.91 *** | (0.000) | 2.39 *** | (0.000) | 0.99 | (0.985) | 0.63 | (0.276) |
| Q04_09: Antimicrobial resistance (AMR) is not just a problem in hospitals: it is already spreading to healthy people and the environment. | 0.93 | (0.831) | 1.44 | (0.274) | 0.96 | (0.889) | 0.81 | (0.679) |
| Q04_10: If antimicrobial resistance (AMR) continues to spread, antibiotics will lose their effectiveness, and surgery and anticancer drug treatments may become more difficult. | 0.99 | (0.973) | 1.24 | (0.545) | 0.73 | (0.262) | 0.41 | (0.059) |
| Q04_11: In some regions, medical associations are taking the lead in taking measures against antimicrobial resistance (AMR). | 1.14 | (0.604) | 1.09 | (0.799) | 1.04 | (0.884) | 0.64 | (0.315) |
The multilevel mixed-effects ordered logistic regression models were applied with adjustment of sex and regions. The answers for each question were divided into three groups (no percieved importance, neutral, perceived importance)
AOR: Adjusted Odd Ratios
p-values in parentheses
* p < 0.05, ** p < 0.01, *** p < 0.001
Age-based variations in AMR awareness and practices
Age-related differences in AMR attitudes are presented in Tables 3 and 4. In Table 3, physicians in older groups (≥ 50) demonstrated lower agreement than those in the younger group (≤ 49) for all statements, though the differences were not statistically significant. In Table 4, the answers of physicians varied by different groups and different statements. For example, doctors at age ≥ 60 were significantly more likely to perceive importance that taking action against AMR can reduce the future impact of infectious diseases (Q04_08) (AOR = 2.39, p = 0.000) compared to younger doctors (≤ 49). However, this age group demonstrated significantly lower perceived importance of the statistics on deaths due to AMR worldwide (AOR = 0.49, p = 0.006).
Besides, Figs. 3 and 4 also shows the perceived importance of appropriate antibiotic practices across age groups. In all statements in group 03 and nine out of eleven items in group 04, younger physicians (≤ 49 years) reported greater concern about the urgency of AMR prevention compared to older physicians (50 + years). Regarding the familiarity of AMR action plan and manuals of MHLW, Figs. 5 and 6 show that younger physicians (≤ 49) were higher rates in capacity of explaining the NAP, while those aged 50–59 had the highest understanding. The use of MHLW manuals was highest among the youngest age group, whereas familiarity without usage was more common among older physicians. More details of the difference of responses age can be seen in Supplementary Figs. 3 and 4.
Fig. 3.
Mean and 95% CI of responses by age of physician for intentions to review their antibiotic use. CI: Confidence Interval Q03_01: WHO recommends prioritizing the use of basic Access group (note) antibiotics and promotes the appropriate use of antibiotics. (Note: These are antibiotics that are used as the first or second choice for common infections and have little risk of developing resistance) Q03_02: The Japanese government aims to reduce antibiotic usage by 15% by 2027 (compared to 2020 levels) by promoting the appropriate use of antibiotics Q03_03: Infectious disease experts stress the importance of appropriate use of antibiotics to prevent drug resistance Q03_04: You can prevent future drug resistance by prescribing antibiotics appropriately in your daily practice Q03_05: Appropriate use of antibiotics reduces the chances that not only the patient but also those around them will develop drug-resistant bacterial infections Q03_06: Appropriate use of antibiotics reduces side effects and complications and improves treatment outcomes Q03_07: Many doctors are reviewing how they use antibiotics in outpatient care, and the amount of antibiotics used has decreased Q03_08: By providing appropriate explanations to patients, antibiotic prescriptions can be reduced without reducing patient satisfaction Q03_09: Patients who visit the doctor with symptoms such as fever or cough just want to get better quickly, and do not necessarily want to be prescribed antibiotics Q03_10: Prescribing antibiotics in situations where they are not medically necessary can cause unexpected side effects such as allergies and enteritis Q03_11: For the treatment of acute pharyngitis, it is recommended that antibiotics be administered only when it is caused by group A streptococcus
Fig. 4.
Mean and 95% CI of responses by age of physician for perceptions of the importance of AMR measures. CI: Confidence Interval Q04_01: The WHO has positioned antimicrobial resistance (AMR) countermeasures as a major public health issue and is calling on countries around the world to take action Q04_02: The Japanese government has formulated an action plan to combat antimicrobial resistance (AMR) and is working on various measures Q04_03: Infectious disease experts are calling for the immediate implementation of measures against antimicrobial resistance (AMR) Q04_04: It is important that you take the first step in combating antimicrobial resistance (AMR). There are things that every doctor can do Q04_05: It is estimated that by 2050, antimicrobial resistance (AMR) could cause 10 million deaths per year worldwide Q04_06: In Japan, the number of deaths directly related to antimicrobial resistance (AMR) is estimated to be approximately 23,000 per year (2019) Q04_07: Many doctors responded that they are conscious of antimicrobial resistance (AMR) measures in their daily medical practice Q04_08: By taking action against antimicrobial resistance (AMR), we can reduce the impact of infectious diseases in the future Q04_09: Antimicrobial resistance (AMR) is not just a problem in hospitals: it is already spreading to healthy people and the environment Q04_10: If antimicrobial resistance (AMR) continues to spread, antibiotics will lose their effectiveness, and surgery and anticancer drug treatments may become more difficult Q04_11: In some regions, medical associations are taking the lead in taking measures against antimicrobial resistance (AMR)
Fig. 5.
Percentage of familiarity to Japanese national action plan on AMR by age groups
Fig. 6.
Percentage of reported using MHLW’ manuals by age groups
Associations between the familiarity to NAP/MHLW manuals and responses to the statements on AMR or antibiotic use.
In Tables 5 and 6, the participants who do not understand the NAP have significant higher agreement with statements that appropriate antibiotic prescription prevents future resistance (Q03_04) or the recommendation of WHO on using basic Access group antibiotics and appropriate antibiotic use (Q04_01), and the role of doctor to take the first step in combating AMR (Q04_04). However, the perceived importance of impact of AMRs on antibiotic effectiveness with other treatments (Q04_10) was strongly associated with understanding the NAP. Physicians who understood the NAP were more likely to be aware of the effectiveness of antibiotics, and impact of AMR on surgery and anticancer drug treatments.
Table 5.
Association between the familiarity to NAP on AMR with questions related to physicians’ intentions to review their antibiotic use +
| Familiarity of National Action Plan of AMR Reported understanding NAP vs. Not understanding NAP |
||
|---|---|---|
| AOR. | p | |
| Q03_01: WHO recommends prioritizing the use of basic Access group antibiotics and promotes the appropriate use of antibiotics. | 1.13 | (0.117) |
| Q03_02: The Japanese government aims to reduce antibiotic usage by 15% by 2027 (compared to 2020 levels) by promoting the appropriate use of antibiotics | 1.09 | (0.519) |
| Q03_03: Infectious disease experts stress the importance of appropriate use of antibiotics to prevent drug resistance | 0.84 | (0.157) |
| Q03_04: You can prevent future drug resistance by prescribing antibiotics appropriately in your daily practice | 0.71 * | (0.025) |
| Q03_05: Appropriate use of antibiotics reduces the chances that not only the patient but also those around them will develop drug-resistant bacterial infections | 1.26 | (0.414) |
| Q03_06: Appropriate use of antibiotics reduces side effects and complications and improves treatment outcomes. | 1.26 | (0.054) |
| Q03_07: Many doctors are reviewing how they use antibiotics in outpatient care, and the amount of antibiotics used has decreased. | 0.95 | (0.796) |
| Q03_08: By providing appropriate explanations to patients, antibiotic prescriptions can be reduced without reducing patient satisfaction | 0.93 | (0.560) |
| Q03_09: Patients who visit the doctor with symptoms such as fever or cough just want to get better quickly, and do not necessarily want to be prescribed antibiotics. | 0.91 | (0.487) |
| Q03_10: Prescribing antibiotics in situations where they are not medically necessary can cause unexpected side effects such as allergies and enteritis. | 1.21 | (0.410) |
| Q03_11: For the treatment of acute pharyngitis, it is recommended that antibiotics be administered only when it is caused by group A streptococcus | 0.90 | (0.481) |
+ Compare “Agree” vs. “Disagree & Neutral”, and “Disagree & Neutral” was treated as Reference group [1]
The multilevel mixed-effects generalized linear models were used with adjustments of age, sex, specialty of physicians and regions
p-values in parentheses
AOR: Adjusted Odd Ratios; Ref. Reference;
* p < 0.05, ** p < 0.01, *** p < 0.001
Table 6.
Association between the familiarity to NAP of AMR with questions related to on physicians’ perceptions of the importance of AMR measures +
| Familiarity of National Action Plan of AMR (Reported understanding NAP vs. Not understanding NAP) |
||
|---|---|---|
| AOR | p | |
| Q04_01: The WHO has positioned antimicrobial resistance (AMR) countermeasures as a major public health issue and is calling on countries around the world to take action. | 0.68*** | (0.001) |
| Q04_02: The Japanese government has formulated an action plan to combat antimicrobial resistance (AMR) and is working on various measures. | 1.59 | (0.110) |
| Q04_03: Infectious disease experts are calling for the immediate implementation of measures against antimicrobial resistance (AMR). | 1.18 | (0.479) |
| Q04_04: It is important that you take the first step in combating antimicrobial resistance (AMR). There are things that every doctor can do | 0.61 *** | (0.000) |
| Q04_05: It is estimated that by 2050, antimicrobial resistance (AMR) could cause 10 million deaths per year worldwide. | 0.98 | (0.929) |
| Q04_06: In Japan, the number of deaths directly related to antimicrobial resistance (AMR) is estimated to be approximately 23,000 per year (2019). | 0.99 | (0.952) |
| Q04_07: Many doctors responded that they are conscious of antimicrobial resistance (AMR) measures in their daily medical practice. | 0.80 | (0.065) |
| Q04_08: By taking action against antimicrobial resistance (AMR), we can reduce the impact of infectious diseases in the future. | 0.89 | (0.449) |
| Q04_09: Antimicrobial resistance (AMR) is not just a problem in hospitals: it is already spreading to healthy people and the environment. | 1.34 | (0.114) |
| Q04_10: If antimicrobial resistance (AMR) continues to spread, antibiotics will lose their effectiveness, and surgery and anticancer drug treatments may become more difficult. | 1.40 * | (0.030) |
| Q04_11: In some regions, medical associations are taking the lead in taking measures against antimicrobial resistance (AMR). | 1.12 | (0.490) |
+Compare “Perceived importance” vs. “No perceived importance & Neutral”, and “No perceived importance & Neutral” was treated as Reference group [1]
The multilevel mixed-effects generalized linear models were used with adjustments of age, sex, specialty of physicians and regions
AOR: Adjusted Odd Ratios
p-values in parentheses
* p < 0.05, ** p < 0.01, *** p < 0.001
Tables 7 and 8 present the associations between the use of MHLW manuals and the factors related to AMR facts or attitudes, stratified by awareness of the NAP on AMR. The use of MHLW manuals remained positive even among doctors who didn’t understand the NAP, particularly those who agreed with statements related to direct impact or side effects of AMR. For example, among doctors unaware of the NAP, a higher likelihood of MHLW manual usage was observed in those who agreed with the following statements: Q03_06 (Appropriate use of antibiotics reduces side effects and complications and improves treatment outcomes), Q03_08 (By providing appropriate explanations to patients, antibiotic prescriptions can be reduced without reducing patient satisfaction).
Table 7.
Association between the mhlw’s manuals usage and group 03 statements by level of NAP familiarity+
| Statements | Familiarity to MHLW manuals (Use manuals vs. Don’t use manuals) |
|||||
|---|---|---|---|---|---|---|
| Group 1 Reported not understanding NAP (n = 148) |
Group 2 Reported understanding NAP (n = 132) |
All respondents (n = 280) | ||||
| AOR. | p | AOR. | p | AOR. | p | |
| Q03_01: WHO recommends prioritizing the use of basic Access group antibiotics, and promotes the appropriate use of antibiotics. | 2.29 | (0.255) | 0.75 | (0.182) | 0.91 | (0.509) |
| Q03_02: The Japanese government aims to reduce antibiotic usage by 15% by 2027 (compared to 2020 levels) by promoting the appropriate use of antibiotics | 0.87 | (0.802) | 0.96 | (0.886) | 0.87 | (0.570) |
| Q03_03: Infectious disease experts stress the importance of appropriate use of antibiotics to prevent drug resistance | 0.20 | (0.136) | 1.20 | (0.695) | 0.77 | (0.585) |
| Q03_04: You can prevent future drug resistance by prescribing antibiotics appropriately in your daily practice | 1.12 | (0.872) | 1.04 | (0.828) | 1.04 | (0.844) |
| Q03_05: Appropriate use of antibiotics reduces the chances that not only the patient but also those around them will develop drug-resistant bacterial infections | 3.25 | (0.072) | 0.93 | (0.847) | 1.17 | (0.741) |
| Q03_06: Appropriate use of antibiotics reduces side effects and complications and improves treatment outcomes. | 2.76** | (0.006) | 1.73** | (0.010) | 2.29*** | (0.000) |
| Q03_07: Many doctors are reviewing how they use antibiotics in outpatient care, and the amount of antibiotics used has decreased. | 0.71 | (0.674) | 1.20 | (0.383) | 1.23 | (0.451) |
| Q03_08: By providing appropriate explanations to patients, antibiotic prescriptions can be reduced without reducing patient satisfaction | 3.62* | (0.027) | 0.83 | (0.386) | 0.98 | (0.905) |
| Q03_09: Patients who visit the doctor with symptoms such as fever or cough just want to get better quickly, and do not necessarily want to be prescribed antibiotics. | 1.02 | (0.988) | 1.19 | (0.530) | 1.24 | (0.511) |
| Q03_10: Prescribing antibiotics in situations where they are not medically necessary can cause unexpected side effects such as allergies and enteritis. | 0.47 | (0.255) | 0.81 | (0.163) | 0.63 | (0.204) |
| Q03_11: For the treatment of acute pharyngitis, it is recommended that antibiotics be administered only when it is caused by group A streptococcus | 0.86 | (0.840) | 1.29 | (0.324) | 1.22 | (0.454) |
| Understand NAP (vs. Don’t understand NAP) | 5.04*** | (0.000) | ||||
+ Compare “Agree” vs. “Disagree & Neutral”, and “Disagree & Neutral” was treated as Reference group [1]
The multilevel mixed-effects generalized linear models were used with all variables in Q03 groups and adjusted with age, sex, specialty of physicians and regions
p-values in parentheses
NAP: National Action Plan on AMR; MHLW: Ministry of Health and Labour Welfare
AOR: Adjusted Odd Ratios; Ref. Reference; * p < 0.05, ** p < 0.01, *** p < 0.001
Table 8.
Association between the mhlw’s manuals usage and group 04 statements by NAP familiarity level +
| Statements | Familiarity to MHLW manuals (Use manuals vs. Don’t use manuals) |
|||||
|---|---|---|---|---|---|---|
| Group 1 Reported not understanding NAP (n = 148) |
Group 2 Reported understanding NAP (n = 132) |
All respondents (n = 280) |
||||
| AOR | p | AOR | p | AOR. | p | |
| Q04_01: The WHO has positioned antimicrobial resistance (AMR) countermeasures as a major public health issue and is calling on countries around the world to take action. | 0.46 | (0.411) | 1.03 | (0.884) | 1.01 | (0.933) |
| Q04_02: The Japanese government has formulated an action plan to combat antimicrobial resistance (AMR) and is working on various measures. | 0.63 | (0.557) | 0.90 | (0.627) | 0.80 | (0.394) |
| Q04_03: Infectious disease experts are calling for the immediate implementation of measures against antimicrobial resistance (AMR). | 4.06 | (0.190) | 0.73 | (0.198) | 0.86 | (0.623) |
| Q04_04: It is important that you take the first step in combating antimicrobial resistance (AMR). There are things that every doctor can do | 2.74 | (0.364) | 1.09 | (0.769) | 1.29 | (0.481) |
| Q04_05: It is estimated that by 2050, antimicrobial resistance (AMR) could cause 10 million deaths per year worldwide. | 1.07 | (0.784) | 1.77 | (0.091) | 1.40 | (0.329) |
| Q04_06: In Japan, the number of deaths directly related to antimicrobial resistance (AMR) is estimated to be approximately 23,000 per year (2019). | 2.64 | (0.110) | 1.89*** | (0.000) | 1.82*** | (0.000) |
| Q04_07: Many doctors responded that they are conscious of antimicrobial resistance (AMR) measures in their daily medical practice. | 1.12 | (0.938) | 1.18 | (0.277) | 1.21 | (0.492) |
| Q04_08: By taking action against antimicrobial resistance (AMR), we can reduce the impact of infectious diseases in the future. | 0.33 | (0.555) | 0.77 | (0.398) | 0.80 | (0.577) |
| Q04_09: Antimicrobial resistance (AMR) is not just a problem in hospitals: it is already spreading to healthy people and the environment. | 0.31 | (0.161) | 1.69 | (0.499) | 1.26 | (0.759) |
| Q04_10: If antimicrobial resistance (AMR) continues to spread, antibiotics will lose their effectiveness, and surgery and anticancer drug treatments may become more difficult. | 0.29 | (0.149) | 0.62 | (0.419) | 0.60 | (0.343) |
| Q04_11: In some regions, medical associations are taking the lead in taking measures against antimicrobial resistance (AMR). | 6.75 | (0.178) | 1.03 | (0.959) | 1.27 | (0.588) |
| Understand NAP | 4.92*** | (0.000) | ||||
+Compare “Perceived importance” vs. “No perceived importance & Neutral”, and “No perceived importance & Neutral” was treated as Reference group [1]
The multilevel mixed-effects generalized linear models were used with all variables in Q04 groups and adjusted with age, sex, specialty of physicians and regions
AOR: Adjusted Odd Ratios
p-values in parentheses
* p < 0.05, ** p < 0.01, *** p < 0.001
In contrast, factual knowledge about AMR did not appear to be associated with MHLW manual usage among doctors do not understand the NAP but more positive among those who understand the NAP. For instance, Q04_06 (Number of deaths due to AMR in Japan in 2019) was significantly associated with MHLW manual usage among doctors understand the NAP.
Discussion
The study highlighted significant specialty and age-related differences in perception of the importance of AMR and review their antimicrobial use among clinic doctors in Japan. Internal medicine physicians showed a higher likelihood of reducing antibiotic prescriptions and the greatest concern about AMR facts, while pediatricians demonstrated the highest adherence to MHLW manuals. Otorhinolaryngologists, despite understanding the NAP, reported lower adherence to antimicrobial stewardship and lower perceived importance of AMR, suggesting a gap between the awareness and attitudes towards AMR impact or antibiotic use [33, 34]. Younger physicians (≤ 49) prioritized AMR urgency and prevention actions more than their older counterparts, who valued AMR actions for future impact reduction but lacked a sense of urgency. The disproportion of gender of physicians (85% men) reflected the national data of physicians in clinics (78%) [35], however, we did not find any statistical association between the gender and the familiarity to NAP on AMR or reported understanding of Manuals from MHLW. Physicians perceived higher importance for the statements emphasizing peer reviews of antimicrobial misuse (Q04_07), associated risks (Q03_10), and broader societal impacts, such as environmental contamination (Q04_09). These findings suggest that such themes could be prioritized in educational interventions to enhance AMR awareness and adherence.
Specialty differences in adherence to appropriate antimicrobial use
Our study found that internal medicine physicians exhibit the highest understanding on AMR and appropriate antimicrobial use. This finding aligns with a previous study in Germany indicating that internal medicine specialists were more likely to reduce antibiotic prescriptions and follow guidelines strictly after joining some training courses on multidrug-resistant organisms in 12 months [36]. However, variability in adherence to appropriate prescribing behaviors persists with the influence of patient expectations, as well as time constraints, communication difficulties, and diagnostic uncertainty as supported by prior studies on prescribing behaviors [37].
Pediatricians in our study showed the highest adherence to antimicrobial stewardship manuals of MHLW, consistent with findings from Hersh et al., who reported that pediatricians were vigilant in promoting appropriate antibiotic use to prevent potential harms for children in the future [38]. Nevertheless, adherence can be influenced by external factors, for example, parental pressure, trust, quality of clinician-parents relationship, conflicting messages on efficacy of antibiotics, and past experiences [37, 39, 40]. McKay’s study further reported that physician perception of patient’s desire for antibiotics, rather than patient’s actual desire for an antibiotic, was significantly associated with antibiotic prescription [12].
Otorhinolaryngologists reported high awareness of the NAP but lower adherence to antimicrobial stewardship, suggesting a potential disconnect between perceived knowledge and prioritization of AMR in clinical practice. This could stem from overconfidence in their understanding, differing interpretations of the NAP’s relevance, or clinical priorities favoring immediate symptom relief over long-term AMR prevention. This finding is similar to the study in US where otorhinolaryngologists tended to prescribe broad-spectrum antibiotics for younger patients more frequently and for conditions like acute rhinosinusitis, often in response to patient satisfaction concerns [34]. This trend suggests a need for targeted education and interventions to improve practical adherence to antimicrobial stewardship principles in this specialty.
Age-related differences in AMR awareness and adherence
Our study revealed that younger physicians (≤ 49) are more proactive in implementing appropriate antimicrobial use, often being more aware of the latest manuals and willing to adopt new practices. This result is supported with findings from another Japanese study by Aoyama where they found that antibiotics were more likely to be prescribed in clinics owned by older physicians. Some studies in European countries also insisted on the important determinant of young doctor perspectives on antibiotic use and resistance [13, 41, 42].
Younger physicians in our study displayed a balanced experience with updated knowledge, generally showing good adherence to antimicrobial stewardship. In contrast, older physicians demonstrated a strong appreciation for the broader impact of AMR but showed less urgency in addressing it. This aligns with a systematic review suggesting that older physicians obtained lower clinical knowledge, less adherence to treatment standards, and poorer performance on diagnosis, screening, and preventive care measures [43]. Furthermore, older physicians were also reported to bring higher care costs and higher mortality rates, except in cases involving high-volume practitioners [44]. Another study also found a negative association between increasing physician experience and performance, suggesting that experience alone may not guarantee optimal performance [43]. These findings underscore the need for targeted educational interventions to enhance manual adherence and AMR awareness across different physician demographics.
The effectiveness of the AMR related messages and the use of MHLW manuals
Effective communication about the risks of antibiotic misuse is crucial for changing behaviors and improving adherence to standards. Compared to the message insisting on the statistics (such as number of deaths attributed to AMR), the messages emphasizing unexpected side effects, prevention of drug resistance, and reduced infection risks were more agreeable to all physicians, particularly older physicians and otolaryngologists. This finding aligns with the nudge principles which highlights how the presentation of information can influence decision-making [26, 45]. Our finding may imply that framing the consequences of antibiotic misuse in terms of patient outcomes and public health impact resonates more effectively with physicians than simply presenting resistance statistics. By emphasizing real-world implications, such messages can foster a sense of urgency and responsibility among prescribers [28].
Our study highlighted the importance of background and experience of the physicians in designing AMR messages as understanding physicians’ attitudes and knowledge is essential for shaping effective communication strategies [41]. Educational initiatives focusing on AMR resistance mechanisms and the long-term public health consequences of AMR, as advocated by Tigges et al. and Zhou et al., are crucial for fostering awareness and encouraging stewardship [46, 47].
The low rates of agreement among Japanese doctors on the global and domestic mortality consequences of AMR suggest a relative lack of concern compared to their counterparts in other countries. This may reflect the skepticism about the severity of AMR, highlighting a critical barrier to effective antimicrobial stewardship [14]. Addressing such barriers requires overcoming resistance to changing established practices, skepticism about AMR’s impact, and insufficient training on updated guidelines. It is essential for targeted training and systemic support for rational antibiotic prescribing [48] and a comprehensive education and policy reform that build trust and engagement [49].
Strengths of the study
This study is among the first to explore the effectiveness of AMR messages and apply the nudge concept to identify key leverage points for improving the impact of these messages on physician behavior. By using a nationwide cross-sectional survey, the study provides a comprehensive understanding of specialty- and age-based differences in AMR awareness and stewardship practices among doctors working in clinics in Japan. Including physicians who recently managed patients with acute respiratory tract infections ensures the findings’ clinical relevance. The use of validated questionnaires with excellent reliability (Cronbach’s alpha = 0.96) strengthens data quality, while the application of ordinal logistic regression to adjust for confounding variables enhances result validity.
Limitations
Despite many positive findings, our study also has several limitations. First, the study’s cross-sectional design limits the ability to establish causal relationships. The short survey period may limit representativeness of the study. The reliance on self-reported data may introduce recall bias and social desirability bias, potentially inflating adherence to stewardship practices.
Second, the focus on clinic-based physicians may restrict the generalizability of findings to hospital settings, while the brief survey period may overlook temporal variations in behaviors. Although the study evaluates the effectiveness of AMR messages, it primarily focuses on national manuals, potentially overlooking the influence of international standards on physician behavior. Besides, some outcomes such as NAP understanding and perceived importance of AMR statements may be affected by subjectivity, as physicians’ responses may reflect perceived rather than actual knowledge or attitudes. Objective measures, such as direct assessment of guideline adherence, could strengthen future studies.
Third, some other potential biases related to sample selection using panel data should also be acknowledged. The study participants were recruited from physicians registered with Nikkei Medical, who may have a higher interest in information gathering compared to non-registered physicians. This could result in an overestimation of AMR awareness levels, as the general physician population may have lower awareness. Besides, the age distribution of clinic-based doctors in our study was younger than the national average in Japan. Nationwide, more than 50% of physicians working in clinics are in their 60 s, whereas only about 20% are under 50 [35]. This age discrepancy may introduce bias, as older physicians were underrepresented in our sample, potentially leading to an underestimation of the awareness gap between younger and older physicians. Additionally, the eligibility criterion of seeing 10 or more patients with ARTIs in the prior three months relied on self-reported data, which may be subject to recall bias or overreporting. Future studies should aim to include a more representative sample of physicians to address these potential biases.
Conclusions
This study reveals significant variability in clinic physicians’ awareness and adherence to antimicrobial stewardship across specialties and age groups in Japan. Internal medicine physicians showed the highest adherence, while pediatricians were the most familiar with AMR manuals. Otorhinolaryngologists reported high awareness of the NAP but lower adherence to antimicrobial stewardship, possibly due to a disconnect between perceived knowledge and prioritization of AMR. Younger physicians (< 50 years) were more proactive in addressing AMR, compared to older physicians. Effective communication, particularly emphasizing the consequences and broader societal impacts of AMR and the peer reviews from other medical doctors or experts towards the impact of AMR or appropriate use of antibiotics, received the highest acceptance by physicians even with those who were not aware of NAP. These findings highlight the need for targeted educational interventions and impactful messages to elderly physicians and specific professions to improve antimicrobial stewardship in clinics and address AMR more effectively.
Supplementary Information
Acknowledgements
Not applicable
Abbreviations
- AMR
Antimicrobial resistance
- AOR
Adjusted Odd Ratio
- CI
Confidence Interval
- COVID-19
Coronavirus Disease 2019
- HICs
High-income countries
- LMICs
Low- and middle-income countries
- MHLW
Ministry of Health, Labor, and Welfare
- MRSA
Methicillin-resistant Staphylococcus aureus
- NAP
National Action Plan
- PDR
People’s Democratic Republic
- SD
Standard Deviation
- US
The United States of America
- USD
US Dollar
- UK
United Kingdom
- WHO
World Health Organization
Authors’ contributions
Conceptualization: YG, YF, FO; data collection: YG; methodology: YG, ADD; software: YG, ADD; formal analysis: ADD, YG; writing—original draft preparation: YG, ADD; writing—review and editing: YG, ADD, YF, FO. All authors have read and agreed to the published version of the manuscript.
Funding
This work was supported by JSPS KAKENHI Grant Number 20H05632.
Data availability
The data are not publicly available due to participant privacy restrictions but can be obtained upon reasonable request to the corresponding author (YG).
Declarations
Ethics approval and consent to participate
The study received approval from the Research Ethics Committee of the Institute of Science Tokyo (Number C2023-047 issued on December 15, 2023). The research was conducted in accordance with the principles of the Declaration of Helsinki and relevant national guidelines. Informed consent was obtained electronically, with participants indicating consent by checking a box and completing the questionnaire.
Consent for publication
Not applicable.
Competing interests
YG received an advisory fee from bioMérieux Japan Ltd., and an educational grant from MSD Ltd.ADD, YF, FO have no competing interests to declare.
ADD, YF, FO have no competing interests to declare.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Naghavi M, Vollset SE, Ikuta KS, Swetschinski LR, Gray AP, Wool EE, et al. Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050. Lancet. 2024;404:1199–226. 10.1016/S0140-6736(24)01867-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.WHO. Antibiotic resistance—fact sheet. 2023. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance.
- 3.World Health Organization. Global action plan on antimicrobial resistance. Geneva Switzerland: WHO Regional Office for South-East Asia; 2016. [Google Scholar]
- 4.Dar OA, Hasan R, Schlundt J, Harbarth S, Caleo G, Dar FK, et al. Exploring the evidence base for national and regional policy interventions to combat resistance. Lancet. 2016;387:285–95. 10.1016/S0140-6736(15)00520-6. [DOI] [PubMed] [Google Scholar]
- 5.Chaves NJ, Cheng AC, Runnegar N, Kirschner J, Lee T, Buising K. Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals. Intern Med J. 2014;44:568–74. 10.1111/imj.12373. [DOI] [PubMed] [Google Scholar]
- 6.Sanchez GV, Roberts RM, Albert AP, Johnson DD, Hicks LA. Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States. Emerg Infect Dis. 2014;20(12):2041–7. 10.3201/eid2012.140331. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Gіder Ö, Ocak S, Top M. Evaluation of electronic prescription implications in Turkey: an investigation of the perceptions of physicians. Worldviews Evid Based Nurs. 2015;12:88–97. 10.1111/wvn.12082. [DOI] [PubMed] [Google Scholar]
- 8.Baudet A, Kichenbrand C, Pulcini C, Descroix V, Lesclous P, Thilly N, et al. Antibiotic use and resistance: a nationwide questionnaire survey among French dentists. Eur J Clin Microbiol Infect Dis. 2020;39:1295–303. 10.1007/s10096-020-03849-0. [DOI] [PubMed] [Google Scholar]
- 9.Keizer J, Braakman-Jansen LMA, Kampmeier S, Köck R, Al Naiemi N, Te Riet-Warning R, et al. Cross-border comparison of antimicrobial resistance (AMR) and AMR prevention measures: the healthcare workers’ perspective. Antimicrob Resist Infect Control. 2019;8:123. 10.1186/s13756-019-0577-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Donisi V, Sibani M, Carrara E, Del Piccolo L, Rimondini M, Mazzaferri F, et al. Emotional, cognitive and social factors of antimicrobial prescribing: can antimicrobial stewardship intervention be effective without addressing psycho-social factors? J Antimicrob Chemother. 2019;74:2844–7. 10.1093/jac/dkz308. [DOI] [PubMed] [Google Scholar]
- 11.Schrier L, Hadjipanayis A, Del Torso S, Stiris T, Emonts M, Dornbusch HJ. European antibiotic awareness day 2017: training the next generation of health care professionals in antibiotic stewardship. Eur J Pediatr. 2018;177:279–83. 10.1007/s00431-017-3055-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.McKay R, Mah A, Law MR, McGrail K, Patrick DM. Systematic review of factors associated with antibiotic prescribing for respiratory tract infections. Antimicrob Agents Chemother. 2016;60:4106–18. 10.1128/AAC.00209-16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Aoyama R, Tsugawa Y, Ishikane M, Kitajima K, Sato D, Miyawaki A. Clinic characteristics and antibiotic prescribing for acute respiratory infections in Japan. JAMA Netw Open. 2024;7:e2440406. 10.1001/jamanetworkopen.2024.40406. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Zetts RM, Stoesz A, Garcia AM, Doctor JN, Gerber JS, Linder JA, et al. Primary care physicians’ attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study. BMJ Open. 2020;10:e034983. 10.1136/bmjopen-2019-034983. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Mazińska B, Hryniewicz W. Polish physicians’ attitudes towards antibiotic prescription and antimicrobial resistance. Pol J Microbiol. 2017;66:309–19. 10.5604/01.3001.0010.4856. [DOI] [PubMed] [Google Scholar]
- 16.Hashimoto H, Saito M, Sato J, Goda K, Mitsutake N, Kitsuregawa M, et al. Indications and classes of outpatient antibiotic prescriptions in Japan: a descriptive study using the National database of electronic health insurance claims, 2012–2015. Int J Infect Dis. 2020;91:1–8. 10.1016/j.ijid.2019.11.009. [DOI] [PubMed] [Google Scholar]
- 17.MHLW. National Action Plan on Antimicrobial Resistance 2023–2027. 2023. https://www.mhlw.go.jp/content/10900000/001096228.pdf.
- 18.MHLW. Manual of Antimicrob Stewardship 3rd Ed, Main Volume Microorganisms Coming to an Issue for Infect in Inpatients. 2023. https://www.mhlw.go.jp/content/10900000/001265278.pdf.
- 19.MHLW. Manual of Antimicrob Stewardship (1st Edition). 2017. https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000193504.pdf.
- 20.MHLW. Man of Appropriate Use of Antimicrob Stewardship, 2nd Ed (in Japanese). 2019. https://www.mhlw.go.jp/content/10900000/000573655.pdf.
- 21.Jindai K, Kusama Y, Gu Y, Honda H, Ohmagari N. Narrative review: the process of expanding the manual of antimicrobial stewardship by the government of Japan. Intern Med. 2020. 10.2169/internalmedicine.4760-20. advpub. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Kusama Y, Tsuzuki S, Muraki Y, Koizumi R, Ishikane M, Ohmagari N. The effects of japan’s national action plan on antimicrobial resistance on antimicrobial use. Int J Infect Dis. 2021;103:154–6. 10.1016/j.ijid.2020.11.158. [DOI] [PubMed] [Google Scholar]
- 23.Raban MZ, Gonzalez G, Nguyen AD, Newell BR, Li L, Seaman KL, et al. Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review. BMJ Open. 2023. 10.1136/bmjopen-2022-062688. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Thaler RH, Sunstein CR. Nudge. Improving decisions about health, wealth, and happiness. New Haven, CT, US: Yale University Press; 2008. [Google Scholar]
- 25.Lamprell K, Tran Y, Arnolda G, Braithwaite J. Nudging clinicians: a systematic scoping review of the literature. J Eval Clin Pract. 2020;27:175–92. 10.1111/jep.13401. [DOI] [PubMed] [Google Scholar]
- 26.Nwafor O, Singh R, Collier C, DeLeon D, Osborne J, DeYoung J. Effectiveness of nudges as a tool to promote adherence to guidelines in healthcare and their organizational implications: A systematic review. Soc Sci Med. 2021;286. 10.1016/j.socscimed.2021.114321. [DOI] [PubMed]
- 27.Hallsworth M, Chadborn T, Sallis A, Sanders M, Berry D, Greaves F, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet. 2016. 10.1016/S0140-6736(16)00215-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Yoong SL, Hall A, Stacey F, Grady A, Sutherland R, Wyse R, et al. Nudge strategies to improve healthcare providers’ implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews. Implement Sci. 2020. 10.1186/s13012-020-01011-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Nikkei Research Inc. Healthcare Research in Japan. 2025. https://www.nikkei-r.co.jp/english/healthcare/. Accessed 29 Jul 2025.
- 30.Imai K, Oh A, Morishita A, Inoue Y. Physician awareness and understanding of primary immunodeficiency disorders: a web-based study in Japan. Immunol Med. 2023;46:45–57. 10.1080/25785826.2022.2137966. [DOI] [PubMed] [Google Scholar]
- 31.Nishigaki N, Shimasaki Y, Yoshida T, Hasebe N. Physician and patient perspectives on hypertension management and factors associated with lifestyle modifications in japan: results from an online survey. Hypertens Res. 2020;43:450–62. 10.1038/S41440-020-0398-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.StataCorp. Stata Statistical Software: Release 18. 2023.
- 33.Limato R, Nelwan EJ, Mudia M, Alamanda M, Manurung ER, Mauleti IY, et al. Perceptions, views and practices regarding antibiotic prescribing and stewardship among hospital physicians in Jakarta, Indonesia: a questionnaire-based survey. BMJ Open. 2022;12:e054768. 10.1136/BMJOPEN-2021-054768. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Smith SS, Kern RC, Chandra RK, Tan BK, Evans CT. Variations in antibiotic prescribing of acute rhinosinusitis in United States ambulatory settings. Otolaryngol Head Neck Surg. 2013;148:852–9. 10.1177/0194599813479768. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.e-stat.go.jp. Statistics on physicians, dentists, and pharmacists in Japan in 2022. Japanese Government Statistics. 2022. https://www.e-stat.go.jp/stat-search/files?page=1&stat_infid=000040155752. Accessed 29 Jul 2025.
- 36.Spachmann PJ, May M, Vetterlein MW, Fritsche H-M, Steffen S, Schostak M, et al. Awareness and perception of multidrug-resistant organisms and antimicrobial therapy among internists vs. surgeons of different specialties: results from the German MR2 survey. Casp J Intern Med. 2019;10:132–41. 10.22088/cjim.10.2.132. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Fletcher-Lartey S, Yee M, Gaarslev C, Khan R. Why do general practitioners prescribe antibiotics for upper respiratory tract infections to meet patient expectations: a mixed methods study. BMJ Open. 2016;6:e012244. 10.1136/bmjopen-2016-012244. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Hersh AL, Gerber JS, Hicks LA, Pavia AT. Lessons learned in antibiotic stewardship: fluoroquinolone use in pediatrics. J Pediatr Infect Dis Soc. 2015;4:57–9. 10.1093/jpids/piu044. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Bosley H, Henshall C, Appleton JV, Jackson D. A systematic review to explore influences on parental attitudes towards antibiotic prescribing in children. J Clin Nurs. 2018;27:892–905. 10.1111/jocn.14073. [DOI] [PubMed] [Google Scholar]
- 40.Fletcher-Miles H, Gammon J. A scoping review on the influential cognitive constructs informing public AMR behavior compliance and the attribution of personal responsibility. Am J Infect Control. 2020. 10.1016/j.ajic.2020.01.007. [DOI] [PubMed] [Google Scholar]
- 41.Beović B, Doušak M, Pulcini C, Béraud G, Paño Pardo JR, Sánchez-Fabra D, et al. Young doctors’ perspectives on antibiotic use and resistance: a multinational and inter-specialty cross-sectional European society of clinical microbiology and infectious diseases (ESCMID) survey. J Antimicrob Chemother. 2019;74:3611–8. 10.1093/jac/dkz375. [DOI] [PubMed] [Google Scholar]
- 42.Lévin C, Thilly N, Dousak M, Beraud G, Klesnik M, Uhan S, et al. Perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance. Med Mal Infect. 2019;49:241–9. 10.1016/j.medmal.2018.09.003. [DOI] [PubMed] [Google Scholar]
- 43.Soumerai S, Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005. 10.7326/0003-4819-142-4-200502150-00008. [DOI] [PubMed] [Google Scholar]
- 44.Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ (Online). 2017;357. 10.1136/bmj.j1797. [DOI] [PMC free article] [PubMed]
- 45.Balawi A. A review of the main differences between behavioral and traditional economics: a focus on the impact of nudge theory on public policies and its applications. Mod Manag Rev. 2023;28:17–31. 10.7862/rz.2023.mmr.22. [Google Scholar]
- 46.Tigges P, Greser A, Gágyor I, Kraft J, Maun A, Schmiemann G, et al. Addressing AMR and planetary health in primary care: the potential of general practitioners as change agents. Front Public Health. 2024;12:1383423. 10.3389/fpubh.2024.1383423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Zhou JJ, Patel SJ, Jia H, Weisenberg SA, Furuya EY, Kubin CJ, et al. Clinicians’ knowledge, attitudes, and practices regarding infections with multidrug-resistant gram-negative bacilli in intensive care units. Infect Control Hosp Epidemiol. 2013;34:274–83. 10.1086/669524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Esmaily HM, Vahidi R, Fathi NM, Wahlström R. How do physicians and trainers experience outcome-based education in rational prescribing? BMC Res Notes. 2014;7:944. 10.1186/1756-0500-7-944. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Earnshaw S, Mancarella G, Mendez A, Todorova B, Magiorakos AP, Possenti E, et al. European antibiotic awareness day: a five-year perspective of Europe-wide actions to promote prudent use of antibiotics. Euro Surveill. 2014;19. 10.2807/1560-7917.es2014.19.41.20928. [DOI] [PubMed]
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Data Availability Statement
The data are not publicly available due to participant privacy restrictions but can be obtained upon reasonable request to the corresponding author (YG).