Insights into antimicrobial resistance awareness among Sri Lankan medical practitioners: a qualitative study

Abstract

Objectives

The objective of this study was to explore medical practitioners’ understanding of antimicrobial resistance (AMR) and its aspects, such as its causes, possible outcomes and how doctors can contribute to its prevention.

Design and setting

This qualitative study was conducted in Sri Lankan healthcare settings.

Participants

Using convenience sampling, the study included allopathic medical practitioners aged 18–60 years, excluding intern-medical officers, until data saturation.

Intervention

One-on-one interviews were conducted online or in person, depending on each participant’s preference. A structured questionnaire was used to triangulate the information.

Results

Data were categorised into four: (1) understanding, awareness and identifying AMR as an issue among medical practitioners, (2) knowledge and understanding of factors that contribute to AMR development among medical practitioners, (3) knowledge and understanding of the outcome of AMR and (4) knowledge and understanding of preventive measures against AMR among medical officers. Interviewees showed an awareness of AMR; however, their knowledge was not up to date. Key reasons for inappropriate antibiotic use included unavailability and poor quality of antibiotics and unawareness of updated guidelines, especially in the government sector. In the private sector, patient pressure, the need to attract patients and the high cost of investigations contributed to misuse. Additionally, low patient literacy about AMR was a significant factor.

Conclusion

This study revealed that although medical practitioners in Sri Lanka are aware of AMR, their knowledge remains limited in certain areas. Several challenges contributed to inappropriate antibiotic use, including the availability and quality of antibiotics, external pressures from patients and financial constraints. The findings of this study highlight the urgent need for continuous medical education and public awareness campaigns to improve both practitioner and patient understanding of AMR. Addressing these issues is essential for effectively preventing and managing AMR in healthcare settings in Sri Lanka.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The qualitative approach provided in-depth insights into medical practitioners’ understanding of antimicrobial resistance (AMR) and factors influencing antibiotic misuse.

• Interviews conducted in both online and in-person formats ensured flexibility and broader participation.

• The study captured perspectives from both public and private healthcare settings, offering a comprehensive view of AMR management challenges.

• The use of convenience sampling may have introduced selection bias, potentially limiting the generalisability of the findings.

• Participant data may be influenced by recall or social desirability biases.

Introduction

The WHO has named antimicrobial resistance (AMR) one of the top 10 threats to global health.¹ The process of microbes becoming resistant is natural. However, the rapid emergence of antibiotic-resistant microorganisms is a consequence of human activities, such as the misuse of antibiotics in many sectors, including the health sector. Antibiotic resistance gives rise to several adverse patient outcomes and burdens a country’s healthcare costs.^{2 3} Inappropriate antibiotic use in healthcare includes inaccurate dosing, insufficient duration, unsuitable frequency, non-compliance, unmonitored self-medication and selling antimicrobial agents without a prescription.⁴ Although antibiotic misuse is widespread worldwide, developing countries are disproportionately affected owing to their higher rates of infection and limited resources.⁵ One of the most significant factors influencing AMR prevention is the need for proper knowledge and training of practitioners regarding antimicrobial use in infections.

Numerous studies in developing countries have found that antibiotics are often used in daily practice for fever and respiratory diseases, regardless of aetiology.^{6 7} As a lower- to middle-income economy, Sri Lanka is similar to that of other comparable countries. High levels of antibacterial drug use during the first contact are a well-known problem in Sri Lanka. In many countries, including Sri Lanka, doctors are the primary prescribers. A prescriber’s decision may be driven by factors, such as knowledge,⁸ fear of losing patients and lack of information on rational antibiotic use, in addition to the high workload and lack of facilities that limit opportunities to deliver evidence-based care.⁹

Sri Lanka operates a dual healthcare system comprising both public and private sectors. The public (state) sector is the primary and most widespread healthcare provider. The state health sector possesses a well-structured healthcare system that provides free-of-charge universal healthcare to all citizens through a connected network of government-owned hospitals, primary healthcare centres, tertiary healthcare institutions and specialised medical institutions. The Ministry of Health in Sri Lanka oversees policy implementation and administrative aspects. It ensures that essential medical services and material supplies, disease surveillance programmes and antimicrobial stewardship programmes are accessible to people across the nation. The state sector structure includes teaching hospitals, provincial and district general hospitals, divisional hospitals and rural hospitals catering to different levels of healthcare needs.

Furthermore, Sri Lanka has a well-established public and community health system, which is critical in disease prevention, health promotion and primary-level healthcare delivery. The private sector is smaller in scale yet plays a significant role in first-contact healthcare, specialist services and diagnostic services. Medical officers who are employees of the state sector are legally permitted to work in the private sector during off-duty hours.

Sri Lanka has established its national AMR stewardship programme, guided by the National Strategic Plan 2021–2022, which was later updated to 2023–2028 and supported by the WHO. The programme is led by the Ministry of Health of Sri Lanka, in collaboration with the Sri Lanka College of Microbiologists. It focuses on promoting rational antibiotic use through implementing national guidelines, Access, Watch and Reserve (AWaRe) categorisation, and standardised prescription charts. Despite the stewardship programmes in place, evidence shows that community-acquired antibiotic resistance is on the rise,¹⁰ and current knowledge and correct practices regarding the rational use of antibiotics among prescribers in both state and private healthcare institutions are more critical than ever. Understanding the Sri Lankan context of AMR knowledge among doctors is paramount in planning and implementing strategies to reduce AMR in the country. The study’s primary objective, as described here, was to explore medical practitioners’ understanding of AMR and its aspects, including the causes and potential outcomes, as well as how doctors can contribute to the prevention of antibiotic resistance.

Methodology

A qualitative study was conducted for an 11-month period from June 2023 using one-to-one in-depth interviews. The study population included practising allopathic medical practitioners aged 18–60 years who had obtained complete registration with the Sri Lanka Medical Council. Participants were recruited using convenience sampling. Semi-structured interview guides with open-ended questions were employed in an unbiased and non-judgmental manner. Although the data collectors did not receive formal qualitative research training, all investigators who participated in data collection engaged in comprehensive research group discussions where interview techniques were extensively reviewed and practised. Multiple rehearsal sessions were conducted to standardise the interview approach and ensure consistency across data collectors. Interviews were conducted in English via video conferencing or in person, according to the participant’s preference, and lasted approximately 25–30 min on average. All interviews were audio-recorded and transcribed verbatim.

Pilot study

Before commencing data collection, the interview guide was piloted with a small advisory group of five practising medical practitioners to ensure the appropriateness, clarity and relevance of questions to the target population. The pilot participants were selected using convenience sampling and had similar characteristics to the main study population (registered medical practitioners aged 18–60 years). Pilot interviews were conducted using the same format as the main study (in-person or online, lasting approximately 25–30 min).

The pilot study results indicated that the interview questions were clearly understood and elicited relevant, detailed responses regarding AMR awareness and practices. Minor modifications were made to the interview guide based on pilot feedback, including rephrasing two questions for clarity and adding one probe question to explore antibiotic-prescribing pressures in private practice settings. Pilot participants were not included in the final study sample.

Data analysis

Thematic analysis was performed using an immersive approach. Interview transcripts underwent open coding, with codes subsequently categorised and grouped thematically. Two independent coders performed the analysis, followed by discussions to resolve discrepancies and ensure inter-coder reliability through consensus. Cross-coding was conducted to enhance reliability and validity. Data collection continued until saturation was achieved, defined as the point when no new themes or significant information emerged from successive interviews. An online questionnaire (a documented version of which is provided in online supplemental file 4) was administered to the same participants to facilitate data triangulation.

Patient and public involvement

A small advisory group of practising medical practitioners was consulted during the study design phase to ensure the relevance and appropriateness of the interview guide to the target population. No patients or members of the public were directly involved in the design, conduct or reporting of this research.

Ethical considerations

Ethical approval was obtained from the Ethics Review Committee, Faculty of Medicine & Allied Sciences, Rajarata University of Sri Lanka (No. ERC/2023/020). Potential participants were approached at their workplaces to assess willingness to participate.

Participants were approached directly at their workplaces or clinical practice settings. Complete registration with the Sri Lanka Medical Council (SLMC) was verified through examination of participants’ SLMC registration cards before enrolment. No personal data were obtained directly from the SLMC. The researchers described the study’s goals and procedure, and participants were allowed to ask questions or seek clarification. Written informed consent was obtained for participation, audio recording, transcription and anonymous publication of data. Audio recordings and transcribed data were stored in password-protected folders, ensuring secure access restricted to the research team only.

Results

Sample characteristics

The sample consisted of 21 medical practitioners (42.3% male). The mean age of the participants was 33.04 (SD ±5.19) years, and the mean duration of service as a registered medical practitioner was 6.15 (SD ±5.52) years (table 1).

Table 1. General characteristics of the participants.

Number	Sex	Age (years)
AMR/01/2023	F	Early 40s
AMR/02/2023	F	Late 30s
AMR/03/2023	M	Late 30s
AMR/04/2023	M	Early 40s
AMR/05/2023	M	Mid 40s
AMR/06/2023	F	Mid 40s
AMR/07/2023	F	Late 20s
AMR/08/2023	F	Late 20s
AMR/09/2023	F	Mid 30s
AMR/10/2023	F	Mid 30s
AMR/11/2023	M	Early 30s
AMR/12/2023	F	Early 30s
AMR/13/2023	M	Mid 30s
AMR/14/2023	F	Late 20s
AMR/15/2023	F	Late 20s
AMR/16/2023	F	Late 20s
AMR/17/2023	F	Early 30s
AMR/18/2023	M	Late 20s
AMR/19/2023	F	Late 20s
AMR/20/2023	F	Early 30s
AMR/21/2023	M	Late 20s
AMR/22/2023	F	Late 20s
AMR/23/2023	M	Mid 30s
AMR/24/2023	M	Early 30s
AMR/25/2023	M	Late 20s
AMR/26/2023	M	Early 30s

AMR, antimicrobial resistance.

The results are presented under the following categories and main subcategories, which were derived during the analysis (online supplemental file 5, table 2).

Awareness and identifying antimicrobial resistance as an issue among medical practitioners

Interviews conducted with allopathic medical practitioners in Sri Lanka underscored the escalating prevalence of AMR, which contributes to increased mortality rates and complications. Although numerical specifics were not provided, participants drew on extensive clinical experience to emphasise the gradual development of AMR across various clinical settings in Sri Lanka.

Antimicrobial resistance knowledge and experience in the Sri Lankan healthcare setting

All the interviewed medical practitioners were aware of antibiotic resistance, and the majority of them demonstrated a comprehensive understanding of AMR, attributing their knowledge to tertiary education and personal experiences. Furthermore, they highlighted the continual acquisition of insights through professional expertise and ongoing self-education. All participants believed that AMR had become a major health-related problem in Sri Lanka and had worsened over time.

We see 1/3 or 20%–30% of patients needing very high spectrum antibiotics, things like piperacillin, tazobactam or beyond that to control infections. We especially see many patients with urinary infections who require antibiotics. In the past, we used third-generation cephalosporins or Co-amoxiclav. However, nowadays, most of the time, we need to go beyond them to treat. (AMR/01/2023)

When I was an undergraduate, amoxicillin was one of the easily available, very inexpensive antibiotics doctors could prescribe. However, because doctors frequently use it for non-relevant cases, we have seen the development of resistance to amoxicillin …. Later, co-amoxiclav, a combination of amoxicillin and clavulanic acid, was distributed and super-efficient for everything. In the government outpatient departments and the private sector, doctors start co-amoxiclav even for simple coughs and fevers, so it is now recorded that there is a developing resistance for co-amoxiclav. Currently, for some patients with severe bacterial respiratory tract infections, oral co-amoxiclav is ineffective. I think this is one of the examples of antibiotic resistance. (AMR/10/2023)

I think the antimicrobial resistance in Sri Lanka is worse at the moment because even in hospitals, we see lots of culture reports with multi-resistant organisms, and for even simple infections, we may have to use very high-level antibiotics. I think in Sri Lanka, it’s a huge emerging problem. (AMR/11/2024)

Antimicrobial resistance: global situation

Although none of the interviewees could remember statistics on AMR in the global context, they universally recognised its substantial and escalating impact. Developed countries implement strict regulations on antibiotic usage, which have reduced the emergence of AMR, unlike developing nations, where these measures might be absent or not as rigorously enforced. In addition, they mentioned that there are currently limited antibiotics due to a lack of research on new antibiotic development being conducted.

Frankly speaking, I don’t know the exact figures as such. However, I know developed countries have stringent regulations on the usage of antibiotics. I think it’s a problem in developing countries, where there is no proper system to control ‘over-the-counter’ prescriptions. I think antimicrobial resistance might be much more prevalent in developing countries than in developed countries. (AMR/01/2023)

I don’t know what the extent of it is, but it is affecting the world. I think when antimicrobial resistance develops, since there’s a lot of migration, the resistance can propagate to a pandemic level. (AMR/07/2023)

I don’t know about the figures, but according to my knowledge, there is an increased prevalence of antibiotic resistance in the world, both in developed and developing countries. (AMR/24/2024)

Knowledge and understanding of factors contributing to antimicrobial resistance development

All the medical practitioners emphasised that healthcare providers play a significant role in developing AMR through the misuse of antimicrobials. The participants further noted that the behaviours of patients, pharmacists and doctors have contributed to the misuse of antimicrobial drugs, ultimately leading to the development of AMR.

Antibiotic misuse

All participants identified antibiotic misuse as the most important contributing factor to AMR. Several factors contribute to this issue, including doctors prescribing antibiotics unnecessarily, patients requesting antibiotics even when there is no actual indication, the inaccessibility of quick diagnostic tools and the unavailability of standard methods to control infections. All medical practitioners emphasised that everyone involved in healthcare needs to work together to prevent this problem from worsening and ensure that antibiotics remain effective for future generations.

Nowadays, people go to the pharmacy, tell their symptoms to the pharmacist and take antibiotics over the counter. It is totally a misuse of antibiotics. Most of our pharmacists issue antibiotics without a prescription from a doctor. Our doctors sometimes fail to take a proper history or conduct a thorough clinical examination. I don’t say always, but usually, in a private clinic setup, they don’t take proper history and don’t do proper examination of patients…. They don’t collect proper samples before starting antibiotics, so all these factors may lead to antibiotic resistance. (AMR/06/2023)

The first issue is the lack of knowledge regarding the topic among healthcare workers and the general public. Another issue is that people obtain antibiotics from pharmacies without a prescription, and another thing I think is that medical officers tend to give antibiotics in the private sector at the first visit to attract people to their medical centre. (AMR/25/2024)

Paediatricians, in their private clinics, sometimes have to start antibiotics on parents’ request. This occurs mainly in the private sector because they can insist on management. Most of the time, those parents lack a proper understanding of antimicrobial resistance, so according to their understanding, they try to influence the doctor to start antibiotics for their children. That’s a common request I have seen, so it has become a habit to prescribe antibiotics to fulfil the parents’ requirements. Even general practitioners prescribe antibiotics in that manner. The child could have come out of that infection due to the natural progression of the disease, but then parents might think, “ok, that is due to this antibiotic”, and next time when they come, they ask for the antibiotics. (AMR/01/2023)

I think in Sri Lanka, it’s a huge emerging problem, mainly because I think we misuse antibiotics because we try to start with very high doses and high antibiotics. Even in general practice, people often try to cure illnesses with two or three doses. I think mainly this antibiotic misuse is a huge problem in Sri Lanka. (AMR/11/2023)

Some doctors just want the quick response for illnesses for the patient so that they can attract patients to their private practice. We have to avoid that attitude. (AMR/01/2023)

Unavailability of antibiotics

Two participants cited the lack of appropriate antibiotics in government healthcare institutions as a reason for antibiotic misuse. Unavailability of proper antibiotics often leads medical officers to treat patients with whatever antibiotics are available, rather than the most suitable option. Similarly, in the private sector, practitioners may be compelled to prescribe readily available antibiotics in local markets that are affordable for the patients, irrespective of their appropriateness for the patient’s condition.

Strangely, we don’t have things like ampicillin or cefuroxime in the hospital wards! However, we have meropenem and cefotaxime. Although we want to start ampicillin, we don’t have the option, so we have to go for higher spectrum antibiotics. (AMR/01/2023)

In resource-poor settings like in Sri Lanka, sometimes even if you know that you can manage with first-line or second-line drugs, if only the third-line antibiotic is available, then you have to go for third line, especially when it comes to intravenous drugs. What is available has to be used. (AMR/02/2023)

Quality of available antibiotics

Nineteen participants indicated that although they like to follow the available guidelines to choose the appropriate antibiotic, seven of them noted that the quality of antibiotics available in the setup is not acceptable.

We get some idea from the NICE guidelines, but the choice of antibiotics depends on what is available in the hospital, and the duration of antibiotics also depends on many factors. Although the national guideline says that 3 to 5 days of antibiotics is enough for cystitis, we don’t practice that. We administer antibiotics for at least 7 days, as the quality and efficacy of the available drugs are not entirely certain. Thus, we can’t always go beyond the guidelines. We do take some guidance from the guidelines, but when we practice, sometimes we deviate from the guidelines due to practical things. (AMR/01/2023)

Especially, if you take third-world countries, the choice of antibiotics varies. The side effects and quality of antibiotics differ significantly from what we receive in Sri Lanka compared with what we would get in the UK or the USA. For example, co-amoxiclav in Lanka usually causes diarrhoea. (AMR/07/2023)

Antibiotics misuse in the veterinary field and agriculture farming

In Sri Lanka, the misuse of antibiotics is rampant due to lax regulations, as indicated by seven participants. According to them, people often obtain antibiotics over the counter, and pharmacists dispense them without proper prescriptions. This practice also extends to the veterinary field, where antibiotics are prescribed without accurate diagnoses, contributing to AMR. Despite a smaller animal agricultural sector compared with countries like India and New Zealand, Sri Lankan practitioners recognise the significant impact of veterinary antibiotic use on AMR, as these resistant genes can transfer through the food chain to humans. However, there’s a lack of comprehensive understanding among practitioners regarding the veterinary sector’s contribution to AMR.

I have heard of, but to be frank, I don’t have any evidence that they are using over-the-counter antibiotics on pets and animal farms without proper diagnosis or proper duration or dosage. (AMR/02/2023)

Antibiotic misuse did in veterinary, which has no such regulations in our country. (AMR/11/2023)

This statement reflects a participant’s perspective on AMR within the farming community.

Outdated guidelines and unavailability of reliable guidelines/unawareness about guidelines

One key point emphasised by participants is the crucial need for updated national guidelines on AMR tailored to specific settings in Sri Lanka. Interviewees highlighted the absence of comprehensive and regularly updated guidelines covering all infections, exacerbating the challenge of combating AMR effectively.

We have national guidelines, but to my knowledge, it has not been revised. The last guideline, I think it was, was published in 2012, and afterward, these national guidelines have not been revised. (AMR/01/2023)

Public awareness and knowledge of antibiotics and antimicrobial resistance

In Sri Lanka, 15 out of the 26 participants perceived a stark contrast in understanding of antibiotics and AMR between the general population and medical professionals. The public’s lack of awareness often leads to antibiotic misuse, whereas healthcare providers, though familiar with AMR, lack updated knowledge and precise figures, underestimating the gravity of the issue in the local context.

Most of the people in 1 to 2 days they stop the antibiotic when the symptoms are not there. That is a major problem. (AMR/02/2023)

Actually, most people are not completing the antibiotic course, and the other thing is they are doing doctor shopping. They take antibiotics from the one doctor, 1 to 2 days, then; if it is not answering, they go to another doctor, and he will prescribe another antibiotic. (AMR/03/2023)

Knowledge and understanding of outcomes of antimicrobial resistance

Healthcare impact

When infections become resistant to antibiotics, treating them becomes more challenging, according to the majority of the participants. This leads to prolonged hospital stays and increased healthcare costs. Additionally, three participants indicated that the prolonged use of broad-spectrum antibiotics can disrupt the body’s natural microbial balance, leading to secondary infections.

In essence, antibiotic resistance not only directly impacts patient health by limiting treatment options and increasing the severity of infections but also indirectly affects their quality of life through prolonged hospital stays, heightened morbidity and elevated mortality rates.

There can be an increase in virulence in the organisms, so you would find it difficult to treat even a simple infection that can disseminate and cause all the complications simply due to ineffectiveness of the antibiotic used, which can ultimately increase morbidity as well as mortality. (AMR/01/2023)

We see a lot of patients coming with multi-resistant urinary tract infections and respiratory infections, so that people can end up with long hospital stays and a lot of drug side effects. We may have to use very hi-fi antibiotics. Finally, they end up with renal impairment, and patients get complications. Patients can have very complicated courses and, because of that, very high mortality and morbidity. (AMR/11/2023)

Economic consequences

According to the participants, the economic consequences of AMR include the financial burden associated with antibiotic-resistant infections, including healthcare costs, lost productivity and expenses related to developing new treatments.

Most of the simple antibiotics are not answering, and we should consider strong antibiotics, as they will be costly. In Sri Lanka, we are in an economic crisis, so we may not have any antibiotics shortly. (AMR/03/2023)

Patient has used a lot of antibiotics frequently and awkwardly. Sometimes, the condition might not respond to the antibiotics we give, so this may take the patient’s time, money and good family time. The patient has to stay in the hospital for a long time, they have to spend a lot of money and quality family time will be lost, and on the other hand, they have to go for frequent investigations. (AMR/06/2023)

The antibiotic trials are very costly and all, so these very few antibiotics are coming. (AMR/11/2023)

Global health threat and community impact

The improper use of antibiotics in Sri Lanka doesn’t just endanger the local population; it also contributes to the global threat. As resistant pathogens emerge and travel across borders, they can fuel a pandemic. The participants explained this in the following quotes:

A doctor who is prescribing unusual doses or non-relevant antibiotics is not only harming the patient, but he is also prescribing to the community. Antibiotic resistance can develop within the community, so it can be a burden to the community as well. (AMR/10/2023)

Antibiotic effectiveness

Reduced antibiotic effectiveness is a critical outcome of AMR. The majority of participants emphasised the importance of preserving antibiotic effectiveness in combating bacterial infections and protecting public health.

There are few antibiotics. I think during this era, only a few antibiotics are in the world because no recent research has been done for antibiotics…. (AMR/04/2023)

Knowledge and understanding of the preventive measures of antimicrobial resistance among medical officers

Surveillance and monitoring

The participants highlighted the importance of surveillance systems for tracking antibiotic resistance trends and antimicrobial consumption patterns as preventive measures of AMR. According to their purview, such information should be used in decision-making and interventions related to AMR.

It is better to know the organism by region rather than going by countries. (AMR/10/2023)

Patient education

Many individuals emphasised the vital role of educating patients to encourage responsible antibiotic usage while they are under the doctor’s care. This education should include effective communication methods to convey the risks of antibiotic resistance and stress the importance of sticking to treatment plans.

If the patient is requesting to start on the antibiotic, I would talk with the patient, identify the concern and explain to the patient the problem with starting antibiotics. I will ensure that I will not prescribe antibiotics without a strong indication. (AMR/10/2023)

I always explain to them why I’m not giving an antibiotic unnecessarily, and I always tell them the difference between bacterial and viral infections. I explain which sort of infections the antibiotics can work for. (AMR/01/2023)

Multidisciplinary collaboration

Participants recognised the importance of teamwork among healthcare professionals, including microbiologists, pharmacists and infection control specialists, to tackle AMR effectively.

In the hospital setup, we get the microbiologist’s opinion. (AMR/02/2023)

We always take the microbiologist’s opinion and go ahead with antibiotics. (AMR/06/2023)

When escalating to high antibiotics, we usually get the microbiologist’s opinion. We usually make a referral so they know the extent of the patient’s condition and whether we are overprescribing or underprescribing. (AMR/07/2023)

Public health policies

The participants emphasised the significance of enhancing healthcare professionals’ awareness of current and evolving public health policies and guidelines concerning antimicrobial use and resistance surveillance. Many practitioners lack knowledge about existing policies, underscoring the need for better dissemination.

I think it’s time for us to look for health policies because it will invariably help us to improve awareness and improve guidelines, rules and regulations in this country as well. (AMR/07/2023)

Antimicrobial formulary restrictions

The participants emphasised the role of antimicrobial formulary restrictions and pre-authorisation.

My junior colleagues are not allowed to start antibiotics without a rational reason. Unless they can justify why, what is the need for the antibiotic? It’s to promote rational management, so in that way, we try to control as much as possible, and the other important thing. (AMR/01/2023)

Education and training

The doctors recognised the importance of ongoing education and training for healthcare professionals on AMR, including continuing medical education programmes and workshops on AMR prevention and management. This is a significant option for preventing AMR, as most healthcare professionals in Sri Lanka have not kept their knowledge up to date regarding this topic.

First, we have to brush up the knowledge of the prescribing doctors. Although they have got it from an undergraduate or medical school, it isn’t enough. The knowledge has to be revised frequently with the emerging evidence and all. (AMR/02/2023)

I think we have to improve the awareness among our doctors regarding antibiotic prescription. Thus, we have to start antibiotics when there are clear indications, and there should be culture and ABST available whenever possible, unless the patient is in septic shock. We have to change them according to the sensitivity pattern, and we also have to encourage doctors to go through the drug chart to see whether the duration of the antibiotic is decided and, when to stop the antibiotic, whether they are going in the correct frequency. I think awareness is critical as a doctor. (AMR/11/2023)

I think the education about the diseases and frequent reading is important to prevent this antimicrobial resistance. (AMR/24/2024)

Research and innovation

According to the participating medical practitioners, boosting research endeavours and innovations in creating novel antibiotics, diagnostic tools and treatment approaches, coupled with raising awareness about ongoing research, can effectively tackle emerging resistance patterns and combat AMR in Sri Lanka.

I would suggest you look into the actual data and try whether we can get an idea about the extent of this disease in the hospital setup; when you give data only, it will become valid. Whatever we say, it’s just a fact. It will invariably help us improve awareness, policies, guidelines, rules, and regulations in this country. (AMR/01/2023)

Discussion

This study showed a widespread awareness of AMR among medical practitioners in Sri Lanka. Medical practitioners recognise AMR as a significant health problem, attributing its rise to various factors such as antibiotic misuse, limited antibiotic availability and deficiencies in regulations and guidelines. This awareness is not limited to knowledge about Sri Lanka; participants also acknowledge the global impact of AMR, especially in developing countries where regulatory frameworks might be less stringent. Previous studies have also noted good awareness about AMR among medical practitioners worldwide.11,15

The findings of this study highlight several key factors contributing to the development of AMR in Sri Lanka, including antibiotic misuse driven by patient demand, inadequate diagnostic tools and the influence of pharmaceutical marketing practices. In the private healthcare sector, financial considerations and patient expectations significantly influence prescribing behaviours, contributing to widespread antibiotic misuse. The medical practitioners employed in private medical centres may feel compelled to meet these demands to retain their patient base, often resorting to broad-spectrum antibiotics as a quick fix. This practice contributes to the development of antibiotic resistance in the community.

Furthermore, some rural private and state general practice centres often lack resources for thorough patient investigations and face pressure to manage patient costs. Consequently, they rely heavily on clinical experience, patients’ signs, symptoms and initial antibiotic responses to prescribe. Cost considerations also influence antibiotic choices, sometimes leading to the prescription of cheaper options rather than the most suitable antibiotics. The antibiotic prescription is driven by the patient’s demands, despite the correct knowledge of healthcare practitioners, which has been highlighted by previous authors as well.¹⁵ Addressing this dynamic presents a critical challenge in promoting responsible antibiotic stewardship within Sri Lanka. One participant highlighted that although the doctors were willing to opt for the narrow-spectrum options, such as first-generation cephalosporins, they were compelled to prescribe more advanced antibiotics, as they were the only available options in government hospitals. The policies followed by the medical supplies authorities are not freely accessible; thus, the reason for this is unclear. However, limited data on antibiotic sensitivity patterns in the country has shown that for first-line options, a reasonable level of resistance has prevailed. For example, the National Laboratory-Based Surveillance of Antimicrobial Resistance (2011)¹⁶ found that coliforms showed 52.9% resistance to cefotaxime, whereas only 9% of the isolates were resistant to meropenem. Although the percentage-wise value is comparably high, the authors believe that the sample size of that surveillance is too small, and the sample selection may not be representative of the country. Thus, if the purchasing policies were taken based on the limited available evidence, they need to be reconsidered, and the research/ surveillance evidence should be sought out as soon as possible.

A key fact identified in the study is the poor adherence to the prescribed antibiotic regimen by the general population. According to the doctors’ understanding, patients typically discontinue antibiotics within 1 to 2 days once their symptoms resolve. This raises a question about the extent to which patients understand the importance of completing a full antibiotic course. Nevertheless, the practice of ‘doctor shopping’, that is, seeking multiple consultations when symptoms persist, leads to repeated antibiotic prescriptions. These patterns underscore the importance of examining the underlying causes of poor compliance, which may include gaps in awareness, inadequate patient counselling and misconceptions about antibiotic efficacy. Addressing these issues is essential for strengthening antimicrobial stewardship and reducing the risk of the development of community antibiotic resistance.

The Ministry of Health and the Sri Lanka College of Microbiologists, in collaboration, have developed a national strategic plan for the 2023–2028 period, which is a commendable effort. The present study was conducted in 2024. However, the doctors who participated in the study were unaware of such a plan. The interview, however, does not include direct questioning on the National Strategic Plan or any other steps taken by the government to any possible bias. The AWARe programme, which was launched in 2022 and included a comprehensive approach to educating medical students and healthcare workers, would also be a good step towards making the ordinary medical office aware of the possible ways they could contribute to AMR prevention. The participants emphasised the need for updated guidelines tailored to local contexts, increasing awareness of existing policies and promoting greater multidisciplinary collaboration among healthcare professionals.

Despite the development of a comprehensive national strategic plan for AMR by the Ministry of Health and the Sri Lanka College of Microbiologists, our findings reveal a significant communication gap between policymakers and frontline medical practitioners. Most participants were unaware of the existence of this national plan or its objectives, which points to insufficient dissemination and engagement strategies. This lack of awareness may undermine the effective implementation of policy measures at the clinical level, reducing their potential impact on antimicrobial stewardship. Improving communication channels and ensuring that updates, guidelines and strategic plans reach all healthcare providers, particularly those in private practice and rural settings, is critical. Without this, efforts to curb AMR may fall short, as knowledge and coordinated action among prescribers remain fragmented.

Furthermore, each doctor must stay up to date on policy updates. Participants pointed out the increased healthcare costs, prolonged hospital stays and increased morbidity and mortality associated with antibiotic-resistant infections. Moreover, the global nature of AMR underscores the need for coordinated efforts to prevent its spread across borders. The consequences of AMR extend beyond healthcare, encompassing economic and global health implications, as well as previously recognised.^{17 18}

This study has several methodological limitations that must be acknowledged. The use of convenience sampling may have introduced selection bias, limiting the representativeness of the sample. Medical practitioners who were more accessible or willing to participate may have had different levels of awareness or attitudes towards AMR compared with those not included, which could impact the generalisability of the findings. Additionally, the study did not explicitly sample practitioners from both urban and rural settings in a balanced manner; the contextual differences between these settings may influence prescribing practices and AMR perceptions but were not fully explored in this study. Another significant limitation is the potential influence of social desirability bias during interviews, where participants may have overstated positive practices or awareness related to AMR due to perceived expectations from the interviewer. Recall bias is also a possibility, as participants recount experiences and behaviours that may not have been entirely accurate. Furthermore, the relatively small sample size, typical for qualitative studies, limits the extent to which findings can be generalised to the broader population of medical practitioners in Sri Lanka.

Future studies employing probabilistic sampling, recruiting larger samples and including diverse settings would be valuable in providing more robust and representative insights into the factors influencing AMR awareness and prescribing practices. This study research identifies several preventive measures and solutions to combat AMR effectively. These include regulations, surveillance and monitoring systems to track resistance trends, patient education initiatives to promote responsible antibiotic use and multidisciplinary collaboration among healthcare professionals. Some of these have already been brought to the forefront, and steps have been taken to implement them. The national strategic plan for combating AMR is being worked on by the Sri Lanka College of Microbiologists, which should be appreciated, and some hope could be put in.¹⁹

Conclusion

This study sheds light on the critical issue of AMR awareness among medical practitioners in Sri Lanka. The findings underscore the urgent need for comprehensive strategies to address the multifaceted challenges posed by AMR. The efforts should target enhancing the good practices among medical practitioners, implementation of regulatory reforms and fostering multidisciplinary collaboration for a rational use of antibiotics. Further, the authors would like to stress the need for public education regarding AMR and its harmful effects on society owing to the inappropriate use of antibiotics.

Data availability statement

Data are available upon reasonable request.