title: "If it's a broad spectrum, it can shoot better":inappropriate antibiotic prescribing in Cambodia.
abstract: BACKGROUND
  Cambodia is affected by antibiotic resistance but interventions to reduce the level of resistance require knowledge of the phenomena that lead to inappropriate prescribing. We interviewed physicians working in public hospitals to explore the drivers of inappropriate antibiotic prescribing.
  
  
  METHODS
  Hospitals participating in a knowledge, attitudes and practices survey prior to this study were purposively selected and physicians were randomly recruited to participate in focus group discussions. Nvivo version 10 was used to inductively code the qualitative transcripts and manage thematic data analysis.
  
  
  RESULTS
  Inappropriate antibiotic prescribing was a common practice and driven by seven factors: prescribing habit, limited diagnostic capacity, lack of microbiology evidence, non-evidence-based clinical guidelines, perceived patient demand, poor hygiene and infection control, and perceived bacterial resistance to narrow spectrum antibiotics."Every day, doctors are not performing appropriately. We have made lots of mistakes with our antibiotic prescribing."When a patient's clinical condition was not responsive to empiric treatment, physicians changed to a broader spectrum antibiotic and microbiology services were sought only after failure of a treatment with a broad-spectrum antibiotic. This habitual empirical prescribing was a common practice regardless of microbiology service accessibility. Poor hygiene and infection control practices were commonly described as reasons for 'preventive' prescribing with full course of antibiotics while perception of bacterial resistance to narrow-spectrum antibiotics due to unrestricted access in the community resulted in unnecessary prescribing of broad spectrum antibiotics in private practices.
  
  
  CONCLUSIONS
  The practice of prescribing antibiotics by Cambodian physicians is inappropriate and based on prescribing habit rather than microbiology evidence. Improvement in prescribing practice is unlikely to occur unless an education program for physicians focuses on the diagnostic capacity and usefulness of microbiology services. In parallel, hygiene and infection control in hospital must be improved, evidence-based antibiotic prescribing guidelines must be developed, and access to antibiotics in community must be restricted.
authors.affiliation: School of Public Health and Community Medicine, UNSW Medicine, UNSW, Level 3 Samuels Building, Sydney, NSW 2052 Australia.
authors.forename: Chhorvoin
authors.identifier: 0000-0002-2987-4460
authors.initials: C
authors.lastname: Om
authors.affiliation: Diagnostic Microbiology Development Program, # 23 (First Floor), Street 310, BKK 1, Khan Chamcar Morn, Phnom Penh, Cambodia.
authors.forename: Frances
authors.initials: F
authors.lastname: Daily
authors.affiliation: Institute of Tropical Medicine, Nationalestraat 155, Antwerp, 2000 Belgium.
authors.forename: Erika
authors.initials: E
authors.lastname: Vlieghe
authors.affiliation: Diagnostic Microbiology Development Program, # 23 (First Floor), Street 310, BKK 1, Khan Chamcar Morn, Phnom Penh, Cambodia.
authors.forename: James C
authors.initials: JC
authors.lastname: McLaughlin
authors.affiliation: School of Public Health and Community Medicine, UNSW Medicine, UNSW, Level 3 Samuels Building, Sydney, NSW 2052 Australia.
authors.forename: Mary-Louise
authors.identifier: 0000-0003-0453-8425
authors.initials: ML
authors.lastname: McLaws
keywords: Antibiotic resistance; Infection control; Microbiology; Prescribing habit; Preventive; Qualitative study