Physicians' perspectives on antimicrobial resistance and rational antibiotic prescribing

Antimicrobial resistance poses a growing global threat. In real-world practice, antimicrobial prescribing is shaped by clinicians' cognitive biases and perceptions of resistance risk, potentially driving unnecessary broad-spectrum antibiotic use and increased antimicrobial pressure.

We conducted a questionnaire-based study among physicians to assess perceptions on antimicrobial resistance magnitude, determinants of prescription, and barriers to de-escalation. Clinician-estimated resistance rates were compared with observed data, and the main factors influencing antimicrobial prescription were analyzed.

82 physicians were surveyed; 76% were attendings; 37% internal medicine, 30% pediatrics, and 11% infectious diseases (adult and pediatric). Clinicians consistently overestimated carbapenem-resistant (CR) Klebsiella pneumoniae and Escherichia coli, methicillin-resistant Staphylococcus aureus, and VRE (Holm-adjusted P < .001). Non-ID clinicians overestimated resistance rates compared with ID physicians (CR E coli 26.7% vs 8.8%, CR K pneumoniae 23.4% vs 10.0%, MRSA 35.6% vs 16.6%, and vancomycin-resistant Enterococcus spp 28.3% vs 12.2%, all P < .05).

This study reveals a gap between perceived and observed resistance rates, indicating cognitive biases that favor broad empirical therapy and delayed de-escalation. Differences by specialty underscore the role of specialized training, while fear- and severity-driven decision-making reflects a defensive prescribing approach that may undermine antimicrobial stewardship efforts.