Of the 294 medical staff members targeted; 287 completed the survey, giving a response rate of (97.6%). 188 (65.5%) from governmental hospitals and 99 (34.5%) from private hospitals. The proportion of female to male respondents was 58.2% vs. 41.8% respectively. 178 (62.1%) of respondents their age between 20-30 years; and 113 (39.4%) had experience between 3-5 years. 77 (26.8%) of respondents were from medical specialty and 67 (23.3%) were from surgical specialty. About 60.0% of participants were registrars while only 31% were house officers. Details of demographic characteristic of respondents were shown in Table 1.

(Table 2) shows that regarding AMR; of total respondents, 27.4% agreed that knowledge and poor skills were the important causes of inappropriate use of antimicrobials, 31.4% thought that providing local antimicrobial guidelines may help in control AMR, 45.3% rated that their colleagues in institution sometimes consider AMR problem before prescribing, 48.8% stated that inappropriate empirical therapy contributing to AMR. Regarding attitude in antibiotics prescribing; 39.4% of prescribers most of the time make sure that antibiotic is cost-effective when prescribing, about 98.0% consider AMR when decided to prescribe antibiotics either most of the time or some of the time, most of them 54.0% prescribe antibiotics for one week and positive microbiological results is the main factor influence decision of 37.2% of the prescribers.

a. Familiarity of Prescriber with Terms

More than quarter of healthcare professionals (26.4%) were familiar with the term antimicrobial stewardship whereas nearly half of healthcare professionals are not familiar with the term antimicrobial stewardship (49.7%). Figure 1:

b. Knowledge about ASP Effectiveness

(Figure 2) shows that; about half of participants they don’t know any information regarding statements of effectiveness of ASP asked. On average about one third of respondents replied that ASA is effective. Where (37.0%) respond that ASP effective in improving patient outcomes, (33.3%) respond its effective in improving patient safety, (34.1%) respond its effective in reduce health costs and about (31.5%) respond ASP is effective in reducing resistance.

Most of respondents (49.5%) do not know whether ASP play role in antimicrobial prescribing or not, while (43.0%) believe that ASP play vital role and (7.5%) do not believe it is play role on antibiotic prescribing. (23.1%) of respondents strongly agree sufficient education on ASP should be given to hospitals departments, (30%) agree and (2.9%) disagree with this statement. Unfortunately, (44.0%) of them don’t know.

Only 27 (9.5%) of respondents mentioned that they had ASP in their hospital, 39 (13.5%) having policy and team of ASP in their department and 65 (22.7%) saw evidence of ASP over the past years. An average of (40.0%) they do not have any ASP policy or team or saw ASP evidence and an average of (45.0%) they really don’t know about any of the statements mentioned, Figure 3.

The level of knowledge on antimicrobial stewardship was good among 130 (45.3%) of the participants. Positive attitude on antimicrobial stewardship was identified among 106 (36.9%). However; good practice was observed among small fraction 23 (8.0%) of the participants. There were observed correlation only between attitude with practice (P=0.0001), which means that prescribers with positive attitude had the better practices towards antimicrobial Stewardship.

Chi –square correlation test was made between demographic data and level of KAP of prescribers towards antimicrobial stewardship. The results showed that age, occupation and experience are significant predictors of prescriber’s knowledge and attitude towards antibiotic stewardship (P- value < 0.05), but not practice. No significance associations between level of KAP and gender, hospital type and specialty (p-value ≥ 0.05), Table 3.

Antibiotic resistance is an emerging public health problem, and resistance pathogens currently exist for which no first-line treatment is effective and is aggravated by the lack of development of new antimicrobial agents 37. It has been demonstrated that physicians will not alter their management practices unless they are both aware of and in agreement with the changes that are being proposed. Thus, a better understanding the knowledge, attitudes and practices of resident house staffs is crucial to efforts to reduce inpatient antibiotic resistance, as they prescribe a substantial portion of these agents in hospitals where problems of antibiotic resistance.38 However, to our knowledge, the KAP studies regarding ASP are not too many in Sudan, but studies regarding AMR are many. In this concern; we performed this cross-sectional study to assess knowledge, attitude and practices of prescribers toward the antimicrobial stewardship program. This study is focus extensively in registrars and house officers and to lesser extent to consultants and specialist, and includes physicians in medicine, surgery, pediatric and Obs/Gyn in six governmental hospitals and four private hospitals in Khartoum state. Majority of the respondents in our study was females (58.2%) and (62.1%) of the respondents were belongs to age of 20-30 years. (39.4%) of them have an experience of 3-5 years.

Physicians had a reasonable idea of AMR and the major factors contributing to the problem. Wide spread use and inappropriate use were believed to be important general causes of resistance by all of the respondents. A pervious study conducted in Sudan 2013 found that the same reasons were the main cause of AMR for 80.0% of respondents. 39 The prevalence of self-medication with antibiotics in the community in Khartoum State, capital of Sudan is alarmingly high and documented in several occasions. 40,41 However, physician s decisions in prescribing may be influenced by several factors such as patient clinical condition, cost-effectiveness of antibiotics, duration of empirical therapy. Antimicrobial resistance considered in prescribing decision to approximately all of respondents, only 2.2% of them AMR do not. In terms of practices related to prescribing, 37.2% agreed that microbiology lab results influencing prescribing decision to start antimicrobial therapy. Similar results obtained from a previous study assessing physicians' knowledge and perception of antimicrobial resistance; found updating about local antibiotic resistance pattern and accessing to current antibiogram (37.4 and 34.6% respectively) were the main cofounders.39 Carla et al. 42 reported that "physician s education about antimicrobial therapy" and "knowing pathogens and antimicrobial susceptibility" were ranked as the 2 most important strategies (44.2% and 30.3%). Current antibiograms for the most hospitals in our country are not readily available and there is need of improving access to results of local antimicrobial susceptibility tests because there is currently no feedback to the staff about the local resistance trends at the surveyed hospitals. In addition to that acquiring antibiotics without a prescription from pharmacies in Khartoum State does seem to be a cultural artifact of the loosely regulated sales of antibiotics in Sudan.

As far as knowledge of stewardship programs is concerned all health professionals had fair knowledge regarding the familiarity of the term Antimicrobial stewardship program only (26.4%) know the term. However, (49.7%) of participants did not know the term and a significant percentage of them had never heard of the term ASP (20.9%), which indicates paucity of implementation strategies and education regarding various stewardship programs across the capital state hospitals. This was high when compared to studies conducted in Ethiopia36 and India43 (10.3% and 15.0% respectively) of health care providers stated they were, not familiar with i.e., never heard the term. This might be due to the absence of education, basic training and promotion of antimicrobial stewardship program across the country. (46.4%) of participants feel ASP is very effective and effective in improving patient outcomes, (44.5%) in improving patient safety, in reducing resistance (57.5%) and reducing healthcare costs (45.7%). There are very few participants who feel antibiotics stewardship is not effective (4.7%, 4.7%, 6.2%, and 6.5% with respect to the statements asked). Surprisingly ranges of (36.3%-50.4%) of respondents answered "I don't know" for the above mentioned points. These findings are in agreement with several studies done about KAP towards ASP.44,45 A major reason for the large scale prescription of antibiotics is inadequate knowledge about the consequences of bacterial resistance. Contradictory reducing antibiotic use through implementation of stewardship programs was believed effective in ameliorating resistance by only (57.5%). This discrepancy may be due to a lack of awareness of the effectiveness of antibiotic restriction or to skepticism about its feasibility in actual practice.

The attitude of the study participants with regards towards stewardship program was found to be casual and lax. About half of respondents (49.5%) don t know the role of ASP of their practice, (45.3 %) of participants was not believed that other doctors in institution consider the potential of AMR. (43.0%) was believed antimicrobial play a role. (53.1%) of participants feel that they need sufficient education about ASP. Providing education on antimicrobials stewardship for health professional were also suggested as the most important interventions by other studies. 35,46 Regarding the practice of AS polices on their hospitals only (9.5%) apply AS programs. A survey of Australian hospitals 47 found that only 4.8% of private hospitals restricted the use of broad-spectrum antimicrobials versus 93.8% in the public metropolitan sector. For the implementation of an AS program, team efforts and interdisciplinary involvement of different health care professionals are mandatory. Unfortunately, such practices to have team and policy were being performed by only (13.5%) the participants of this study in their hospitals. This is consistent with findings from other surveys, which showed that physicians preferred voluntary changes in prescribing practices, rather than interventions, which imposed limitations. 25,48 There was much less support in interventions that restrict physicians' behavior and practice such as antibiotic restriction and antibiotic polices interventions, perhaps because they restrict physician s autonomy and complicate antibiotic prescribing practice. The findings of this study draw attention toward interprofessional issues that must be resolved. Otherwise, the positive attributes of AS programs will be difficult to achieve

The level of knowledge of the respondents showed that it was good among moderate numbers of respondents 130 (45.3%). However most of them showed negative attitude towards ASP 106 (63.1%) and majority showed poor practice 264 (92.0%). There was no observed correlation between knowledge and attitude, knowledge with practice (p-value ≥ 0.05). Only attitude with practice shows significance correlation (P=0.0001), which means that prescribers with positive attitude had the better practices towards antimicrobial stewardship. This is consistence with other study.36 Age, occupation and experience are the only significant predictors of prescriber's knowledge and attitude towards antibiotic stewardship, while no association between these factors and practice. Our findings were parallel with other studies results which indicated that demographic characteristics were unrelated to KAP. 49,50 The likelihood of producing behavioural change in professional practice improves if interventions are adapted to address institution specific barriers and limitations. Success of any ASP is ultimately dependent on the education of prescribers to influence change on the prescribing culture of an institution. While many ASP may focus on restricting antibiotics or the development of policies, if prescribers themselves are not actively engaged, effects of ASP interventions will most likely be minimal and short-lived, and efforts may outweigh the benefits of such interventions.

Reviews of ASP from around the world have shown that ASP is still evolving as we gain more experience. Accordingly, the Ministry of health should develop and adopt guidelines and policies to implement and monitor antimicrobial stewardship in all government and private health institutions country wide with continuous audit. Results of audits have to highlighted for us areas that we need to focus on in the future and the need for further audits to review the success of stewardship programs and interventions. This study has some limitations. First, preceptor-ship is a volunteer contribution at surveyed institutions, and there is no official registry of preceptors; therefore, questionnaire was distributed only to those whom the data collector encountered during their routine service hours at the hospitals; as majority interviewed were registrars, with low experience. Secondly, as with most surveys, it is possible that respondents might give socially desirable answers, rather than their true opinions or practices. Finally, one may question whether the attitude of doctors in other parts of Sudan to antimicrobial stewardship is reflected by the results of this survey. As this survey was conducted in the limited numbers of public and private hospitals, the generalizability of the results to other health care settings remains to be demonstrated.