Common Barriers, Attitudes and Practices of Veterinary Practitioners Regarding Antimicrobial Resistance and Stewardship in Bangladesh

Usage of antimicrobials in veterinary practices has always been under scrutiny due to the perceived risk of resulting in antimicrobial-resistant pathogens. This creates the necessity for understanding the role of the prescriber group. Hence, we conducted a cross-sectional survey among veterinary practitioners from August to November 2019 in the Chattogram district of Bangladesh, aiming to assess the practitioner’s perceptions regarding antimicrobial prescribing and antimicrobial resistance (AMR) issue. We collected responses from 100 veterinarians engaged in the treatment of the large animal, poultry, and pet animal through a self-administrated questionnaire. Proportions were calculated for categorical variables and the results are presented using visual aids. Our study revealed two key barriers - scarcity of enough information on antimicrobial used, and the lack of training in the proper prescription of antimicrobials. Participants recognized that prescribing too many varieties of antimicrobials and the use of an incomplete course of drugs as two very important causes for the development of antimicrobial resistance. In addition, prescription of inappropriate doses and incentives from pharmaceutical companies were dubbed as important causes. We also found that along with clinical features and types of organisms, the availability of drugs in the local market and the economic conditions of farmers have potential impacts on the antimicrobials prescribing decision of the veterinarians. However, all participants recognized the emerging threats of AMR. Results suggested that capacity building of veterinarians and the maintenance of strong coordination are crucial in ensuring the proper engagement of veterinarians as the front-line fighters for tackling the AMR issue.

antimicrobial stewardship, and operational and monitoring and evaluation frameworks still exist 5 .
Despite the efforts to promote the culture of prudent use of antimicrobials, antimicrobialresistant microbes (superbugs) continue to emerge. The veterinary sector is one of the major sector of concern that can lead to constrained the proliferation of antimicrobial-resistant microbes and play a key role in safeguarding both human and animal health. As a result, the fourth objective of BNAP focuses on the optimized use of antimicrobials, throughout the veterinary sector, which is critical in curbing the AMR issue 5 . Thus, the success of the existing and future interventions requires the active participation of veterinarians as a key player for administering antimicrobials in animals.
Even though researchers have investigated different antimicrobial resistance patterns of microorganisms and resistant genes, there has been either no or very few studies focusing on the role of veterinarians regarding AMR in Bangladesh. Therefore, this study attempted to understand the common barriers, practices, and attitudes of field veterinarians from different disciplines towards antimicrobial uses and antimicrobial resistance. Results could be used as baseline evidence to advocate the efficient interventions and action plans to tackle the AMR issue through improving the antimicrobial stewardship practices in Bangladesh.

Methodology Study Design
We carried out a cross-sectional survey among veterinarians who suggest antimicrobials in their everyday practices. Our target participants were all registered veterinarians involved in the treatment of large animals, poultry, and pet animals in the Chattogram district of Bangladesh, as well as interns and graduate students working in the teaching veterinary hospital under Chattogram Veterinary and Animal Sciences University (CVASU). Wildlife veterinarians were excluded from our study as they were very small in number and were less likely to prescribe antimicrobials in the study area. There were almost 150 veterinary doctors providing veterinary services in Chattogram, associated with government veterinary hospitals, private clinics, different private companies, or served as freelance-practitioners. Target students were almost 50 at the time of the survey. We employed purposive sampling to enroll participants from the target groups based on their willingness to participate. We drafted a semi-structured questionnaire that inquired into the barriers, attitudes, and practices of veterinarians in the English language and provided to each practitioner through direct meetings between the period of August to October in 2019. Before the interview, the purpose of the study was informed to all participants and oral consent was obtained from each of them. No incentives were given for participating in the survey.

Data Collection Tool
The survey questionnaire was designed in collaboration with experienced veterinarians, relevant researchers, and epidemiologists. The questionnaire was intended to extract information on demographics, barriers and factors influencing antimicrobial prescription, perception of threat, causes of AMR, commonly used antimicrobials beliefs and attitudes towards antimicrobial resistance and stewardship. Data collection was performed with the assistance of a group of trained veterinary students working as research intern under "One Health Center for Research and Action". Most of the questions contained Likert-type responses measured on a 5point scale from very important to least important but the questions regarding the perception of threat included strongly agree to strongly disagree. 'Unsure', 'neutral' and 'other' options were also provided in different close-ended questions.

Ethical Consideration
This study was carried out in accordance with the recommendations of the Chattogram

Results
Among total veterinary participants, 32% were engaged in the private sector, 23% in the government livestock department, 18% declared themselves as freelance-practitioners, 14% were interning doctors, and rest 13% were duty doctors in different institutional or private vet clinics.
The majority of participants (89%) were male and 11% were female. 61% of respondents acknowledged they have faced difficulties in selecting the correct antimicrobials during prescription. 63% of them also pointed out the scarcity of adequate sources of information on the use of antimicrobials and 67% claimed that they did not receive any formal training on antimicrobial prescribing within the last one year.
The perceptions of the participants regarding the contribution of different causes for the development of AMR have been presented in Figure 1. Prescription of wide varieties of antimicrobials and the ignorance of farmers to complete the full course of the drugs were two very important factors, selected by the respondents of the study, which leads to the rise of AMR.   The respondents were also concerned about the extent of negative impacts and risks created by AMR globally, nationally, as well as in their own practices, a concern which was also