Antimicrobial resistance (AMR) is considered a global health and development challenge. It is rising the human and animal morbidity and mortality rates while increasing the prevalence of AMR organisms in the environment [1]. It is an emerging global challenge that is thought to account for more than 700,000 human deaths annually [2]. For decades, microbes, particularly bacteria, have become increasingly resistant to various antimicrobials. The World Health Organization estimates that AMR is responsible for a staggering number of deaths annually. A 2019 WHO report estimated that 1.27 million deaths were directly attributable to bacterial antibiotic resistance. In addition, WHO projections are even more alarming, that by 2050 AMR could cause 10 million deaths each year, incurring a cumulative economic cost of a staggering $100 trillion USD [3].

Estimate of bacterial AMR in WHO African region from clinical and surveillance data bases and national antimicrobial consumption data confirm a substantial burden for the current and future health of the continent [4]. African countries have inadequate laboratory facilities to monitor AMR which hugely contribute to increasing drug resistance globally. In fact, resistance has been reported for diseases such as typhoid, cholera, meningitis, dysentery, TB, malaria and AIDS. Between 2008 and 2011 cotrimoxazole resistance was reported against Vibrio cholerae from affected countries. In the contrary, same pathogens remained extremely sensitive to quinolones and cyclines [5].

The burden of antimicrobial resistance (AMR) in Kenya goes further to confirm AMR as a global challenge. In Kenya, there’s no readily available data on the exact number of deaths attributable solely to AMR, but studies suggest a concerning situation. The 2019 WHO report on global AMR estimates that 8,500 deaths in Kenya were attributable to AMR, with an additional 37,300 deaths associated with AMR [6]. Kenya has the 177th highest age-standardized mortality rate per 100,000 populations associated with AMR across 204 countries. These numbers highlight the potential impact of AMR on mortality in the country. Consequences of irrational treatment and erroneous diagnosis, unregulated antimicrobial use, knowledge gap in antimicrobial courses, side effects and dosage limits are found to be the leading causes of AMR [7]. AMR has resulted to hard-to-treat infections with previous working antibiotics depicting unforeseen future in health care [8]. In addition, AMR has impacted serious infections and long hospitalizations, increased treatment failures and increased costs in healthcare [9]. Irrational use of antibiotics is catalysed by buying over the counter antibiotics without prescriptions. LMIC private retail chemists are potential primary patient care areas for self-prescribed antibiotics among patients [10]. Inappropriate antimicrobial use in LMICs hospitals has been fuelled by poor antimicrobial stewardship activities, deficit surveillance and diagnostic facilities and lack of antimicrobial treatment guidelines [11]. In LMICs, the AMR is worsened by: (i) inaccessible to rational antimicrobial therapy [12]; (ii) feeble regulations in the treatment and dispensing of antimicrobials for humans [13]; (iii) feeble audits and surveillance of AMU and AMR levels [13]; (iv) standard treatment guidelines that are not updated [14]. Inadequate community knowledge, poverty, lack of healthcare services has potentiated to inappropriate antimicrobial use (AMU) [15]. With the rates of AMR increasing worldwide and very few new antibiotics being developed, existing antibiotics are becoming a limited resource. It is therefore essential that antibiotics only be prescribed and that last-resort antibiotics be reserved for patients who truly need them. This responsible use is the foundation of the concept of antimicrobial stewardship (AMS).

According to the World Health Organization (WHO), antimicrobial stewardship is defined as “A battery set of actions which fuels the responsible use of antimicrobials. This definition can be actionable at the personal level as well as national and global level, and across human, animal health and the environment” [16]. This was originally coined for application in the hospital setting to optimise antimicrobial use, leading to the term "antimicrobial stewardship" (AMS) [17]. The idea has since enlarged to incorporate the governance of the health sector as a whole, accenting responsibility for population health and comfort, managing health systems at national and global levels [17]. Today, the three pillars of an integrated approach strengthening health systems, are AMS, infection prevention and control (IPC) and medicine and patient safety. Linkages of these pillars to other important activities of infection management and robust AMR surveillance and a dependable quality medicines supply, will ultimately contribute to the goal of achieving universal health coverage [18]. The World Health Organization (WHO) announced AMR as a major global problem and started a global action plan to combat the challenge [2]. Therefore, enhancing knowledge and surveillance skills was one of the parts of this action plan endorsing a universal antimicrobial resistance surveillance system. The WHO’s global strategy highlighted the need for appropriate antibiotic use along with the critical role of healthcare workers [19]. Effective implementation of the plan will help control AMR by promoting the careful use of antimicrobials [18].

Health care providers including doctors, pharmacists, and nurses play a key role in tackling antimicrobial resistance because they have the insight and knowledge to prescribe and dispense antibiotics during clinical practice as well as in promoting patients’ compliance to therapies and avoid self-medication [20]. Unfortunately, the misuse and overuse of antibiotic prescriptions by health care providers has been found to be a problem [21]. Roughly, studies have reported that 30-50% of patients in hospitals have incorrect indication for antibiotic, the antibiotic of choice or the dosage limit. Study in China showed that 30-60% of intensive care units cases, had inappropriately prescribed antibiotics [22]. Minimizing the irrational use of antibiotics is the best way to curb the spread of AMR, and this can be done by behaviour change in prescribing and dispensing practices among healthcare providers.

Evidence focused questionnaires like knowledge, attitude and practices (KAP) surveys can be used to analyse the factors influencing health care providers’ prescribing and dispensing behaviours [23]. In recent past, studies have shown insufficient knowledge on rational use of antibiotics among Chinese medical undergraduate students [24]. In addition, the medical students would self-prescribe unnecessary antimicrobials for infections [25]. Furthermore, a study in United States of America showed that knowledge and attitude regarding antibiotic use differed among antibiotic Hispanic consumers and non-Hispanic consumers. In fact, Hispanic consumers believed antibiotics could cure colds, thereby self-prescribing antibiotics, as well as obtaining antibiotics from grocery stores, family and friend or using earlier illness unconsumed antibiotics [26]. Self-prescribing is associated with increased antibiotic resistance as you miss appropriate judious provider care and opt to visit grocery shops to buy over-the counter antibiotics [27]. In India, one study reported that laypeople had rough idea and knowledge about AMR and AMS [28]. In contrary, a study done in Egypt showed health care providers had a good knowledge and attitude about AMS [29]. In addition to that Nigerian study conducted in tertiary hospitals reported that knowledge and attitude of antimicrobial prescriptions and AMR is wanting worsened by physicians’ inappropriate antibiotics prescriptions [30].

Furthermore, one particular study conducted in Bhutan strongly supported the need to involve the community pharmacies as participants in training and policy making processes to help address growing threat of antimicrobial resistance [31].

Therefore, we conducted a KAP survey to evaluate the awareness of antimicrobial usage and antimicrobial resistance among public and private tertiary care hospitals (levels 3,4 & 5) in Kisii County, Kenya, as such important information is lacking in Kisii.

This KAP survey on AMS, is aimed at addressing the growing threat of AMR in the region through understanding the health care providers’ knowledge, attitudes and practices on prescription and dispensing of Antimicrobials. This data will go a long way in enhancing insightful knowledge and understanding of AMR among healthcare workers in Kisii County through effective communication, education, and training programs.

Nevertheless, strengthening the existing knowledge and evidence-based practices in our region will be through conducting consistent surveys, surveillance and research activities within the Kisii County healthcare system and promoting the optimisation of antimicrobial use to public health sector.