Introduction

An antibiotic is any chemical compound, derived from a living organism or produced synthetically, whose therapeutic activity is manifested at very low doses, specifically by inhibiting bacterial growth (bacteriostatic effect) or destroying the bacteria (bactericidal effect).1,2

Alexander FLEMING’s discovery in 1928 of the inhibition of the growth of a colony of Staphylococcus aureus in the presence of a Penicillium culture led to the discovery of penicillin and ushered in the era of antibiotics. Other antibiotics were then developed, which was a great advance for medicine.3–5

Despite this extraordinary progress, the use of antibiotics has led to the emergence of bacterial resistance. Bacterial resistance to antibiotics is a complex phenomenon, resulting from the natural evolution of microbes.6 However, it has been intensified by human activity, which not only accelerates the rate at which micro-organisms develop, but also by selective pressure due to the overuse of antibiotics in humans, animals and agriculture.7

In the case of penicillin, discovered in 1928, the first signs of resistance were recorded as early as 1940. Prepared in 1948, tetracyclines and macrolides have experienced resistance since 1953 and 1985, respectively.4,5

According to the World Health Organization (WHO), bacterial resistance to antibiotics is one of the three main threats to public health in the 21st century.8 Bacterial resistance to antibiotics calls into question the ability to treat even the most common infections. All healthcare sectors and all bacterial species are affected. Limiting its spread requires comprehensive, concerted prevention based first and foremost on the correct use of antibiotics, hand hygiene and the prevention of factors that encourage infections.9 This implies the commitment of healthcare providers, who also seem to be unaware of the scale of the problem.10

In view of the scarcity of data on healthcare providers’ knowledge, attitudes and practices on the subject, across the global, African and regional literature; it was important that an assessment be carried out among healthcare providers in the provincial city of Kinshasa after which conducted in Kisangani in 2011,11 in order to find out what they really know about the issue or problem of bacterial resistance to antibiotics.

We therefore sought to find out whether the professional profile of healthcare providers really influences the situation of bacterial resistance to antibiotics. The sole aim of this study was to assess the knowledge, attitudes and practices of healthcare providers in the city of Kinshasa.

Materials and Methods Setting

This study took place in the provincial city of Kinshasa, which is also the capital of the DRC. It covers an area of 9965 km2 and has a population of around 12,641,463. It is subdivided into four administrative districts (Tshangu, Funa, Mont-Amba and Lukunga). The city of Kinshasa has 35 Health Zones (HZ), 21 of which (2 rural, 1 urban-rural and 18 urban) were selected for the study. These 21 HZs comprise 26 health facilities, including 25 general referral hospitals and one tertiary-level health facility represented by the “Cliniques Universitaires de Kinshasa”. The choice of these 25 health facilities was dictated by their membership of the Kinshasa provincial health division, as shown in Figure 1.

Figure 1 Study Health zones and settings in Kinshasa provincial health division.

Type and Period of Study

This is a cross-sectional, descriptive, multicentre study. It took place from 2 December 2019 to 29 February 2020, a period of three months.

Study Population

The study population consisted of healthcare providers, including doctors, nurses and trainees in their final year of medical study.

Inclusion Criteria All doctors (general practitioners or specialists), nurses and trainees in their final year of medical studies who were officially part of the nursing staff in the health facilities selected for the study; Were present at their place of work or place of training on the day of the survey; Having freely agreed to take part in the study by completing the study questionnaire.Sampling

We used convenience sampling to select the health zones and health facilities. This choice was guided by feasibility, as these health facilities are those managed by the provincial health division of Kinshasa and belonging to the State and therefore easily accessible administratively.

As regards the choice of healthcare providers at the level of health facilities, we proceeded by stratified random sampling proportional to the population selected. To achieve this, we obtained from the Kinshasa provincial health division (“Bureaux de Gestion de Ressources et d’Appui Technique”) a list of the general referral hospitals selected, together with their respective staffing levels in terms of doctors and nurses.

For trainees in their final year of medical studies, we obtained their numbers from the respective directorates of the general referral hospitals. The study population consisted of doctors, nurses and trainees working in the selected health facilities. The sample size was proportional to the population size of each category of healthcare provider in each health facility.

The sample size was calculated using Schwartz’s formula: n = Z2 P(1-P)/d2

n- sample size = 430 (n calculated)

Z- confidence interval = 95% (1.96)

P- expected proportion = 50% (0.5)

d- tolerated margin of error = 5% (0.05).

This being the case, we needed the population size (N) to calculate the actual size of our sample using the following formula: No = n/(1+n/N).

Data Collection

Information was collected from healthcare providers (doctors, nurses and trainees in their final year of medical study) using a questionnaire-based interview with SMART phones (Tecno W5 Lite and SAMSUNG Galaxy A2, South Korea 2018) equipped with the KOBO Collect application.

Variables of Interest

General characteristics: gender; age; qualification of the healthcare provider; seniority of the healthcare provider; department in which the healthcare provider is assigned within the hospital.

Variables relating to knowledge of antibiotics: antibiotic resistance worldwide, in the DRC, in daily practice; overuse of antibiotics in the community; confidence in knowledge of antibiotics; antibiotic prescribing; estimated rate of Klebsiella spp. resistance to Ceftriaxone; factors contributing to antibiotic resistance in the DRC.

Variables related to the attitude of the healthcare provider: attitude towards the microbiology laboratory; attitude towards microbiology laboratory results; teaching or training on antibiotics; source of information on antibiotics.

Variables relating to the practice of antibiotic therapy: practice of prescribing antibiotics and antibiograms; practice of using antibiotics against certain bacteria; practice of using antibiotics in certain situations; proportion of febrile patients prescribed an antibiotic; proportion of prescribers who request biological tests before prescribing an antibiotic.

Survey Instrument

The survey instrument was developed on the basis of an earlier questionnaire used for a study carried out in Kisangani in 2011,11 which we translated from English into French, and adapted by adding other questions suggested by infectiologists from “Cliniques Universitaires de Kinshasa”. And a pilot study was conducted with 40 health providers; before launching the actual survey.

The survey ultimately comprised 41 valid questions.

Fifteen questions concerned healthcare providers’ knowledge of antibiotic therapy and bacterial resistance to antibiotics; Eleven questions concerned attitudes to antibiotic therapy and bacterial resistance and to the microbiology laboratory service; Ten questions related to antibiotic therapy practices by healthcare providers; In addition, information was collected on the sources of information used (n = 2 subdivided questions); Three questions dealt with socio-demographic and professional characteristics. A knowledge score was calculated as the sum of correct answers to these questions. One point was awarded for each question on knowledge of antibiotic use and bacterial resistance. The total score was 11. Four scores were established: excellent (9–10), very good (7–8), good (5–6) and not so good (<5).Data Analysis

The data were entered using the KOBO Collect application installed on Android phones and then downloaded, at the end of the survey, on a laptop running Office 2013, including Excel 2013. After verification and cleaning, the data were exported to SPSS version 21.0 for analysis.

Descriptive statistics were used to describe the basic characteristics of the survey data. Means and standard deviations were calculated for normally distributed continuous variables, while proportions were calculated for categorical variables. Pearson’s chi-squared test or Fisher’s exact test were used to test associations between dependent variables and each independent variable. A significance level of α = 0.05 was used for the tests.

Results

Of the 430 respondents included, 428 had been interviewed, giving a participation rate of 99.6%. Of the 428 respondents recruited, 54.7% were nurses followed by 35.2% doctors.

The most representative age group was between 35 and 49 years (43%) and the average age was 38.7 ±10.6 years. Two hundred and thirty-one respondents were female (54%). The sex ratio was predominantly female (1.17).

Fifty percent of respondents had been with the company for 1–5 years, 37.1% for more than 5 years and 12.9% for less than a year (Table 1).

Table 1 Socio-Demographic and Professional Characteristics of Respondents

Respondent Recruitment Department

Recruitment was carried out in all the departments of the selected hospitals, but with a fairly large number in internal medicine (n = 114, ie 26.6%), followed by paediatrics (n = 100, ie 23.4%), surgery (n = 99, ie 23.1%) and finally gynaeco-obstetrics (n = 90, ie 21.0%). A small number of healthcare providers participated in the anaesthesia-intensive care unit (n = 9 ie 2.1%) and in the following specialities: otorhinolaryngology, dentistry, ophthalmology (n = 6 ie 1.4%) and other related services (n = 10 ie 2.3%), as shown in Figure 2.

Figure 2 Respondent recruitment services.

Sources of Information on Antibiotic Use

The most frequently consulted source of information was the internet (56.5%), followed by antibiotic usage guides and leaflets (42.2%). Over 85% of doctors and trainees in their final year of medical school consulted the internet more often than nurses (31.2%), with a statistically significant difference (p<0.0001).

On the other hand, nurses were more likely to consult antibiotic usage guides and leaflets, followed by pharmaceutical representatives and pharmacists, compared with doctors and trainees in their final year of medicine, with a statistically significant difference (p<0.0001). In addition, more than 65% of final-year medical trainees used lecture notes compared with doctors and nurses (31.2% and 22.6% respectively), with a statistically significant difference (p<0.0001).

The WHO guide to the management of infectious diseases was consulted more often by a third of final-year medical trainees, followed by doctors (23%) and nurses (10.2%), with a statistically significant difference (p = 0.0002) (Table 2).

Table 2 Sources of Healthcare Providers’ Knowledge of Antibiotic Use

Knowledge of Healthcare Providers About Antibiotic Therapy

Out of a score of 11, the average score was 4.5/11 points. Only 1.9% (n = 8) of respondents had obtained an excellent score (9–11); a very good score (7–8) was obtained by 9.1% (n = 39) of respondents. The good score (5–6) was obtained by 37.4% (n = 160) of respondents. The other respondents (51.6%, ie n = 221/438) had a worse score (<5).

The most difficult questions were those concerning: the treatment to be given in the event of upper respiratory tract infection (40 correct answers/428, 9.3%), then whether or not to reduce the dose of antibiotic in the event of renal failure (60 correct answers/428, 14.0%) and finally recognition of the local rate of resistance of Klebsiella spp. to ceftriaxone (54 correct answers/428, 12.6%). For the first two questions, doctors and nurses seem to have the same level. The last question made a difference, with a fairly good percentage (33.3%) of trainees in their final year of medical study answering correctly, compared with (8.5%) and (11.5%), respectively, of doctors and nurses, with no statistically significant difference (p = 0.2009).

In addition, more than 40% (47.9%, 205/428, p<0.0001) of respondents gave a correct answer to the question relating to lower respiratory tract infection in a 35-year-old man, with a significant difference, and for the question relating to urinary tract infection in a 50-year-old patient, half of respondents (50.7%, 217/428, p<0.0001) gave a correct answer, again with a significant difference. Finally, more than half the respondents (56.8%, 243/428, p<0.0001) gave a correct answer to the question relating to meningeal infection with Gram-positive lanceolate diplococcus in a 10-year-old patient, with a statistically significant difference.

In addition, less than 20% of respondents (17.1%, 73/428) correctly answered the question on the treatment to be given to a 50-year-old diabetic with a coagulase-negative staphylococcal infection, namely: Local care with physiological solution alone.

In addition, more than 20% (21.0%, 90/428) of respondents gave the correct answer, ie no antibiotics to be prescribed for a patient whose stools contain Salmonella non Typhi, while more than 10% (12.6%, 54/428) clearly gave the percentage (50–75%) of Klebsiella spp. resistance to ceftriaxone in the DRC (Table 3).

Table 3 Percentage of Correct Answers from Healthcare Providers According to Knowledge of Antibiotic Therapy

Attitudes, Knowledge of the Current Extent of Bacterial Resistance to Antibiotics and Other Factors

The practice of self-medicating antibiotics in the DRC was recognized by 94.2% of respondents as being one of the causes of bacterial resistance to antibiotics. Self-medication was known to be a practice favoring bacterial resistance in the DRC by almost all doctors (n = 150, ie 98.7%) and trainees in their final year of training (n = 41, ie 97.6%), and by the majority of nurses (n = 212, ie 90.5%), with a statistically significant difference (p = 0.0025) (Table 4).

Table 4 Knowledge of the Current Extent of Bacterial Resistance to Antibiotics

Ninety percent (90.4%) of respondents agreed that hand hygiene limits nosocomial infections. The majority of our respondents, including doctors (93.4%), recognized that hand hygiene was a factor limiting the spread of nosocomial infections, followed by nurses (89.7%) and finally trainees in their final year of medical studies (83.3%), with a statistically non-significant difference (p = 0.1262).

Eighty-seven-point seven percent of respondents agreed that the local level of bacterial resistance should be known before prescribing an antibiotic. The importance of knowing the local level of bacterial resistance before prescribing antibiotics was recognized more by doctors (n = 138, ie 90.9%), followed by nurses (n = 200, ie 85.4%) and finally by trainees in their final year of medical studies (n = 37, ie 88.0%), with a statistically non-significant difference (p = 0.2993).

Bacterial resistance to antibiotics was recognized as a problem in the DRC by 81.3% of respondents. This was primarily the case for doctors (n = 142, ie 93.4%), followed by trainees in their final year of medicine (n = 38, ie 90.4%) and finally nurses (n = 168, ie 71.7%), with a statistically significant difference (p<0.0001).

Bacterial resistance was recognized by 74.8% of respondents as a problem in their daily practice. Seventy-one percent of respondents recognized bacterial resistance as a global problem. For both variables, the finding was the same for all categories of provider, with a statistically significant difference (p<0.0001).

Practices, Factors Guiding Healthcare Providers’ Choice of Antibiotic to Prescribe

The majority of respondents (n = 387, ie 90.4%) considered it useful to have the results of the antibiogram before prescribing an antibiotic, and 319 (74.5%) thought that the antibiogram facilitated the correct choice of antibiotics to be prescribed.

More than half of the doctors (n = 85, ie 57.9%) acknowledged that they adapted the antibiotic therapy after the results of the susceptibility test, compared with a third of the nurses (n = 77, ie 32.9%) and final-year medical trainees (n = 13, ie 30.9%), with a statistically significant difference (p<0.0001).

Over 60% (n = 263/438) of respondents (nurses, trainees in their final year of medical studies and doctors) were able to prescribe antibiotics on the advice of a colleague.

In addition, the majority of doctors (n = 99 ie 65.1%) admitted prescribing antibiotics on the basis of their availability, followed by a third of final-year medical trainees (n = 16 ie 38.0%) and nurses (n = 85 ie 36.3%), with a statistically significant difference (p<0.0001). However, half of the nurses (137 ie 58.5%) and a quarter of the doctors (37 ie 24.3%) as well as a quarter of the trainees in their final year of medical studies (11 ie 26.2%) would have liked to have received training in the rational prescription of ATBs before prescribing them, with a statistically significant difference (p<0.0001).

In addition, more than 60% (150/234) of nurses, followed by a third (16/42) of trainees in their final year of medicine, were able to prescribe antibiotics at the request of patients, with a statistically significant difference (p<0.0001).

Finally, less than half of the 175 respondents (40.9%), represented by around 60% of the doctors, said that they took account of the results of the antibiogram when adapting antibiotic therapy (Table 5).

Table 5 Factors Guiding Healthcare Providers’ Choice of Antibiotic to Prescribe

Discussion

The aim of this study was to help promote the rational use of antibiotics and the reduction of bacterial resistance by improving the knowledge, attitudes and practices of healthcare providers in Kinshasa.

The results of this study showed that respondents had a low level (4.5/11) of knowledge about the indication for antibiotics and laboratory (microbiological) data. A concerning direct correlation exists between the low average knowledge scores of healthcare professionals in Kinshasa regarding antibiotic prescription practices and their prescribing behaviors. This knowledge deficit contributes to issues such as over-prescription, unnecessary prescriptions, and the inappropriate selection of antibiotics. Consequently, these practices have a detrimental impact on patient outcomes, resulting in increased antimicrobial resistance, treatment failures, prolonged illnesses, higher mortality rates, and increased healthcare costs. It is imperative to address these concerns within the healthcare setting to enhance patient care and mitigate the risks associated with antibiotic misuse.

A direct link can be established between knowledge levels and clinical decisions. The low knowledge score is a fundamental driver of poor prescribing practices and clinical decisions.12 However, other factors, such as providers’ attitudes towards using microbiology services to guide their prescribing, did not have enough influence on their decision to prescribe antibiotics. Only 40.6% of our respondents used the results of the antibiogram to adapt antibiotic therapy.

Knowledge of the Indication for Antibiotic Therapy

The overall mean score for the knowledge questions (4.5/11 points) was lower than the result of the similar survey carried out in Kisangani (4.9/8 points) and Peru (6.0/7 points).11,13 This difference is thought to be due to the methodology used in these previous studies, which used the self-administered questionnaire technique, whereas in the present study, the data were collected by means of an interview, and therefore there was no possibility of consulting a colleague or note to copy the response. Also, in the present study, the majority of respondents (54.7%) were nurses, whereas in Peru and Kisangani studies the majority of respondents were doctors. Doctors were better equipped than nurses because of their training. This would probably be linked to the pre-requisites for antibiotic therapy, taking into account the academic background of these different categories of healthcare provider.

Given the current proportion of incorrect responses for upper respiratory tract infection, the majority of respondents (90.7%) will initiate antibiotic therapy. This is clearly a target for future intervention. Similarly, it is striking that many respondents did not know the level of local Klebsiella spp. resistance to ceftriaxone. The disproportionately low awareness of local resistance rates (eg, only 12.6% knew Klebsiella spp. resistance to ceftriaxone) is a critical issue with severe implications for patient care and the fight against antimicrobial resistance. This lack of awareness stems from several interconnected factors such as weak or absent surveillance systems, poor data dissemination and communication channels, insufficient training and education and financial constraints. With all the above-mentioned reasons highlighted the need for more robust local epidemiological surveillance and reporting systems is not unexpected in an environment with few microbiology laboratories, such as the DRC.14 Similar results have been observed in Peru13 but also in industrialized countries.15 Among the indicators of antibiotic prescription patterns, the WHO has listed the proportions of cases of diarrhea and upper respiratory tract infection treated with antibiotics. According to a compilation of community studies, the proportion of patients receiving antibiotics in both conditions varies between 40 and 60%.16 In the present study, however, we found that this proportion was higher, at 90.7%.

The present study showed a low level of theoretical knowledge about the indication for antibiotics, which was particularly noticeable among nurses. Similar results have been reported by other authors, notably in Ethiopia and the Gambia, where doctors showed a better knowledge of antibiotics than nurses.17,18 This lower proportion of nurses than doctors who indicated the correct treatment of simple diarrhea and viral infections of the upper respiratory tract reflects the level of irrational prescription of antibiotics. Even though they make up the majority of healthcare providers. This observation was also made in a study carried out in the Gambia on antibiotic prescribing practices in health establishments.18

Doctors showed a better (46%) level of knowledge about the use of antibiotics than students (43%). This is not surprising, as the doctors have some experience in prescribing and using antibiotics, whereas the students are still in the process of training. Our results are similar to those found in Kisangani11 and Riyadh.19

Antibiotic Prescribing Attitudes and Practices and Bacterial Resistance

Bacterial resistance to antibiotics (which was considered to be the most important consequence of inappropriate antibiotic use in our survey) was reported to be, firstly, a problem in the country and, secondly, a problem in healthcare facilities worldwide. The virtual non-existence of microbiology laboratories in health facilities was thought to explain this state of ignorance, as has also been reported elsewhere.11 But also the lack of training in full employment, as other studies have shown.11,18,19 In Kinshasa and the entire Democratic Republic of Congo, and like in other low and middle-income countries, laboratories and point-of-care are practically non-existent; in Kinshasa, there is one reference laboratory for the country; however, its capacity must be strengthened on all levels. Currently, there are two tools being developed in the field of microbiology, particularly in bacteriology: the MiniLab® which is a point-of-care and the Antibiogo® application. Once these are implemented and evaluated in our environments, they would be of major benefit.

Factors Guiding Prescribing Decisions and Recommendations for Improving Antibiotic Prescribing

Although more respondents reported that the results of microbiology analyses (antibiogram) are necessary for the choice and correct prescription of antibiotics, the majority do not rely on the results of the antibiogram to choose the appropriate antibiotic for patients with an infectious disease of bacterial origin. Similar practices have been reported in The Gambia and Namibia.18,20

It is not surprising that most respondents said they did not use microbiology laboratories, as in all countries with limited resources, in the DRC microbiology laboratories are rare. What’s more, even where laboratory services exist in certain hospital structures, the maintenance of these laboratories and the regular supply of inputs are lacking, thus affecting their services and the availability of results.21 This high level of perceived value indicates an understanding of the importance of the use of antibiograms in guiding appropriate antibiotic therapy and combating antimicrobial resistance. However, the significant gap between this agreement and their widespread use points to substantial structural and logistical barriers such as laboratory access and infrastructure, the limited availability of microbiology labs, lack of essential equipment and reagents and the high cost of diagnostic test are the significant problems we have, like in other low- and middle-income countries.

When making prescribing decisions, factors such as advice from a colleague on their previous knowledge of antibiotics or quick reference leaflets were highly valued, especially by nurses. These were the most available sources. This is consistent with the results of the Gambia study.18 The availability of unbiased information about antibiotics is a prerequisite for appropriate antibiotic prescribing.22

In the current context, several observations have been made. Firstly, information from pharmaceutical companies is ranked highest in terms of accessibility. Although it is least appreciated for its usefulness. This confirms the leading role of the pharmaceutical industry as the main source of information in the contexts of countries with limited resources. However, it is worrying that drug promotions in these contexts are not always content-oriented or based on scientific evidence.23 On the other hand, antibiotic usage guides, and in particular the WHO guide, were less used. As expected, university courses were much more of a source of information for final-year medical students than for doctors and nurses, which highlights the potential role of university teaching as a forum for intervention in antibiotic prescribing. This observation was also made by the study conducted in Kisangani.11 Is here the place to emphasize, the need for ongoing training in microbiology for healthcare providers, in order to strengthen their ability to prescribe antibiotics rationally. In contrast to previous studies in middle-income countries,13 in the present study, it should be noted that the internet was the source most consulted, according to their statement, by more than half the respondents, in contrast to the study by Thriemer et al.11 This could be explained by the fact that, today, there is more access to the internet than there was more than a decade ago, and the socio-economic level being different in the two cities (Kinshasa and Kisangani). Integrating WHO and national treatment guidelines, into electronic platforms represents a powerful intervention that would significantly enhance antibiotic decision-making in Kinshasa, provided certain conditions are met in the context of low- and middle-income countries. However, its success is contingent upon addressing fundamental infrastructural, financial, and well-trained, qualified human resource challenges to ensure widespread adoption and effective utilization. Because many healthcare providers believe that if they do not prescribe antibiotics to patients who request them, they will be considered incompetent. And this could lead to patients being referred elsewhere.12

In the present study, we did not insist on the collaboration of infectious disease specialists and microbiology laboratories, given their very limited numbers. To improve antibiotic prescribing, respondents clearly indicated the need for local guidelines, prescribing training and a course on antimicrobial stewardship must be include in medical curricula, as reported in other studies around the world.11,12,14,18,19 In our country, like in low- and middle-income countries, the tailored CME (Continuing Medical Education) programs are better than a point-of-care mobile application. However, mobile health solutions should not be neglected, as they are proving increasingly necessary for better patient care, especially in less well-off communities like ours.24

Limits and Strengths of the Study

This study had certain limitations. Respondents in the subgroups of doctors, nurses and final-year medical trainees had different levels of experience, making it difficult to generalize the results. In addition, as most of the questions were structured with fixed options to choose from as answers, respondents may have selected the most favorable and socially acceptable answers. To limit these problems, respondents were assured of strict confidentiality and additional response options were provided in some questions, although only a small percentage of respondents completed them. As with all cross-sectional surveys, these results provide only a snapshot of one possible cause of inappropriate antibiotic prescribing.

Nevertheless, this study has the merit of being the first in Central Africa and the second in Sub-Saharan Africa to have questioned all the key players (doctors, nurses and trainees in their final year of medical school) about antibiotic prescribing.

KAP studies provide much-needed information on antibiotic prescribing. They are complementary to the monitoring of bacterial resistance to antibiotics and their consumption, which constitute prime information for devising possible interventions on the rational prescribing of antibiotics.16

Given that this survey had a very high response rate and included different levels of healthcare providers who are the main providers of patient care in several healthcare settings, the results reliably provide the most important factors influencing antibiotic prescribing among different healthcare providers and could be applicable in comparable settings.

Conclusion

This study has shown that there is little knowledge of the antibiotic indication, and only a minority of respondents use microbiology analyses as a guide for therapeutic decision-making, even when the results are available. Furthermore, the results of our work show that the situation is not very reassuring, and deviant behavior by healthcare providers remains a major concern.

Thus, if antibiotics are to be used rationally and bacterial infectious diseases treated effectively, the importance of organizing active microbiological surveillance of bacterial resistance to antibiotics and regular training programs must be stressed.

Finally, a collective awareness is needed to fight effectively and sustainably against the scourge of bacterial resistance to antibiotics.

Abbreviations

KAP, knowledge, attitudes and practices; HZs, Health Zones; WHO, World Health Organization; ATBs, antibiotics; DRC, Democratic Republic of the Congo; ie, id est; CSF, cerebrospinal fluid; IV, intravenous; med, medication; PO, per os; +, associated; mHealth, mobile health; CME, Continuing Medical Education.

Data Sharing Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethics Approval and Consent to Participate

This study was conducted in accordance with the 2016 Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects.

The protocol for this study was approved by the Ethics Committee of the Kinshasa School of Public Health under number ESP/ CE/ 124/ 2019.

A consent form was given to each respondent and read by him or her, then explained by the investigator, and the respondent was informed that he or she could withdraw from the study at any time without any consequences for him or herself or any personal benefit for participating in the study. However, the results obtained could contribute to the advancement of knowledge in the field of bacterial resistance to antibiotics.

Acknowledgments

The authors would like to thank all the health authorities in the provincial city of Kinshasa and all the doctors, nurses and trainees in their final year of medical studies who willingly took part in this study.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This study was financed out of our own funds.

Disclosure

The authors declare that they have no conflicts of interest.

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