The point-prevalence study was performed for the time period of 1^st of January to 30^th of April 2020. This data was collected by the clinical pharmacist in a secure databased (Excel). Training was provided for the clinical pharmacist on data entry using a structured data collection tool. The point-prevalence survey was performed by members of the AMS team on all admitted patients prescribed at least one antimicrobial agent for suspected or confirmed infection.

The following data were extracted from the EMR:

1. General Information: patient demographic information such as age and gender, hospital length of stay, intensive care admission, comorbidities such as diabetes mellitus, renal impairment, the requirement of hemodialysis, penicillin allergy, and if any surgery performed during current admission.
2. Antimicrobial related information: prescriber special- ity, indication for antimicrobial prescription, antimi- crobial international non-proprietary name, start date, dose, frequency, route of administration.
3. A.M.S. team intervention related Information: whether intervention is needed or not and type of intervention, and prescriber agreement with A.M.S. recommen- dations and 72 hours review of antimicrobial prescription.
4. Ordered tests related information: collected micro- biological cultures, isolated organisms, multiplex poly- merase chain reaction, and radiological examinations.

Statistical Analysis was done using Excel program. Descriptive statistics were used to describe the baseline demographic data and clinical characteristics. Categorical variables are presented as counts and percentages, whereas continuous variables are presented as mean.

Community-acquired infections: if patients presented with infection less than 48 hours from hospital admission [4].

Hospital-acquired infections: if patients presented with infection more than 48 hours from hospital admission [4].

Appropriate antimicrobial prescription: antimicrobial prescription is considered appropriate if it is complying with the recommendations of the Infectious Disease Society of America (IDSA) practice guidelines in terms of indication, antimicrobial used, dose, frequency, route, and duration [5-11].

Prospective audit and feedback: defined as a review of the antimicrobial therapy by the AMS team after the agent has been prescribed accompanied by suggestions to optimize use [12].

Antibiotic course: defined as any a single or combination of antimicrobials prescribed for a suspected or confirmed infection.

Polymerase Chain Reaction (PCR) Multiplex Test: a technology that is used for rapid and simultaneous detection of multiple organisms and resistance markers using a fluorescently labeled probe and more than one primer [13].

A total of 666 patients were reviewed during the study period. The mean age is 42.2 ± 15.58 years (14-92 years). Fifty-four percent (54%) were males. The mean hospital length of stay is 6.7 ± 11.55 days (1 – 130 days). Fifteen patients (2.25%) died during this period. Table 1 lists patients' characteristics and comorbidities.

Table 1
Patients characteristics.

Characteristic	Number
Male	360 (54%)
ICU admission	96 (14.4%)
Diabetes mellitus	94 (14.1%)
Creatinine level > 120 mmol/L	38 (5.7%)
Hemodialysis	12 (1.8%)
Cancer	43 (6.4%
Surgery during current admission	79 (11.8%)
Penicillin allergy	28 (4.2%)

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Table 1
Patients characteristics.

A total of 771 infectious diagnoses were recorded (Table 2). Some patients were having more than one episode of infection during their hospital stay (105/666). Out of all diagnoses, 3.2% (25/771) were hospital-acquired, and 96.8% (746/771) were community-acquired. There were 11 cases of hospital-acquired pneumonia, 5 cases of ventilator-associated pneumonia, 4 cases of Clostridioides difficile, 3 cases of catheter-related bloodstream infection, one case of catheter-associated urinary tract infection, and one case of surgical site infection.

Table 2
Top 15 infectious diagnoses.

Diagnoses	Number
Community-acquired pneumonia	135 (17.5%)
COVID-19	124 (16.1%)
Intra-abdominal infection	75 (9.7%)
Influenza	67 (8.7%)
Bronchitis	57 (7.4%)
Urinary tract infection	45 (5.8%)
Gastroenteritis	29 (3.7%)
Skin and soft tissue infection	22 (2.8%)
Pharyngitis	22 (2.8%)
Obstetrics/gynaecological Infection	21 (2.7%)
Tonsillitis	20 (2.6%)
Sepsis of un-identified source	15 (1.5%)
Hospital-acquired pneumonia	11 (1.4%)
Aspiration pneumonia	10 (1.3%)
Meningitis	6 (0.8%)

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Table 2
Top 15 infectious diagnoses.

Respiratory tract infection was the most common diagnosis encountered, followed by intra-abdominal and urinary tract infections. Table 2 lists the top 15 infectious diagnoses.

In 37 cases (4.8%), antimicrobials were prescribed for non-infectious diagnoses, such as renal colic (9 cases), biliary colic (6 cases), non-infectious diarrhea (6 cases), intestinal obstruction (3 cases), non-specific abdominal pain (2 cases), cough (3 cases), hemorrhoids (2 cases), non-infective exacerbation of certain chronic diseases such as sickle cell vaso-occlusive crises (3 cases), inflammatory bowel disease (2 cases) and chronic obstructive pulmonary disease (1 case).

Antibiotics were also prescribed for patients with a confirmed viral infection (7.1%/55/771). Out of 124 patients with confirmed COVID 19, 72 patients received antibiotics (58%). Seventy percent (70%) of antibiotics prescribed for those patients were not indicated. Other confirmed viral infections that were prescribed antibiotics inappropriately are infectious mononucleosis (2 cases), dengue fever (one case), and cytomegalovirus infection (one case).

More than 77% of patients (44 out of 57 cases) diagnosed with bronchitis received antibiotics unnecessarily. Similarly, 72% of patients with acute pharyngitis (16 out of 22 cases) and 27% (8 out of 29 cases) of patients with gastroenteritis were on antibiotics without clinical or laboratory indication.

A total of 994 courses of antimicrobials were prescribed during the study period. The internal medicine department accounted for 310 courses/31.1%, followed by pulmonology (203 courses/20.4%) and intensive care unit (152 courses/15.2%). One thousand three hundred ninety-one (1391) antimicrobials were prescribed, of which 1074 (77.2%) were started empirically, and 317 (22.8%) were started based on culture or PCR multiplex report. Table 3 lists the antimicrobial prescribed.

Table 3
Prescribed antimicrobials (Total 1391).

Antimicrobial	Number
Ceftriaxone	263 (18.91%)
Lopinavir / Ritonavir	121 (8.70%)
Metronidazole	110 (7.91%)
Hydroxychloroquine	92 (6.61%)
Levofloxacin	91 (6.54%)
Oseltamivir	87 (6.25%)
Meropenem	67 (4.82%)
Cefuroxime	58 (4.17%)
Clarithromycin	56 (4.03%)
Piperacillin/Tazobactam	51 (3.67%)
Moxifloxacin	50 (3.59%)
Amoxicillin clavulanate	46 (3.31%)
Chloroquine	42 (3.02%)
Ciprofloxacin	35 (2.52%)
Azithromycin	32 (2.30%)
cefepime	30 (2.16%)
Ertapenem	25 (1.80%)
linezolid	20 (1.44%)
Amikacin	13 (0.93%)
Caspofungin	13 (0.93%)
Favipiravir	11 (0.79%)
Vancomycin	11 (0.79%)
Others*	67 (4.82%)

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Table 3
Prescribed antimicrobials (Total 1391).

The antimicrobial prescription was considered 'appropriate' in 70.3% (979/1393), and as 'not indicated' in 19.7% (273/1393) of cases. In the remaining 10% (141/1393) of cases, antimicrobials were indicated but required AMS team intervention such as dose modification or therapeutic drug monitoring. Table 4 lists the interventions suggested by the AMS team. The MRP agreed with 135 (32.6%) AMS team Only 4.6% of recommendations were made after patients were discharged.

Table 4
Antimicrobial stewardship team interventions (Total 141).

Intervention	Number
Change antimicrobial	48 (34.0%)
Add antimicrobial	20 (14.18%)
Increase frequency of antimicrobial	19 (13.48%)
Increase dose of antimicrobial	19 (13.48%)
Add loading dose	14 (9.93%)
Decrease dose of antimicrobial	6 (4.26%)
Decrease frequency of antimicrobial	5 (3.55%)
Therapeutic drug monitoring	5(3.55%)
Add blood/microbiological test	4 (2.84%)
De-escalate	1 (0.71%)

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Table 4
Antimicrobial stewardship team interventions (Total 141).

More than 50% of antimicrobials prescribed were reviewed at 72 hours (53.4%/743/1391). Out of 743 antimicrobials that were reviewed at 72 hours, 30% (221/743) required (A.M.S.) team interventions. Stopping the antimicrobial agent was the most common recommendation (70%/155/221), followed by increasing the dose (9%/20/221) and changing antimicrobial agent (6.3%/14/221). The M.R.P. agreed with 32.1%/71/221 of the AMS team review recommendations.

In this study, we found a total of 29.7% of antimicrobial prescriptions were either not indicated (19.7%) or required AMS interventions (10%). In the US, several studies have found a comparable prevalence of unnecessary antimicrobial prescriptions. Hecker et al. (2003) found that 30% of antimicrobial days were unnecessary [14]. A prospective, observational study conducted in Cleveland, Ohio, found that 39% of fluroquinolone days were deemed unnecessary [15]. Similar results have been found in other countries. A study conducted in 18 tertiary care hospitals in Turkey, 25.7% and 15.9% of prescriptions were considered clinically and microbiologically inappropriate, respectively [16]. In the United Kingdom, there is a high rate of inappropriate antimicrobial prescriptions in general practice, especially for otitis externa (67.3%) and upper respiratory tract infections (38.7%) [17]. In the Netherlands, only 46% of antibiotics prescribed to treat respiratory tract infections by general practitioners adhered to guideline recommendations [18]. Some countries have an even higher prevalence of inappropriate antimicrobial prescriptions. In longitudinal surveillance conducted in Pakistan, 70.3% had at least one inappropriate antimicrobial, and 62.8% of patients with respiratory tract infections were considered to have inappropriate therapy [19].

In our study, we found the following three clinical scenarios where antimicrobials were often prescribed inappropriately:

1. Non-infectious aetiology, such as biliary colic, renal colic, and non-infective exacerbation of certain conditions such as chronic obstructive pulmonary disease, representing 4.8% of all cases.
2. Treating confirmed viral infection with antibiotics such as COVID-19, cytomegalovirus infection, and dengue fever, representing 7.1% of all cases.
3. Treating some self-limiting conditions, which are most commonly caused by viral infections such as bronchitis, gastroenteritis, and pharyngitis.

The compliance to AMS team recommendations in our study was only 32.6%, which is considered low compared with other studies. Singh et al. (2018) reported 54% compliance with AMS recommendations in their research [20]. Thakkar et al. (2011) implemented a plan-do-study-act ('PDSA') approach to improve compliance with AMS recommendations. Over 11 months period, the compliance has increased from 30% to 71% [21]. In a retrospective quasi-experimental study conducted in a university hospital in London over 12-months, more than 98% of AMS team interventions were accepted by medical/surgical teams [22]. A study to evaluate the compliance with AMS recommendations found that it was 90.5% for medical services and 82.1% for surgical services [23]. A study of 160 patients used a care bundle for AMS consisting of documentation of indication for antibiotic prescription, collection of cultures before antibiotic use, appropriate empiric antibiotic, de-escalation to a narrower spectrum agent based on culture results. The rate of acceptance of AMS recommendations was 91% [24].

Several factors are leading to the low compliance with AMS recommendations at our hospital, including physicians' resistance to change, lack of hospital-based guidelines for the treatment of common infections, and pressures from patients and families.

In a study of the barriers facing AMS at small hospitals in the US, it was found that the lack of dedicated ID-trained staff, time constraints, insufficient IT support, and limited financial resources were among the main barriers to AMS in hospitals having less than 200 beds [25]. Baubie et al. (2019) studied the barriers to AMS implementation at a 1,300-bed tertiary- care private hospital in Kerala, India [26]. They identified high antibiotic use in the community, high physician workload, physician resistance to change, and limited availability of a clinical pharmacist as barriers to AMS implementation. An interesting finding in the study conducted in a tertiary- care hospital in Ethiopia is that fear of treatment failure and retribution from senior physicians were significant reasons for broad-spectrum antibiotic prescription, especially among junior physicians [27]. Enani (2016) evaluated antimicrobial stewardship programs in Gulf Cooperation Council (G.C.C.) countries using a cross-sectional questionnaire survey. The majority of responders (75%) reported a lack of funding and personnel as significant barriers to program implementation. Ten percent of responders reported resistance from prescribers as a considerable barrier to A.S.P [28].

An effective AMS is a key factor in reducing antimicrobial resistance. In our study, the prevalence of inappropriate antimicrobial prescription is similar to that found in other studies worldwide. However, the compliance with AMS recommendations is much lower than described in several other studies. Finding the reasons behind this low rate will be of great importance to find solutions to overcome the barriers for implementing AMS at our hospital.