Understanding how veterinarians' knowledge, attitudes, and practices influence antibiotic prescription: a systematic review of survey studies.

Introduction: The misuse and/or overuse of antibiotics in animals has been a subject of concern due to the intensification of antimicrobial resistance (AMR). Veterinarians are at the front line of antibiotic prescription and their decision-making process is impacted by several non-clinical factors. The aim of this systematic review was to identify and understand how veterinarians' attitudes, knowledge, perceptions, and experience influence antibiotic prescription practices.

Methods: We systematically searched MEDLINE/PubMed, Web of Knowledge, and CAB International databases. Quantitative and mixed methods studies with veterinary graduates were included, with no time restrictions. Articles written in English, Spanish, and Portuguese were considered. Quality assessment was performed with JBI's cross-sectional critical appraisal tool.

Results: Our search retrieved 4722 documents, with 59 being included. Articles' publication year ranged from 2004 to 2023, with most (n = 55) using a quantitative approach, and the remaining ones (n = 4) using mixed methods. Veterinary practices were categorized into four groups: livestock (n = 24), small animals (n = 14), equine (n = 5), and mixed practice (broader scope; n = 17). Intrinsic factors identified as potentially influencing veterinarians' antibiotic prescription included: socio-demographic factors (n = 39) and attitudes and concerns: self-confidence (n = 31); need to satisfy clients' expectations (n = 19); fear (n = 27); lack of knowledge (n = 21). Extrinsic factors were also identified in several studies: clients' lack of knowledge and/or training regarding AMR, appropriate antimicrobial use, and good production practices (n = 24); substandard hygiene conditions and biosecurity protocols (n = 14); time constraints (n = 4); cost of laboratory tests (n = 12); antibiotic policies and/or guidelines (n = 22); antibiotics cost (n = 20), and withdrawal period (n = 11); animal-related factors (n = 21), namely breeding and animals' behavior.

Conclusion: This systematic review provides an updated and comprehensive understanding of non-clinical factors that can influence veterinarians' antibiotic prescription practices. High client demand, self-confidence, need to satisfy clients' expectations, deficient biosecurity, fear, lack of awareness from animal owners and farmers about AMR and appropriate antimicrobial use, and inadequate policies/guidelines were associated with higher antibiotic prescription among veterinarians. Many of the identified factors are potentially modifiable. Within the One Health approach, this can help in the design of interventions focusing on appropriate antibiotic use in animals to tackle AMR.