Responses were obtained from 50 respondents per country across the four HCP groups of interest (Table S1 in the Supplementary Material). Participant characteristics are outlined in Table 1. A total of 189 (63.0%) worked in a public setting, and 288 (96.0%) had more than 6 years of experience in their field.

Providers View Diagnostic Practices to Have a Positive Impact on AMS Activities and Patient Outcomes

Participants were asked to outline how diagnostic technologies (Table S2 in the Supplementary Material) are used within their hospital inpatient setting. Traditional, culture-based testing was routinely used for all patients with symptoms of infection by 82.7% of participants. More advanced diagnostics were less frequently utilised for all patients with symptoms of infection (7.0–43.0%). Next-generation sequencing and matrix-assisted laser desorption/ionization-time of flight gas chromatography mass spectrometry (MALDI-TOF GC–MS) were rarely used routinely in all countries (0.0–16.0% and 4.0–20.0%, respectively). There was slightly higher routine usage of next-generation sequencing in China (16.0%) and MALDI-TOF GC–MS in the USA (20.0%). Instead, more participants considered these advanced diagnostics to be used on a case-by-case basis for selected or severely ill patients.

To gain insight into the impact and utility of current diagnostic practices at their hospital, participants were asked to select factors that in their opinion improved patient, economic, and AMS outcomes. Most participants reported diagnostic practices led to the following outcomes at their hospital: treatment adjustment (86.3%), early and accurate detection of pathogens (82.7%), treatment de-escalation (81.3%), improved patient outcomes (81.0%), spectrum of antibiotics being narrowed (79.0%), decreased inappropriate use of antibiotics (78.3%), organisational economic outcomes (71.3%), decreased AMR (70.3%), and decreased need for additional lab testing (66.3%) (Fig. 1).

Fig. 1

Reported impact of current diagnostic testing landscape/practices on patient, economic and AMS outcomes. Participants were asked to select the most appropriate option for each outcome listed on the basis on the current diagnostic testing landscape/practices in your hospital. AMR antimicrobial resistance, AMS antimicrobial stewardship. n = 300 per outcome

Barriers Were Identified That Inhibit Effective Use of Diagnostic Tests

When asked about challenges to the use of diagnostic tests, the most frequently selected responses were cost of individual tests (42.3%), cost of set-up/initial outlay to purchase equipment (35.7%), concerns relating to sensitivity/accuracy (29.0%), lack of education/awareness on new diagnostic tests (25.7%), and access to diagnostic tests (25.0%) (Fig. 2). “Cost of individual tests” was the most selected answer in India (74.0%) and the USA (50.0%), where private health insurance or patient out-of-pocket fees are common, and Brazil (54.0%), which has a universal healthcare system, but Brazilian citizens can also opt to buy private insurance or pay out-of-pocket. The most common responses were “lack of clinical data” for China (48.0%), “concerns around accuracy and sensitivity/specificity of the diagnostic test” for Germany (44.0%), and “access to diagnostic tests” for Italy (34.0%).

Fig. 2

Most commonly reported challenges to the use of diagnostic tests across the treatment pathway. AMR antimicrobial resistance, AMS antimicrobial stewardship, HCP healthcare professional. n = 50 respondents per country. Respondents could select up to five answers

Participants were asked to estimate the average time between sample collection of bacterial, fungal, and viral specimens to results being returned per diagnostic step at their hospital. Over half of participants selected turnaround times of 12 h or less for identification (54.2%) and initial antimicrobial susceptibility testing (AST) (53.6%); whereas slower turnaround times were more frequently reported for comprehensive AST and resistance gene identification (Table S3a in the Supplementary Material). Forty-seven participants (15.8%) estimated a TTR of 2 h or less for identification. Additional analyses found that 85% (n = 40) of these participants had access to multiple rapid diagnostic tests for identification and, of the remaining 15% (n = 7) who estimated a TTR of 2 h or less based on one diagnostic test, 85% were pharmacists. Many participants indicated that turnaround times were suboptimal to inform antimicrobial prescribing decisions: 46.9% considered TTRs were “sometimes” or “not” quick enough for identification, 48.0% for initial AST, 60.9% for comprehensive AST, and 63.4% for resistance gene identification (Table S3b in the Supplementary Material). This pattern was also present in higher-income countries like the USA and Italy. In the USA, 57.1% of participants reported suboptimal TTR for identification, 53.1% for initial AST, 79.6% for comprehensive AST, and 67.3% for resistance gene identification. In Italy, 55.1% of participants reported suboptimal TTR for identification, 51.0% for initial AST, 63.3% for comprehensive AST, and 61.2% for resistance gene identification. In Germany, suboptimal TTRs were more frequently reported for comprehensive AST (64.0%) and resistance gene identification (76.0%) compared with identification (36.0%) and initial AST (28.0%).

Further, participants selected factors (from a provided list) that lead to diagnostic testing and/or return of results being too slow to impact patient care. Lack of a 24 h a day/7 days a week (24/7) microbiology lab (24.9%), shortage of laboratory staff (21.6%), and a lack of rapid diagnostic testing (18.8%) were most frequently reported as the main reason for suboptimal turnaround times (Table 2). There were country-level differences in the primary issues relating to turnaround time: “lack of rapid diagnostic testing” was most common for Brazil (45.5%) and the USA (29.5%); “lack of 24/7 microbiology lab” for India (39.5%) and Italy (33.3%); “shortage of laboratory staff” for Germany (31.9%) and the USA (29.5%); and “lack of protocols” for China (22.2%) (Table S4 in the Supplementary Material).

Table 2 Factors which are considered to lead to diagnostic testing and/or return of results being too slow to impact patient careThere Are Barriers to Ensuring the Appropriate Use of Antimicrobials and Efficient Stewardship, with Country-Specific Challenges

Survey participants were asked to comment on their level of agreement with the following statements:

“The appropriate use of newly released antimicrobials may depend on suitable diagnostics being available.”

“The lack of diagnostic test availability is a barrier to the appropriate use of new antimicrobials.”

Among participants, 82.0% agreed (29.0% completely; 53.0% somewhat) and 61.3% agreed (16.7% completely; 44.7% somewhat) with these statements, respectively (Fig. S1 in the Supplementary Material). “Agree” responses to the latter statement varied considerably by country: 92.0% in Brazil, 82.0% in India, 68.0% in Italy, 60.0% in China, 48.0% in the USA, and 18.0% in Germany. Furthermore, lack of diagnostic test availability resulted in a specific challenge for India, where participants reported guidelines were always/frequently not followed because of a lack of diagnostic test availability (42.0%, compared to 6.0–18.0% for the other five countries) and as a result of antibiotics not being available because of access restrictions (38.0%, compared to 6.0–16.0% for the other five countries; Fig. S2 in the Supplementary Material).

Participants were asked to select the greatest challenges to the use of narrow-spectrum antibiotics. The most commonly reported obstacle across all countries was “high resistance rates” (52.0% overall). Other common challenges included “slow turnaround time to receiving AST data” (31.7%), “presence of multidrug resistant organisms (MDROs) based on local AMR data” (31.0%), “fear of not treating the causative organism conclusively due to sensitivity and specificity of diagnostic tests” (31.0%), and “slow turnaround time to receiving diagnostic test results” (27.0%) (Fig. 3).

Fig. 3

Most commonly reported challenges to the use of narrow-spectrum antibiotics. AMR antimicrobial resistance, AMS antimicrobial stewardship, AST antimicrobial susceptibility testing, HCP healthcare professional, ID infectious diseases, MDROs multidrug resistant organisms. n = 50 respondents per country. Respondents could select up to five answers

When asked about their views on investment in AMS compared with investment in other healthcare issues at their facility/institution, overall responses were similar for investment being “much greater/greater” (27.7%), “comparable with other healthcare issues” (36.0%), and “somewhat/seriously lacking” (32.3%) (Fig. S3a in the Supplementary Material). However, at a country-level, 46.0% and 56.0% of participants in China and India, respectively, considered that investment in AMS was much greater/greater than other healthcare issues, whereas investment in AMS was perceived as somewhat/seriously lacking by 44.0% of participants in both Brazil and Germany. Participants were also asked about their views on resourcing (staff, funding, and equipment) of the AMS program and broader AMS efforts at their facility/institution. Overall, 54.3% responded that resources were “abundant/sufficient,” while 40.3% felt that resources were “somewhat/seriously lacking” (Fig. S3b in the Supplementary Material). In Germany, 22.0% of participants reported that resources were seriously lacking, compared to 0.0–8.0% in other countries. The most common resource that was lacking varied by country: “diagnostic test availability” in China (80.0%) and Brazil (60.9%), “AMS team staffing” in Italy (94.4%) and the USA (52.9%), and “clinical staff to manage the AMS program and broader AMS efforts” in India (66.7%) and Germany (62.9%) (Fig. S3c in the Supplementary Material).

Guidelines Are Important for HCPs in All Countries Surveyed, But Opportunities Exist for Guideline Improvements to Aid AMS

Participants indicated that guidelines are highly consulted in clinical practice, with international, national, regional, and local guidelines being “always” or “sometimes” consulted by at least 87.0% of participants and with slightly greater emphasis placed on local and national guidelines (Table S5a in the Supplementary Material). Guideline adherence was considered high, with 46.3% of participants selecting “high adherence” and 48.0% selecting “some adherence” for antimicrobial recommendations, and 41.0% selecting “high adherence” and 48.3% selecting “some adherence” for diagnostic recommendations (Fig. S4a in the Supplementary Material). In China, perceived adherence to antimicrobial and diagnostic guidelines was higher (74.0%) in comparison to other countries (36.0–44.0%; Fig. S4b, c in the Supplementary Material). Participants considered current guidelines to be useful, with at least 80% rating all types of guidelines as “very useful” or “somewhat useful,” again, with greater utility ascribed to local and national guidelines (Table S5b in the Supplementary Material). Only 18.0% believed guidelines were “very recent and up to date” (Table S5c in the Supplementary Material). When asked what could improve guidelines, “more frequent guideline updates” was selected by half of all responders (50.6%) whilst the most frequent country-level responses were for guideline recommendations to “follow local data/resistance patterns” (Brazil, 80.0%; India, 76.9%; USA, 64.3%; Italy, 60.0%), “greater education” (Germany, 51.0%), and “capabilities in detecting AMR” (China, 75.0%) (Table 3).

Table 3 Factors which survey participants believe would make guidelines more useful