Physicians’ Awareness, Attitudes, and Barriers to Voriconazole Therapeutic Drug Monitoring in Kuwait: A National Cross-Sectional Survey

BACKGROUND: Therapeutic drug monitoring (TDM) of voriconazole is recommended to optimize treatment outcomes and minimize toxicity, owing to its nonlinear pharmacokinetics and substantial interindividual variability. However, data on clinicians' awareness, attitudes, and perceived barriers remain limited. This study assessed these domains among physicians managing invasive fungal infections in Kuwait. METHODS: A cross-sectional survey was conducted among intensivists, hematology/oncology and solid organ transplant physicians, infectious disease specialists, pulmonologists, and clinical microbiologists across 10 public hospitals. A validated self-administered questionnaire was used. Descriptive and nonparametric analyses were performed. RESULTS: Of 206 invited physicians, 115 responded (55.8%), and 106 were eligible for analysis. Median (IQR) awareness was 57.1% (57.1), with 53.8% scoring <60%, indicating suboptimal knowledge. Higher awareness was associated with age >40 years (p = 0.034), consultant/senior specialist status (p = 0.038), and clinical microbiology practice (p = 0.002). Median (IQR) attitude score was 4.0 (1.0); 70.8% demonstrated positive attitudes, particularly those aged >40 years (p = 0.021) and with >10 years' experience (p = 0.007). Median (IQR) barrier score was 4.0 (1.0), reflecting substantial implementation challenges. Common barriers included logistical coordination (67.9%), limited understanding of monitoring protocols (66.0%), and absence of clear local or national guidelines (65.1%). Barriers were more pronounced in tertiary hospitals (p = 0.018) and among physicians managing antifungal prophylaxis (p < 0.001). CONCLUSIONS: Despite generally positive attitudes, physicians in Kuwait demonstrated limited awareness and reported significant implementation barriers. Targeted education improved logistical support, and development of national guidelines are needed to enhance TDM uptake and optimize antifungal therapy.