Knowledge, Attitudes and Practice Regarding Antimicrobial Resistance and Antimicrobial Use among Undergraduate Medical Students in Majmaah, Saudi Arabia

Naser Ashraf Tadvi^1*, Hamad Abdulaziz Al Olah², Abdullah Bejad Al Mjlad², Mazin Talal Al Shammari², Mishary Malik Al Shammari², Sajid Hussain¹ and Waqas Sami³

^*Correspondence: Naser Ashraf Tadvi, Department of Basic Medical Sciences, College of Medicine, Al-Majmaah, 11952, Saudi Arabia, Email:

Author info »

Introduction

Antimicrobial resistance (AMR) is a serious global concern, as many people across the world use antibiotics inappropriately [1,2]. AMR occurs when bacteria, parasites, viruses, and fungi become resistant to antimicrobial agents that are used for treating the infections they cause [3]. Antimicrobial agents such as antibiotics are mainstays for the treatment of infections, and many life-saving interventions, such as cancer chemotherapy and major surgeries, depend on effective antimicrobial agents to succeed [4,5]. Unfortunately however, the current dependence on antibiotics, to treat disease, prevent disease, and stimulate livestock growth, has increased AMR exponentially. When antibiotics are used, selection pressure is created, potentially forcing the exposed bacteria to mutate or acquire pieces of DNA to develop AMR [6]. The selection pressure resulting from the overwhelming use and misuse of antibiotics is exacerbating the AMR phenomenon [7].

Despite this known fact, approximately 10 million tons of antibiotics are used globally every 10 minutes, which is mostly not justified by medical use [8]. Multidrug-resistant (MDR) pathogens are spreading rapidly in many parts of the world, causing severe medical and economic consequences. It is estimated that at least every 10 minutes, a patient dies in the USA or Europe because of fatal infections caused by antibiotic resistant bacteria [9].

Antibiotics are the most frequently prescribed drugs, but they are often misused [10,11]. This contributes to the spread of resistant strains of bacteria [12]. One of the causes for antimicrobial misuse is incorrect prescribing by physicians [13-15]. There are many factors that can influence doctors’ decisions, leading them to fail to uphold the principles of good clinical practice. Examples of these include the fear of possible future complications in their patients and the desire to fulfill patients’ expectations [16]. Patients’ incorrect habits and their lack of knowledge also represent another leading cause of AMR [17].

To limit the alarming threat of AMR, the World Health Organization launched the Global Action Plan on Antimicrobial Resistance [18]. This plan was signed off by most member states, including Saudi Arabia, during the World Health Assembly in 2015 [19]. One of the important pillars of this plan is to improve awareness of AMR.

Educational initiatives on the correct use and prescription of antimicrobial agents, addressing both the general population and health care professionals, should thus be promoted [20]. The future doctors and other health care professionals must be fully aware of the increasing problem of antibiotic resistance [21,22].

Therefore, this study was conducted to identify knowledge, attitudes, and practice regarding antimicrobial use and resistance among undergraduate medical students.

Materials and Methods

A cross-sectional study to find out the knowledge, attitudes, and practice regarding antimicrobial use and resistance among undergraduate medical students was conducted at the College of Medicine and the College of Applied Medical Sciences at Majmaah University, Saudi Arabia. The study was conducted between January 2018 to June 2018 after obtaining the ethical approval from the ethics committee of the Deanship of Scientific Research at Majmaah University. This study included nursing, physiotherapy, and medical students at Majmaah University. Study participants who declined to participate in the study were excluded.

The data was entered and analyzed using IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. Pearson-Chi Square was applied to associate the responses of students of the two colleges in relation to knowledge, attitudes, and practice. Logistic regression analysis was conducted to test the relationships between dependent and independent categorical variables. A pvalue of <0.05 was considered as statistically significant.

Results

The questionnaire was distributed to more than 237 students; 150 students were from the College of Medicine, Majmaah University, and 87 students were from the College of Applied Medical Sciences, Majmaah University, which includes the College of Nursing, College of Physiotherapy, and College of Laboratory Medical Sciences. Only 126 (84%) of the students from the College of Medicine consented and returned completed questionnaires, and 64 (73.56%) of the students from the College of Applied Medical Sciences returned completed questionnaires.

Table 1 shows the characteristics of the sample. The total sample size was 190. All the participants in the study were male. No significant differences were found between the two groups of students regarding the percentage of students who had a family member who worked in a health-related field and the percentage of students who had used an antibiotic in the last year. The participation rate of first-year students was the lowest rate for both colleges.

Table 1: Description of the sample

Table 2 shows the responses of the students to the knowledge-related questions about antibiotics. Correct answers (corresponding to either “strongly agree” or “strongly disagree,” depending on the statement) were >70% for more than half of the questions in the Medicine group and <50% for all the questions in the College of Applied Medical Sciences group.

Table 2: Response of the students to knowledge-related questions about antibiotics on a 4-point Likert scale

Table 3 represents the responses of the students to questions on knowledge of the term “antibiotic resistance” and if they responded ‘yes’ to the questions, whether they were exposed to this term in a university course.

Table 3: Response of the students to knowledge-related questions (yes/no)

Table 4 shows awareness of AMR among the students. The awareness was low, at <70%, for all questions in both the groups, but the College of Medicine students were more aware than the College of Applied Medical Sciences students.

Table 4: Awareness of antibiotic resistance

Table 5 represents the attitudes and practice of the students regarding antibiotic consumption. The inappropriate use of antibiotics was significantly higher among the College of Applied Medical Sciences students in comparison to the College of Medicine students.

Table 5: Attitudes and practice of students regarding consumption of antibiotics

Table 6 shows the logistic regression results, including both the odds ratios and p values. The College of Medicine students showed significantly higher knowledge and were more aware of AMR. There were no significant differences in attitudes and practice.

Table 6: Results of logistic regression

Discussion

In most of the countries there are problems with antibiotics being consumed inappropriately and the people taking these medications have poor knowledge about the use of antibiotics and their adverse effects and hazards. The extensive and irrational use of antimicrobial agents in therapy is one of the major causes underlying the spread of AMR, and efforts to increase awareness and knowledge about this issue are of utmost importance.

Therefore, antimicrobial stewardship practices should be ensured to standardize the prescribing behavior of our future doctors. Educational initiatives on the correct use and prescription of antimicrobial agents, addressed to both the general population and health care professionals, should thus be promoted [20]. Future doctors and other health care professionals must be fully aware of the increasing problem of AMR [21,22].

Level of awareness and knowledge regarding antimicrobial use and resistance

The findings of this study showed that the College of Medicine students taking the Bachelor of Medicine and Bachelor of Surgery (MBBS) course had better knowledge about antibiotics, use of antibiotics in bacterial infections, and the fact that they should not be used in viral infections than the College of Applied Medical Sciences students. 92.9% of the College of Medicine students were aware of the term “antibiotic resistance.” The College of Medicine students demonstrated less knowledge about the fact that antibiotics have no role in pain and inflammation and the problems associated with antibiotic use, such as the fact that they can destroy the normal flora and cause secondary infections and allergic reactions. This may be due to the inclusion of second- and third-year students in the study who are still not exposed to these concepts, and there is a need for early sensitization and emphasis regarding these aspects. The overall knowledge and awareness of the College of Applied Medical Sciences students was poor.

The results of this study of medical students concur with the findings of studies by Abbo et al. [24] and Napolitano et al. [25]. In a study by Huang et al., it was noted that knowledge of antibiotic use among medical students was significantly higher than that among non-medical students, but there was no significant difference between first-year medical and non-medical students [26]. In another study, only 32.9% of subjects were aware that antibiotics are effective for bacterial infection, while around 7% believed that antibiotics can be used to treat viral infection [27]. Similar findings were observed in studies performed by Barakh et al. and Awad et al. [28,29].

Attitudes and practice of medical students regarding antimicrobial use and resistance

Despite the good knowledge and awareness regarding antimicrobial use, especially among the College of Medicine students, the use of antibiotics in the previous year was higher among the College of Medicine students than among the College of Applied Medical Sciences students. This practice showed no correlation with the presence of a family member working in a health-related field. The practice of taking antibiotics inappropriately (e.g., for fever or a cold) was lower among the College of Medicine students. Incorrect behavior was noticed among the College of Applied Medical Sciences students regarding all aspects of practice, and this may be associated with their lower awareness of the facts regarding antimicrobial use and the hazards that accompany it. The results of this study are similar to the results of a study conducted by Sanya et al. [30]. The results of studies carried out by Khan et al. [31] and Suafian et al. [32] were less promising than the results of our study regarding medical students, which may be due to different sociocultural aspects and exposure to information in the curriculum.

Factors that lead to misuse of antimicrobial agents

The self-use of antimicrobial agents was found to be higher among the College of Medicine students in comparison to the College of Applied Medical Sciences students. Education and degree could influence the attitudes and practice regarding antimicrobial use, as seen in our study. Also, year of study could influence the choice of taking antibiotics without a doctor’s consultation. Medical students may feel more confident about their knowledge in the final years of study and they may be more liable to misuse antibiotics in comparison to students in their initial years of study. The inappropriate use of antimicrobial agents (especially to treat colds and fever and the use of leftover medicines) was low among College of Medicine students, implying that awareness and knowledge can reduce the misuse of antibiotics.

Lack of enforcement of drug regulations, which prohibit the purchase of antibiotics without a prescription, is a prime determinant of their overuse and misuse [32]. The World Health Organization has recommended training for medical undergraduates regarding the prudent prescription of antimicrobial agents [33]. It is necessary that our future doctors are equipped with better knowledge regarding appropriate antimicrobial use and resistance [33].

Conclusions

This study highlighted the need for educating medical students, especially allied health care students, regarding appropriate antibiotic use and resistance. The study also demonstrated disparities between knowledge and practice, as the students had some knowledge but still had poor practice.

Our recommendation is to introduce specific courses and training about antibiotics and AMR into the core curriculum of the College of Medicine and the College of Applied Medical Sciences. Emphasis should be placed on correct prescribing rules and prevention of inappropriate use. Implementation of an antimicrobial stewardship program for medical students should be ensured in order to standardize the prescribing behaviors of our future doctors. Educational initiatives on the correct use and prescription of antimicrobial agents, in the form of campaigns or awareness programs addressed at both the general population and health care professionals, should be promoted.

Acknowledgement

The authors would like to acknowledge the Deanship of Scientific Research at Majmaah University for the constant helpful support of the staff. Also, we thank the Student Fund of the Deanship of Students Affairs

Contributions

All the participants contributed equally

Funding

This project was funded by the Deanship of scientific research, Student fund, Majmaah University.

Conflict of Interest

The authors declare that there is no conflict of interest regarding the publication of this article.

References

1. Sugden R, Kelly R, Davies S. Combatting antimicrobial resistance globally. Nat Microbiol 2016; 1:16187.
2. Laxminarayan R, Sridhar D, Blaser M, et al. Achieving global targets for antimicrobial resistance. Science 2016; 353:874-5.
3. www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
4. Saravanan R, Raveendaran V. Antimicrobial resistance pattern in a tertiary care hospital: An observational study. J Basic Clin Pharm 2013; 4:56-63.
5. Teillant A, Gandra S, Barter D, et al. Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: A literature review and modelling study. Lancet Infect Dis 2015; 15:1429-37.
6. Zowawi HM, Harris PN, Roberts MJ, et al. The emerging threat of multidrug-resistant Gram-negative bacteria in urology. Nat Rev Urol 2015; 12:570-84.
7. Laxminarayan R. Antibiotic effectiveness: Balancing conservation against innovation. Science 2014; 345:1299-301.
8. Zowawi HM, Forde BM, Alfaresi M, et al. Stepwise evolution of pandrug-resistance in Klebsiella pneumoniae. Sci Rep 2015; 5:15082.
9. Harbarth S, Balkhy HH, Goossens H, et al. Antimicrobial resistance: One world, one fight! Antimicrob Resist Infect Control 2015; 4:49.
10. Chambers HF. General principles of antimicrobial therapy. Goodman Gilman’s the pharmacological basis of therapeutics. McGraw-Hill, USA 2006; 1095-111.
11. World Health Organization. Antimicrobial resistance: Global report on surveillance. WHO 2014.
12. Centers for Disease Control and Prevention. Antibiotics aren't always the answer. Atlanta (GA) 2014.
13. Tonkin-Crine S, Yardley L, Little P. Antibiotic prescribing for acute respiratory tract infections in primary care: A systematic review and meta-ethnography. J Antimicrob Chemother 2011; 66:2215-23.
14. Butler CC, Rollnick S, Pill R, et al. Understanding the culture of prescribing: Qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ 1998; 317:637-42.
15. Kumar S, Little P, Britten N. Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. BMJ 2003; 326:138.
16. Rodrigues AT, Roque F, Falcão A, et al. Understanding physician antibiotic prescribing behaviour: A systematic review of qualitative studies. Int J Antimicrob Agents 2013; 41:203-12.
17. Gualano MR, Gili R, Scaioli G, et al. General population's knowledge and attitudes about antibiotics: A systematic review and meta-analysis. Pharmacoepidemiol Drug Saf 2015; 24:2-10.
18. World Health Organization. Global action plan on antimicrobial resistance. WHO 2015.
19. Zowawi HM. Antimicrobial resistance in Saudi Arabia: An urgent call for an immediate action. Saudi Med J 2016; 37:935-40.
20. McNulty CA, Lecky DM, Farrell D, et al. Overview of e-Bug: An antibiotic and hygiene educational resource for schools. J Antimicrob Chemother 2011; 66:3-12.
21. Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence 2013; 4:192-202.
22. Ohl CA, Luther VP. Health care provider education as a tool to enhance antibiotic stewardship practices. Infect Dis Clin North Am 2014; 28:177-93.
23. Scaioli G, Gualano MR, Gili R, Antibiotic use: A cross-sectional survey assessing the knowledge, attitudes and practices amongst students of a school of medicine in Italy. PLoS ONE 2015; 10:0122476.
24. Abbo LM, Cosgrove SE, Pottinger PS, Medical students' perceptions and knowledge about antimicrobial stewardship: How are we educating our future prescribers? Clin Infect Dis 2013; 57:631-8.
25. Napolitano F, Izzo MT, Di Giuseppe G, et al. Public knowledge, attitudes, and experience regarding the use of antibiotics in Italy. PLoS One 2013; 8:84177.
26. Huang Y, Gu J, Zhang M, et al. Knowledge, attitude and practice of antibiotics: A questionnaire study among 2500 Chinese students. BMC Med Educ 2013; 13:163.
27. Shehadeh M, Suaifan G, Darwish R, et al. Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan. A pilot study. Saudi Pharma J 2012; 20:125-33.
28. Barakh NA, Al Gain S, Barrak AA, et al. The assessment of knowledge, attitude and practice of antibiotics usage among Saudi female students in princess Nourah university (PNU). LIFE: Int J Health Life Sci 2015; 2:24-40.
29. Awad A, Aboud E. Knowledge, attitude and practice towards antibiotic use among the public in Kuwait. PLoS One 2015; 10:1-15.
30. Sanya TE, Titilayo OF, Adisa R, et al. Use of antibiotics among non-medical students in a Nigerian university. Afr Health Sci 2013; 13:1149-55.
31. Khan AKA, Banu G, Reshma KK. Antibiotic resistance and usage-A survey on the knowledge, attitude, perceptions and practices among the medical students of a southern Indian teaching hospital. J Clin Diagn Res 2013; 7:1613-6.
32. Suaifan GA, Shehadeh M, Darwish DA, et al. A cross-sectional study on knowledge, attitude and behavior related to antibiotic use and resistance among medical and non-medical university students in Jordan. Afr J Pharm Pharmacol 2012; 6:763-70.
33. World Health Organization. The evolving threat of antimicrobial resistance: Options for action, 2012. Geneva, Switzerland: World Health Organization 2013.