|Year : 2021 | Volume
| Issue : 2 | Page : 113-119
A cross-sectional study to evaluate the knowledge and attitude of medical students concerning antibiotic usage and antimicrobial resistance
Mohan B Sannathimmappa1, Vinod Nambiar1, Rajeev Aravindakshan2
1 Department of Microbiology, College of Medicine and Health Sciences, National University of Science and Technology, Sohar, Sultanate of Oman
2 Department of Community Medicine, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
|Date of Submission||10-May-2020|
|Date of Acceptance||08-Sep-2020|
|Date of Web Publication||29-Jun-2021|
Dr. Mohan B Sannathimmappa
Department of Microbiology, College of Medicine and Health Sciences, National University of Science and Technology, PO Box: 391, PC: 321, Al Tareef, Sohar
Sultanate of Oman
Source of Support: None, Conflict of Interest: None
Introduction: Antimicrobial resistance (AMR) is a major global health problem, which is mainly promoted by injudicious antibiotic usage. The main strategy to control AMR is to emphasize the appropriate use of antibiotics, which can be achieved by creating awareness about AMR, changing the attitude of medical students who are the future prescribers. This study aimed to evaluate the knowledge and attitude of fifth-year medical students regarding antibiotic use and AMR.
Materials and Methods: A descriptive cross-sectional study was conducted among 125 fifth-year medical students of the College of Medicine and Health Sciences, Sohar. A self-administered questionnaire was used to assess the knowledge and attitude regarding antibiotic use and AMR. The data were statistically analyzed and expressed as numbers and percentages.
Results: Of 125 participants, the majority (>90%) were aware of AMR and its global impact. Nearly three in four knew that antibiotics are used to treat bacterial infection. However, most of the students had lacunae in their knowledge regarding contributing factors and consequences of AMR. A minority of students lack the right attitude toward rational antibiotic usage and adequate infection control practices. The majority of them were unaware of strict guidelines pertaining to judicious antibiotic usage and adequate infection control policies implemented in hospitals, as recommended by the World Health Organization.
Conclusion: The results of our study reflect lacunae in students' knowledge regarding antibiotic usage and AMR. Therefore, there is a need for an implementation of effective medical curricula to improve medical students' knowledge regarding AMR and the appropriate use of antibiotics.
The following core competencies are addressed in this article: Patient care, Medical knowledge, Professionalism, Systems-based practice, Practice-based learning and improvement, Interpersonal and communication skills.
Keywords: Antibiotic stewardship, Drug resistance , Infection control, Knowledge, Treatment failure
|How to cite this article:|
Sannathimmappa MB, Nambiar V, Aravindakshan R. A cross-sectional study to evaluate the knowledge and attitude of medical students concerning antibiotic usage and antimicrobial resistance. Int J Acad Med 2021;7:113-9
|How to cite this URL:|
Sannathimmappa MB, Nambiar V, Aravindakshan R. A cross-sectional study to evaluate the knowledge and attitude of medical students concerning antibiotic usage and antimicrobial resistance. Int J Acad Med [serial online] 2021 [cited 2022 Jan 27];7:113-9. Available from: https://www.ijam-web.org/text.asp?2021/7/2/113/319803
| Introduction|| |
Antimicrobial resistance (AMR) and ever-increasing infections are a serious threat to public health in the modern world, especially in developing countries with a considerable burden on patient's health, health-care system, and the global economy.,,, The gradual increase in several multidrug-resistant bacterial strains in the last couple of decades poses a dreadful threat in treating infectious diseases and is associated with increased treatment failure, longer hospital stay, higher medical costs, increased mortality, and a higher risk of disease spread., A recent study reported that approximately 700,000 deaths are occurring annually due to infection with resistant pathogens and it would increase to 10 million annually by 2050 if it is not addressed urgently. The development of AMR in microorganisms is a natural phenomenon. However, it will be accelerated by many folds with the indiscriminate use of antibiotics in humans, animals, and agriculture due to selective pressure., Misuse or inappropriate prescription of antibiotics by the doctors is the major factor contributing to the development and spread of resistant pathogens., There are multiple factors that influence the inappropriate use of antibiotics by doctors such as inability to differentiate between viral and bacterial infections, fear of possible associated complications of infection in patients, patients' demand for antibiotics, and pressure and incentives by pharmaceutical companies. Poor infection control practices, substandard medicines, easy availability of antibiotics over the counter, self-medication by the patient, lack of rapid diagnostic tests, and lack of awareness about AMR and its consequences among health-care workers and the general population are other significant factors conferring to the development of AMR.,,,
AMR is a serious challenge to modern medicine and there is an urgent need for intervention to overcome this worldwide emerging problem. All health-care professionals have a pivotal role to play in controlling AMR and preserving the efficacy of antibiotics. The World Health Organization's Global Action Plan on AMR highlights the importance of training health professions. Therefore, educational training to both health professions and general public regarding AMR and its consequences, rational use of antibiotics, and control measures of AMR must be promoted. The major move toward the training of health-care professionals is at the undergraduate level. It is desirable to focus on the medical students, who are the future doctors and key stakeholders of the health-care system. They must be made fully aware of challenges posed by AMR, responsible use and prescription of antibiotics, and various preventive measures to combat AMR.,,, It is important to scrutinize baseline knowledge of medical students for proper development and implementation of a highly effective training program on antibiotic use and controlling measures of AMR. On a thorough literature review, we could not find any studies in this region related to the assessment of medical students' knowledge and attitude toward antibiotic use and AMR. Hence, the present study aimed at evaluating fifth-year medical students' existing knowledge concerning antibiotic use, contributing factors and consequences of AMR, and attitude toward judicious antibiotic usage and preventive measures of AMR.
| Materials and Methods|| |
It is a cross-sectional, questionnaire-based study conducted in the Department of Microbiology, College of Medicine and Health Sciences (CoMHS), National University of Science and Technology, Sohar campus. The study was carried out between September and December 2019 and the study group included 130 fifth-year medical students of the academic year 2019–2020. The study was approved by the Institutional Research and Ethical Committee (Approval no: CMHS/REC/024/18/C) and the prior informed consent was obtained from all the voluntary participants.
The CoMHS offers a 7-year MD degree. The whole medical curricula were divided into premedical (year 1–3), preclinical (year 3 and 4), and clinical (year 6 and 7) years. Biology, chemistry, basic physiology, anatomy, and medical microbiology were the major subjects taught in premedical years, while clinical anatomy, clinical physiology, clinical microbiology, pathology, pharmacology, and preventive medicine were the courses taught in years 4 and 5. In clinical years, students were trained in various clinical subjects of the medicine course. A predesigned well-structured questionnaire developed and modified after a thorough scientific literature review was used as a data collection tool.,,,, The questionnaire was validated for its contents and relevance by microbiology, pharmacology, and medicine subject experts. The final questionnaire [Questionnaire 1] included items to assess the various aspects of the participants' knowledge, awareness, and attitude toward antibiotic use, contributing factors of AMR, and strategies to control drug resistance. The study group was approached for voluntary participation through personal communication. Students were explained about the objectives of the study and the need for their participation. A predesigned self-administered questionnaire was distributed to all the voluntary participants in the classroom on a pre-notified date and time. The filled-in questionnaire was collected, the data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) software, version 22. IBM Chicago. The qualitative data were expressed in terms of numbers and percentages.
| Results|| |
Of 130, 125 (96.13%) fifth-year medical students voluntarily participated in the study. All most all the participants (98.4%) were aware of AMR and 92.8% believe that it is a major global health concern. Approximately 25% had a misconception that antibiotics can be used to treat either viral infections or both viral and bacterial infections. In addition, 45.6% stated that antibiotics help patients in speedy recovery from the flu or common cold. About 66.4% (n = 83) had the correct knowledge about the consequences associated with the indiscriminate use of antibiotics [Table 1]. The majority of the participants agreed that one should complete the course of the antibiotic (85.6%) irrespective of presence or absence of clinical symptoms and about 72.8% stated that skipping even one or two doses would contribute to the development of antibiotic resistance [Table 1]. Nearly half of the participants were unaware of facts such as the use of substandard drugs (54.4%), early initiation of broad-spectrum antibiotics for mild infection (60%), misuse of antibiotics in animal husbandry (52.4%), inadequate infection control practices (38.4%), and lack of rapid tests for diagnosing infection (44%) are major contributors to the emergence of AMR [Table 1].
|Table 1: Knowledge and awareness about antibiotic use and antimicrobial resistance|
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The response of the majority of participants to most of the questions concerning attitude and behavior toward antibiotic use was favorable [Table 2]. About 90% expressed that they take antibiotics only after doctor's consultation. Nearly three-fourth of the participants stated that they always complete the antibiotic course (72%), regularly check the expiry date of the antibiotic (75.61%), and do not take antibiotics for common cold or flu (75.2%). However, there was a significant lack of accurate knowledge regarding the control strategies of AMR among the majority of the participants (81.6%). Interestingly, the majority of participants (94.4%) expressed the necessity of special education training on AMR (94.4%) to all the medical students. About 93.6% indicated their willingness to strict adherence to the antibiotic policy once they become certified doctors.
|Table 2: Attitudes and behaviors about antibiotic use and antimicrobial resistance control strategies|
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| Discussion|| |
Imparting knowledge concerning AMR and the proper use of antibiotics is indispensable in bringing down the rising menace of AMR. Medical students are the future prescribers of antibiotics, and hence, the initiative for rationalizing the appropriate use of antibiotics must start from their level. It is essential to assess their baseline knowledge in this regard to implement effective training programs to achieve the goal of minimizing AMR. The present study assessed the knowledge and attitude of fifth-year (preclinical) medical students regarding antibiotic usage, contributing factors of AMR, and preventive strategies.
More than 90% of our participants were well aware of AMR and its serious global health impact. Three-fourth of our participants had accurate knowledge that antibiotics are used to treat bacterial infections. Similar findings were reported by many previous studies conducted globally.,, However, their knowledge about contributing factors for AMR and its consequences is relatively poor. About 23% had a misunderstanding that antibiotics are effective against both viruses and bacteria which is similar to a study by Seid et al. in which 28% had this misconception. In our study, 54.4% of students correctly indicated that the use of antibiotics will not speed up the recovery from common cold or flu, which is due to viral etiology. This outcome is in line with the study by Ahmad et al. where 62% of students indicated correctly but is less compared to the study by Jamshed et al. where 95% of students correctly answered this question., Inappropriate use of antibiotics is the single most factor contributing to AMR. Incorrect knowledge concerning the prescription of antibiotics could worsen the problem of drug resistance. Therefore, students must be trained precisely that antibiotics should be used to treat only bacterial infections.
In this study, 66.4% of the participants were aware of the consequences of antibiotic over usage and emergence of AMR such as treatment failure, increased adverse effects, prolongation of illness, and an additional burden of medical expenses. This finding is slightly less compared to studies by Bharath et al. and Khan et al. who reported that 79% and 85% of the participants were aware of the consequences of AMR, respectively.,
Nearly half of the respondents in our study were unaware of major risk factors contributing to the emergence and spread of multidrug-resistant bacteria such as overuse of antibiotics in humans, animals, and agriculture; use of substandard and expired drugs; inadequate infection control practices; lack of rapid diagnostic tests; and use of broad-spectrum antibiotics as initial therapeutic agents. This result was comparable to previous studies, in which 65% of students in Jamshed et al. and 35% in Bharath et al. have understood about the factors contributing to AMR., Brahmbhatt et al. and Dyar et al. in their studies reported that 24% and 21% respondents, respectively, believed that infection control practices including hand hygiene are not important for the emergence of AMR., In comparison, slightly more of our respondents (38.4%) had this misbelief. Therefore, medical students must be emphasized of these major risk factors of AMR and also principal mechanisms of emergence of antimicrobial resistance. In addition, undergraduates' attention needs to be drawn on the importance of practicing simple measures like handwashing as a cost-effective preventive measure of AMR.
In this study, a minority of students (24.8%) agreed to have taken antibiotics for common cold or sore throat, and a broad-spectrum antibiotic should be taken early for recovery from the common cold (26.4%). In a similar study conducted by Khan et al., 38% and 60% of participants agreed for antibiotic usage for common cold and early initiation of antibiotic therapy for recovery from viral infection, respectively, which is relatively high compared to our study. Furthermore, the majority of our study participants completed the antibiotic course (72%), started antibiotics after consultation with a doctor (89.6%), and they have the habit of checking the expiry date of the antibiotic before using it (75.61%). Our study results were consistent with Bharath et al. in which 75% and 92% of respondents completed the antibiotic course and obtained the antibiotics after doctor's consultation, respectively.
The principal factor influencing the emergence and dissemination of multidrug-resistant organisms is because of failure to formulate, implement, and adhere to strict policies and programs related to infection control practices and antibiotic usage., In line with this, majority of our participants (81.6%) lack complete awareness regarding antibiotic policies and practice guidelines formulated by the World Health Organization toward the control of AMR. The students should be made aware of these important facts, and a sense of responsibility must be nurtured at the beginning of their medical course that benefits not only the patients but also the society at large. Interestingly, the vast majority of the participants (94.4%) suggested that special training on appropriate antibiotic usage, contributing factors and consequences of AMR, and measures to prevent AMR are indispensable. Therefore, the implementation of medical curricula regarding antibiotic use and AMR at the inception of students to the medical course and updating their knowledge time to time is one of the crucial needs toward combating AMR.
The present study report has some limitations. It is a single-centered study with a small sample size involving fifth-year medical students of the CoMHS. The study results could have been more meaningful if the study was conducted with a larger sample size by including all the students of CoMHS and possibly students of other medical colleges in Oman.
| Conclusion|| |
The current study revealed lacunae in knowledge, attitude, and practices regarding antibiotic usage and AMR among fifth-year medical students of CoMHS. The results of the study suggested that emphasizing on imparting accurate knowledge and practices regarding rationalized use of antibiotics and infection control practices are absolutely necessary to prevent the rapid emergence of AMR and thereby to improve the health of the patients and reduce health-care costs. This can be achieved by formulating and implementing effective training programs on antibiotic usage, contributing factors of AMR, and strategies to control the menace of AMR at the beginning of the preclinical year in medical education.
We express our sincere appreciation to all the fifth-year medical students of the College of Medicine and Health Sciences, National University of Science and Technology, for their voluntary participation in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The study was approved by Institutional Research and Ethical committee (REG NO. CMHS/REC/024/18/C). The authors declare that they followed applicable EQUATOR Network (http:// www. equator-network. org/) research reporting and reproducibility guidelines.
| References|| |
Seid MA, Hussen MS. Knowledge and attitude towards antimicrobial resistance among final year undergraduate paramedical students at University of Gondar, Ethiopia. BMC Infect Dis 2018; 18:312. https://doi.org/10.1186/s12879-018-3199-1
Scaioli G, Gualano MR, Gili R, Masucci S, Bert F, Siliquini 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:e0122476.
O Neill J. AMR: Tackling a crisis for the health and wealth of nations. Rev Antimicrob Resist 2014; 2014:1-16.
Lee CR, Cho IH, Jeong BC, Lee SH. Strategies to minimize antibiotic resistance. Int J Environ Res Public Health 2013; 10:4274-305. doi: 10.3390/ijerph 10094274.
Palmer AC, Kishony R. Understanding, predicting and manipulating the genotypic evolution of antibiotic resistance. Nat Rev Genet 2013; 14:243-8. doi: 10.1038/nrg3351
Padmanabha TS, Nandini T, Manu G, Madhav KS, Ravi Shankar M. Knowledge, attitude, and practices of antibiotic usage among medical undergraduates of a tertiary care teaching hospital: an observational cross-sectional study. Int J Basic Clin Pharmacol 2016; 5:2432-7. DOI: http://dx.doi.org/10.18203/2319-2003.ijbcp20164100
Gualano MR, Gili R, Scaioli G, Bert F, Siliquini R. General population's knowledge and attitudes about antibiotics: A systematic review and meta-analysis. Pharmacoepidemiol Drug Saf 2015; 24:2-10. doi: 10.1002/pds. 3716.
He QW, Xu XH, Lan FJ, Zhao ZC, Wu ZY, Cao YP, et al
. Molecular characteristic of Mcr-1 producing Escherichia coli
in a Chinese University Hospital. Ann Clin Microbial Antimicrob 2017; 16:32. DOI: 10.1186/s12941-017-0207-z.
Dyar OJ, Hills H, Seitz LT, Perry A, Ashiru-Oredope D. Assessing the knowledge, attitudes and behaviors of human and animal health students towards antibiotic use and resistance: A pilot cross-sectional study in the UK. Antibiotics (Basel) 2018; 7:1-8. DOI: 10.3390/antibiotics7010010.
Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence 2013; 4:192-202. doi: 10.4161/viru. 23706
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. DOI: 10.1016/j.idc. 2014.02.001.
Bharath VD, Kalpana LA. Comparative study to assess the awareness of antibiotic resistance among first and second year medical undergraduate students in a medical college. Int J Basic Clin Pharmacol 2018; 7:1567-71. DOI: 10.18203/2319-2003.ijbcp20183025.
Tamboli TJ, Pundarikaksha H, Ramaiah M, Bhatt KA, Prasad SR. Impact of an educational session on knowledge and attitude towards antimicrobial prescribing and awareness about antimicrobial resistance among undergraduate medical, dental and nursing students: A comparative study. Int J Basic Clin Pharmacol 2016; 5:1544-50.
Yang K, Wu D, Tan F, Shi S, Guo X, Min Q, et al
. Attitudes and perceptions regarding antimicrobial use and resistance among medical students in Central China. Springerplus 2016; 5:1779. doi: https://doi.org/10.1186/s40064-016-3454-0
Belkina T, Al Warafi A, Eltom EH, Tadjieva N, Kubena A, Vlcek J. Antibiotic use and knowledge in the community of Yemen, Saudi Arabia, and Uzbekistan. J Infect Dev Ctries 2014; 8:424-9. DOI: 10.3855/jidc. 3866.
Kanneppady SS, OO AM, Lwin OM, Al-Abed AA, Kanneppady SK. Knowledge, attitude, and awareness of antibiotic resistance among medical students. Arch Med Health Sci 2019; 7:57-60. DOI: 10.4103/amhs.amhs_104_18. [Full text]
Sharma S, Jayakumar D, Palappallil DS, Kesavan KP. Knowledge, attitude, and practices of antibiotic usage and resistance among the second year MBBS students. Int J Basic Clin Pharmacol 2016; 5:899-903. DOI: 10.18203/2319-2003.ijbcp20161542.
Brahmbhatt KR, Patel AB. Knowledge of antimicrobial resistance among undergraduate medical students in a Medical College of Gujarat; institution based cross-sectional study. Int J Community Med Pub Health 2018; 5:754-8. DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph 20180263
Ahmad A, Khan MU, Patel I, Maharaj S, Pandey S, Dhingra S. Knowledge, attitude, and practice of Bsc Pharmacy students about antibiotics in Trinidad and Tobago. J Res Pharmacy Prac 2015; 4:37. DOI: 10.4103/2279-042X.150057.
Jamshed SQ, Elkalmi R, Rajiah K, Al-Shami AK, Shamsudin SH, Siddiqui MJ, et al
. Understanding of antibiotic use and resistance among final year pharmacy and medical students: A pilot study. J Infect Dev Ctries 2014; 8:780-5.
Khan AK, 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. JCDR 2013; 7:1613. doi: 10.7860/JCDR/2013/6290.3230.
[Table 1], [Table 2]