Knowledge of Antibiotic Use and Resistance Among Medical Students in Saudi Arabia

Introduction

Antimicrobial resistance (AMR) is a worldwide concern that affects both developed and developing countries and thus requires a global response. According to global estimates, AMR could cause 10 million deaths annually by 2050 and result in a $100.2 trillion loss in gross domestic product if not addressed adequately.^1,2 Hence, international efforts are underway to promote responsible antibiotic use and combat resistance.³

As a high-income country, Saudi Arabia faces specific challenges in addressing AMR due to high antibiotic usage rates. These challenges include limited access to proper healthcare, which can lead to antibiotic overuse; self-medication practices; and a healthcare infrastructure that facilitates the spread of resistant organisms.⁴ Therefore, in 2017, the country developed a National Action Plan on AMR, which is accordant with the World Health Organization’s (WHO’s) global action plan for controlling and preventing AMR.⁵ Moreover, the healthcare component of Saudi Arabia’s Vision 2030 focuses on disease prevention, improved care quality (including appropriate antibiotic use), and adherence to international standards (including strategies and action plans for addressing AMR).^6,7

The WHO has strongly emphasised the significance of providing comprehensive and practical training to medical students to ensure the responsible and appropriate prescription of antibiotics.⁸ Understanding the difficulties linked to antibiotic utilization and AMR is of utmost significance for aspiring healthcare professionals. Similarly, prioritizing their education and providing them with the essential expertise and abilities is vital to empower them in promoting responsible antibiotic practices within their specific domains.^9,10 For instance, a study on medical students’ perceptions of antibiotic use identified factors contributing to inappropriate usage, including limited knowledge applicability, insecurity, clinical inertia, doctor-patient relationship challenges, unawareness of updates, and inability to assess validity. Surprisingly, students lacked awareness of AMR, but the study identified modifiable factors that could improve antibiotic utilization.¹¹

However, there is a global deficiency in the clinical understanding of essential infectious disease concepts among medical students, as indicated by low scores on knowledge questionnaires and clinical scenario assessments.¹² These findings highlight the need for improvement in medical education worldwide – including both developed and developing countries – to enhance the understanding and skills of medical students in this critical area.^13–15

Assuring that medical students have a thorough understanding of the proper use of antibiotics is essential in spreading the right message within communities, as these students play a vital role in shaping the future of medicine and are considered essential pillars of the healthcare system.^3,16 Their knowledge and perspectives regarding the use of antibiotics have a major impact on the consequences associated with such use in Saudi Arabia.¹⁷ Although this is a widely recognised problem, few studies have investigated medical students’ knowledge in Saudi Arabia.^18,19 Therefore, this study aims to gain a better perspective on the knowledge of antibiotic use and resistance among medical students in Jeddah, Saudi Arabia.

Materials and Methods

Study Design

A cross-sectional study was conducted with medical students at medical College in Jeddah, Saudi Arabia. Over a span of three months, from 1 September to 30 November 2023, electronic questionnaires were sent to the students to gather data. The participants were given details in the questionnaire about the aim of the research and informed that their involvement was voluntary.

Questionnaire Tool

The survey used in this research was adapted from a previous study by Leal et al.²⁰ Initially, the questionnaire was formulated in English, and proficient bilingual individuals translated it into Arabic, the local language. It underwent revisions to ensure its suitability for the population.

To validate the questionnaire, academic and clinical pharmacology experts provided feedback, and their suggestions were incorporated into the final form to improve it.

To validate our questionnaire, we distributed it to a random sample of 25 medical students to identify issues and make revisions. Involving experts and conducting a pilot study enhance a questionnaire’s validity and reliability. The final questionnaire comprised 37 questions and was designed using online cloud-based questionnaire development software (Google Forms). The questionnaire was divided into three sections; the first section gathered information, the second evaluated students’ knowledge of antibiotic usage, and the third section focused on students’ understanding of antibiotic resistance.

Sample Size and Data Collection

The sample size was calculated using Slovin’s formula, with a population of 284 medical students in Saudi Arabia, following Akbar et al; the confidence interval (CI) was 95%, and the margin of error was 5%.¹⁸

The participants were approached via social media platforms (Twitter, Instagram, WhatsApp, Telegram, and email). All responses were obtained through the Google Forms website and securely stored on a server. Only respondents who completed all 37 questions of the three-part survey were included in the analysis, while those with incomplete responses were excluded. The data collected from the Google Forms spreadsheets were transferred to Microsoft Excel.

Statistical Analysis

A statistical analysis was performed using SPSS (version 26, IBM). The categorical variables are presented as frequencies and percentages. Mann–Whitney and Kruskal–Wallis tests were used to compare the two outcomes (antibiotic use and resistance), numerical variables, and sociodemographic data, with the results expressed as medians, interquartile ranges, and p values.

Generalised linear regression models were constructed to predict the high scores in the students’ knowledge of antibiotics and antibiotic resistance based on the statistically significant sociodemographic data for each primary outcome. The regression results are presented as beta coefficients and their respective 95% CIs. A p-value of < 0.05 was taken to indicate statistical significance.

Ethical Approval

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board and Research Ethics Committee of Batterjee Medical College in Jeddah, Saudi Arabia, with the following reference number: RES-2022-0059. Before answering the questionnaire, we included the following informed consent statement: You are invited to participate in a research study on antibiotic use and resistance. This research aims to gain a better perspective on the knowledge of antibiotic use and resistance among medical students in Jeddah, Saudi Arabia. It is conducted by Batterjee Medical College in Jeddah, Saudi Arabia. Participation is voluntary and anonymous. If you agree to participate in this study, you can start answering the questionnaire. Participation may not benefit you directly, but it will help us learn about Antibiotic Use and Resistance in Saudi Arabia. Thank you for your time and collaboration.

Results

Sociodemographic Data

We received 360 responses. However, seven medical students were excluded because of incomplete responses, yielding a response rate of 98%. Therefore, the study encompassed a total of 353 medical students, with the majority falling within the age range of 18–25 years, constituting 95.70% of the participants. Females represented 76.80% of the participants.

First-year medical students represented 28.60% of the participants, followed by second-year students (27.2%). Most students reported not having any chronic diseases, comprising a significant (90.70%) portion of the sample. The chronic diseases reported include anaemia, asthma, type 1 diabetes mellitus, and depression. Of the students, 89.80% stated that they did not take any regular medications besides antibiotics. The medications reported included insulin; nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen; paracetamol; and selective serotonin reuptake inhibitors (SSRIs), such as sertraline and venlafaxine (Table 1).

Table 1 Sociodemographic Data (n = 353)

Students’ Knowledge of Antibiotics

As shown in Table 2, most participants (92.40%) agreed that antibiotics are effective against bacteria, whereas only 25.20% agreed that antibiotics are effective against viruses. More than half (53.80%) believed that bacterial infections can be resolved without antibiotics. While 67.40% of the participants agreed that antibiotics should be continued as prescribed even after symptoms disappear and the infection subsides, 26.10% agreed that it is acceptable to increase the prescribed dose or repeat doses frequently to treat infections rapidly. Surprisingly, 45.90% agreed that “penicillin” is another word for antibiotics. Of the students, 67.40% agreed that antibiotics should be continued as prescribed even after symptoms disappear and the infection subsides.

Table 2 Students’ Knowledge of Antibiotic Use

Students’ Knowledge of Antibiotic Resistance

A significant majority of the respondents, 78.20%, agreed that the unnecessary use of antibiotics makes them less effective, as shown in Table 3. Meanwhile, 28.60% of participants agreed that if, during antibiotic treatment (course), a patient feels well or cured, they can stop taking the medicine. Of the respondents, 64% acknowledged the possibility of someone carrying antibiotic-resistant bacteria without being symptomatic. More than half (56.90%) agreed that infections caused by resistant bacteria are increasing in Saudi Arabia. Moreover, a significant majority, 75.10%, believed that healthcare workers can play an effective role in reducing antibiotic resistance in Saudi Arabia. Notably, 38.20% of participants agreed that viruses can become resistant to antibiotics, and 24.60% agreed that antibiotic resistance is out of control and there is nothing they could do about it.

Table 3 Students’ Knowledge of Antibiotic Resistance

There was no significant association between the sociodemographic data and knowledge of either antibiotic use or antibiotic resistance based on the medians, interquartile ranges, and p values, as shown in Table 4. The value of Cronbach’s alpha is 0.767, which means that the internal consistency of the data is acceptableIn terms of predictors of knowledge about both antibiotic and antibiotic resistance, no statistical significance was found except for males who had low knowledge about antibiotics [Beta = −1.429, 95% CI (−2.618, −0.241), P value = 0.019] as shown in Tables 5 and 6.

Table 4 Association Between Sociodemographic Data and Students’ Knowledge of Antibiotic Use and Antibiotic Resistance

Table 5 Predictors of Student’s Knowledge About Antibiotic Based on the Statistically Significant Sociodemographic Data

Table 6 Predictors of Student’s Knowledge About Antibiotic Resistance Based on the Statistically Significant Sociodemographic Data

Discussion

The major goal of this study was to evaluate medical students’ knowledge of antibiotic use and resistance. Most respondents were under the age of 25, and most were female, a gender predominance that has been observed in several studies (with proportions of 71.8%, 63.7%, and 64% reported, respectively).^21–23

Interestingly, in our study, males had low knowledge about antibiotics [P value = 0.019], suggesting that differences in learning styles may contribute to varying levels of comprehension of antibiotics among students. In contrast, another study revealed that more male respondents had a better knowledge of antimicrobial use and AMR than females (70.4% vs 55.1%; P=0.035).²⁴ Males and females commonly exhibit differences in studying styles, including learning preferences, study strategies, time management, and subject preferences.²⁵ For instance, males often favour hands-on and visual approaches, while females lean toward collaboration and organisation.^25,26 However, these general observations can vary among individuals due to personal factors. Effective studying styles should align with individual strengths, preferences, and learning goals.²⁷

Regarding the students’ knowledge of antibiotic use, 25.20% thought that antibiotics are useful against viral infections, including the common cold (32.90%). Similarly, another study in Saudi Arabia showed that 18.1% of medical students thought that antibiotics can be used for viral infections, as did 20% in an Italian study.^28,29 While 28.30% of our students reported that they knew what penicillin was and that this term is not synonymous with “antibiotics”, a previous study conducted in Saudi Arabia found that 85% of the students knew that penicillin is a form of antibiotics but not another word for antibiotics.³⁰ In our study, more than half of the students (51.30%) disagreed that an antibiotic’s dose or frequency can be increased to treat infections faster. Similarly, studies have shown that medical students know that increasing the dose or frequency of a medication without proper medical guidance can have serious consequences.^15,31 For example, it may lead to an increased risk of side effects, toxicity, or drug interactions. Additionally, it is important to complete the full course of treatment as prescribed, even if symptoms improve, to ensure that the infection is completely eradicated.^{28–30,32,33}

Regarding the students’ knowledge of antibiotic resistance, most participants (83.90%) acknowledged that bacteria can develop resistance to antibiotics, indicating a good understanding of antibiotic resistance. This echoes the results of a previous study, which showed that 92.91% of students in the healthcare sector possess a good level of knowledge regarding AMR.^9,34 However, another study showed that medicine (66%) and pharmacy (95%) students had a better understanding of antibiotic resistance than nursing and other health science students.³⁵ A study of 425 medical students at the University of California showed that a programme focused on stewardship, which involved self-paced learning and a collaborative workshop, had an impact on the knowledge and attitudes of preclinical medical students, prompting them to work together for effective antimicrobial stewardship.³⁶

More than half of our participants (56.90%) agreed that infections caused by resistant bacteria are increasing in Saudi Arabia. In the same way, several studies from individual institutions in Saudi Arabia have reported that rates of AMR for both Gram-positive and Gram-negative bacteria are on the rise.^37–39 For instance, a national study conducted in Saudi Arabia showed that 32% of Staphylococcus aureus is methicillin-resistant, while 33% of Streptococcus pneumoniae is resistant to penicillin G, and 26% is resistant to erythromycin.⁴⁰ There is currently a need to develop well-structured curricula that cater to undergraduate students in multiple fields, including medicine, pharmacy, and dentistry. These curricula should primarily focus on medicine, microbial virulence, mechanisms of resistance, and responsible antibiotic usage.^34,41

Several recommendations can be implemented to improve medical education on antibiotic use and antimicrobial resistance, including Enhancing the curriculum by integrating comprehensive education on antibiotic use, resistance mechanisms, and AMR prevention through dedicated courses, lectures, workshops, and case-based learning activities.^10,42 Foster interdisciplinary collaboration among medical, pharmacy, and nursing schools to provide a holistic understanding of antibiotic use and resistance, promoting teamwork in addressing AMR.⁴³ By offering practical training opportunities like clinical rotations, students can directly observe and participate in appropriate antibiotic prescribing practices, antimicrobial stewardship programs, and real-world scenarios related to AMR.⁴⁴ Utilize simulation exercises and virtual patient cases to simulate clinical situations involving antibiotic prescribing and resistance, allowing students to practice decision-making skills in a safe environment.^45,46

Other recommendations include encouraging lifelong learning through continuing education, promoting interprofessional education, supporting research initiatives, incorporating a global perspective, fostering partnerships and collaboration, and implementing regular assessments with constructive feedback.^41,47 By implementing these recommendations, medical education can effectively prepare future healthcare professionals to tackle the challenges of antibiotic use and antimicrobial resistance.⁴⁸

This study has a few limitations. First, our study may not be universally representative because of its design (based on an online survey), as it might not capture the responses from medical students who do not use social media. Second, the study was performed at one educational institute in Jeddah, Saudi Arabia. Similar studies should be implemented across multiple institutes to have a better understanding of these processes and take the necessary steps to overcome this global issue. Despite these limitations, the present study of medical students in Saudi Arabia will add to our knowledge in this area, as Saudi Arabia still has a limited number of studies addressing knowledge of antibiotic use and resistance among medical students.

Conclusion

Enhancing the curriculum to address the knowledge gap observed among males regarding antibiotics is crucial. This can be accomplished by integrating subjects such as resistance mechanisms and responsible antibiotic usage into the educational framework, utilizing diverse pedagogical methods such as lectures, workshops, and clinical rotations. It is imperative to provide comprehensive training to medical students that emphasizes responsible antibiotic practices, necessitating improvements in medical education on a global scale. Through an improved curriculum and practical experiences, efforts can be made to cultivate responsible antibiotic use among upcoming healthcare professionals.