Knowledge, attitude and practice study about antibiotics usage among medical undergraduates of a tertiary care teaching hospital of Haryana, India: an observational cross-sectional study

INTRODUCTION

Antibiotics are probably one of the most successful forms of chemotherapy in the history of medicine. Their use has significantly reduced the mortality and morbidity associated with infectious disease. The beginning of the modern “antibiotic era” started with the discoveries of Paul Ehrlich and Alexander Fleming.¹ Penicillin discovered by Fleming was called as “wonder drug’’ because of lives it saved after its discovery.² In early 1945, Fleming predicted that the high public demand of antibiotics would determine an “era of abuse”, which eventually became a reality.^3,4 The overuse of antibiotics clearly drives the evolution of resistance. Epidemiological studies have demonstrated a direct relationship between antibiotic consumption and the emergence and dissemination of resistant bacteria strains.^5-11

Antibiotic resistance (ABR) has now become a global health problem. It has significantly increased the mortality and morbidity related to infectious diseases as well as the economic burden due to these types of infections.¹² There is global consensus on development of new strategies for prevention of antibiotic abuse and hence decreasing the prevalence of ABR. One of the most important strategies is to educate general population as well as health care personnel about antibiotic abuse. WHO states that all healthcare workers and medical students should be educated on rational antimicrobial prescribing or ‘‘Antimicrobial stewardship’’ and this is an integral part of ABR containment activities.^13,14

Medical students should be given more education during their undergraduate training regarding antibiotic resistance and appropriate prescribing. This is a crucial time period during which the importance of these issues should be emphasized, because once the doctors become qualified, it is difficult to change their deeply entrenched views and behaviour.¹⁵ Before strengthening any training program for any group, it is advised to be aware about knowledge, attitude and practices of that group. As medical students are taught about antibiotic usage and resistance during 2nd year of their curriculum, this study was planned with the objective to assess the knowledge, attitudes and the practices of 2nd year medical students about antibiotic usage.

METHODS

The present study was questionnaire based cross-sectional study conducted among 2nd year undergraduate medical students from tertiary care teaching hospital (Israna, Panipat, Haryana) after taking clearance from institutional ethics committee. All students were informed about the objectives of the study. A total of 130 students agreed to voluntarily participate and those who were not willing to participate in the study were excluded. The study was conducted during a period of two weeks from 5 to 20 May, 2021.

Data were collected through specifically developed structured questionnaire, which was developed based on the literature review of comparable studies.^16-18 The questionnaire was validated by subject experts for its content and relevance. Before the commencement of main study, a small-scale pilot study was conducted among small number of students using the structured questionnaire. Based on the pilot study outcome, the questionnaire was further modified and improved.

The Institutional Ethics Committee permission was taken prior to initiation of the study. Each participant was allotted 20 minutes to answer the questionnaire. They were asked to complete the questionnaire anonymously. Informed consent was also obtained from the participants, to utilise their data for research purposes. The questionnaire was divided in three parts, assessing the participants’ knowledge, attitude and practice respectively. The participants’ knowledge was assessed by using a set of ‘yes’ and ‘no’ questions. Attitude was analyzed by using a 5-point Likert scale, whose responses ranged from ‘strongly agree’ to ‘strongly disagree’. The participants’ practice of antibiotic use was assessed by using a Likert scale which ranged from ‘always’ to ‘never’.

For simplifying the analysis, we reduced the five point response options of the Likert scale into three scale agree/disagree/uncertain and yes/no/uncertain for Attitude and Practice assessment respectively. The possible answers “strongly agree” and “agree” were considered as a “agree” answer, while the possible answers “disagree” and “strongly disagree” were considered as a “disagree” answer and remaining were uncertain. The possible answers “always” and “usually” were considered as a “yes” answer, while the possible answers “seldom” and “never” were considered as a “no” answer and possible answers “sometimes” were labeled as same. The results were tabulated as percentages.

RESULTS

The response rate was 100 percent among the 130 medical students who volunteered to participate in the study. The results are tabulated as percentages in Table1, Table 2 and Table 3.

Out of study participants, 93.07% (n=121) of the students were aware that antibiotic resistance has become an important and serious global public health issue and about same no. of participants (93.84%, n=122) agreed that indiscriminate antimicrobial use can lead to the emergence of the antibiotic resistance. All of the students were aware that antibiotics can be used to cure infections caused by bacteria but 7.69% of students were not aware that common cold and influenza were not caused by the bacteria.

However, the attitude of the students about antibiotic use and resistance was found to be casual and negligent. 21.53% (n=28) of study participants believed that they should take antibiotics when they have cold to prevent from getting a serious illness. 38.46% (n=50) of students considered taking antibiotics whenever they had fever. 30.00% (n=39) of participants thought that skipping one or two doses of antibiotics did not contribute to development of antibiotics resistance. 43 participants (33.07%) thought that antibiotics were safe drugs and hence could be used commonly used.

Majority of students (84.61%) however consulted a doctor before taking antibiotics and majority of them completed full course of antibiotics. Most of the study participants (93.07%) always checked the expiry date of antibiotics before taking them.

DISCUSSION

This study provides useful information about the knowledge, attitudes and the practices of 2nd year undergraduate medical students about antibiotic resistance and usage.

The emergence of antibiotics resistance is a growing problem worldwide.¹⁹ Irrational use of antibiotics leads to progressive loss of bacterial sensitivity to antibiotics resulting in antibiotics resistance causing various clinical and economic impacts.²⁰

WHO has also highlighted the irrational use of antibiotics as public health problem. WHO even set the theme of World Health Day as ‘Combat Antimicrobial Resistance: No Action Today, No Cure Tomorrow’.^21,22 India has also recognized the problem of Antibiotics Resistance (ABR) and Government of India launched “National Programme on Containment of Antimicrobial Resistance” under the 12th five year plan (2012-2017). The main objectives of this programme are to establish a laboratory based AMR surveillance system of 30 network labs in the country and to generate quality data on antimicrobial resistance for pathogens of public health importance, to strengthen infection control guidelines and practices and promote rationale use of antibiotics and to generate awareness among healthcare providers and in the community about rationale use of antibiotics.²³

Majority of students in our study had fair knowledge about use of antibiotics, irrational use of antibiotics leading to resistance and ABR becoming an important and serious global public health issue. Similar response was noted in previous studies.^24-26

The current study demonstrated that students’ attitude was casual and non-serious compared to their level of knowledge. 21.53% of study participants thought that antibiotics should be used to prevent getting a serious illness in common cold and 35.38% of them said to use antibiotics as first drug of choice in case of cold and sore throat. 30.00% of students thought that skipping one or two doses did not contribute to the development of antibiotic resistance. Similar results were seen in previous studies.^24,27-28

The self reported practices of study participants with regards to antibiotics use were found to be satisfactory, in contrast to the casual attitude. Majority of study participants consulted a doctor before starting an antibiotic and majority of them completed the full course of treatment. Similar results were seen in previous studies.^24-28 Self medication practice among medical students was found to be more prevalent in some similar previous studies.^29-31 Another similar study stated that more than 60 % of the participants thought that antibiotics should be prescribed for viral illnesses assuming bacterial etiology.³² Such wrong beliefs cause high rates of antibiotics consumption, leading to antibiotics resistance.³³ But in our study, majority of the participants were aware that diseases like sore throat and common cold are not of bacterial etiology and hence they did not recommend antibiotics.

The main causes of the emergence of antibiotics resistance are the failure to implement policies and programs in preventing infections and also failure to follow the antibiotics usage guidelines strictly.³⁴ Hence teaching about antibiotics usage as well as the principles of the protocol development for antibiotics use in health care facilities should form an integral part of the undergraduate teaching curriculum.³⁵

The main limitation of this study was that it was based on a convenience sample which involved only one batch of second year undergraduate medical students from one single teaching hospital.

CONCLUSION

This study provides useful information about the knowledge, attitudes and the practices of 2nd year undergraduate medical students about antibiotic resistance and usage. There is the need for appropriately teaching the medical students regarding antibiotic usage and resistance and more emphasis should be given in academics regarding the subject which can create a moral responsibility toward the judicious use of antibiotics among medical students.

ACKNOWLEDGEMENTS

We would like to thank all the students who participated in the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Aminov RI. A brief history of the antibiotic era: lessons learned and challenges for the future. Front Microbiol. 2010;1:134.
2. 2. Lobanovska M, Pilla G. Penicillin's Discovery and Antibiotic Resistance: Lessons for the Future? Yale J Biol Med. 2017;90(1):135-45.
3. 3. Bartlett JG, Gilbert DN, Spellberg B. Seven ways to preserve the miracle of antibiotics. Clin Infect Dis. 2013;56(10):1445-50.
4. 4. Spellberg B, Gilbert DN. The future of antibiotics and resistance: a tribute to a career of leadership by John Bartlett. Clin Infect Dis. 2014;2(2):S71-5.
5. 5. Ventola CL. The antibiotic resistance crisis: part 1: causes and threats. P T. 2015;40(4):277-83.
6. 6. Centers for Disease Control and Prevention, Office of Infectious Disease Antibiotic resistance threats in the United States. 2013. Available at: http://www.cdc.gov/drugresistance/threat-report-2013. Accessed on May 14 2021.
7. 7. Congressional Research Service Report Life expectancy in the United States. Mar, 2005. Available at: http://www.cnie.org/nle/crsreports/05mar/RL32792.pdf. Accessed on May 15 2021.
8. 8. Spellberg B, Gilbert DN. The future of antibiotics and resistance: a tribute to a career of leadership by John Bartlett. Clin Infect Dis. 2014;2(2):S71-5.
9. 9. Viswanathan VK. Off-label abuse of antibiotics by bacteria. Gut Microbes. 2014;5(1):3-4.
10. 10. Read AF, Woods RJ. Antibiotic resistance management. Evol Med Public Health. 2014;2014(1):147.
11. 11. The antibiotic alarm. Nature. 2013 Mar 14;495(7440):141. doi: 10.1038/495141a. PMID: 23495392.
12. 12. World Health Organization. ANTIMICROBIAL RESISTANCE: Global Report on Surveillance. Geneva: WHO; 2014. Available at: https://www.who.int/antimicrobial-resistance/publications/surveillancereport/en/. Accessed on May 18, 2021.
13. 13. World Health Organization. The evolving threat of antimicrobial resistance. Options for action. 20 Avenue Appia, 1211 Geneva 27, Switzerland. 2012. Available at: http://apps.who.int/iris/bitstream/10665/44812/1/9789241503181_eng.pdf. Accessed on May 22 2021.
14. 14. Vickers H. International antibiotic resistance crisis. Better training needed to maintain therapeutic arsenal. Student BMJ. 2011;19;d3207.
15. 15. Simpson SA, Wood F, Butler CC. General practitioners’ perceptions of antimicrobial resistance: a qualitative study. Journal of Antimicrobial Chemotherapy. 2007;59:292-96.
16. 16. Eng JV. Consumer attitudes and use of antibiotics. Emerging Infectious Diseases. 2003;9(9):1128-35.
17. 17. 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.
18. 18. Huang Y, Gu J, Zhang M, Ren Z, Yang W, Chen Y, et al. Knowledge, attitude and practice of antibiotics: A questionnaire study among 2500 Chinese students. BMC Med Educ. 2013;13:163.
19. 19. Spellberg B, Guidos R, Gilbert D, Bradley J, Boucher HW, Scheld WB, Bartlett et al. The epidemic of antibiotic-resistant infections: A call to action for the medical community from the Infectious Diseases Society of America. Clin. Infect. Dis. 2008;46:155-64.
20. 20. Maragakis LL, Perencevich EN, Cosgrove SE. Clinical and economic burden of antimicrobial resistance. Expert Rev Anti Infect Ther. 2008;6:751-63.
21. 21. World Health Organization. The evolving threat of antimicrobial resistance Options for action. Geneva: World Health Organization, 2012. Available at: http://whqlibdoc.who.int/publications/2012/9789241503181_eng.pdf. Accessed on May 25 2021.
22. 22. World Health Day. Antibiotic resistance: No action today, no cure tomorrow. 2011. Available at: http://www.who.int/mediacentre/news/statements/2011/whd_20110407/en/index.html. Accessed on May 25 2021.
23. 23. National Centre for Disease Control. Available at: https://ncdc.gov.in/index1.php?lang=1&level=2&sublinkid=384&lid=344. Accessed on June 2 2021.
24. 24. Mahajan MM, Dudhgaonkar S, Deshmukh DSN. A Questionnaire based Survey on the Knowledge, Attitude and Practises about Antimicrobial Resistance and Usage among the Second year MBBS Students of a Teaching tertiary care Hospital in Central India. Int J of Pharmc Res. 2014;4(4):175-9.
25. 25. Afzal 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 Aug;7(8):1613.
26. 26. 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(3):899-903.
27. 27. Khajuria K, Kaur S, Sadiq S, Khajuria V. KAP on antibiotic usage and resistance among second professional medical students. Int J Basic Clin Pharmacol. 2019;8:68-73.
28. 28. Padmanabha TS, Nandini T, Manu G, Savkar MK, Shankar RM. Knowledge, attitude and practices of antibiotic usage among the medical undergraduates of a tertiary care teachinghospital: an observational cross-sectional study. Int J Basic Clin Pharmacol. 2016;5:2432-7.
29. 29. Azevedo MM, Pinheiro C, Yaphe J, Baltazar F. Portuguese students’ knowledge of antibiotics: a cross-sectional study of secondary school and university students in Braga. BMC Public Health. 2009;9:359.
30. 30. Sakeena MHF, Bennett AA, Jamshed S, Mohamed F, Herath DR, Gawarammana I, et al. Investigating knowledge regarding antibiotics and antimicrobial resistance amongpharmacy students in Sri Lankan universities. BMC Infect Dis. 2018;18:209.
31. 31. Ayepola OO, Onile‑Ere OA, Shodeko OE, Akinsiku FA, Ani PE, Egwari L. Dataset on the knowledge, attitudes and practices of university students towards antibiotics. Data Brief. 2018;19:2084‑94.
32. 32. Steinberg I. Clinical Choices of Antibiotics: Judging Judicious Use. The American Journal of Managed Care. 2000;6(23):1178-88.
33. 33. Zafar SN. Self-medication amongst university students of Karachi: Prevalence, knowledge and attitudes. JPMA. 2008,58:214-17.
34. 34. World health organization. Prevention and containment of antimicrobial resistance. Available at http://www.searo.who.int/entity/antimicrobial_resistance/sea_cd_273.pdf?ua=1. Accessed on June 4, 2021.
35. 35. Nathwani D, Davey P. Antibiotic prescribing-are there lessons for physicians? J Med. 1999;92:5:287-92.