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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 89-95

Antibiotic use and resistance: Awareness among students of Prince Mohammad Bin Fahd University in Saudi Arabia

1 College of Sciences and Human Studies, Prince Mohammad Bin Fahad University, AlKhobar, Eastern Province, Kingdom of Saudi Arabia
2 College of Nursing-A, King Saud Bin Abdul Aziz University for Health Sciences, Al Mubarraz, King Abdullah Military City, Kingdom of Saudi Arabia

Date of Submission08-May-2020
Date of Decision08-Jun-2020
Date of Acceptance14-Jul-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Lina Alzayer
Prince Mohammad Bin Fahad University, P. O. Box: 1664, Al-Khobar 31952
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sccj.sccj_22_20

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Background and purpose: Antibiotic misuse in Saudi Arabia is becoming an increasing concern. It leads to the development and acceleration of antibiotic resistance. One of the established approaches to tackle the problem is through improving public awareness of appropriate antibiotic use. This study examined the level of awareness of university students about the correct use of antibiotics and the issue of antibiotic resistance. Methods: A cross-sectional study was designed, using a self-administered online questionnaire that was sent to all students of Prince Mohammad Bin Fahd University in the Eastern Province of Saudi Arabia. Results: The total number of participants was 320 students, of whom 210 were female (65.6%) and 110 were male (34.4%). About a third (34.7%) of the students had poor knowledge regarding the fact that antibiotics should only be used for bacterial infections. In addition, just over half (50.0%–57.5%) of the students could not classify the common viral infections as antibiotic untreatable infections. On the other hand, the majority (84.1%) of the respondents were highly aware of the correct source and the correct use of antibiotic prescriptions. Similarly, 73.4% of students revealed a high awareness level of how to address the issue of antibiotic resistance. However, around one-third (35.3%) of them incorrectly thought that antibiotic-resistant bacteria cannot spread from one person to another. Conclusion: Establishing an educational intervention program is needed in Saudi universities to improve students' awareness of the specific conditions that can be treated with antibiotics. In addition, it is essential for students to know that antibiotic resistance can affect anyone, of any age, in any country, and that it can be accelerated by the improper use of antibiotics.

Keywords: Antibiotics, awareness, misuse, resistance, Saudi Arabia

How to cite this article:
Alzayer L, Ambani Z, Ganendran LM. Antibiotic use and resistance: Awareness among students of Prince Mohammad Bin Fahd University in Saudi Arabia. Saudi Crit Care J 2020;4:89-95

How to cite this URL:
Alzayer L, Ambani Z, Ganendran LM. Antibiotic use and resistance: Awareness among students of Prince Mohammad Bin Fahd University in Saudi Arabia. Saudi Crit Care J [serial online] 2020 [cited 2023 Mar 29];4:89-95. Available from: https://www.sccj-sa.org/text.asp?2020/4/3/89/296834

  Introduction Top

Since the advent of the “antibiotic age” in the early twentieth century,[1] antibiotics have been saving human lives for many decades. However, improper use of these powerful medications is directly related to the dangerously increasing incidence of antibiotic resistance, one of the biggest threats to global health.[2]

Meaning of antibiotics misuse

Antibiotics misuse can have multiple definitions. Among these are self-medication with previously prescribed antibiotics; following the advice of someone other than a physician including a friend, a family member, or even a pharmacist; and noncompliance with the prescription regime. Examples include missing doses, taking suboptimal doses, and discontinuation of the antibiotic after the alleviation of symptoms.[3]

Determinants of antibiotic misuse

Literature reviews have identified multiple determinants of the misuse of antibiotics in the community. One of these factors is the background of the patients. It was shown that age, education, and socioeconomic status of the patient can influence the use of antibiotics.[4] Another contributing factor is patients' previous experience of antibiotic use and expectations of how antibiotics can affect common ailments. For example, previous studies have reported a widely spread misconception that antibiotics are able to treat common upper respiratory tract infections (URTIs) which are generally viral infections that should not be treated with antibiotics.[5] These expectations lead to patients coming to physicians expecting an antibiotic prescription in the belief of a reduction in symptoms severity for these nonbacterial conditions.[6] Moreover, knowledge, beliefs, and attitudes of patients can also contribute to antibiotics misuse. A study found evidence that poor understanding of the correct use of antibiotics and the conditions that can be treated by antibiotics was linked to their improper use.[7]

Outcomes of antibiotic misuse

Improper use of antibiotics can lead to the development of side effects, rising costs of health-care services, and most importantly the development of antibiotic resistance.[8] Bacteria can develop the ability to defeat the drugs that are designed to kill them.[9] When bacteria become resistant, the effectiveness of antibiotics is reduced or eliminated.[10] This may result in failure of treatment, recurrence of infections, increased clinic visits, and increased mortality.[2]

Prevalence of antibiotic misuse in Saudi Arabia

A systematic review of antibiotic misuse in Saudi Arabia has reported a high prevalence of all forms of the incorrect use of antibiotics, ranging from 41% to 92%.[9] Moreover, another review has shown that surveillance studies on antibiotic resistance in Saudi Arabia have demonstrated that 32%–45% of the monitored bacteria were found to be multidrug resistant.[10],[11],[12] This is evidenced by the increasing emergence and spread of different bacterial species among the Saudi population.[10]

Thus, it is well accepted that the misuse of antibiotics results in the development of antibiotic resistance. The World Health Organization (WHO) endorsed a global action plan to tackle this issue.[13] The first objective of the plan is to improve awareness and understanding of antibiotic resistance. Furthermore, the Saudi Ministry of Health launched initiatives related to the Saudi Vision 2030 that aims to empower the Saudi health sector.[14] One of the programs that have been implemented is a health awareness campaign about antibiotics. In light of the government initiatives to improve awareness on the correct use of antibiotics, the objectives of the current study are to assess the awareness of university students in Saudi Arabia about the indications for antibiotics use, the correct use of antibiotics, and the issue of antibiotic resistance.

  Methods Top

Ethics statement

The objective of this study was to assess the awareness of Prince Mohammad Bin Fahd University (PMU) students on the use of antibiotics. The data were collected via an online questionnaire that was sent to all students. As the university does not yet have an Ethics Review Board, written approval for the use and distribution of the questionnaire was granted by the Deanship of Student Affairs, who is the responsible body for approval of any research involving students. All procedures followed were in accordance with the Helsinki Declaration as revised in 2013.

Setting and participants

A cross-sectional study was conducted to achieve the study objective. Descriptive survey design with convenience sampling was used. Both female and male students from PMU in the Alkhobar City of Saudi Arabia were invited to participate in the research. Data collection was done using a self-report online questionnaire. A link to the questionnaire was sent to all PMU students and was available from April 4, 2018, until July 20, 2018. A reminder E-mail notification was sent to all students on June 27, 2018. The survey was received by 2000 students. The minimum effective sample size was calculated using the online sample size calculator (RaoSoft, Inc.,®) to be 322, with a confidence interval of 95% and margin of error of 5%.[15] A total of 320 students participated in this study.

Validity and reliability of the questionnaire

Before sending the questionnaire to the students, a content validity test was conducted in which a senior physician in Ras Tanura General Hospital, Alkhobar, was asked to comment on the extent to which the items of the questionnaire were valid and reliable. The questionnaire was claimed to be valid in which it seemed, in the view of the expert, to cover all aspects of the students' knowledge of antibiotics (i.e. it could measure the intended variables accurately). Face validity was assessed in a pilot sample of 30 students. These students had to complete a follow-up questionnaire where they were asked to write their thoughts regarding the purpose of the questionnaire and whether or not they feel that items were an adequate measure of their antibiotics knowledge. As a consequence of the pilot study results, one question was removed as it appeared misleading (asking if they know what antibiotic means) and another question was rephrased as it was difficult to understand (urine infection was used in place of a urinary tract infections). Cronbach's alpha was used to calculate the internal consistency of the items (α = 0.631). Missing responses were avoided by having the online questionnaire to prevent the next question appearing until the previous one was answered, given that the students were requested to answer the questionnaire to the best of their knowledge.

Study tool

The questionnaire was developed based on a review of relevant literature addressing assessment tools for the evaluation of the knowledge, attitude, and practice of antibiotics usage.[3],[16],[17],[18],[19],[20],[21],[22] Modifications of the existing tools were made to fit the objectives of this study. The final assessment tool used in this study consists of 24 items divided into four sections:


There are four items in this section which acquires demographic information of the participants [Table 1].
Table 1: Demographic profile of participants (n=320)

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Part one

This part of the survey evaluates the students' knowledge of the indications for antibiotics use. It consists of 7 items that use a nominal scale (Yes/No) as shown in [Table 2] (Part One). A scalar-scoring system is used to evaluate the participants' knowledge level. A score of one is given to each correct answer and a score of zero is given to each incorrect answer. The total score is used to rank the level of knowledge (the maximum possible score for this part is seven) and subsequent qualitative analysis was conducted to rank the knowledge score into 3 categories 0–2 (poor knowledge level), 3–5 (moderate knowledge level), and 6–7 (good knowledge level).
Table 2: Students' responses regarding the correct use of antibiotics

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Part two

The main aim of this part is to evaluate the students' knowledge regarding the correct use of antibiotics. As presented in [Table 2] (Part Two), this part contains six items using a nominal scale (Yes/No). The same scoring system as in Part One is used, and the maximum possible score is six. The categories of the knowledge level score are changed to 0–1 (poor knowledge level), 2–4 (moderate knowledge level), and 5–6 (good knowledge level).

Part three

This section focuses on evaluating the students' knowledge on the issue of antibiotic resistance. It consists of 7 items using a nominal scale (Yes/No). The same scoring system and the same knowledge level categories as in Part One are used here [Table 2], Part Three].

Statistical analysis

The scoring system that was applied converts all responses in Parts One, Two, and Three of the questionnaire from a nominal scale (Yes/No) to a numeric scale (0/1) based on the correct answers. The scores of the correct answers in each part were then summed and the mean score was accordingly calculated. All the collected data were coded and analyzed using the Statistical Package for the Social Sciences (SPSS 16.0 for Windows® (Chicago, IL)). Descriptive statistics were used to analyze the data. All the categorical variables were presented as frequencies and proportions, while all the numerical data were presented as mean ± standard deviation. Inferential statistics were used to check for a significant association between the demographic characteristics of the participants and their knowledge. Independent t-test was used for continuous variables and one-way ANOVA analysis was used for categorical variables. In both cases, P < 0.05 was considered statistically significant for all the statistical tests.

  Results Top

A total of n = 320 students participated in the survey. Overall, higher participation was observed from the female students (n = 210, 65.6%). The majority of the respondents (295; 92.2%) were Saudi nationals. Overall, 300 (93.8%) of the respondents do not have children. The most prevalent age groups were students in the 18–21 years (n = 150) and 22–25 years (n = 135). Demographic information of the participants is shown in [Table 1].

Knowledge level about the reasons of antibiotics use

[Table 2] (Part One) indicates that around two-thirds of the students (65.3%) were aware that antibiotics treat bacterial infections and not viral infections. [Figure 1] (Part One) shows an overall moderate antibiotics use knowledge level among most PMU students (69.1%). Nevertheless, 49.1%–55.0% of the students provided incorrect answers about whether antibiotics are able to treat respiratory infections, skin infections, and urine infections.
Figure 1: Distribution of the knowledge levels of the students regarding (Part One) the reasons for antibiotic use, (Part Two) the source of antibiotics, and (Part Three) the issue of antibiotic resistance

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Knowledge level of the correct use of antibiotics

As shown in [Table 2] (Part Two), the majority of students were aware that antibiotics should be taken exactly as directed by the doctor (84.1%). In addition, 76.2% of the students thought it was not acceptable to use antibiotics based on a self-prescription or nonphysician prescription. On the other hand, 38.4% of students thought a course of antibiotics could be stopped if the patient felt better, and 35.6% agreed that pharmacist advice for antibiotics was a valid prescription. [Figure 1] (Part Two) shows similar trends of both moderate and good knowledge level of students regarding how to correctly use antibiotics.

Knowledge level of antibiotic resistance

Based on the results shown in [Table 2] (Part Three), 83.4% of the students recognized antibiotic resistance as a serious health issue, and 75.0% of them thought it was directly related to the overuse of antibiotics. The majority of students were aware that the issue of antibiotic resistance can be prevented by practicing good personal hygiene (84.7%), by minimizing the use of antibiotics (78.1%), and by completing the entire course of any prescribed antibiotics (76.6%). The evaluation of the students' knowledge regarding the issue of antibiotic resistance revealed a good knowledge level (score 6 or higher) across the majority of the students (73.4%), as illustrated in [Figure 1] (Part Three).

Mean score comparison, in [Table 3], shows no statistical difference (all P > 0.05) between any of the demographical information of the participants (gender, age, nationality, and parental status) and their knowledge level of why and how antibiotics are taken and how they relate to antibiotic resistance. In both genders, for example, the mean knowledge score for the conditions in which antibiotics are used for is just above 3.5. The mean score for students who are aged above 30 years was slightly higher (4.75 ± 1.28) which could have suggested that this group is more knowledgeable about the reasons for antibiotic intake; however, likewise, this difference did not reach statistical significance (P = 0.071). Nationality and parental status were also not significant as the mean scores revealed similar knowledge levels among the Saudis, non-Saudis, those who have children, and those who do not have children.
Table 3: Mean knowledge score of students based on their demographics for part one, two, and three of the survey

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  Discussion Top

The present study showed that most PMU students have a moderate-to-high knowledge level regarding what antibiotics are used for, how to use them appropriately, as well as the consequences of antibiotics misuse. This knowledge level was not surprising as all participants were university students, and previous studies have reported a proportional relationship between the awareness of antibiotics and the educational status.[23],[24]

However, there was confusion regarding the specific medical conditions that antibiotics can treat. Barely half of all respondents could identify whether the common cold, fever, sore throat, skin infection, and urine infection are caused by bacteria or viruses, and hence they could not identify whether these conditions should be treated with antibiotics or not. Some of this confusion can be explained by improper clinical communication between patients and physicians. Doctors often do not explain to patients the biological agent responsible for the diagnosed disease.[18] Moreover, unnecessary prescription of antibiotics can cause confusion about whether these common diseases are bacterial or viral.[8] For example, a study found that antibiotics are frequently inappropriately prescribed for URTIs on a global scale.[25] Another systematic review found that antibiotics were prescribed for URTIs in 40%–87% of the cases in Saudi Arabia, 63%–79% in Vietnam, 68.4% in Malaysia, 44%–75% in America, and 31.3% in Taiwan.[26]

Most students (64.4%) knew that the only correct source for obtaining antibiotics is through a prescription from a doctor. In contrast, 35.6% of students felt that it is acceptable to use antibiotics based on the advice of a pharmacist. This belief is most likely based on personal experience and observation, as there is a high rate of nonprescribed antibiotic sales in Saudi Arabia. A study conducted in Riyadh, Saudi Arabia, found that antibiotics were dispensed without a medical description in 77.6% of community pharmacies.[27] Another study found that only one out of 88 pharmacies in the Eastern province refused to sell antibiotics without a prescription.[28]

When responding to the question of when to stop taking prescribed antibiotics, more than one third (38.4%) of PMU students incorrectly thought they could discontinue antibiotic intake once they felt better. This finding is consistent with the results of two independent Saudi studies conducted in Northern Border University and in King Khalid University Hospital, in which they both revealed that two-thirds of the participants stopped taking their prescribed antibiotic course because they felt better.[4],[18]

Although the majority of students seemed to have good knowledge about the issue of antibiotic resistance, 35.3% of students incorrectly thought that antibiotic-resistant bacteria cannot spread from person to person. In fact, students need to understand that they are still at risk of antibiotic resistance even if they correctly use antibiotics because bacteria that are resistant to antibiotics can spread in the same way that nonresistant bacteria spread. Therefore, it should be emphasized to the students that using antibiotics correctly as well as following infection prevention and control precautions are required to limit the spread of antibiotic resistance.

The multivariate analysis revealed that gender, age, nationality, and parental status had no significant relationship with the students' knowledge level of antibiotics. This was unexpected as previous literature has been using these relationships as indicators of antibiotics misuse. For example, two Saudi studies independently found significant associations between antibiotic misuse, age, and gender.[9],[29] In addition, the multi-country public survey on antibiotic usage conducted by the WHO found large variations in public antibiotic awareness levels based on geographical background and household composition.[13] However, the lack of significant association in the present findings can be related to the fact that the majority of the participants in this study have a similar background in which only 35 of them (10.9%) are aged above 25 years, only 25 of them (7.8%) are not Saudi nationals, and only 20 of them (6.2%) have children in their household. Therefore, most of the participants are from a similar age group, similar culture, and similar socioeconomic status, and hence they are most probably exposed to similar public health awareness.


Since a self-reported survey was used in this study, there is a degree of bias where respondents provide an answer which they believe is expected, and hence the outcomes depend on the honesty of the participants. Moreover, a closed question quantitative research methodology was used, which limits the ability to further explore the Student's level of understanding.

The current study only addresses the knowledge of PMU students about the reasons for antibiotic intake, the correct use of antibiotics, as well as their knowledge about antibiotic resistance. Future studies could make a comparison between the antibiotic knowledge of PMU students and students from other universities in Saudi Arabia.

  Conclusion Top

This study has highlighted a need to promote awareness about the correct use of antibiotics within the PMU student community. Although PMU students showed moderately sufficient awareness about the misuse of antibiotics and the issue of antibiotic resistance, improving their awareness regarding which conditions can be treated with antibiotics is crucial to prevent them from using antibiotics for conditions that are not, in fact, treatable with these medicines. In addition, emphasis must be given to taking the full course of antibiotics in order to increase the effectiveness of the medication. Suggested strategies include creating a campaign within the university to increase awareness, specifically during the WHO World Antibiotic Awareness Week every November. Health topics addressing the use of antibiotics should be included in the university curriculum in order to encourage students to explore this public health issue. In the bigger picture, an action is needed from health-care providers and health educators in the whole community to encourage the correct use of antibiotics and hence decrease the incidence and the spread of antibiotic resistance.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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