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Abstract

Introduction

Resistance to antibiotics is a threat confronting health care system worldwide. Nurses play a significant role in combating this threat.

Objectives

The present study examined the knowledge and attitude of nurses towards antibiotic use and prevention of antibiotic resistance.

Methods

The research involved a cross-sectional study conducted in a multi-cultural tertiary healthcare setting. The participants were 341 nurses. A structured self-administered questionnaire with a good validity and reliability (α = 0.7) was used.

Results

The nurses surveyed showed moderate awareness of antibiotic resistance and a fair attitude towards its prevention. There was no significant correlation of demographic features with their overall knowledge and attitude (p > 0.05).

Conclusions

Nurses perform a crucial part in infection control, but often lack knowledge of methods to prevent antibiotic resistance. This paucity highlights the importance of tailored interventions to help nurses improve their awareness of antibiotic resistance and create a favorable attitude towards its prevention.

Keywords

knowledge nurses attitudes antibiotics antibiotic resistance antibiotic resistance prevention

Antibiotics are unequivocally one of the greatest innovations in medicine, but the threat of antibiotic resistance (AR) is now approaching a tipping point. Treatment of infections such as tuberculosis and pneumonia, handling of neonatal disorders, and provision of lifesaving care, such as chemotherapy and surgical procedures, have been seriously compromised as a result of AR (Hiltunen et al., 2017; Martinez, 2012). The reason for this condition was explained as prophylactic antibiotics are commonly administered as part of surgery, organ transplantation, and cancer chemotherapy to prevent infections (Bow, 2013; Bratzler et al., 2013). Rising AR impacts these procedures’ efficiency and could lead to severe medical consequences (i.e., high morbidity, amputation, or demise) (Smith & Coast, 2013). Notably, most common surgical procedures and cancer chemotherapy are almost impossible if AR is not tackled urgently (Nursing Times, 2015). In the USA, it is projected that the organisms leading to surgical site infections (38.7% to 50.9%) and infections following chemotherapy (26.8%) exhibited their resistance towards the standard prophylactic antibiotics (Teillant et al., 2015). Besides, the present situation, which may perhaps be said to mark the beginnings of a post-antibiotic era, urgently calls for newer types of medicine and innovative methods of treatment (Fitchett, 2015).

Studies have shown considerable variability in antibiotic use across countries, with the sale and availability of antibiotics differing widely (Swedres-Svarm, 2012). Heavy antibiotic consumption, it has been reported, aggravates AR (European Centre for Disease Prevention and Control, 2013). Underlying the distribution and use of antibiotics are varying levels of awareness of bacterial resistance among healthcare professionals (Alzoubi et al., 2009). Several misconceptions about the conditions that prompt the use of antibiotics in various illnesses have been reported (Abu-Mostafa et al., 2017; André et al., 2010; Guntu et al., 2016). In a public survey conducted across twelve countries, two-thirds of the respondents claimed that they were aware of AR, though they were not sure of its consequences and prevention. In this context, national and international organizations (such as World Health Organization-WHO and the US Centers for Disease Control-CDC) have proposed strategies to control AR. Education has been identified as a key factor in battling AR (CDC, 2013).

The decreasing effectiveness of antibiotics imposes enormous health and economic burdens on societies globally. Measuring the economic outcomes of antibiotic resistance can help policy-makers and healthcare professionals set priorities (Gandra et al., 2014).

Review of Literature

Researchers have identified gaps in the knowledge and perception of practitioners regarding antibiotic prescription. In research conducted by Asante et al., 2017, in which 379 prescribers participated, with the majority of them being nurses (50%), the researchers noted gaps in the knowledge and perception of antibiotic prescriptions among prescribers. Likewise, awareness of the problems posed by antibiotic prescription was observed to be low among health practitioners in Gambia (Chaw et al., 2017). Along comparable lines but in a very different social context, in a study conducted at an outpatient clinic in the United States, prescriptions were given to 41% patients having clinical diagnoses of conditions that did not require antibiotics (Havers et al., 2018).

Determinants of nurses’ attitudes and actions in their prescription of antimicrobial medication have been researched in the field. Guidelines/protocols, safety, tolerability and effectiveness of the antimicrobial drugs themselves, patient/parent pressure, and training/experience have been examined as regulating factors (Ness et al., 2016). It is a matter of great concern that large numbers of health professionals, including nurses and doctors, lack up-to-date knowledge of AR (Abera et al., 2014). Several investigators highlighted a notable point concerning the insufficient training of healthcare professionals during their bachelor's degree course in the area of antibiotic use and resistance (Wright & Jain, 2004). Accordingly, Ahmad et al. (2015) revealed that pharmacy students possess good knowledge of antibiotic use. Nevertheless, those students’ had a poor attitude over antibiotic use. Compounding the problem is the phenomenon of self-medication, which has come to be identified as global in scope. Antibiotic self-prescription is prevalent among the general public and health professionals (Belkina et al., 2014; Mouhieddine et al., 2015). The key factors contributing to this phenomenon are friendly advice on self-prescription of antibiotics and access to pharmacies (Al Rasheed et al., 2016). Collectively, these phenomena strongly imply the need for a change in attitude toward antibiotic use. Educational strategies and carefully developed guidelines may improve the quality of antibiotic prescribing (Fleming et al., 2013).

Using medicines of quality and strength appropriate to clinical need minimizes the development and spread of resistance (WHO, 2001). This can be achieved through antimicrobial stewardship — a coordinated set of strategies designed to improve the use of antimicrobial agents (Trivedi et al., 2014). Studies have shown that nurses play a major role in initiatives taken to combat AR (Carter et al., 2018; Edwards et al., 2011; Ellen et al., 2017; Gillespie et al., 2013).

Antibiotic stewardship programs include mixed interventions, such as auditing, restriction of specific antibiotics, restriction of treatment duration, and antibiotic cycling or mixing (Cobos-Trigueros et al., 2016). Implementing antimicrobial stewardship programs has been shown to reduce hospital costs and use of antibiotics (Karanika et al., 2016). In 2017, a recent systematic review by Baur et al. (2017) make the case for the co-implementation of improved hand-hygiene interventions with antibiotic stewardship programs for better outcomes. Moreover, nurses can play a significant role in such effort as those are viewed as resource-persons in the implementation and sustenance of infection control practices. Also, nurses can take part in antibiotic stewardship and contribute to the success of care programs. However, nurses should be competent and have the right attitude to provide correct and in-depth information about antibiotic use, which, in turn, would help reduce resistance in patients and the general public. With these concerns and purposes in view, this study was undertaken to examine the knowledge and attitude of nurses regarding antibiotic use and prevention of AR.

Methods

Design and Participants

An institutional cross-sectional study was conducted in an acute healthcare environment in Riyadh, Saudi Arabia, from October 2018 to July 2019. A convenience sampling technique was adopted to choose participants for the study. A sample size of 350 was calculated through the single proportion formula for a finite population. The survey obtained a 97% response rate, with 341 responses to 350 questionnaires that were handed out. Nurses who chose not to take part were excluded from the evaluation.

Data Collection

Data were collected using a structured self-administered questionnaire designed specifically for this study after an extensive review of the literature. The questionnaire comprised three parts. Part 1 included the demographic information of the participants (9 items). Part 2 was related to the nurses’ knowledge of AR. It comprised 20 items categorized into three dimensions: facts about antibiotics, antibiotic resistance, and prevention of AR. All items were in the format of multiple-choice questions containing four different answers, with one right answer. Every correct answer was awarded a score of 1, while a wrong response was given a score of 0. A score of 10 (i.e., 50% correct answers) was used as the cut-off point to determine the level of knowledge; a score >10 was labeled ‘good knowledge’. Part 3 investigated the attitude of nurses towards prevention of AR (15 items). The items were rated on a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). A score of 2.5 (50%) was labeled ‘poor attitude’, 2.6 (51%)–3.0 (59%) as ‘moderate’, and >3 (60%) as ‘good attitude’. A pilot study with a sample size of 120 was conducted to test the validity and reliability of the questionnaire. The tool was validated by 5 experts and the modifications recommended were incorporated into the tool. The reliability of the tool was measured using overall Cronbach's alpha value, which was equal to 0.7. In the current study, nurses were provided with comprehensive information pertaining to the proposed study protocol, and the expected outcomes. The nurses were then invited to participate, consent was obtained, and data collected using the structured questionnaire. Hard-copies of the questionnaire were distributed to the nurses; participating nurses were asked to drop their completed questionnaires in a box outside their department to maintain confidentiality.

Institutional Review Board Approval

Approval was obtained from the Institutional Review Board in the study setting. All the participants were visited in their units by the researchers and informed about the purpose of the study. It was made clear to them that participation was voluntary and their consent was then obtained. Data were collected from the completed questionnaires received. Confidentiality and anonymity were maintained throughout the study.

Data Analysis

The data were entered into a Microsoft Excel spreadsheet, validated for errors, coded, and exported to Statistical Package for Social Science (SPSS) Version 25 for analysis. Descriptive statistics were recorded for the demographic variables. Cronbach's alpha was used to assess the reliability of the survey instrument. Correlation (r) analysis was computed to understand the relation between knowledge of and attitudes toward antibiotics and antibiotic resistance prevention. The Chi-square test was used to find the association between knowledge and demographic variables, as also between attitude and demographic variables. All inferences were drawn at a 95% confidence interval with level of significance of 0.05.

Results

Demographic Characteristics

The majority of the participants [301 (88.3%)] were female. The mean age of the participants was 35.1 years; the mean nursing experience was 12 years. As for the professional qualification of the participants, 67.7% of them had a bachelor's degree, 28.7% a diploma, and 3.5% a master's degree. Most of the participants worked in critical/specialized (44.7%) and Medical (36.5%) nursing practice. 84.8% of the participants were registered nurses (Table 1).

Table 1.
Demographic Characteristics of the Study Population (n = 341).

Characteristics Description

Age (years) Mean ± SD 35.1 ± 6.5

min–max 22–56

Total years of nursing experience Mean ± SD 12 ± 5.8

Range 0–33

Sex Male 40 (11.7%)

Female 301 (88.3%)

Highest professional qualification Diploma 98 (28.7%)

Bachelor 231 (67.7%)

Master 12 (3.5%)

Working Unit Medical 124 (36.5%)

Surgical 28 (8.2%)

Critical/Specialized 152 (44.7%)

Out patient department 36 (10.6%)

Job title Registered nurse 289 (84.8%)

Shift manager 45 (13.2%)

Unit manager 7 (2.1%)

Nurses’ Knowledge About Facts About Antibiotics, Facts About Antibiotic Resistance, and Prevention of AR

Concerning the facts about antibiotics, effective handwashing is the most important procedure to prevent infection from microorganisms. This item rated the highest, with a score of 97.1%. The lowest score of 29.1% was observed in the item ‘antibiotic resistance’, which is defined as bacterial changes that reduce or eliminate the effectiveness of antibiotics. A total of eleven items were found below 60% and nine items had a score of above 60% as seen in Table 2.

Table 2.
Knowledge Score of Nurses About Facts on Antibiotics, Antibiotic Resistance and Prevention of Antibiotic Resistance: Percentages of Correct Answers.

No Questions (%) Correct Answers

1 Antibiotic is a medication that kills or slows down the growth of bacteria. 55.7%

2 Antibiotics can have side effects, like allergic reactions and diarrhea. 67.5%

3 The common side effects of antibiotics are rash, nausea, vomiting, and diarrhea. 64.8%

4 The microorganism that can be killed by antibiotics is normal and infectious flora. 30.0%

5 The effectiveness of antibiotics will be reduced if the full course is not completed. 69.9%

6 Nosocomial infection is the type of infection acquired in the health care setting. 78.3%

7 Antibiotic resistance is defined as bacteria changes in a way that reduces or eliminates the effectiveness of antibiotics. 29.1%

8 Developing new generations of antibiotics is not considered a cause of antibiotic resistance. 47.8%

9 Antibiotic resistance can affect any age group. 55.7%

10 Overuse of antibiotics is the most important factor leading to antibiotic resistance around the world. 85.6%

11 Infections caused by antibiotic-resistance are difficult and sometimes impossible to treat. 56.6%

12 Antibiotic resistance spread through animal and human 56.8%

13 Treating a viral infection with an antibiotic is an example of improper use of antibiotic therapy. 44.4%

14 Effective handwashing is the most important procedure for the prevention of infection from microorganisms. 97.1%

15 Immunization and infection prevention is considered as the most important factor in preventing antibiotic resistance. 31.6%

16 The antibiotic stewardship program aims to improve the use of antibiotics and prevent antibiotic resistance. 72.5%

17 Antibiotic therapy should be started ideally when there is a positive microbiological result. 92.6%

18 A patient expressing that antibiotics can be taken when symptoms are gone indicates a lack of knowledge 56.6%

19 Implementing infection prevention and control practices is the key action that a nurse should take to prevent resistant infections and their spread. 49.9%

20 Prospective audit, formulary restriction, and preauthorization and guidelines, and clinical pathways are considered as antibiotic stewardship strategies to combat antibiotic resistance. 94.4%

Attitude Towards Prevention of Antibiotic Resistance

As mentioned above in the ‘Data Collection’ section, participant attitudes were measured on a 5-point Likert scale, with scores ranging from 1 (strongly agree) to 5 (strongly disagree).

As regards the attitude of nurses towards antibiotic self-use, participants reported a mean score of 1.7 for general symptoms of the flu and a mean score 1.6 for antibiotics without a prescription. A good mean score of 4.1 found that participants read and understood the instructions before using antibiotics. A mean score of 2.2, reported for those nurses who kept antibiotics in stock, indicates their attitude towards self-use of antibiotics.

As for the nurses’ attitude towards strategies to prevent AR, their responses resulted in a mean score of 4.0. This indicates their attitude toward taking part in infection-control activities such as sanitation, hand washing, food, and water safety, and vaccination, all of which aim to minimize the spread of antimicrobial resistance. Also, a mean score of 4.0 was seen in escalated issues related to misuse of antibiotics. Half of all participants, with a mean score of 4.3, advised patients to complete the prescribed antibiotic course. A mean score of 4.0 showed how respondents saw themselves playing an active role in educating patients and families about the risk of AR. In the present survey, a mean score of 4.1 was reported that the respondents are advising other healthcare professionals as the appropriate use of antibiotics is important.

Moreover, a mean score of 4.0 showed respondents’ attitude toward their active contribution to institutional policies and guidelines focusing to control antibiotic resistance, which is the responsibility of a nurse. The respondents advocated the use of new generations of antibiotics that can fight diseases more effectively with caution with a mean score of 3.9. Those respondents were also recommending computer-based surveillance facilitating good antibiotic stewardship is important (mean score = 3.9). Further, those agreed that advising incorporating active interventions along with education to prevent antibiotic resistance is necessary one (mean score = 4.0). It is the responsibility of a nurse to follow clinical pathways in the management of infectious diseases is the responsibility of a nurse (mean score = 4.0) (Table 3). These data show the attitude of nurses towards prevention of antibiotic resistance.

Table 3.
Attitude of Nurses Towards Antibiotic use and Prevention of Antibiotic Resistance.

Items Mean ± SD

Antibiotic can be taken for the flu to get better quickly 1.7 ± 0.9

Antibiotics can be taken without a prescription 1.6 ± 0.8

Instructions are read and understood before taking antibiotics. 4.1 ± 1.0

Antibiotics can be kept in stock to be used whenever feeling sick. 2.2 ± 1.2

Participation in infection control activities help in minimizing the spread of antimicrobial resistance. 4.0 ± 0.9

Reporting and escalating issues related to misuse of antibiotics is the responsibility of a nurse. 4.0 ± 0.8

Advising patients to complete the prescribed antibiotic course even if they feel better quickly is necessary. 4.3 ± 0.9

Participation in special training on antibiotic resistance is recommended for all health care professionals. 4.3 ± 0.8

Advising other healthcare professionals in the appropriate use of antibiotics is important. 4.1 ± 0.8

Playing an active role in educating patients and families on the risk of antibiotic resistance is the responsibility of a nurse. 4.0 ± 0.8

Active contribution to institutional policies and guidelines which aim to control antibiotic resistance is the responsibility of a nurse. 4.0 ± 0.9

Advocating the use of new generations of antibiotics that can fight diseases more effectively with caution. 3.9 ± 0.8

Recommending computer-based surveillance to facilitate good antibiotic stewardship is important. 3.9 ± 0.8

Advising incorporating active interventions along with education to prevent antibiotic resistance is necessary. 4.0 ± 0.8

Following clinical pathways in the management of infectious diseases is the responsibility of a nurse. 4.0 ± 0.8

Nurses’ Overall Knowledge and Attitude Regarding Antibiotic use and Prevention of Antibiotic Resistance

Knowledge of antibiotics among the nurses was observed to be 54.3% with moderate knowledge, 26.4% with good knowledge and 19.4% with poor knowledge. Nurses’ knowledge concerning antibiotic resistance was seen to be 51.6% with moderate knowledge, 31.1% with poor knowledge and 17.3% with good knowledge. Knowledge of prevention of antibiotic resistance was seen to be 62.5% with moderate knowledge, 26.5% with good knowledge and 11.1% with poor knowledge. The overall score on knowledge regarding antibiotics and antibiotic resistance was 68.3% with moderate knowledge, and only 14.7% reported having good knowledge. The overall score on attitude showed 76.7% with good attitude and 23.3% with poor attitude (Table 4).

Table 4.
Overall Assessment of Knowledge and Attitude.

Components Categories n (%)

Percentage on facts about antibiotics (Knowledge) <50 66 (19.4%)

50–79 185 (54.3%)

80–100 90 (26.4%)

Percentage on facts about antibiotic resistance (Knowledge) <50 106 (31.1%)

50–79 176 (51.6%)

80–100 59 (17.3%)

Percentage on prevention of antibiotic resistance (Knowledge) <50 38 (11.1%)

50–79 213 (62.5%)

80–100 90 (26.4%)

Percentage on Knowledge (Overall score) <50 58 (17.0%)

50–79 233 (68.3%)

80–100 50 (14.7%)

Percentage on Attitude (Overall score) <60 244 (76.7%)

60–79 74 (23.3%)

80–100 0 (0%)

Correlation Between Knowledge and Attitude

As can be seen in Table 5, the results showed a very low correlation between the overall knowledge score and attitude score, where r = 0.024 and p-value = 0.177 (p > 0.05). This shows that there is no statistically significant correlation between knowledge and attitude in respect of antibiotics and antibiotic resistance. 64.9% of nurses who showed a moderate attitude also had moderate knowledge. There was a low score on attitude among the nurses who showed a moderate knowledge level, as seen by a reported score of 69.3%. Thus, there was no correlation between good attitude with low, moderate, and good knowledge.

Table 5.
Correlation Between Knowledge and Attitude.

Attitude Knowledge Result

<60 (low) 60–79 (moderate) 80–100 (good) Total

<60 (low) 43 (17.6%) 169 (69.3%) 32 (13.1%) 244 (76.7%) r = 0.024p = 0.177

60–79 (moderate) 10 (13.5%) 48 (64.9%) 16 (21.6%) 74 (23.3%)

80–100 (good) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

Total 53 (16.7%) 217 (68.2%) 48 (15.1%) 318 (100.0)

Association of Knowledge with the Demographic Variables

A significant correlation (p < 0.001) was seen among the nurses’ working unit and their knowledge about AR prevention. More experienced nurses had a higher score in their overall knowledge of AR than their counterparts with less experience, but the association was not statistically significant. Knowledge pertaining to infection gained in the healthcare environment (p < 0.001) and particular features of infections caused by AR (p = 0.007) showed a strong correlation with the participant's working unit. The overall expertize observed was highest among critical/specialized unit nurses (63.8 ± 14.3), followed by nurses in the ambulatory unit (60.7 ± 20.7). There was no statistically significant association between overall knowledge and specific AR training.

Association of Attitude with the Demographic Variables

No statistically significant association was observed between demographic variables such as age, job title, total years of experience, or specific training received on antimicrobial resistance, and the overall attitude towards prevention of AR. No significant statistical association between the overall attitude of participants and gender (p = 0.317) was observed either. However, there was a significant correlation in the nurses’ working unit (p = 0.010) with their overall attitude. These differences pertained to their taking part in infection-control activities (p = 0.017), reporting and escalating issues related to the misuse of antibiotics (p = 0.013), and advising patients to complete the course of antibiotics (p = 0.032). There was a significant correlation between AR-specific training and the overall score for attitude (p = 0.020). No significant association was observed between the nurses’ professional qualifications and their overall attitude toward prevention of antibiotic resistance (p = 0.106). Interestingly, though, a high attitude score was seen among master's degree holders (56.4 ± 4.4), and a statistically significant positive attitude was observed among master's degree holders in reading instructions before administering antibiotics (p = 0.001) and not maintaining antibiotics in stock (p = 0.041). A positive attitude was also recorded in respect of advising patients to complete the full course of antibiotic medication (p = 0.035), advising health care professionals on inappropriate antibiotic use (p = 0.018), taking part in training (p = 0.017), recommending computer-based surveillance (p = 0.015), and taking advice on incorporating active interventions along with education to prevent antibiotic resistance (p = 0.02).

Discussion

Prevention of AR requires a multi-sectoral response, and every individual has a role to play in this context. Healthcare professionals, especially nurses, play an important role in the effort to prevent this global crisis. The experience and mindset of nurses has an impact on caregiving and education. The present research aimed to measure the awareness and attitudes of nurses towards the prevention of AR. There are several noteworthy findings in our study.

Only half of the respondents knew that bacteria can become resistant to antibiotics. The responses showed that nurses were not knowledgeable in this basic concept of antibiotic resistance.

More than half of all respondents had only moderate knowledge of the basics of antibiotics. A similar finding in another study reported that nurses performed poorly on a survey of knowledge, attitudes, and practices related to antibiotic use (Nair et al., 2019). However, our finding contradicts that of three studies in which nurses showed good familiarity with antibiotics (Jayaweerasingham et al., 2019) and knowledge of antibiotics (Sadasivam et al., 2016) (Sanneh et al., 2020). Another study revealed disparity among nurses concerning the awareness and understanding of optimal antibiotic prescribing practices. It revealed that Prescribers with a high awareness score showed positive prescribing actions (Farley et al., 2018). Conflicting opinions of nurses and medical residents concerning the need for antibiotics were reported in yet another study (Ahouah et al., 2019). Collectively, these findings highlight the need for training to address these issues and reinforce the central role of nurses in AR prevention strategies.

In the present study, none of the participants showed a clear, positive attitude, and a majority of the participants (76.7%) had only a fair attitude towards antibiotic use and the prevention of antibiotic resistance. This finding is consistent with a study that reported a negative attitude of nursing staff toward antibiotic use (Sadasivam et al., 2016). Another study reported that trainee nurses reported that intake of antibiotics would help prevent colds from worsening and lead to early recovery, thereby demonstrating a fair attitude (Jayaweerasingham et al., 2019). Yet another study indicated that 37.2% of respondents never discarded leftover antibiotics but rather kept them in stock, and thus revealed their attitude toward antibiotic use (Alex, 2019). In the present study, nurses showed a favorable attitude toward an antimicrobial stewardship program and activities related to such a program. In accord with the findings of this study, a study done in Pakistan reported that most healthcare professionals (HCPs), including nurses showed a positive attitude towards hospital-based antimicrobial stewardship programs (ASPs) regardless of their poor awareness about ASPs (Hayat et al., 2020).

As regards training, only a minority of participants (21%) in the present study had attended specific training on AR; a majority (94.7%) of the participants expressed the need for training on ASPs. This is consistent with the findings of Abera et al. (2014), which stated that most nurses expressed the need for ASPs. According to Alex (2019), it is observed that 87% of students of a medical school expressed the need for more education about AR. These findings illustrate the need for continuing education initiatives to enhance awareness of HCPs (Ahmad et al., 2015). Only a few participants reported that they actively participated in infection-control activities and strategies at the institutional level. The present study noted a positive attitude towards some aspects of prevention; however, the overall attitude of participants towards prevention of AR was negative. This contradicts the finding of Kistler et al. (2017), who reported evidence-based positive attitudes and behaviors of nurses. These findings indicate that a lot of work needs to be done to educate nurses and lay the foundation for an effective ASP.

In our study, we observed no statistically significant association of demographic variables like age, gender, and years of experience with knowledge and attitude towards antibiotics and antibiotic resistance. This finding contradicts to the results of a study by Hayat et al. (2020) who reported a significant association between age and years of experience with the knowledge regarding AR. However, the present study observed a significant association between the nurses’ working unit (p < 0.001) and knowledge about the prevention of AR. Similar to other studies, nurses with a master's degree showed a better attitude towards avoiding AR, but there was no statistically significant correlation between AR knowledge and training. This illustrates the need for devising innovative approaches and methods to train nurses and for educational intervention with nurses to encourage appropriate antibiotic use and AR prevention.

Strengths and Limitations

The present study addresses the major problem of antibiotic resistance and how nurses can play a vital role in devising and implementing strategies to prevent antimicrobial resistance. It also reports the lack of thorough knowledge of antibiotics among the participating nurses and an unfavorable attitude on their part in respect of the prevention of antibiotic resistance. Our study has also identified the need for training and focused intervention for clinical nurses on antimicrobial stewardship and on involving them in the prevention of antibiotic resistance. The present study, however, is limited to nurses in a multicultural health care setting in Riyadh, Saudi Arabia, which limits the generalizability of the findings. The use of antibiotics was basically self-reported, and the response may not be accurate due to difference in the ability of the participants to recall information or due to the tendency to give a socially acceptable answer rather than their actual belief about antibiotic use and prevention of antibiotic resistance. Despite these limitations, this study provides an insight into the frontline nurses’ knowledge and attitude towards prevention of antibiotic resistance.

Implications for Practice

Participation in antimicrobial stewardship programs and prevention of antibiotic resistance requires knowledge and a proactive attitude towards antibiotic resistance. This study identified that nurses need to improve their knowledge and have the right attitude to contribute effectively to strategies of antibiotic resistance prevention and to get involved in antimicrobial stewardship programs. The study provides baseline data in its research setting to develop a program that can enhance the knowledge and attitude of nurses.

Conclusions

Nurses, as frontline health workers, have an important role in the prevention of antibiotic resistance. The present study showed that nurses themselves are not fully aware of the basics of antibiotics antibiotic resistance and the methods to be employed in its prevention. As such, this study highlights the importance of tailored interventions to improve awareness and create a favorable attitude among nurses towards the prevention of antibiotic resistance.

Characteristics	Description
Age (years)	Mean ± SD	35.1 ± 6.5
min–max	22–56
Total years of nursing experience	Mean ± SD	12 ± 5.8
Range	0–33
Sex	Male	40 (11.7%)
Female	301 (88.3%)
Highest professional qualification	Diploma	98 (28.7%)
Bachelor	231 (67.7%)
Master	12 (3.5%)
Working Unit	Medical	124 (36.5%)
Surgical	28 (8.2%)
Critical/Specialized	152 (44.7%)
Out patient department	36 (10.6%)
Job title	Registered nurse	289 (84.8%)
Shift manager	45 (13.2%)
Unit manager	7 (2.1%)

No	Questions	(%) Correct Answers
1	Antibiotic is a medication that kills or slows down the growth of bacteria.	55.7%
2	Antibiotics can have side effects, like allergic reactions and diarrhea.	67.5%
3	The common side effects of antibiotics are rash, nausea, vomiting, and diarrhea.	64.8%
4	The microorganism that can be killed by antibiotics is normal and infectious flora.	30.0%
5	The effectiveness of antibiotics will be reduced if the full course is not completed.	69.9%
6	Nosocomial infection is the type of infection acquired in the health care setting.	78.3%
7	Antibiotic resistance is defined as bacteria changes in a way that reduces or eliminates the effectiveness of antibiotics.	29.1%
8	Developing new generations of antibiotics is not considered a cause of antibiotic resistance.	47.8%
9	Antibiotic resistance can affect any age group.	55.7%
10	Overuse of antibiotics is the most important factor leading to antibiotic resistance around the world.	85.6%
11	Infections caused by antibiotic-resistance are difficult and sometimes impossible to treat.	56.6%
12	Antibiotic resistance spread through animal and human	56.8%
13	Treating a viral infection with an antibiotic is an example of improper use of antibiotic therapy.	44.4%
14	Effective handwashing is the most important procedure for the prevention of infection from microorganisms.	97.1%
15	Immunization and infection prevention is considered as the most important factor in preventing antibiotic resistance.	31.6%
16	The antibiotic stewardship program aims to improve the use of antibiotics and prevent antibiotic resistance.	72.5%
17	Antibiotic therapy should be started ideally when there is a positive microbiological result.	92.6%
18	A patient expressing that antibiotics can be taken when symptoms are gone indicates a lack of knowledge	56.6%
19	Implementing infection prevention and control practices is the key action that a nurse should take to prevent resistant infections and their spread.	49.9%
20	Prospective audit, formulary restriction, and preauthorization and guidelines, and clinical pathways are considered as antibiotic stewardship strategies to combat antibiotic resistance.	94.4%

Items	Mean ± SD
Antibiotic can be taken for the flu to get better quickly	1.7 ± 0.9
Antibiotics can be taken without a prescription	1.6 ± 0.8
Instructions are read and understood before taking antibiotics.	4.1 ± 1.0
Antibiotics can be kept in stock to be used whenever feeling sick.	2.2 ± 1.2
Participation in infection control activities help in minimizing the spread of antimicrobial resistance.	4.0 ± 0.9
Reporting and escalating issues related to misuse of antibiotics is the responsibility of a nurse.	4.0 ± 0.8
Advising patients to complete the prescribed antibiotic course even if they feel better quickly is necessary.	4.3 ± 0.9
Participation in special training on antibiotic resistance is recommended for all health care professionals.	4.3 ± 0.8
Advising other healthcare professionals in the appropriate use of antibiotics is important.	4.1 ± 0.8
Playing an active role in educating patients and families on the risk of antibiotic resistance is the responsibility of a nurse.	4.0 ± 0.8
Active contribution to institutional policies and guidelines which aim to control antibiotic resistance is the responsibility of a nurse.	4.0 ± 0.9
Advocating the use of new generations of antibiotics that can fight diseases more effectively with caution.	3.9 ± 0.8
Recommending computer-based surveillance to facilitate good antibiotic stewardship is important.	3.9 ± 0.8
Advising incorporating active interventions along with education to prevent antibiotic resistance is necessary.	4.0 ± 0.8
Following clinical pathways in the management of infectious diseases is the responsibility of a nurse.	4.0 ± 0.8

Components	Categories	n (%)
Percentage on facts about antibiotics (Knowledge)	<50	66 (19.4%)
50–79	185 (54.3%)
80–100	90 (26.4%)
Percentage on facts about antibiotic resistance (Knowledge)	<50	106 (31.1%)
50–79	176 (51.6%)
80–100	59 (17.3%)
Percentage on prevention of antibiotic resistance (Knowledge)	<50	38 (11.1%)
50–79	213 (62.5%)
80–100	90 (26.4%)
Percentage on Knowledge (Overall score)	<50	58 (17.0%)
50–79	233 (68.3%)
80–100	50 (14.7%)
Percentage on Attitude (Overall score)	<60	244 (76.7%)
60–79	74 (23.3%)
80–100	0 (0%)

Attitude	Knowledge	Result
<60 (low)	43 (17.6%)	169 (69.3%)	32 (13.1%)	244 (76.7%)	r = 0.024p = 0.177
60–79 (moderate)	10 (13.5%)	48 (64.9%)	16 (21.6%)	74 (23.3%)
80–100 (good)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Total	53 (16.7%)	217 (68.2%)	48 (15.1%)	318 (100.0)

Footnotes

Acknowledgments

We acknowledge the research center at the study setting for the grant and scientific editing services.

Ethical Considerations

Approval for the study was obtained from the Nursing Research Committee and the Institutional Review Board of the hospital under IRB Log Number 18-593. Written informed consent was obtained from all subjects after explaining the purpose of the study. Participation in the study was purely voluntary. Confidentiality and anonymity were maintained throughout the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the King Fahad Medical City (grant number RFA:018-049).

ORCID iD

Diana S. Lalithabai

References

Abera

Kibret

Mulu

(2014). Knowledge and beliefs on antimicrobial resistance among physicians and nurses in hospitals in amhara region. Ethiopia. BMC pharmacology and toxicology, 15(1), 26. https://doi.org/10.1186/2050-6511-15-26

Abu-Mostafa

N. A.

Al-Mejlad

N. J.

Al-Yami

A. S.

Al-Sakhin

F. Z.

Al-Mudhi

S. A.

(2017). A survey of awareness related to the use of antibiotics for dental issues among non-medical female university students in Riyadh, Saudi Arabia. Journal of Infection and Public Health, 10(6), 842–848. https://doi.org/10.1016/j.jiph.2017.01.015

Ahmad

Khan

M. U.

Patel

Maharaj

Pandey

Dhingra

(2015). Knowledge, attitude and practice of B. Sc. Pharmacy students about antibiotics in Trinidad and Tobago. Journal of research in pharmacy practice, 4(1), 37. https://doi.org/10.4103%2F2279-042X.150057

Ahouah

Lartigue

Rothan-Tondeur

(2019). Perceptions of antibiotic therapy Among nursing home residents: perspectives of caregivers and residents in a mixed exploratory study. Antibiotics, 8(2), 66. https://doi.org/10.3390/antibiotics8020066

Alex

I. O.

(2019). Knowledge of antibiotic use and resistance among students of a medical school in Nigeria. Malawi Medical Journal, 31(2), 133–137. https://doi.org/10.4314%2Fmmj.v31i2.5

Al Rasheed, A., Yagoub, U., Alkhashan, H., Abdelhay, O.,Alawwad, A., Al Aboud, A., & Al Battal, S. (2016). Prevalence and predictors of self-medication with antibiotics in Al wazarat health center, Riyadh city, KSA. BioMed Research International, 2016:3916874. https://doi.org/10.1155/2016/3916874

Alzoubi

Ayoub

Al-Sakaji

Al-Azzam

Mhaidat

Masadeh

(2009). Awareness of bacterial resistance among physicians, pharmacists and nurses. International Journal of Occupational Medicine and Environmental Health, 22(4), 363. https://doi.org/10.2478/v10001-009-0034-3

André

Vernby

Berg

Lundborg

C. S.

(2010). A survey of public knowledge and awareness related to antibiotic use and resistance in Sweden. Journal of Antimicrobial Chemotherapy, 65(6), 1292–1296. https://doi.org/10.1093/jac/dkq104

Asante

K. P.

Boamah

E. A.

Abdulai

M. A.

Buabeng

K. O.

Mahama

Dzabeng

Gavor, E., Annan, E. A., Owusu-Agyei, S., Gyansa-Lutterodt, M., Ghana Antimicrobial resistance working group. (2017). Knowledge of antibiotic resistance and antibiotic prescription practices among prescribers in the brong ahafo region of Ghana; a cross-sectional study. BMC health Services Research, 17(1), 422. https://doi.org/10.1186/s12913-017-2365-2

10.

Baur

Gladstone

B. P.

Burkert

Carrara

Foschi

Döbele

Tacconelli

(2017). Effect of antibiotic stewardship on the incidence of infection and colonization with antibiotic-resistant bacteria and clostridium difficile infection: A systematic review and meta-analysis. The Lancet Infectious Diseases, 17(9), 990–1001. https://doi.org/10.1016/S1473-3099(17)30325-0

11.

Belkina

Al Warafi

Eltom

E. H.

Tadjieva

Kubena

Vlcek

(2014). Antibiotic use and knowledge in the community of Yemen. Saudi Arabia, and Uzbekistan. The Journal of Infection in Developing Countries, 8(04), 424–429. https://doi.org/10.3855/jidc.3866

12.

Bow

E. J.

(2013). There should be no ESKAPE for febrile neutropenic cancer patients: The dearth of effective antibacterial drugs threatens anticancer efficacy. Journal of Antimicrobial Chemotherapy, 68(3), 492–495. https://doi.org/10.1093/jac/dks512

13.

Bratzler

D. W.

Dellinger

E. P.

Olsen

K. M.

Perl

T. M.

Auwaerter

P. G.

Bolon

M. K.

Weinstein

R. A.

(2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surgical Infections, 14(1), 73–156. https://doi.org/10.1089/sur.2013.9999

14.

Carter

E. J.

Greendyke

W. G.

Furuya

E. Y.

Srinivasan

Shelley

A. N.

Bothra

Larson

E. L.

(2018). Exploring the nurses’ role in antibiotic stewardship: A multisite qualitative study of nurses and infection preventionists. American Journal of Infection Control, 46(5), 492–497. https://doi.org/10.1016/j.ajic.2017.12.016

15.

Centres for Disease Control and Prevention (US) (2013). Antibiotic resistance threats in the United States, 2013. Centres for Disease Control and Prevention, US Department of Health and Human Services. [Cited 2018 December 04] Available from: https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf

16.

Chaw

P. S.

Maria Schlinkmann

Raupach-Rosin

Karch

Pletz

M. W.

Huebner

Mikolajczyk

(2017). Knowledge, attitude and practice of gambian health practitioners towards antibiotic prescribing and microbiological testing: A cross- sectional survey. Transactions of The Royal Society of Tropical Medicine and Hygiene, 111(3), 117–124. https://doi.org/10.1093/trstmh/trx027

17.

Cobos-Trigueros

Solé

Castro

Torres

J. L.

Rinaudo

De Lazzari

Martínez

J. A.

(2016). Evaluation of a mixing versus a cycling strategy of antibiotic use in critically-ill medical patients: Impact on acquisition of resistant microorganisms and clinical outcomes. PLoS One, 11(3), e0150274. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0150274

18.

Edwards

Drumright

L. N.

Kiernan

Holmes

(2011). Covering more territory to fight resistance: Considering nurses’ role in antimicrobial stewardship. Journal of Infection Prevention, 12(1), 6–10. https://doi.org/10.1177%2F1757177410389627

19.

Ellen, M. E., Hughes, F., Shach, R., & Shamian, J. (2017). How nurses can contribute to combating antimicrobial resistance in practice,research and global policy. International Journal of Nursing Studies, 71, A1-A3. https://doi.org/10.1016/j.ijnurstu.2017.02.023

20.

European Centre for Disease Prevention and Control. Annual Epidemiological Report: Reporting on 2011 surveillance data and 2012 epidemic intelligence data. [Internet]. 2013 [Cited 2018 December 04] Available from: https://www.ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/annual-epidemiological-report-2013.pdf

21.

Farley

Stewart

Davies

M. A.

Govind

Van den Bergh

& Boyles

T. H.

(2018). Antibiotic use and resistance: knowledge, attitudes and perceptions among primary care prescribers in South Africa. SAMJ: South African Medical Journal, 108(9), 763–771. https://doi.org/10.7196/samj.2018.v108i9.12933

22.

Fitchett

J. R.

(2015). Antibiotics, copayments, and antimicrobial resistance: Investment matters. The Lancet Infectious Diseases, 15(10), 1125–1127. https://doi.org/https://doi.org/10.1016/S1473-3099(15)00057-2

23.

Fleming

Browne

Byrne

(2013). The effect of interventions to reduce potentially inappropriate antibiotic prescribing in long-term care facilities: A systematic review of randomised controlled trials. Drugs & Aging, 30(6), 401–408. https://doi.org/10.1007/s40266-013-0066-z

24.

Gandra

Barter

D. M.

Laxminarayan

(2014). Economic burden of antibiotic resistance: How much do we really know? Clinical Microbiology and Infection, 20(10), 973–980. https://doi.org/10.1111/1469-0691.12798

25.

Gillespie

Rodrigues

Wright

Williams

Stuart

R. L.

(2013). Improving antibiotic stewardship by involving nurses. American Journal of Infection Control, 41(4), 365–367. https://doi.org/10.1016/j.ajic.2012.04.336

26.

Guntu

Vasireddy

K. S.

Yerram

(2016). Knowledge, attitude, and beliefs on antibiotic use and misuse in adults: A survey in the community of guntur. Value in Health, 19(3), A97. https://doi.org/10.1016/j.jval.2016.03.1762

27.

Havers

F. P.

Hicks

L. A.

Chung

J. R.

Gaglani

Murthy

Zimmerman

R. K.

Jackson

M. L.

(2018). Outpatient antibiotic prescribing for acute respiratory infections during influenza seasons. JAMA network open, 1(2), e180243–e180243. https://doi.org/10.1001/jamanetworkopen.2018.0243

28.

Hayat, K., Rosenthal, M., Gillani, A. H., Chang, J., Ji, W., Yang, C., & Fang, Y. (2020). Perspective of key healthcare professionals on antimicrobial resistance and stewardship programs: A multicenter cross-sectional study from Pakistan. Frontiers in Pharmacology, 10, 1520. https://doi.org/10.3389/fphar.2019

29.

Hiltunen

Virta

Laine

A. L.

(2017). Antibiotic resistance in the wild: An eco- evolutionary perspective. Philosophical Transactions of the Royal Society B: Biological Sciences, 372(1712), 20160039. https://doi.org/10.1098/rstb.2016.0039

30.

Jayaweerasingham

Angulmaduwa

Liyanapathirana

(2019). Knowledge, beliefs and practices on antibiotic use and resistance among a group of trainee nurses in Sri Lanka. BMC research Notes, 12(1), 601. https://doi.org/10.1186/s13104-019-4640-2

31.

Karanika

Paudel

Grigoras

Kalbasi

Mylonakis

(2016). Systematic review and meta-analysis of clinical and economic outcomes from the implementation of hospital-based antimicrobial stewardship programs. Antimicrobial Agents and Chemotherapy, 60(8), 4840–4852. https://doi.org/10.1128/AAC.00825-16

32.

Kistler

C. E.

Beeber

Becker-Dreps

Ward

Meade

Ross

Sloane

P. D.

(2017). Nursing home nurses’ and community-dwelling older adults’ reported knowledge, attitudes, and behavior toward antibiotic use. BMC nursing, 16(1), 12. https://doi.org/10.1186/s12912-017-0203-9

33.

Martinez

J. L.

(2012). Natural antibiotic resistance and contamination by antibiotic resistance determinants: The two ages in the evolution of resistance to antimicrobials. Frontiers in Microbiology, 3, 1. https://doi.org/10.3389/fmicb.2012.00001

34.

Mouhieddine

T. H.

Olleik

Itani

M. M.

Kawtharani

Nassar

Hassoun

Mohsen

(2015). Assessing the Lebanese population for their knowledge, attitudes and practices of antibiotic usage. Journal of Infection and Public Health, 8(1), 20–31. https://doi.org/10.1016/j.jiph.2014.07.010

35.

Nair

Tripathi

Mazumdar

Mahajan

Harshana

Pereira

, Carolina, J., Halder, D., & S. Burza (2019). Knowledge, attitudes, and practices related to antibiotic use in paschim bardhaman district: A survey of healthcare providers in west bengal, India. PLoS One, 14(5), e0217818. https://doi.org/10.1371/journal.pone.0217818

36.

Ness

Price

Currie

Reilly

(2016). Influences on independent nurse prescribers’ antimicrobial prescribing behaviour: A systematic review. Journal of Clinical Nursing, 25(9-10), 1206–1217. https://doi.org/10.1111/jocn.13249

37.

Nursing Times (2015 October 16). Antibiotic resistance poses threat to surgery and chemo. Retrieved from https://www.nursingtimes.net/clinical-archive/perioperative-nursing/antibiotic-resistance-poses-threat-to-surgery-and-chemo-16-10-2015/

38.

Sadasivam

Chinnasami

Ramraj

Karthick

Saravanan

(2016). Knowledge, attitude and practice of paramedical staff towards antibiotic usage and its resistance. Biomedical and Pharmacology Journal, 9(1), 337–343. https://doi.org/10.13005/bpj/944

39.

Sanneh

Jallow

H. S.

Singhateh

Sabally

Sey

A. P.

Jallow

A. W.

Jah

S. L.

(2020). Knowledge, attitude and practice of health care workers on antibiotic resistance and usage in the Gambia. GSC Biological and Pharmaceutical Sciences, 13(2), 007–015. https://doi.org/10.30574/gscbps.2020.13.2.0177

40.

Smith, R., & Coast, J. (2013). The true cost of antimicrobial resistance. Bmj, 346. https://doi.org/https://doi.org/10.1136/bmj.f1493

41.

Swedres Svarm. Swedish Antibiotic Utilisation and Resistance in Human Medicine. Swedish Veterinary Antimicrobial Resistance Monitoring. [Internet]. 2012 [Cited 2018 December 04] Available from https://www.sva.se/globalassets/redesign2011/pdf/om_sva/publikationer/swedres_svarm20 12.pdf

42.

Teillant

Gandra

Barter

Morgan

D. J.

Laxminarayan

(2015). Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: A literature review and modelling study. The Lancet Infectious Diseases, 15(12), 1429–1437. https://doi.org/10.1016/S1473-3099(15)00270-4

43.

Trivedi

K. K.

Dumartin

Gilchrist

Wade

Howard

(2014). Identifying best practices across three countries: Hospital antimicrobial stewardship in the United Kingdom, France, and the United States. Clinical Infectious Diseases, 59(suppl_3), S170–S178. https://doi.org/10.1093/cid/ciu538

44.

Wright

E. P.

Jain

(2004). Survey of antibiotic knowledge amongst final year medical students. Journal of Antimicrobial Chemotherapy, 53(3), 550–551. https://doi.org/10.1093/jac/dkh096

45.

World Health Organization (2001). How to develop and implement a national drug policy. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/42423/924154547X.pdf?sequence=1

Knowledge,Attitude and Beliefs of Nurses Regarding Antibiotic use and Prevention of Antibiotic Resistance

Abstract

Introduction

Objectives

Methods

Results

Conclusions

Keywords

Review of Literature

Methods

Design and Participants

Data Collection

Institutional Review Board Approval

Data Analysis

Results

Demographic Characteristics

Nurses’ Knowledge About Facts About Antibiotics, Facts About Antibiotic Resistance, and Prevention of AR

Attitude Towards Prevention of Antibiotic Resistance

Nurses’ Overall Knowledge and Attitude Regarding Antibiotic use and Prevention of Antibiotic Resistance

Correlation Between Knowledge and Attitude

Association of Knowledge with the Demographic Variables

Association of Attitude with the Demographic Variables

Discussion

Strengths and Limitations

Implications for Practice

Conclusions

Footnotes

Acknowledgments

Ethical Considerations

Declaration of Conflicting Interests

Funding

ORCID iD

References