|Year : 2022 | Volume
| Issue : 4 | Page : 245-252
Awareness of antibiotic resistance among medical students in Kerala State, India: A cross-sectional study
Anju P Reena, Abraham M Ittyachen
Department of Medicine, M.O.S.C Medical College and Hospital, Ernakulam, Kerala, India
|Date of Submission||21-Jun-2022|
|Date of Decision||21-Jul-2022|
|Date of Acceptance||17-Aug-2022|
|Date of Web Publication||17-Oct-2022|
Prof. Abraham M Ittyachen
Department of Medicine, M.O.S.C Medical College and Hospital, Kolenchery, Ernakulam - 682 311, Kerala
Source of Support: None, Conflict of Interest: None
Background: Antibiotic resistance is a natural phenomenon, but its misuse has expedited resistance. One of the best measures to tackle antibiotic resistance in the community would be to educate medical students and create awareness among them regarding antibiotic resistance. The objectives of this study were to assess the level of awareness of antibiotic resistance among undergraduate medical students and to determine the factors affecting the awareness. Materials and Methods: This is a cross-sectional study using a structured questionnaire among undergraduate medical students from the 1st year to the 4th year. Results: Three hundred and fifty-four undergraduate medical students from the 1st year to the 4th year were enrolled. More than 80% of students were from the 18–22-year age group, and more than half were female. Only 56.2% of participants had adequate awareness of antibiotic resistance. The academic year was not significantly associated with the awareness. Age and gender also had no significant association. Parent's education, parent's occupation, parents being medical practitioners and family income also had no significant association. Conclusion: Awareness levels regarding antibiotic resistance among medical students were slightly above 50%. Moreover, it seems to be a worldwide phenomenon too. Further studies are recommended to evaluate the practices and attitudes regarding the same. A “catch them young” policy would be a good step to tackle antimicrobial resistance at its inception itself. Moreover, it should start at the local level. Similar studies can be conducted among medical practitioners and health-care workers and at the community level.
Keywords: Antibiotic resistance, antibiotic stewardship, medical education, medical student, nosocomial infection
|How to cite this article:|
Reena AP, Ittyachen AM. Awareness of antibiotic resistance among medical students in Kerala State, India: A cross-sectional study. Curr Med Issues 2022;20:245-52
|How to cite this URL:|
Reena AP, Ittyachen AM. Awareness of antibiotic resistance among medical students in Kerala State, India: A cross-sectional study. Curr Med Issues [serial online] 2022 [cited 2022 Dec 1];20:245-52. Available from: https://www.cmijournal.org/text.asp?2022/20/4/245/358652
| Introduction|| |
Antibiotics are an indispensable part of modern medicine. However, as time passed, deadly bacteria started evolving, developing immunity and resistance to these drugs. Although antibiotic resistance is a natural phenomenon through processes such as mutation and gene transfer, its misuse has expedited resistance.
Numerous infections which were previously cured easily by antibiotics have started getting incurable. This, in turn, leads to prolonged hospital stays, increasing the risk of nosocomial infections, and escalating mortality rates. Deaths due to these multidrug-resistant bacteria or superbugs are estimated to be more than 700,000 per year.
India is one of those countries with a significant “antimicrobial resistance” problem. Even potent antibiotics are accessible in the country without appropriate prescriptions. While some studies show adequate awareness among health-care professionals and students, many show abuse, casual attitude, and lack of awareness regarding this issue and so this calls for an urgent need for better perception.,,
A lot of efforts to tackle this multifaceted crisis have been emerging in the country, for instance, antimicrobial stewardship program. However, there is often inadequate implementation of these measures. Today's medical students are tomorrow's physicians. Therefore, one of the best measures that can be taken up is to educate medical students and create awareness among them regarding antibiotic resistance. Such measures if begun earnestly in the budding stages of a medical career can go a long way in managing this catastrophe. As an initial step, awareness of antibiotic resistance among medical students needs to be evaluated.
| Materials and Methods|| |
Study design and setting
This study was done through a cross-sectional design using a structured questionnaire in the setting of a rural-based medical college in Kerala state in the southern part of India. The objectives of the study were as follows:
- To assess the level of awareness of antibiotic resistance among undergraduate medical students
- To determine factors affecting the awareness about antibiotic resistance among medical students.
Undergraduate medical students from the 1st year to the 4th year were part of the study. This included both preclinical and clinical students.
All students who were present during the study duration and who gave consent for participating were included in the study.
All students who were absent during the study duration and who did not give consent for participating were excluded from the study.
A structured questionnaire that was used in another study [Table 1] was used in this study (permission from the authors was obtained for the same). The questionnaire had two parts. The first part contained questions on demographic variables including age, sex, education, occupation, and income of parents. The second part contained 44 questions (including subquestions) to evaluate the awareness of antibiotic resistance of the participant. Each one of these 44 questions carried one mark. A minimum score of 22 (50%) was needed for the participant to have adequate awareness about antibiotic resistance.
- Independent variables: Age, gender, education of parents, occupation of parents, and socioeconomic status of the participant
- Dependent variables: Awareness of misuse of antibiotics, knowledge about development and consequences of antibiotic resistance, and attitude regarding antibiotic course completion.
Two posters published by the World Health Organization on the occasion of world antibiotic awareness week (November 16–22, 2015) were distributed as handouts to all participants who completed the study.
First, the nature and purpose of the study was explained to the students. Then, a structured questionnaire was given to the participants. Due to the unexpected COVID-19 pandemic, the data collection was done using a mixed approach, with distribution of questionnaire both online via Google docs and in person. A handout regarding the topic “Antibiotic Resistance” was distributed to all the participants who completed the study as an attempt to raise awareness about the same. Data analysis was performed using R software. An awareness class on antibiotic resistance was also conducted online using Google Meet after data analysis.
Categorical variables were summarized using frequency and percentage. Quantitative variables were summarized using median and interquartile range (IQR). To study the factors associated with the knowledge, attitude, and awareness of antibiotic resistance in medical students, Chi-square test or Fisher's exact test was performed. The association of awareness with the demographic variables was assessed this way. Statistical analysis was performed using R software. P < 0.05 was considered statistically significant.
The research was approved by the Institutional Ethics Committee (IEC) of the hospital (No: MOSC/IEC/410/2020). Before initiating the study, a participant information sheet was given to all the students and informed consent was obtained from students who were willing to participate in the study.
The study was selected by the Indian Council of Medical Research under its STS research program (STS reference ID: 2020-01965).
| Results|| |
Three hundred and fifty-four undergraduate medical students from the 1st year to the 4th year were enrolled in the study. The majority were from the second year (32.2%) followed by the 1st year (26.3%) and the 4th year (25.1%). More than 80% of students were from the 18 to 22-year age group (80.5%) and more than half the number of students were female (65.3%) [Table 2].
Among the parents (mother and father), there was no significant difference in the literacy level. More than 50% were graduates [Table 3]. Again, on a similar scale, more than 50% of the fathers and mothers were professionals [Table 4]. Majority of the families had a monthly income of <1,00,000 rupees. Only around 11% of the parents were doctors.
The awareness score of antibiotic resistance was summarized as median and IQR. The median score was found to be 26 with Q1 = 10 and Q2 = 34. Out of 354 participants, 56.2% had adequate awareness (score >22) and 43.8% had inadequate awareness (score <22) [Table 5].
Chi-square test/Fisher's exact test was done to check the factors associated with awareness about antibiotic resistance [Table 6]. The academic year was not significantly associated with the awareness about antibiotic resistance among medical students. Age and gender also had no significant association with the awareness. The place of residence was not significantly associated with the awareness levels. Neither father's education nor mother's education had any significant association. Mother's occupation was not significantly associated with the awareness levels. Father's occupation also had no significant association. The monthly income had no significant association with the level of awareness. Parents being medical practitioners also had no significant association with the level of awareness of antibiotic resistance among medical students.
| Discussion|| |
This study was conducted in a medical college in Kerala state in the southern part of India to assess the level of awareness of undergraduate medical students regarding antibiotic resistance and the factors affecting the same. It was a questionnaire-based study, and the results of this study show that 56.2% of participants had adequate awareness of antibiotic resistance. In other studies, reported from Kerala, a wide variation was noted in the level of awareness regarding antibiotic resistance., In studies from other parts of India too, such a disparity was observed.,,, All these studies cannot be considered true representative samples. Nevertheless, the fact that medical students across the country and across the years are aware of antimicrobial resistance is a point of solace as they form the next generation of prescribers in the country. However, there are students who are not aware of antimicrobial resistance, and this should be of concern. Introduction of new syllabi in the 1st year itself and across the different phases of undergraduate medical education dealing with antimicrobial resistance would be a strong step toward creating awareness among new graduates before they earn a license to practice.
Sixty-eight percent and 64% agreed that antimicrobial resistance is an important public health challenge in India and the whole world, respectively. Similar results were observed in a study from Gujarat state in India too. Medical student's perceptions and knowledge about antimicrobial stewardship seem to be an international problem too, with some differences. In a multicentric study from Europe, majority of the students said that antibiotic resistance is a national problem. In a study from the United States of America, differences existed between medical schools in educational resources used, perceived preparedness, and knowledge about antimicrobial use. In a study from East Africa, even final-year students had low scores in knowledge about antimicrobial resistance and antibiotic use in clinical scenarios.
The academic year of the participant was not significantly associated with the awareness level according to our study. This was in contrast to a pan India study which showed that as compared to 1st-year students, knowledge about AMR was significantly higher among their seniors.
A majority of participants (72.6%) said that antibiotics are medicines used against bacteria. This was higher than the study conducted in Gujarat state where only 52% of participants were aware of it. A similar conclusion was drawn in a multicenter study in India among undergraduate medical students.
Majority of the students confirmed that bacteria do not cause common cold or flu. Similar findings were reported in the Gujarat study and pan India study already mentioned., A majority of the students (59.6%) also said that antibiotics are not the first drug of choice for early treatment of cough and sore throat. Like manner, 65.8% of participants were aware of the fact that empirical management of episodes of diarrhea by antibiotics is not necessary.
A high level of knowledge was observed about the fact that antibiotic resistance occurs as a natural phenomenon also. It was found that 63.3% of participants knew that skipping one or two doses of antibiotics does contribute to antibiotic resistance and hence completion of the antibiotic course is necessary. Likewise, a high level of awareness has been observed in another study too. Mixed observations were made by other authors regarding this.,, Similarly, 63.8% of participants opined that antibiotics should not be stopped when symptoms resolve. Seventy-two percent of participants responded that consumption of common antibiotics without prescription contributes to antibiotic resistance. Similarly, 60.7% were aware that antibiotic resistance emerges due to prescription of incorrect antibiotics.
Sixty-four percent of students were affirmative that handwashing has a role in the prevention of antimicrobial resistance. It was in accordance with the study conducted in Gujarat. Similar observations were also made in a European study conducted among medical students. Thirty-six percent of participants were of the view that prevention of drug resistance is not an expensive task. This perception does not harbor well for tomorrow's doctors and should be of concern. When the students were asked, “What does antibiotic resistance lead to?”, 78% responded that antibiotic resistance causes increased health-care expenditure, 75.4% responded that antibiotic resistance leads to prolonged hospital stay, and 71.2% opined that antibiotic resistance leads to decreased cure rate. This was similar to the results reported by the study from Gujarat. These responses are in line with current concerns regarding antimicrobial resistance.
Responses regarding drugs and treatment regimens for some of the important diseases in the community were far from satisfactory. Two-thirds of the participants believed that multidrug resistance is not an issue with malaria. Only a slight majority (57%) could correctly identify DOTS PLUS as a treatment regimen for tuberculosis (DOTS PLUS is part of the national health program in the country). Only 39% of participants responded that bedaquiline is used in the treatment of tuberculosis. Knowledge regarding multidrug therapy as a treatment regimen for drug-resistant leprosy was observed in only 44.9% of the participants.
About half of the participants were of the opinion that antimicrobial resistance can be caused by substandard antibiotics while 19.8% of participants felt that generic drugs do not contribute to antibiotic resistance. Regarding a statement that “second-line drugs are safer than first-line drugs,” opinion was split in the middle with roughly half being for and the other half being against. Only 42.9% of the total participants felt that the information they received regarding antimicrobial resistance was adequate as per the academic year.
This study had some limitations. The questions were mostly based on the causes, consequences, and prevention of antibiotic resistance along with questions regarding treatment regimens and drugs used for selected diseases only. Our study did not assess the behavior and practices regarding antibiotic usage. It was observed that the participants had a fair knowledge about the causes and consequences of antimicrobial resistance. However, the knowledge regarding the prevention of antibiotic resistance was not satisfactory. Likewise, the knowledge regarding drugs and their usage in clinical practice for infectious diseases also needs improvement. It is likely that the knowledge acquired by the students is more theoretical than clinical. A subanalysis comparing the knowledge of the students according to their academic year was also not done.
Medical students should be trained to prescribe consciously and effectively in their undergraduate period itself. It can be done by integrating more clinical as well as nonclinical classes and demonstrations into the curriculum. Their knowledge should be evaluated often so that further interventions can be made according to the need. Academic clubs can be formed under or in association with antibiotic stewardship program, and small extracurricular group activities can be conducted. Volunteers can be encouraged to conduct interactive sessions with the students. They should be made aware of the responsibility of handling and using antibiotics. Students should be trained in communication skills and patient education skills so that they can make the patients understand better the importance of proper usage of antibiotics. Along with knowledge, necessary emphasis should be given in molding the attitude of future doctors regarding the handling of these vital drugs. It is not that medical students are not aware of antibiotic prescription and resistance; they are aware of the same and are often willing to improve gaps in their knowledge. Recently, the undergraduate medical curriculum has undergone a major revision in India. There is poor coverage of antimicrobial resistance and stewardship in this revised curriculum. Changes could be incorporated in the curriculum appreciating the enormous threat that antimicrobial resistance poses to public health.
| Conclusion|| |
According to the observations made in this study, awareness about antibiotic resistance though slightly above 50% is far from satisfactory when such an important determinant of health care is concerned. A “catch them young” policy would be a good step to tackle antimicrobial resistance at its inception itself. Moreover, awareness should start at the local level keeping in mind the repercussions at the national and international level. To summarize, act locally but think globally.
Similar studies to assess the awareness of antibiotic resistance can be conducted among medical practitioners, health-care workers, and the general public.
The authors wish to thank Dr. Kalesh M Karun, Assistant Professor, Department of Biostatistics, M.O.S.C Medical College, Kolenchery, for conducting the data analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chaudhry D, Tomar P. Antimicrobial resistance: The next big pandemic. Int J Community Med Public Health 2017;4:2632-6.
Sharma S, Jayakumar D, Palappallil DS, Kesavan KP. Knowledge, attitude and practices of antibiotic usage and resistance among the second year MBBS students. Int J Basic Clin Pharmacol 2016;5:899-903.
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. J Clin Diagn Res 2013;7:1613-6.
Sahoo KC, Tamhankar AJ, Johansson E, Lundborg CS. Antibiotic use, resistance development and environmental factors: A qualitative study among healthcare professionals in Orissa, India. BMC Public Health 2010;10:629.
Brahmbhatt KR, Patel AB. Knowledge of antimicrobial resistance among undergraduate medical students in a medical college of Gujarat: Institution based cross-sectional study. Int J Community Med Public Health 2018;5:754-8.
Sharma K, Jain P, Sharma A. Knowledge, attitude and perception of medical and dental undergraduates about antimicrobial stewardship. Indian J Pharmacol 2015;47:676-9.
] [Full text]
Meher BR, Srinivasan A, Vighnesh CS, Padhy BM, Mohanty RR. Factors most influencing antibiotic stewardship program and comparison of prefinal- and final-year undergraduate medical students. Perspect Clin Res 2020;11:18-23.
] [Full text]
Gupta MK, Vohra C, Raghav P. Assessment of knowledge, attitudes, and practices about antibiotic resistance among medical students in India. J Family Med Prim Care 2019;8:2864-9.
] [Full text]
Dyar OJ, Pulcini C, Howard P, Nathwani D, ESGAP (ESCMID Study Group for Antibiotic Policies). European medical students: A first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance. J Antimicrob Chemother 2014;69:842-6.
Abbo LM, Cosgrove SE, Pottinger PS, Pereyra M, Sinkowitz-Cochran R, Srinivasan A, et al.
Medical students' perceptions and knowledge about antimicrobial stewardship: How are we educating our future prescribers? Clin Infect Dis 2013;57:631-8.
Lubwama M, Onyuka J, Ayazika KT, Ssetaba LJ, Siboko J, Daniel O, et al
. Knowledge, attitudes, and perceptions about antibiotic use and antimicrobial resistance among final year undergraduate medical and pharmacy students at three universities in East Africa. PLoS One 2021;16:e0251301.
Ajibola O, Omisakin OA, Eze AA, Omoleke SA. Self-medication with antibiotics, attitude and knowledge of antibiotic resistance among community residents and undergraduate students in Northwest Nigeria. Diseases 2018;6:32.
Nogueira-Uzal N, Zapata-Cachafeiro M, Vázquez-Cancela O, López-Durán A, Herdeiro MT, Figueiras A. Does the problem begin at the beginning? Medical students' knowledge and beliefs regarding antibiotics and resistance: A systematic review. Antimicrob Resist Infect Control 2020;9:172.
Gopichandran V, Tirupakuzhi Vijayaraghavan BK. Coverage of antimicrobial resistance in the revised indian medical curriculum: Lip service only? Educ Health (Abingdon) 2020;33:70-3.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]