Open Access Original

Article DOI: 10.7759/cureus.31857

Public Knowledge, Attitudes, and Practices

Towards Antibiotic Use and Antimicrobial
Review began 10/22/2022
Resistance in the Western Region of Saudi Arabia
Review ended 11/20/2022
Published 11/24/2022 Mokhtar Shatla 1, 2 , Fadi S. Althobaiti 3 , Abdulaziz Almqaiti 3

© Copyright 2022
Shatla et al. This is an open access article 1. Community Medicine and Pilgrims Health Care, Umm Al-Qura University, Makkah, SAU 2. Family Medicine,
distributed under the terms of the Creative Menoufia University, Menoufia, EGY 3. Medicine, Umm Al-Qura University, Makkah, SAU
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
Corresponding author: Fadi S. Althobaiti, fadithobaiti@gmail.com
and reproduction in any medium, provided
the original author and source are credited.

Abstract
Introduction
Antimicrobial resistance (AMR) is one of the major concerns for global health. Inappropriate use of
antibiotics is speeding up the process of AMR. The aim of this study was to assess the knowledge, attitude,
and practices (KAP) of the population of the western region of Saudi Arabia towards antibiotic use and AMR.

Methods
A cross-sectional study was conducted using an online questionnaire via social media platforms. It consisted
of four parts: first, the participant's sociodemographic characteristics. Second, an assessment of the
knowledge of antibiotic use and AMR. The third and fourth parts are to evaluate the attitude and practices
towards antibiotic use and AMR.

Results
From a total of 501 participants, 379 (75.6%) were females, and 354 (70.7%) of the participants had a college
degree. Regarding the overall knowledge of antibiotics and AMR, 277 (55.29%) of the respondents had poor
knowledge. In addition, 443 (88.42%) of the participants also reported having an inadequate attitude.
Moreover, inadequate practices related to the use of antibiotics were also reported among 305 (60.89%) of
the participants. Factors associated with the level of knowledge are gender, age, educational level, and
occupational status. Regarding occupation, being in a medical job was associated with a better knowledge of
antibiotics and AMR than other occupations.

Conclusion
Our study revealed poor overall knowledge, attitudes, and practices toward antibiotics and AMR among
participants. Conducting educational health campaigns for the public that aim to promote awareness and
enhance good practices, emphasizing the role of health care providers in health education for the public,
and enforcing strict regulations to control the non-prescription dispensing of antibiotics will help to combat
this issue. However, future research on this topic is required.

Categories: Family/General Practice, Internal Medicine, Infectious Disease

Keywords: antibiotics practices, western region, saudi arabia, antibiotics attitudes, antibiotics knowledge, antibiotics
awareness, antibiotics resistance, antimicrobial resistance, antibiotics

Introduction
Antimicrobials, including antibiotics, antivirals, antifungals, and antiparasitics, are used to prevent and
treat infections in humans, animals, and plants [1]. Antimicrobial resistance (AMR) occurs when microbes
change over time, making antimicrobials ineffective [1]. AMR can occur in microbes naturally, but it can also
be induced by inappropriate use of antimicrobials or unintentional exposure [2]. This results in organisms
that are very challenging to treat and have a significantly high fatality rate [1].

AMR is spreading, creating microbes that cannot be treated with existing medications. Currently, common
organisms that cause different diseases, such as tuberculosis (TB), HIV/AIDS, malaria, sexually transmitted
diseases, urinary tract infections, lung infections, and blood infections, can resist a wide variety of
antimicrobics [2]. Two prior studies conducted in Jeddah, Saudi Arabia, showed a high prevalence of HIV and
TB resistance. Regarding HIV, 41%, 16%, and 13% were resistant to nucleoside reverse transcriptase
inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PI),
respectively. While in TB, among 901 cases, drug-resistant TB was observed in 193 (21.4%) [3-4].

AMR is significantly costly, not just financially but also in terms of global health, food security,

How to cite this article

Shatla M, Althobaiti F S, Almqaiti A (November 24, 2022) Public Knowledge, Attitudes, and Practices Towards Antibiotic Use and Antimicrobial
Resistance in the Western Region of Saudi Arabia. Cureus 14(11): e31857. DOI 10.7759/cureus.31857
 environmental well-being, and socio-economic development. At present, AMR causes approximately
700,000 deaths worldwide each year [2]. In addition, there is approximately one death every 10 minutes in
Europe or the United States of America because of deadly infections caused by antimicrobial-resistant
bacteria [5]. AMR is rising in almost every country [5]. However, a systemic literature review in Saudi Arabia
demonstrated that, in comparison to the 1990s, there has been a significant increase in carbapenem-
resistant gram-negative bacilli (GNB) over the last decade. Additionally, it also revealed an increase in the
prevalence of extended-spectrum beta-lactamase-producing bacteria in Saudi Arabia, with 29% documented
among Escherichia coli (E. coli) and 65% among Klebsiella pneumoniae (K. pneumoniae). Accordingly, these
documented rates were associated with multiple reported outbreaks, and mortalities ranged between 11%
and 40% [6].

A study in 2015 from Riyadh showed a dramatic reduction in the susceptibilities of Acinetobacter baumannii
(A. baumannii) to meropenem and imipenem, where the susceptibilities were 64-81.2% in 2006 and 8.3-11%
in 2012. Consequently, with carbapenem resistance, therapeutic options are extremely limited, making it a
major epidemiological concern [7]. In Saudi Arabia in 2014, a national surveillance of AMR among gram-
positive cocci represented a high resistance rate among Staphylococcus aureus (S. aureus), 32% were
methicillin-resistant (MRSA), and among Streptococcus pneumoniae, 33% were resistant to penicillin G, and
26% were resistant to erythromycin [8].

Regarding multi-drug resistant bacteria in Saudi Arabia, there are many factors associated with its increase.
It is well-established that inappropriate use of antibiotics is an important factor in the development of AMR
[6]. Over-the-counter antibiotics without a prescription is another factor leading to the inappropriate use of
antibiotics, which contributes to more antimicrobial resistance.

A study in 2001 was done in the eastern province of Saudi Arabia and revealed that only one pharmacy out of
88 refused to dispense medication without a prescription for patients claiming to have a UTI [9]. Another
study in 2011 was done in Riyadh among 327 pharmacies and showed that 77.6% of pharmacies dispensed
antibiotics without a prescription [10]. Lack of awareness is another major factor in the misuse of antibiotics
worldwide [11]. Patients' knowledge, attitude, and practice (KAP) are important factors contributing to the
misuse of antibiotics [11-12].

A study in the Hail region of 500 participants found that 26% got antibiotics without a prescription, only
34% finished the full antibiotic course, and 36.2% were unaware of antibiotic resistance and its rise [12]. In
addition, a recent study in 2021 to assess KAP towards antibiotic use and AMR among the general public in
Saudi Arabia showed an insufficient attitude toward antibiotic use. It also suggests reducing antibiotic
misuse by raising awareness [13]. Low knowledge levels were also reported in a 2021 study in Jeddah,
indicating the need to increase public knowledge and raise awareness [14]. Globally, in Kuwait, a KAP study
on antibiotic use in 2015 [15] reported that 72.8% of the respondents had received an antibiotic prescription
in the year before the survey; of those, 36% did not complete the course of treatment. Moreover, 27.5% were
self-medicating primarily for cough, sore throat, and a common cold. A 2021 study conducted in Boyolali,
Indonesia, revealed that most of the participants had insufficient knowledge about the proper usage,
accessibility, and function of antibiotics. Male sex, low income, low educational levels, and residency in
rural areas were associated with inappropriate use of antibiotics [16].

To implement corrective measures regarding antibiotics KAP, first, we need to know the level of awareness
in society currently. Therefore, the aim of this study was to assess the knowledge, attitude, and practices
(KAP) of the population of the western region of Saudi Arabia towards antibiotic use and antimicrobial
resistance.

Materials And Methods

Study design
The study design was cross-sectional and conducted using a validated questionnaire that had been
developed and used in a previous study [10]. The survey was conducted during the period from June to July
2022. This survey aims to evaluate public knowledge, attitudes, and practices among people living in the
western region of Saudi Arabia towards antibiotic use and antimicrobial resistance.

Study population
The study was conducted via an online questionnaire, and our target sample in this study was public adults
who are Arabic and English-speaking individuals living in the Western Region of Saudi Arabia. This study
excluded non-Arabic, non-English-speaking individuals and individuals living outside the Western Region of
Saudi Arabia.

Sampling methodology
The sample was conducted on public people from the 1st of June to the 1st of July 2022 in the Western
Region of Saudi Arabia. We obtained consent from the participants before they started filling out the

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 questionnaire. According to OpenEpi version 3.1, the sample size should not be less than 769 participants.
However, the final sample size that has been included in this study is 501. The questionnaire form is online,
and it has been sent through social media platforms. It consists of four parts of close-ended type questions
in the form of multiple-choice answers. It was made in Arabic and English languages. The first part included
eight items of the participant's sociodemographic characteristics (gender, age, place of living, marital status,
education level, occupational status, monthly income, and source of information). The second part is made
up of 17 items to assess the knowledge of antibiotic use and antimicrobial agents. The third part has ten
items that evaluate the attitude towards antibiotic use and AMR using a five-point Likert scale (strongly
agree, agree, uncertain, disagree, strongly disagree). The fourth part is about assessing the participant's
practice towards antibiotic use and AMR, and it is composed of 17 questions using a five-point Likert scale
(never, rarely, sometimes, often, always). Data was collected from any participant who met our criteria. The
electronic data collection forms did not show any nominative information. Data was automatically entered
into the Excel sheet (Microsoft, Redmond, Washington). After verification, we transferred this data to the
SPSS software (IBM Inc., Armonk, New York) for analysis.

Data analysis
After the data was extracted, it was revised, coded, and fed to the statistical software SPSS version 25. The
results were reported as frequency and percentages. A scoring system was adopted based on Awad and
Aboud, 2015 [15]. Descriptive statistics were obtained for sociodemographic variables. The knowledge,
attitudes, and practices (KAP) scores were calculated as continuous variables by summing the number of
correct responses to the total statements for each category (KAP). One point was assigned to each correct
response and zero otherwise. Eighty percent and above were assigned as a good score for each category
(KAP), and less than 80% were identified as having a poor score. Descriptive analysis based on frequency and
percent distribution was done for all variables, including participants' age, gender, education level, marital
status, occupation, and income. Also, participants' knowledge, attitude, and practice items were tabulated
and graphed. Cross-tabulation was used to assess factors associated with the knowledge level regarding
antibiotics and antimicrobial resistance. The Chi-squared test of independence is used for testing
associations.

Ethical part and confidentiality

Consent was taken from each participant in the questionnaire. The objectives of the research were explained
to the study's participants. Additionally, their consent was obtained prior to participating. They were also
informed that participation was entirely voluntary, and that no personal information would be requested of
them. All participants' identities were kept anonymous and confidential. Responses were accessed by the
research investigators only. Ethical approval was sought from the Biomedical Ethics Committee of Umm Al-
Qura University (UQU).

Results
A total of 629 participants completed the study questionnaire. One hundred twenty-eight were excluded as
they were not from the western region, and 501 participants were included as they fulfilled our inclusion
criteria. Table 1 shows the demographic characteristics of the sample participants (n=501), females (n=379,
75.6%), and males (n=122, 24.4%). Of the total respondents, 255 (50.9%) were in the age group of 18-24
years. Moreover, the majority (354, 70.7%) had a college degree, 230 (45.9%) were students, and 303 (60.5%)
of the study population earned a monthly income of less than 3000 SAR.

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 Variable Response options n %

Male 122 24.4

Gender
Female 379 75.6

< 18 11 2.2

18-24 255 50.9

Age 25-34 91 18.2

35-44 87 17.4

> 44 57 11.4

Single 303 60.5

Married 184 36.7

Marital status
Divorced 11 2.2

Widowed 3 0.6

Primary or below 9 1.8

Middle school 11 2.2

Education level High school 104 20.8

College 354 70.7

Masters or PhD 23 4.6

Student 230 45.9

Unemployed 136 27.1

Occupational status
Medical job 22 4.4

Non-medical job 113 22.6

< 3000 303 60.5

3000-4999 43 8.6
Income (monthly)
5000-10,000 89 17.8

>10,000 66 13.2

TABLE 1: Sociodemographic characteristics (n=501)

Table 2 shows the percentage of responses to each of the seventeen knowledge questions related to
antibiotic use. Of the total respondents, 85.4% knew that antibiotics are not considered over-the-counter
drugs, 86.2% knew that they can be used to treat a bacterial infection, 95.8% knew that some patients may
have an allergy to specific antibiotics, 73.9% knew that not completing the full course of antibiotics may
cause antibiotic resistance, 83.4% knew that antibiotic might kill the beneficial bacteria in skin, stomach or
intestine, and 94.2% were aware that overuse of antibiotics could cause resistance to other antibiotics.

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 Correct
No Yes
option
Knowledge questions related to antibiotic use
n % n % n %

Antibiotics are considered over-the-counter drugs 428 85.4% 73 14.6% 428 85.4%

Antibiotics are medicines used to treat bacterial infections 69 13.8% 432 86.2% 432 86.2%

Antibiotics are medicines used to treat viral infections 245 48.9% 256 51.1% 245 48.9%

Antibiotics are medicines used to treat a cold and cough 253 50.5% 248 49.5% 253 50.5%

Antibiotics are medicines used to treat any illness with a fever 293 58.5% 208 41.5% 293 58.5%

Some patients may have an allergy to specific antibiotics 21 4.2% 480 95.8% 480 95.8%

Some antibiotics can cause diarrhea 68 13.6% 433 86.4% 433 86.4%

Overuse of antibiotics could cause resistance to other antibiotics 29 5.8% 472 94.2% 472 94.2%

Antibiotics may cause drug interaction and reduce certain drugs efficacy 53 10.6% 448 89.4% 448 89.4%

Antibiotics may kill our beneficial bacteria in the skin, stomach, or intestines 83 16.6% 418 83.4% 418 83.4%

Antibiotics do not cause side effects 440 87.8% 61 12.2% 440 87.8%

Using antibiotics when they are not necessary leads to antibiotic resistance 60 12.0% 441 88.0% 441 88.0%

Not completing the full course of antibiotics may cause antibiotic resistance 131 26.1% 370 73.9% 370 73.9%

Using antibiotics without a physician's prescription has nothing to do with antibiotic

304 60.7% 197 39.3% 304 60.7%
resistance

Bacteria that normally live on the skin and in the gut are harmful to your health 373 74.5% 128 25.5% 373 74.5%

Missed doses should be taken as soon as you remember 148 29.5% 353 70.5% 353 70.5%

A missed dose should be skipped 290 57.9% 211 42.1% 290 57.9

TABLE 2: Respondents' knowledge about antibiotics use (n=501)

Figure 1 shows the percentage of responses to each of the ten attitude questions related to antibiotic use. Of
the total respondents, 87.6% trusted the physician's decision when deciding not to prescribe antibiotics, and
the majority (88.9%) believed that doctors should not prescribe antibiotics when not needed. Similarly,
72.6% did not agree that antibiotics should be accessed without a prescription. On the other hand, 40.5% did
not agree to stop antibiotics when symptoms improved. Moreover, 24.8% disagree the use of antibiotics will
speed up the recovery from a cold and cough.

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 FIGURE 1: Respondents' attitude towards antibiotics use (n=501)

Figure 2 shows the percentage of responses to each of the seventeen practice questions related to antibiotic
use. Of the total respondents, 73.9% did not get antibiotics from relatives without visiting a physician, and
57.9% did not keep antibiotic stock at home in case of emergency. Moreover, the majority (73.9%) disagree to
purchase antibiotics from the pharmacy without a prescription, and 77.9% disagree to change the physician
for not prescribing antibiotics. However, 57.7% believe in reading the instruction on the label.

FIGURE 2: Respondents' practices towards antibiotics use (n=501)

Figure 3 shows that most of the respondents had poor knowledge (277, 55.29 %), attitude (443, 88.42%), and
practice (305, 60.88%) related to the use of antibiotics. The mean ± standard deviation of the knowledge
score was 12.92 ± 2.61, attitude was 5.235 ± 1.99, and practice was 11.12 ± 4.37.

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 FIGURE 3: Overall KAP score levels toward antibiotics use
KAP - knowledge, attitude, and practices

Table 3 shows an association between knowledge of antibiotics use and social-demographic variables.
Knowledge and sociodemographic variables are categorical variables; therefore, the Chi-square test of
independence is used for testing the association between them. Significant factors associated with
knowledge were gender, age, educational level, and occupational status (p<0.05). In contrast, marital status
and income have no significant association with participants' knowledge. Among significant factors, only
those participants from medical jobs had better knowledge than respondents' from other occupations.

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 Variables Response options Poor (%) Good (%) χ2 P

Male 81 (66.4) 41 (33.6)

Gender 8.044 0.005**
Female 196 (51.7) 183 (48.3)

< 18 11 (100) 0 (0)

18-24 131 (51.4) 124 (48.6)

Age 25-34 52 (57.1) 39 (42.9) 12.630 + 0.012*

35-44 52 (59.8) 35 (40.2)

> 44 31 (54.4) 26 (45.6)

Single 166 (54.8) 137 (45.2)

Married 103 (56) 81 (44)

Marital status 2.561+ 0.468
Divorced 5 (45.5) 6 (54.5)

Widowed 3 (100) 0 (0)

Primary or below 4 (44.4) 5 (55.6)

Middle school 10 (90.9) 1 (9.1)

Education level High school 62 (59.6) 42 (40.4) 11.841 + 0.016*

College 184 (52) 170 (48)

Masters or PhD 17 (73.9) 6 (26.1)

Student 113 (49.1) 117 (50.9)

Unemployed 85 (62.5) 51 (37.5)

Occupational status 12.178 0.007**
Medical job 8 (36.4) 14 (63.6)

Non-medical job 71 (62.8) 42 (37.2)

< 3000 160 (52.8) 143 (47.2)

3000-4999 30 (69.8) 13 (30.2)

Income (monthly) 4.855 0.183
5000-10,000 48 (53.9) 41 (46.1)

>10,000 39 (59.1) 27 (40.9)

TABLE 3: Association between knowledge of antibiotics and sociodemographic variables

*p<0.05

**p<0.01 poor/good within demographic variables

+ Cell frequency is less than 5, Fisher's exact test is used.

Differences in the mean score of attitude and practice towards antibiotics use related to gender were tested
using the Mann-Whitney U test, which is an alternative to the independent sample t-test in case the
normality assumption is not fulfilled. For other variables, nonparametric alternative to ANOVA (Kruskal-
Wallis) test is used [16]. Kolmogorov-Smirnov and Shapiro-Wilk normality test results are shown in Table 4.
Since p<0.05 for all the variables, which concludes that the normality assumption, is not fulfilled. Similarly,
a boxplot also confirms the non-normality of knowledge, attitude, and practice score (Figure 4). Therefore,
nonparametric alternatives to t-test and ANOVA are suitable for the analysis.

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 Kolmogorov-Smirnov Shapiro-Wilk

Statistic df Sig. Statistic df Sig.

Knowledge .114 501 .000 .960 501 .000

Attitude .116 501 .000 .973 501 .000

Practice .153 501 .000 .915 501 .000

TABLE 4: Normality test for knowledge, attitude, and practices

FIGURE 4: Boxplot of knowledge, attitude, and practices

The mean ± standard deviation of attitude was 5.235 ± 1.99. This score was significantly (p<0.05) lower in
men (4.5983 ±2.1190) than in women (5.4406±1.9144) (Table 5). The mean ± standard deviation of practice
was 11.12 ± 4.37. This score was significantly (p<0.05) lower in men (8.7869 ± 0.42280) than in women
(11.8813± 0.20447) (Table 5). Another significant factor of attitude and practice is age. Marital status is only
significant for practice. Furthermore, the mean scores of education level, occupational status, and income
were insignificant for both attitude and practice.

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 Attitude Practice
Variables Response options
Mean ± SD p-value Mean ±SD p-value

Male 4.5983 ± 2.1190 8.7869 ± 0.42280

Gender 0.000*** 0.000***
Female 5.4406± 1.9144 11.8813± 0.20447

< 18 3.6363± 2.5009 8.9091 ± 5.1274

18-24 5.0509± 1.9545 10.6941± 4.4580

Age 25-34 5.4175± 2.0443 0.015** 12.0694± 4.3507 0.028*

35-44 5.5517± 1.9869 11.5747± 4.0192

> 44 5.5964± 1.8406 11.1277± 4.3767

Single 5.0330 ± 2.0227 10.7162 ± 4.4734

Married 5.5489 ± 1.9579 11.7663 ± 4.2162

Marital status 0.054 0.012*
Divorced 5.5454 ± 1.5075 13.000 ± 1.9493

Widow 5.3333 ± 1.1547 6.6667 ± 3.0550

Primary or below 5.2222 ± 2.4888 10.333 ± 5.0497

Middle school 3.6363 ± 2.3779 8.7273 ± 5.7635

Education level High school 5.1250 ± 2.0322 0.234 10.855 ± 4.2664 0.374

College 5.3107 ± 1.9540 11.336 ± 4.3510

Masters or PhD 5.3478 ± 1.9448 10.608 ± 4.1859

Student 5.1217 ± 1.9918 11.000 ± 4.2713

Unemployed 5.2205 ± 1.9462 11.404 ± 4.4958

Occupational status 0.262 0.666
Medical job 6.0454 ± 1.9634 11.181 ± 4.6356

Non-medical job 5.3274 ± 2.0591 11.044 ± 4.4368

< 3000 5.1518 ± 1.9283 11.347 ± 4.3339

3000-4999 5.0000 ± 2.0931 10.279 ± 4.0492

Income (monthly) 0.053 0.247
5000-10,000 5.1461 ± 2.1243 10.752 ± 4.7536

>10,000 5.8939 ± 1.9855 11.636 ± 4.2304

TABLE 5: Differences in the mean score of attitude and practice towards antibiotic use related to
demographic variables
* p<0.05

** p<0.01

*** p<0.001

Spearman's correlation was used to check the relationship between KAP. There is a significant relationship
between the three variables (p<0.05) (Table 6). The highest correlation was found between attitude and
practice (0.533), followed by 0.525 for the relationship between attitude and knowledge, and then 0.505 for
the relationship between knowledge and practice.

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 Knowledge Attitude Practice

Knowledge 1 0.525*** (0.000) 0.505*** (0.000)

Attitude 0.525*** (0.000) 1 0.533*** (0.000)

Practice 0.505*** (0.000) 0.533*** (0.000) 1

TABLE 6: Correlation between knowledge, attitude, and practices of respondents towards

antibiotics use
*** p<0.001

Discussion
This is a cross-sectional study to assess KAP towards antibiotics and AMR in the western region of Saudi
Arabia. A validated questionnaire from a literature review [13] was used to collect the data. Our study
showed insufficient knowledge, an inadequate attitude, and incorrect practices related to the use of
antibiotics.

Among the most important findings in the knowledge part, a significant percentage of respondents had low
knowledge regarding the role of antibiotics. Almost half (51.1%) of the respondents think that antibiotics
can be used to treat viral infections, while 49.5% think they can be used for a cold and cough. Moreover,
41.5% agreed that antibiotics are medications used to treat any illness with fever. However, most of the
respondents (88.0%) knew that unnecessary use of antibiotics leads to antibiotic resistance, and the majority
(85.4%) knew that antibiotics are not considered over-the-counter drugs. This is in comparison to a previous
study that was done in 2021 across all five regions of Saudi Arabia [13], which shows that 76.5% knew that
antibiotics are used in cases of bacterial infection, and 74.9% knew that antibiotic resistance may be caused
by not completing the course of the antibiotic. In addition, 67.5% knew that the beneficial bacteria that
normally live on the skin or in the stomach/intestines might be killed by antibiotics, and only 56.9% knew
that antibiotics should not be used to treat viral infections. The same study shows that 88% of the
respondents had good knowledge of antibiotic use, which is higher than what we found in our study, which
demonstrates that only 44.71% of the respondents had good knowledge. The low level of knowledge in our
results is almost in line with a study that was done in Indonesia [16], in which only 52.98% of the
respondents had good knowledge. In the Indonesian study, only 61.61% agreed that leftover antibiotics
should not be used again, and only 37.0% knew that they should complete the full course of their antibiotics
and that treatment should not be stopped if their illness has improved. Only 12.91% of the respondents
agreed that antibiotics could not be used to treat infections due to viruses, and around 63.35% of the
respondents think that antibiotics can be used to reduce fever. Inadequate knowledge was also reported in a
Kuwait study [15], which showed that around 66.5% of the sample knew that antibiotics are effective against
bacteria, and only 29.8% agreed that antibiotics are not used to treat viral illnesses. In the same study,
around half (49%) of the respondents knew that unnecessary use of antibiotics can lead to resistance against
them.

In the analysis of attitudes, more than half (59.5%) of the respondents had no problem ending an antibiotic
course of treatment when their symptoms were improving, and this is concerning because not completing
the course of treatment is one of the factors that can lead to the development of antibiotic resistance.
Additionally, 48.7% of the respondents think that antibiotics can prevent any illness from becoming worse,
and only 48.5% agree that natural sources may work better than antibiotics. Moreover, only 24.8% disagree
that the use of antibiotics will speed up the recovery from a cold and cough. However, the majority (87.6%)
trust the physicians' decisions to not prescribe antibiotics for their conditions. Attitudes results from the
same previous Saudi study [13] showed that 92.55% of the total participants agreed to trust the physician's
decision when deciding not to prescribe an antibiotic, 91.87% believed that antibiotics should not be given
by doctors if not needed, and 91.33% disagreed with the accessibility of antibiotics without a prescription.
On the contrary, about two-thirds (66%) did not believe that any illness could be prevented from worsening
by the use of antibiotics. Additionally, 63.7% of the respondents believed that natural sources do not work
better than antibiotics. The overall positive attitude score in this research was 76.80% of the respondents.
Our findings were significantly lower. Only 12% of the participants in our study had good attitudes toward
antibiotic use. The attitudes were no better in the Indonesian study [16]. Around 45% thought that the use
of antibiotics could speed up recovery from a cold, and almost 30% were unsatisfied if they did not get
antibiotics from their physician when they thought they needed them. Furthermore, approximately 35% of
respondents had no problem purchasing antibiotics from pharmacies without a prescription, and half (50%)
of the sample would discontinue their antibiotics as soon as they felt better. Additionally, a quarter (25%)
stored leftover antibiotics for future use.

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 In the Kuwaiti study [15], only 57.6% showed a positive attitude towards completing the course of treatment,
even if they felt better. 66.6% disagreed with buying antibiotics from a pharmacy without a prescription.

Respondents' practices towards antibiotic use showed that 26.1% get antibiotics from relatives without
visiting a physician, and 42.1% expressed a negative practice of keeping antibiotic stock at home for future
use. However, the majority (72.6%) agreed that antibiotics should not be accessed without a prescription,
77.9% disagreed with changing the physician for not prescribing antibiotics, and 73.9% disagreed with
purchasing antibiotics from the pharmacy without a prescription. However, only 66.8% completed the course
of antibiotics when they started it, and only 57.7% agreed to read the instructions on the label. Females
showed better attitudes and practices compared to males. Higher income was associated with a better
attitude, but it was insignificant in relation to practices. Higher levels of education had no significant effect
on respondents' knowledge, attitudes, and practices toward antibiotics. Regarding practices, in the same
previous Saudi study [13], most of the respondents (94.54%) disagreed with getting antibiotics from relatives
regardless of the physician's prescription. 84.83% did not store antibiotics at home for future use.
Additionally, the majority (92.64%) do not purchase antibiotics from the pharmacy without a prescription.
Additionally, 93% of the respondents would not change their physicians if they did not get antibiotics.
However, only 78% read the instructions on the label of the antibiotics. Good practices towards antibiotic
use were found to be present in only 14.4% of the participants in the Saudi study [13]. A higher but
inadequate level was found in our study, in which 39.12% of the participants were reported to have good
practices. In the Indonesian study [16], around 40% of the respondents bought antibiotics from pharmacies
without prescriptions, and 31% took leftover antibiotics to treat reoccurring symptoms. Regarding practices
in the Kuwaiti study [15], around 64.7% of the respondents trusted physicians when they decided not to
prescribe antibiotics, and around 30% preferred to keep leftover antibiotics for future use.

Although most of the respondents (26.1%) in our study do not purchase antibiotics without a medical
prescription, many pharmacies in different regions of Saudi Arabia have been reported to be dispensing
antibiotics to purchasers illegally. In 2001, a study was done in the eastern region of Saudi Arabia, in which
the research team individually visited many community pharmacies complaining of urinary tract infection
(UTI) symptoms. Only one pharmacy out of 88 refused to give medications without a prescription, and 80%
of the given medications were antibiotics [9]. In 2011, the same approach to pharmacies was used in another
study conducted in the Riyadh region. They found that out of 327 visited pharmacies, 244 (77%) illegally
dispensed antibiotics [10].

The lack of sufficient knowledge about antibiotics and antimicrobial resistance leads to wrong beliefs that
eventually manifest themselves as misuse and overuse of antibiotics. These incorrect practices, if not
controlled, would accelerate the emergence of highly resistant organisms and their subsequent
consequences. Several researchers have studied the topic of antibiotic awareness in Saudi Arabia. Recent
research at the time of writing this paper was published in 2021 and studied the population of Jeddah city.
Their work confirms our findings of poor KAP towards antibiotics and antimicrobial resistance in society
[14].

Limitations
Efforts were made to get accurate, precise, and representative results. However, several limitations have
been encountered during this work. First, the use of an online questionnaire to collect data has its own
limitations. Second, the sample size for our study is small relative to the exact number needed for
generalization. Therefore, all results are limited to our study participants only, and further research with a
larger sample size is needed. In addition, most of the respondents to the questionnaire were females
(75.6%), students (45.9%), with or studying for a bachelor's degree (70.7%). Third, respondents were not
further categorized according to their cities or nationalities; rather, their responses were analyzed
collectively, and the results were made for the western region entirely. These factors might have led to
unintended biases in the results. However, our work gives us some understanding of the current situation
and confirms the results of the previous studies that have been done on this subject globally and locally.
Additional study in this field is required, with different approaches focusing on various sociodemographic
traits and different regions of Saudi Arabia.

Conclusions
The purpose of this study was to assess public knowledge, attitudes, and practices (KAP) toward antibiotic
use and antimicrobial resistance. We concluded that most of our study participants had poor overall KAP.
Our results highlight the knowledge gap regarding antibiotics and their appropriate usage. Thus,
interventions need to be implemented to improve public KAP in this area. Some of the suggested
interventions include educational health campaigns for the public that aim to promote awareness and
enhance good practices. Moreover, enforcing more strict regulations to control the non-prescription
dispensing of antibiotics is critical. However, further research on this topic is required to ensure that society
is progressing in the right direction.

Additional Information

2022 Shatla et al. Cureus 14(11): e31857. DOI 10.7759/cureus.31857 12 of 13

 Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Biomedical Research
Ethics Committee of Umm Al-Qura University issued approval HAPO-02-K-012-2022-06-1118. The
Biomedical Research Ethics Committee has evaluated and examined the research proposal and has found it
to be in accordance with the specifications and conditions of the ethics of scientific research. The
Committee has accordingly granted the principal investigator final approval concerning the ethics of
scientific research. Animal subjects: All authors have confirmed that this study did not involve animal
subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors
declare the following: Payment/services info: All authors have declared that no financial support was
received from any organization for the submitted work. Financial relationships: All authors have declared
that they have no financial relationships at present or within the previous three years with any
organizations that might have an interest in the submitted work. Other relationships: All authors have
declared that there are no other relationships or activities that could appear to have influenced the
submitted work.

Acknowledgements
We would like to acknowledge all the participants in the research questionnaire, with special thanks to all
the data collectors who helped us to complete this work: Taif Alwghdani, Khalid Alnafei, Renad Aljadani,
Lulu Alsubaie, Omar Althobaiti, Teaf Althobaiti, and Elaf Aljabri. All the authors have contributed equally to
the work and should be considered co-first authors. The data is stored as anonymized participant
information. Data can be obtained from Fadi S. Althobaiti (Fadithobaiti@gmail.com) upon reasonable
request.

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