Journal of Pharmaceutical Health Services Research, 2024, 15, 1–8

https://doi.org/10.1093/jphsr/rmab068
Advance access publication 4 January 2022
Research Paper

Antibiotic use and resistance in a tertiary care hospital:

knowledge and attitude among patients of orthopaedic
and surgical wards in Malaysia
Zulsairi Mohd Pauzi1,2, Bassam Abdul Rasool Hassan3, Chin Fen Neo1,4
Ali Haider Mohammed3,5,*, , Ali Blebil3,5 and Juman Dujaili3,5

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1
Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam Campus, Bandar Puncak Alam, Selangor,
Malaysia, 2Hospital Kuala Lumpur, Jalan Pahang, Wilayah Persekutuan Kuala Lumpur, Malaysia, 3Department of Pharmacy, Al Rafidain
University College, Baghdad, Iraq, 4Collaborative Drug Discovery Research (CDDR) Group, Pharmaceutical and Life Sciences Community
of Research, Universiti Teknologi MARA, Selangor, Malaysia and 5School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan,
Bandar Sunway, Selangor, Malaysia
*Correspondence: Ali Haider Mohammed, School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500 Bandar Sunway, Selangor,
Malaysia. Email: alishanshool93@gmail.com

Abstract
Objectives The prevalence of antimicrobial resistance (AMR) is rising globally as well as in Malaysia. AMR can lead to difficulty in the treatment
of chronic infection if being neglected. This study aimed to assess the level of knowledge and attitude about antibiotic usage and AMR.
Methods A cross-sectional study design was carried out at the Hospital Kuala Lumpur (HKL), Malaysia, where participants were recruited by
using the non-probability convenience sampling from the six orthopaedic and four surgical wards. A self-administered questionnaire was used
to collect the required data which were then analysed by using SPSS.
Key findings A total number of 390 adult Malaysians (286 from orthopaedic wards and 104 from surgical wards) were involved in the study.
This study showed that the level of knowledge and attitude about antibiotics among the majority of respondents were moderate. However, their
knowledge regarding AMR was very low (i.e. lack of knowledge). In contrast, the majority of them (69.8%) showed a positive attitude towards
antibiotics. Statistical analysis of data revealed that the level of knowledge of AMR was significantly associated with gender, age, race, marital
status, educational level and knowledge about antibiotic resistance terms (P < 0.05) while respondents’ attitude towards antibiotic usage was
significantly associated with gender, race, marital status and education level (P < 0.05).
Conclusions It was necessary to formulate and develop strategies to improve the knowledge and awareness about antibiotics and AMR among
health professionals. These might help them to improve their skills in delivering health information to the patients through a proper counselling
technique.
Keywords: antibiotic; resistance; knowledge; attitude; Malaysia

Introduction low- and middle-income countries was found to be at greater

The World Health Organization (WHO) describes antimicro- risk of the increasing rate due to AMR. This is mainly because
bial resistance (AMR) as ‘the resistance of a microorganism of the over-the-counter availability of antibiotics, the lack
to an antimicrobial drug that was originally effective for the of therapeutic guidelines for prescribers and limited access
treatment of infections caused by it’.[1] AMR is considered to microbiological testing to identify infections quickly and
a very complicated process whereby many biochemical and cost-effectively.[4] Regarding this issue, Bennadi[5] reported
physiological mechanisms were found to play a significant that self-medication is one of the commonest causes for AMR
role in the incidence and development of bacterial resistance. due to erroneous advice from families, friends, neighbours
Although several national and international reports, including and pharmacists, previously prescribed antibiotics, or recom-
recommendations, have been published to overcome this cri- mendations from the advertisement in newspapers or popular
sis, unfortunately, this serious problem still remained un- magazines. A previous literature study revealed that factors,
resolved up to date.[2, 3] Forewarned by this issue, the May including inadequate treatment duration, improper selection
2015 World Health Assembly under WHO has implemented of drug and dosage also play a vital role in the emergence
a global action plan on AMR. The action plan stated that the of AMR.[6, 7] Stimulatingly, AMR may result in an added im-
world was heading towards a ‘post-antibiotic era’. It has been pulse to discover newer antibiotics to fathom the AMR. The
predicted that common infections and minor health injuries strong link between antimicrobial usage and resistance on hu-
will become a menace to public health and thus WHO has mans via food supply has been conceptualized since the same
urged many countries to make instantaneous resolutions to classes of antimicrobials are used in veterinary and human
overcome this global issue.[1] Furthermore, the population of medicine.[8] With all the efforts which have been taken to

Received: 9 August 2021. Accepted: 22 November 2021.

© The Author(s) 2022. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society. All rights reserved. For permissions, please
e-mail: journals.permissions@oup.com
2 Zulsairi Mohd Pauzi et al.

overcome this serious medical problem, AMR still remains a usage is important to inform intervention development plans.
global public health concern.[6] Therefore, the implementation Nevertheless, several studies conducted in Malaysia have high-
of bacterial resistance in antimicrobial agents has become a lighted some important limitations, which may guide for re-
major challenge for public health.[9] invention for future studies. For instance, most of the studies
The WHO indicated that many of the Western Pacific Region regarding the utilization of antibiotics in Malaysia are bound
countries, including Malaysia have poor regulation in control- to the evaluation of public knowledge and attitudes towards
ling the selling and using of antibiotics in both humans and ani- antibiotics in urban areas.[21] On the other hand, the view of
mals. It was estimated about 52% of the Western Pacific Region hospital patients could be quite different as they are more prone
countries were selling antibiotics over the counter without a to empirical and prophylactic treatments. Meanwhile, there is
prescription. There were regulations and laws that are existed to no study being conducted in Malaysia focusing on patients who
control the selling of antibiotics. However, these regulations and are admitted to general hospitals. Therefore, this study was con-
laws were not effective in regulating or controlling the antibiot- ducted to assess the knowledge and attitudes about antibiotics
ics selling and dispensing process.[1] In Malaysia, the Ministry usage and evaluate the level of knowledge about AMR among
of Health (MOH) has established and produced national anti- patients of Malaysian adults with determining the association

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biotics guidelines 20 years ago, but these guidelines are still between participants’ demographic profile, their knowledge
not being adequately implemented.[10] Malaysian Statistic on and attitude. These findings will be considered as an anchored
Medicine from 2011 until 2014 revealed that antibiotics were and important indication for developing proper and continuous
one of the major groups of drugs in the healthcare setting. antibiotics education programs for patients and the public.
Cephalosporins showed a substantial rise in terms of their usage
in which cefepime showed the highest usage with a 164.6%
Materials and Methods
increment from 2011 to 2014.[11] The National Surveillance
of Antimicrobial Resistance (NASR) of Malaysia produces an Study design and participants
annual report that discusses AMR in Malaysia. According to A cross-sectional quantitative study was conducted in
the latest report in 2017, the percentage of Staphylococcus aur- Malaysia where a self-administered questionnaire, including
eus isolated from blood and its resistance towards penicillin G 32 questions was distributed to 390 Malaysian adults who
and erythromycin have been slightly reduced compared with were admitted to orthopaedic and surgical wards in Hospital
the same point obtained in 2016. However, at the same time, Kuala Lumpur (HKL). Orthopaedic and surgical wards were
methicillin-resistant Staphylococcus aureus (MRSA) in 2017 selected to be part of the study area. This is because for the
has been elevated from 18% in 2016 to 19.8%. Regarding past 4 years as an orthopaedic and surgical pharmacist, it had
other types of bacteria being isolated, the NASR report showed been found that upon admission, most of the patients would
that there was an elevation in their resistance rates in 2017 com- bring the balance of medications from home, unfinished anti-
pared with 2016.[12] Malaysia is a part of the Asian Network biotics that had been prescribed from clinics, discharge medi-
for Surveillance of Resistant Pathogens (ANSORP). One of cations from the hospitals, and antibiotics that had been kept
the studies was conducted in 2004 and based on the report, for few years in the pill-box. Participants were recruited if
it showed a distinctive increase in resistance to Streptococcus they were able to converse and understand Bahasa Melayu or
pneumoniae towards beta-lactam and macrolide which was the English language and had known the meaning of antibiotic
highest in the world.[13] This finding was supported by a previ- (i.e. to treat/cure bacterial infection).
ous study which revealed that there was a steady increment of
antibiotic-resistant rate among the isolated S. pneumoniae.[14] Translation, validation and reliability test of
Based on these reports, it can be said that Malaysia is facing a study tools
major medical problem regarding AMR.[12] The questionnaire was adapted from the Multi-Country Public
Several factors (non-adherence, inappropriate use, self- Awareness Survey[22] and tailored to suit the local population
medication and overdose) play a major role in the incidence to assure its applicability. The original questionnaire was in
and prevalence of AMR. All these factors are associated with English. It was then being translated into Bahasa Malaysia and
public knowledge, health literacy and awareness about anti- subjected to a process of forward and backward translation.
biotics.[15, 16] Another study reported that a low level of know- The forward translation was done by a professional translator
ledge among both public and health professional workers who had sector-specific knowledge and experience in translat-
could lead to irrational use of antibiotics among the public.[17] ing surveys, whereby his mother tongue was Bahasa Malaysia.
In Malaysia, Islahuddin et al. stated that the Malaysian general Once authors received the first translation, they would send the
population showed poor knowledge towards AMR and the local language (Malay version) to a different translator whose
authors recommended educational intervention among ordin- mother tongue was English to translate the questionnaire back
ary citizens. It is important to clarify the relationship between to the original language (English version). The authors ensured
the awareness of proper use of antibiotics and the incidence of that the back translator had no professional or personal re-
AMR among the general public.[18, 19] The rational use of anti- lation to the first translator. Then, the reconciliation process
biotics is the main way to prevent and/or reduce the incidence was done by comparing the original questionnaire to the back-
of AMR. It is important to improve the awareness of the public translated questionnaire. In this stage, authors highlighted dis-
about its importance. Shehadeh et al.[20] stressed that the public, crepancies and categorized them as either minor (like wording
especially youngsters have poorer knowledge regarding anti- issues) or significant (like changes in the meaning of a question).
biotics usage and antibiotic resistance and thus they are more Finally, the accuracy and meaning of the translated versions
prone to involve in inappropriate antibiotics consumption. were double-checked by two expertises and recommended
Therefore, an understanding of the current knowledge amendments were discussed before finalized. The authors had
and attitudes of Malaysian patients in regard to antibiotics a meeting with the two translators to discuss all discrepancies
Antibiotic use and resistance 3

and agree on a final translation. During this meeting, one of the 104 of them were from the surgical wards. Table 1 shows
co-authors kept track of all questions and any concern on the that the majority of the respondents (57.7%) were men and
content was noted. It was pretested for content, design, read- participants’ mean age ± standard deviation was 41.63 ±
ability and comprehension on 20 individuals. The modification 16.10. Most of the respondents were Malay (75.9%) and
was made so that the questionnaire was simple to understand 35% of participants had a monthly income of RM1001
and could give more accurate data. The validity and reliability and below. The majority of them were married (55.9%)
had been checked by conducting a pilot study (30 orthopaedic and about 88.7% of them had secondary education levels.
patients). Cronbach’s alpha values for the reliability and in- The main two sources of information for the respondents
ternal consistency were 0.82 and 0.91, respectively. Therefore, about AMR were health workers and media (newspaper,
the questionnaire was to be highly reliable and valid. TV, magazine and radio) by making up 9.2% (n = 36) and
8.7% (n = 34), respectively.
Data collection
The study employed a non-probability convenience sampling Knowledge of respondents about antibiotics and
method in selecting and recruiting the respondents in this study. antimicrobial resistance

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Four hundred twenty-seven participants who fulfilled the inclu- Table 2 shows the general knowledge about antibiotics in
sion criteria were invited to be a part of this study; however, which the majority of the respondents (59.7%) were know-
only 390 of them agreed to participate (the response rate was ledgeable by knowing that antibiotics should be taken ac-
91.3%). The researcher had explained to respondents about cording to the course or duration as prescribed. About
the goal and objective of this study. Besides that, respondents 54.6% of them knew that it was wrong to buy the antibiot-
were given a copy of the consent form explaining the aim and ics or request the antibiotics from doctors whereas 60.0%
the procedures of the study. Respondents had started to fill of them claimed that antibiotics were required for any blad-
up the questionnaires after receiving their consent forms with der or urinary tract infections. Surprisingly, 66.7% of them
signatures. They were assured of confidentiality. The incen- wrongly believed that cold and flu can be treated with anti-
tive was not offered for the completion of the questionnaire. biotics. This indicates that participants had moderate general
There was no prorated payment provided to respondents and knowledge about antibiotics. Moreover, regarding the specific
they had the right to either accept or reject by their own view. knowledge about AMR, results show that 79.4% of partici-
Respondents also fulfilled all the inclusion criteria before en- pants had a poor level of knowledge about AMR. In spite of
gaged in the study. Data collection took place over a period of more than one-quarter of the respondents (27.2%) claimed
approximately 8 weeks from May to July 2019 following an that they had heard about the word ‘antibiotic resistance’.
initial 1-month period of planning and field mapping. Each re- 95.7% of them were unaware of what AMR really means
spondent spent 10–15 min to finishing the questionnaire. and 92.1% of them thought that AMR can happen to those
who frequently took the antibiotics, respectively. Moreover,
Data analysis more than two-quarters of respondents (64.9% and 63.8%)
The survey responses for all 390 participants were collated in were not aware that AMR may cause problems in treating
Microsoft Excel, and the data were analysed using SPSS. The the infection and AMR may contribute to some level of diffi-
result was reported in terms of the frequency and percentage culty in the medical procedure such as surgery, cancer treat-
while a 95% confidence interval was assigned to determine the ment as well as organ transplant as shown in Table 3.
significance. A scoring system was applied to measure the re-
spondents’ knowledge and attitudes towards antibiotics where
it was adapted from a previous literature study.[23] One mark The attitude of respondents towards antibiotics
was given for a correct answer for each part of the question- Table 4 shows that 51.5% of the respondents had considered
naire and a zero mark for an incorrect answer. The cut-off that they would not favour meeting a doctor who had de-
score points for knowledge were stratified into three levels: clared to practice the appropriate antibiotics prescribing prac-
poor (0–4), fair (5–7) and good (≥8). The attitude scoring levels tice. Interestingly, this was reflected in question 6 whereby
were stratified into the negative and positive levels of attitude nearly half of the respondents (43.3%) disagreed with the
with the scores ranged from 0 to 4 and 5 to 7, respectively. doctors if they were not prescribed antibiotics. On the other
The attitude score was calculated as a continuous variable by hand, 48.5% of the respondents preferred doctors who prac-
summing the respondent’s number of appropriate responses to ticed the good antibiotics prescribing habit and 91.4% of the
six statements. One point ‘1’ has been awarded for each appro- respondents had an expectation to request additional infor-
priate response (‘yes’ for positive attitude and ‘no’ for negative mation as well as advice from doctors, pharmacists or nurses
attitude) and zero ‘0’ for each inappropriate or uncertain re- regarding the antibiotics and their precautionary measures.
sponse, with a maximum obtainable correct score of 6 for each Hence, results show that 30.2% of respondents had a nega-
respondent. For inferential statistical analysis, the chi-square tive attitude towards antibiotics.
test was used to predict the relationship between the dependent
variables (level of knowledge and attitude) and independent Association between socio-demographic with the
variables (demographic characteristics). level of knowledge and attitude of respondents
about antibiotics and AMR
Statistical analysis showed that there was a significant rela-
Key Findings
tionship between the knowledge score of participants towards
Socio-demographic characteristics of respondents antibiotics and their gender, age, race, marital status, educa-
A total number of 390 eligible respondents were included tional level and knowledge about antibiotic resistance terms
of which 286 of them were from the orthopaedic wards and (P < 0.05). In addition, participants’ attitude score regarding
4 Zulsairi Mohd Pauzi et al.

Table 1. Socio-demographic characteristics of respondents (N = 390)

Variables Frequency (N) and percentage Variables Frequency (N) and percentage

Age group (years) Gender

18–24 53 (13.6) Male 225 (57.7)

25–30 64 (16.4) Female 165 (42.3)
31–40 95 (24.4) Ward
41–50 61 (15.6) Orthopaedic 286 (73)
51–60 42 (10.8) Surgical 104 (27)
61+ 75 (19.2)
Race Marital status

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Malay 294 (75.9) Single 118 (30.3)
Chinese 43 (11.0) Married 272 (69.7)
Indian 51 (13.1)

Education level Source of information about AMR (n = 106)

Primary school 43 (11.0) Doctor or staff nurse 31 (7.9)
Secondary school 200 (51.3) Pharmacist 5 (1.3)
Matriculation 53 (13.6) Family members or friends 6 (1.5)
University 93 (23.8) Media (newspaper, TV, magazine, radio) 34 (8.7)
Refuse to answer 1 (0.3) Campaign 10 (2.6)
School 13 (3.3)
other 5 (1.3)
Can’t remember 2 (0.5)
Most recent time of antibiotic use

30 days 93 (23.8) 6 months 114 (29.2)

1 year 42 (10.8) Can’t remember 141 (36.2)
Monthly income

Variables Frequency (N) and percentage

≤RM1001 135 (35)
RM1001–2000 70 (17.9)
RM2001–3000 87(22.3)
RM3001–4000 55(14.1)
RM4001–5000 20 (5.1)
RM5001–6000 6(1.5)
RM6001 and above 17 (4.1)

antibiotics was found to be significantly associated only with ectly from their doctors and media. These sources excluded the
gender, race, marital status and education level as shown in other sources of valid medical information in which the public
Table 5. can access and guide with the correct information. Therefore,
it was noted that there was a myriad of misleading informa-
tion which led to the misuses and misconceptions of antibiotics
Discussion
usage. This was highlighted in the study of Qiao et al.[25] which
This study was considered the first of its kind to determine summarised that AMR was used by clients who were exposed
the knowledge and attitude about antibiotics usage and AMR to antibiotics usage rather than through a qualified medical
by focusing on the warded patients in general hospitals in practitioner. When the medicine was administered through a
Malaysia. AMR is a growing concern in the medical field as qualified health practitioner, the patient was given instructions
the development of antibiotic treatments is countered by the so that they knew when to take the antibiotics for treatment
development of antibiotic resistance in patients. While AMR purposes. For example, one of the key instructions for the pa-
is encountered through both food and medicine, most of the tient was to complete the as-prescribed antibiotics despite the
cases involved the misuse of medicine. This is due to the mis- symptoms of the disease had been disappeared.
use and misconceptions around the use of antibiotics which Another key finding was the lacked knowledge of how anti-
is perpetuated through various factors in society. A study by biotics work, which would potentially lead to AMR. There
Mazińska et al.[24] reported that the two most popular sources was a major misconception that antibiotics were a magic
respondents could obtain information on antibiotics were dir- medication that can cure any kind of infection, thus, there was
Antibiotic use and resistance 5

Table 2. Knowledge of respondents about antibiotics (N = 390)

No. Questions Frequency of Percentage Frequency of Percentage

correct answer, N wrong answer, N

1. When do you think you should STOP taking anti- 233 59.7 157 40.3
biotics once you’ve begun treatment?
2. ‘It’s OK to use antibiotics that were given to a friend 270 69.2 120 30.8
or family member, as long as they were used to treat
the same illness’
3. ‘It’s OK to buy the same antibiotics, or request from 213 54.6 177 45.4
a doctor, if you’re sick since they have helped you get
better when you had the same symptoms BEFORE’
Do you think these conditions can be treated with antibiotics?
4 Bladder infection or urinary tract infection (UTI) 156 40.0 234 60.0

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5. Cold and flu 130 33.3 260 66.7
6. Skin or wound infection 267 68.5 123 31.5
7. Sore throat 214 54.9 176 45.2
8. If doctor’s diagnosis for you is viral infection, for 190 48.7 200 51.3
example, cold/flu. Do you want to get antibiotic
prescription?

Table 3. Knowledge of respondents about antimicrobial resistance (N = 390)

No. Questions Frequency of Percentage Frequency of Percentage

correct answer, N wrong answer, N

1. Have you heard any of the terms ‘Antibiotic Resistance’? 106 27.2 284 72.8
2. Antibiotic resistance occurs when your body becomes resistant to 17 4.3 373 95.7
antibiotics and they no longer work as well
3. Many infections are becoming increasingly resistant to treatment by 88 22.6 302 77.4
antibiotics
4. If bacteria are resistant to antibiotics, it can be very difficult or im- 137 35.1 253 64.9
possible to treat the infection they cause
5. Antibiotic resistance could affect me or my family 112 28.7 278 71.3
6. Antibiotic resistance is an issue in other countries but not in Malay- 71 18.2 319 81.8
sia
7 Antibiotic resistance is only a problem for people who take antibiot- 31 7.9 359 92.1
ics regularly
8 Bacteria that are resistant to antibiotics can spread from person to 73 18.7 317 81.3
person
9 Antibiotic-resistant infection could make medical procedures like sur- 141 36.2 249 63.8
gery, organ transplant and cancer treatment much more dangerous

an overreliance on their usage. Besides that, there was lacking tor to AMR in patients. The findings showed that patients
awareness among patients whereby bacteria causing illness often use antibiotics temporarily just to subside their symp-
can develop resistance to antibiotics treatment. Antibiotics toms and once the symptoms were gone; they neglected the
which were previously effective in treating the ailment would usage of the antibiotics. Therefore, when the patient stopped
be ineffective. Many of the patients were unaware of the func- using the antibiotics, they developed resistance to the drugs,
tionality behind antibiotics and therefore they viewed them as and the next time when they went through the antibiotics’
a cure for many diseases. This was highlighted in the study of treatment, it would be ineffective for them. Another form of
Aslam et al.[26], where the patients responded that medicine temporary usage of antibiotics was their usage to cure the
could use to cure a wide range of ailments. This finding was viral infection or minor illness that was unnecessary to be
similar to the study done by Chokshi et al., in which patients treated by antibiotics. These findings were similar to previ-
had been told medicines that they can take when they faced ous literature which investigated the rate at which patients
minor ailments, and antibiotics were noted to be the most completed their antibiotics treatment. While the majority of
popular type of medicine. Therefore, these indicate the high patients completed their course of treatment through anti-
levels of unawareness of the intrinsic details of antibiotics biotics, there was the minority that neglected their treatment
treatments and how they work in curing patients of various before it was completed.[28] This was explained in the study
diseases.[27] of Ha et al.[29] who identified some of the major reasons for
In addition, another significant finding from the study was neglecting antibiotics treatment were kept the antibiotics to
the temporal usage of antibiotics which was a major contribu- cure future ailments and sharing the medicine with other
6 Zulsairi Mohd Pauzi et al.

Table 4. Attitude of respondents about antibiotics (N = 390)

No. Questions Positive Percentage Negative Percentage

attitudes attitudes
(n) (n)

1.1 On that occasion, did you get the antibiotics (or a prescription) from a doctor? 235 94.4 14 5.6
2.1,2 On that occasion, did you get advice from a doctor, nurse or pharmacist on how to take 235 94.1 14 5.9
them?
3.1,2 When a doctor prescribes antibiotics for you, do you want to receive more information on 228 91.4 21 8.6
precautionary measures while taking antibiotics?
4.1 On that occasion, where did you get the antibiotics? 237 95.6 12 4.4
5.3 Do you prefer to consult a doctor that has declared to use antibiotics responsibly? 189 48.5 201 51.5
6.3 When a doctor decided based upon your initial assessment that antibiotic is NOT needed 221 56.7 169 43.3

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at the moment, would you accept if the doctor tells you to observe for few more days or
wait for the diagnostic test’s result before deciding whether to prescribe antibiotics or not?

1
Applied to only those who were able to recall their last antibiotic intake as shown in Table 1 (N = 249, 63.8%).
2
Twelve respondents (4.82%) were excluded as they received the antibiotic neither from doctor nor pharmacist.
3
Applied to all respondents (N = 390).

Table 5. Association between respondents’ demographic and their over several years began to take antibiotics even in smaller
knowledge and attitude scores of towards antibiotic and antimicrobial unsupervised dosages and unfortunately, this made them
resistance susceptible to AMR and may even resort to borrow or share
their antibiotics for temporal relief. Therefore, this indi-
Variables Knowledge score Attitude score cates the downside of sharing or borrowing and lending as-
χ 21 P χ 21 P prescribed antibiotics which should be considered unethical
because of its long-lasting effects.
Gender 4.285 0.042 3.890 0.0482 This study demonstrated that the level of knowledge towards
Age 9.853 0.0001 2
6.471 0.312 antibiotics was significantly associated with patients’ age, race
Race 13.574 0.0092 9.362 0.022 and educational level. This result was found to be comparable
Marital status 7.912 0.0192 6.122 0.0462 with results obtained by other studies.[32, 33] Older participants
Education level 48.634 0.00012 12.810 0.0122
were found to be more knowledgeable as they visited health
centres more often.[32] Besides that, most of the patients who
Heard ‘antibiotic 98.763 0.00012 2.263 0.083
resistance’ term
had long-term disease may become frustrated and terrified,
thus started to read, ask and acquire information to have a
Chi-square test.
1 positive attitude and good hygiene to cure the disease. This
Value is significant <0.05.
2
will promote their health and well-being in the long term.[34, 35]
Chinese respondents had a better knowledge compared with
other races. Malaysian Chinese was found to be more health-
family members or friends who may need the medicines. conscious and tend to approach health workers regularly in
Unfortunately, this made patients became unresponsive to the order to gain information and be more aware of their disease
antibiotics’ treatment, especially in a more serious condition. status and health condition.[36, 37] Additionally, patients with a
Furthermore, this study shared how AMR was often en- higher education level showed better knowledge as they had
countered through shared or borrowed antibiotics. This may a tendency to gain more medical information compared with
grant temporal relief to the patients but was improper which low-educated or uneducated people.[36] This was found to be
should not be practiced in society. Besides that, there was a similar with other relevant studies whereby education level had
lack of control of antibiotics given by medical practitioners been widely testified as having a strong correlation between
to patients. The patients can choose to share their prescrip- antibiotics usage with knowledge and attitude.[37–39]
tions and treatments with those who were around them. Another concern was that some patients believed that a cer-
This caused antibiotics improperly being administered. tain type of antibiotic was effective against all types of bac-
Those who shared their antibiotics with other people may terial infections, therefore, they usually requested physicians
have the good intention of sawing their counterparts had a to prescribe them the same antibiotics that they used before.
relief feeling. But this is unethical because of the long-term This belief may cause unsupervised access to antibiotics or
health complications that could bring to the patients. This inadequate dosages to the patients. This would be a precursor
was highlighted in the study made by Bakar et al.[30] which for developing AMR when inadequate and improper dosages
indicated that most cases of tonsillitis were harder to treat were administered to patients. This was reflected in the study
because the critical signs of AMR were noted in the patients. done by Degeling et al.[40] which stressed that medical prac-
This made health practitioners issued a stronger dosage of titioners should be stern in approving the administration of
antibiotics to their patients to cure tonsillitis inside them. various types of treatment to prevent their mishandling and
This finding was similar to the study done by El Marghani misuse. This indicated that although the medical history of a
et al.[31] which explored the treatment of tonsillitis and the patient can provide the necessary information, a new evalu-
usage of antibiotics. Patients who were prone to tonsillitis ation was still needed each time a patient developed an ail-
Antibiotic use and resistance 7

ment. This will allow a proper diagnosis to be carried out References

and make sure correct prescription of medicines were made, 1. Shrivastava SR, Shrivastava PS. Antimicrobial resistance: glo-
which can reduce the incidence of AMR. bal scenario and its relation with nation’s development. Lib-
yan J Med Sci 2019; 3: 34. https://www.ljmsonline.com/text.
asp?2019/3/1/34/254956
Limitations 2. Davies J, Davies D. Resistance origins and evolution of antibiotic.
Although this study answered the research questions, sev- Microbiol Mol Biol Rev 2010; 74: 417–33. https://doi.org/10.1128/
eral limitations still need to be acknowledged. This study was MMBR.00016-10
mainly focusing on patients who were admitted to ortho- 3. Martínez JL, Baquero F. Emergence and spread of antibiotic resist-
ance: setting a parameter space. Ups J Med Sci 2014; 119: 68–77.
paedic and surgical wards. Thus, future studies should con-
https://doi.org/10.3109/03009734.2014.901444
duct a similar study at other wards including medical, respira-
4. Allcock S, Young EH, Holmes M et al. Erratum: antimicrobial re-
tory and nephrology. Moreover, the questionnaire contained sistance in human populations: challenges and opportunities – ER-
a series of close-ended questions, which might restrict the re- RATUM. Glob Health Epidemiol Genom 2017; 2: e16. https://doi.
spondents’ ability to explain the underlying reasons for cer- org/10.1017/gheg.2017.12

Downloaded from https://academic.oup.com/jphsr/article/15/1/rmab068/6497395 by guest on 10 February 2025

tain outcomes. 5. Bennadi D. Self-medication: a current challenge. J Basic Clin Pharm
2013; 5: 19–23. https://doi.org/10.4103/0976-0105.128253
6. Ventola CL. The antibiotic resistance crisis: part 1: causes and
Conclusion threats. P T 2015; 40: 277–83.
In conclusion, it was important to raise awareness of AMR 7. Bahnassi A. A qualitative analysis of pharmacists’ attitudes and
practices regarding the sale of antibiotics without prescription
and its causes. It was mainly created by the poor habits of
in Syria. J Taibah Univ Med Sci 2015; 10: 227–33. https://doi.
patients in using the antibiotics. It is recommended to raise
org/10.1016/j.jtumed.2014.09.001
awareness of the composition of antibiotics and how they 8. Sadiq MB, Syed-Hussain SS, Ramanoon SZ et al. Knowledge, atti-
work. This would address the issues in which many people tude and perception regarding antimicrobial resistance and usage
think that antibiotics were suitable to be used in treatment for among ruminant farmers in Selangor, Malaysia. Prev Vet Med 2018;
various diseases and conditions. Another recommendation 156: 76–83. https://doi.org/10.1016/j.prevetmed.2018.04.013
would be to revise the distribution policies around the admin- 9. Marston HD, Dixon DM, Knisely JM et al. Antimicrobial re-
istration of the antibiotics and how they are being released to sistance. JAMA 2016; 316: 1193–204. https://doi.org/10.1001/
various clients. Making antibiotics a controlled drug would jama.2016.11764
be too stringent and counterproductive, but it is essential to 10. Shamsuddin S, Akkawi ME, Zaidi ST et al. Antimicrobial drug use
in primary healthcare clinics: a retrospective evaluation. Int J Infect
note that their unsupervised and unjustified administration is
Dis 2016; 52: 16–22. https://doi.org/10.1016/j.ijid.2016.09.013
creating more health issues in society.
11. Haque M, Rahman NAA, McKimm J et al. Antibiotic use: a
cross-sectional study evaluating the understanding, usage and
perspectives of medical students and pathfinders of a public de-
Author Contributions fence university in Malaysia. Antibiotics (Basel) 2019; 8: 154.
https://doi.org/10.3390/antibiotics8030154
Z.M.P. designed the study with B.A.R.H. Z.M.P. and
12. Othman BR, Kuan CH, Mohammed AS et al. Occurrence of
A.H.M. analysed data. C.F.N. reviewed the study, and all au- methicillin-resistant Staphylococcus aureus in raw shellfish at re-
thors reviewed and edited the drafted study. All authors state tail markets in Malaysia and antibacterial efficacies of black seed
that they had complete access to the study data that support (Nigella sativa) oil against MRSA. Food Control 2018; 90: 324–31.
the publication. https://doi.org/10.1016/j.foodcont.2018.02.045
13. Song JH, Jung SI, Ko KS et al. High prevalence of antimicrobial
resistance among clinical Streptococcus pneumoniae isolates
Funding in Asia (an ANSORP study). Antimicrob Agents Chemother
2004; 48: 2101–7. https://doi.org/10.1128/AAC.48.6.2101-
The authors declare that there was no funding for this work. 2107.2004
14. Kang CI, Song JH. Antimicrobial resistance in Asia: current epi-
demiology and clinical implications. Infect Chemother 2013; 45:
Conflict of Interest 22–31. https://doi.org/10.3947/ic.2013.45.1.22
The authors declare that there was no conflict of interest re- 15. Soomro S, Alshammari H, Alabbas Y. Awareness and knowledge
garding the publication of this paper. about antibiotic use and resistance among students of Northern
Border University Saudi Arabia. J Trop Dis 2017; 5: 100–247.
https://doi.org/10.4172/2329-891X.1000247
16. Mason T, Trochez C, Thomas R et al. Knowledge and awareness
Ethical Approval of the general public and perception of pharmacists about anti-
Ethical approval was obtained from the Universiti Teknologi biotic resistance. BMC Public Health 2018; 18: 711. https://doi.
Mara (UiTM) Research Ethics Committee (UiTM/ org/10.1186/s12889-018-5614-3
REC/295/19) and Ministry of Health Malaysia Medical 17. Ghaieth MF, Elhag SR, Hussien ME et al. Antibiotics self-medica-
Research and Ethics Committee (NMRR-19-64-46214). The tion among medical and nonmedical students at two prominent
Universities in Benghazi City, Libya. J Pharm Bioallied Sci 2015; 7:
researcher adhered to the principles of Declaration of Helsinki
109–15. https://doi.org/10.4103/0975-7406.154432
and the Malaysian Good Clinical Practice Guidelines.
18. Islahudin F, Tamezi AM, Shah NM. Knowledge, attitudes and
practices about antibiotic use among the general public in Malaysia.
Southeast Asian J Trop Med Public Health 2014; 45: 1474–82.
Data Availability 19. Hawking MK, Lecky DM, Touboul Lundgren P et al. Attitudes
Data and materials are available upon request. and behaviours of adolescents towards antibiotics and self-care
8 Zulsairi Mohd Pauzi et al.

for respiratory tract infections: a qualitative study. BMJ Open 31. El Marghani AA, Algariri KA, Ridzuan PM et al. Prospective in-
2017; 7: e015308. https://doi.org/10.1136/bmjopen-2016-015308 fluence of phytotherapy on resistant bacterial tonsillitis. J Pure
20. Shehadeh M, Suaifan G, Darwish RM et al. Knowledge, attitudes Appl Microbiol 2019; 13: 167–78. https://dx.doi.org/10.22207/
and behavior regarding antibiotics use and misuse among adults in JPAM.13.1.17
the community of Jordan. A pilot study. Saudi Pharm J 2012; 20: 32. Lugo-Mata ÁR, Urich-Landeta AS, Andrades-Pérez AL et al.
125–33. https://doi.org/10.1016/j.jsps.2011.11.005 Factors associated with the level of knowledge about hypertension
21. Hassali MA, Arief M, Saleem F et al. Assessment of attitudes in primary care patients. Med Univers 2017; 19: 184–8. https://doi.
and practices of young Malaysian adults about antibiotics use: org/10.1016/j.rmu.2017.10.008
a cross-sectional study. Pharm Pract (Granada) 2017; 15: 929. 33. Raupach-Rosin H, Rübsamen N, Schütte G et al. Knowledge
https://doi.org/10.18549/PharmPract.2017.02.929 on antibiotic use, self-reported adherence to antibiotic intake,
22. World Health Organization. Antibiotic Resistance: Multi-Country and knowledge on multi-drug resistant pathogens – results of
Public Awareness Survey. Geneva, Switzerland: World Health Or- a population-based survey in Lower Saxony, Germany. Front
ganization, 2015. Microbiol 2019; 10: 776.
23. Awad AI, Aboud EA. Knowledge, attitude and practice towards 34. Sadeq R, Lafta RK. Knowledge, attitude and practice about hy-
antibiotic use among the public in Kuwait. PloS one 2015; 10: pertension in hypertensive patients attending hospitals in Baghdad,

Downloaded from https://academic.oup.com/jphsr/article/15/1/rmab068/6497395 by guest on 10 February 2025

e0117910. https://doi.org/10.1371/journal.pone.0117910 Iraq. South-East Asia J Public Health 2017; 7: 29–34. https://doi.
24. Mazińska B, Strużycka I, Hryniewicz W. Surveys of public knowl- org/10.3329/seajph.v7i1.34676
edge and attitudes with regard to antibiotics in Poland: did the 35. Mohammed AH, Rasool Hassan BA, Mohd Suhaimi A et al.
European Antibiotic Awareness Day campaigns change attitudes? Factors associated with the level of knowledge about hyperten-
PLoS One 2017; 12: e0172146. https://doi.org/10.1371/journal. sion in Malaysia: a short communication. J Pharm Health Serv Res
pone.0172146 2020; 11: 415–17. https://doi.org/10.1111/jphs.12381
25. Qiao M, Ying GG, Singer AC et al. Review of antibiotic resistance 36. Dawood OT, Hassali MA, Saleem F. Factors affecting knowledge
in China and its environment. Environ Int 2018; 110: 160–72. and practice of medicine use among the general public in the State
https://doi.org/10.1016/j.envint.2017.10.016 of Penang, Malaysia. J Pharm Health Serv Res 2017; 8: 51–7.
26. Aslam B, Wang W, Arshad MI et al. Antibiotic resistance: a run- https://doi.org/10.1111/jphs.12167
down of a global crisis. Infect Drug Resist 2018; 11: 1645–58. 37. Alqarni SA, Abdulbari M. Knowledge and attitude towards antibi-
https://doi.org/10.2147/IDR.S173867 otic use within consumers in Alkharj, Saudi Arabia. Saudi Pharm J
27. Chokshi A, Sifri Z, Cennimo D et al. Global contributors to anti- 2019; 27: 106–11. https://doi.org/10.1016/j.jsps.2018.09.003
biotic resistance. J Glob Infect Dis 2019; 11: 36–42. https://doi. 38. Oh AL, Hassali MA, Al-Haddad MS, et al. Public knowledge
org/10.4103/jgid.jgid_110_18 and attitudes towards antibiotic usage: a cross-sectional study
28. Gajdács M, Albericio F. Antibiotic Resistance: From the Bench to among the general public in the state of Penang, Malaysia. J
Patients. Basel, Switzerland: Multidisciplinary Digital Publishing Infect Dev Ctries 2011; 5: 338–47. https://doi.org/10.3855/
Institute, 2019. jidc.1502
29. Ha TV, Nguyen AMT, Nguyen HST. Public awareness about an- 39. You JH, Yau B, Choi KC et al. Public knowledge, attitudes and be-
tibiotic use and resistance among residents in highland areas of havior on antibiotic use: a telephone survey in Hong Kong. Infec-
Vietnam. Biomed Res Int 2019; 2019: 9398536. https://doi. tion 2008; 36: 153–7. https://doi.org/10.1007/s15010-007-7214-5
org/10.1155/2019/9398536 40. Degeling C, Johnson J, Iredell J et al. Assessing the public accept-
30. Abu Bakar M, McKimm J, Haque SZ et al., Chronic tonsillitis and ability of proposed policy interventions to reduce the misuse of
biofilms: a brief overview of treatment modalities. J Inflamm Res antibiotics in Australia: a report on two community juries. Health
2018; 11: 329–37. https://doi.org/10.2147/JIR.S187032 Expect 2018; 21: 90–9. https://doi.org/10.1111/hex.12589