Knowledge, attitude and practice of healthcare workers towards antibiotic resistance during the COVID-19 pandemic

Abstract

Background

During the novel Coronavirus 2019 (COVID-19) outbreak, there was an overuse of antibiotics in hospitals. The improper use of antibiotics during COVID-19 has increased antibiotic resistance (AR), which has been reported in multiple studies.

Objectives

To assess the healthcare workers’ (HCWs) knowledge, attitude and practice (KAP) in relation to AR during the era of COVID-19, and identify the associated factors with good knowledge, positive attitude and good practice.

Methods

A cross-sectional design was used to assess the KAP of HCWs in Najran, Kingdom of Saudi Arabia (KSA). A validated questionnaire was used to collect participants’ data, which consisted of the following information; socio-demographics, knowledge, attitude and items for practice. Data were presented as percentages and median (IQR). Mann–Whitney and Kruskal Wallis tests were used to compare them. Logistic regression was used to identify the associated factors linked to KAP.

Results

The study included 406 HCWs. Their median (IQR) knowledge score was 72.73% (27.27%–81.82%), attitude score was 71.43% (28.57%–71.43%) and practice score was 50% (0%–66.67%). About 58.1% of the HCWs stated that antibiotics could be used to treat COVID-19 infection; 19.2% of the participants strongly agreed and 20.7% agreed that during the COVID-19 pandemic, antibiotics were overused at their healthcare institutions. Only 18.5% strongly agreed and 15.5% agreed when asked whether antibiotics used properly for the right indication and duration can still result in AR. The significantly associated factors with good knowledge were nationality, cadre and qualification. A positive attitude was significantly associated with age, nationality and qualification. Good practice was significantly associated with age, cadre, qualification and working place.

Conclusion

Although the HCWs had a positive attitude regarding AR during COVID-19, their knowledge and practice need significant improvement. Implementation of effective educational and training programmes are urgently needed. In addition, further prospective and clinical trial studies are needed to better inform these programmes.

Introduction

The ability of bacteria to resist antibiotics has been described as antibiotic resistance (AR). AR has become a global public health crisis due to misuse and overuse of antibiotics.^1,2 In March 2020, the World Health Organization (WHO) announced the novel Coronavirus 2019 (COVID-19) pandemic crisis,³ in which there was overuse of antibiotics in both hospitals and communities.^4,5 Improper use of antibiotics during COVID-19 pandemic increased the AR and was reported globally.^6–16

One of the WHO's objectives is the worldwide action plan on AR, which aims to enhance the awareness regarding this issue.¹⁷ Optimizing the use of antibiotics in healthcare can be fulfilled through holistic cooperation between all different practices. Cooperation in healthcare settings is a key to achieve such objectives. It has been found that a cooperative practice including management, responsibility, experience in drug, actions, tracking, education and reporting has reduced the relative risk of antibiotic use by 34%.¹⁸ Appropriate knowledge about bacterial resistance to antibiotics is important in preventing AR, as insufficient knowledge will drive improper use.^19,20

Strategies and programmes are the key factors that help to tackle or at least reduce the issue of AR. The Antimicrobial Stewardship Program (ASP) is one of these strategies, which aims to ensure proper selection of antimicrobial prescription and optimal use of antibiotics to reduce AR through specific policies and guidelines.²¹ In the Kingdom of Saudi Arabia (KSA), the ASP was launched in 2014,¹⁹ and after 2 years, it was possible to dispense antibiotics without prescription.^22,23 The implementation of ASPs showed positive consequences.²⁴ Thus, continuous education on antibiotics is critical to accept the ASP interventions.²⁵

Knowledge, attitude and practice (KAP) towards AR among healthcare workers (HCWs) is a topical matter to be explored as HCWs guide patients on using antibiotics so they should be the trusted source of information. As a result, in 2020, a study conducted in Riyadh assessing the KAP of physicians regarding ASP found that ∼56% of them identified the term of ASP and 65% knew the variation between bactericidal and bacteriostatic agents.²⁶ It also reported that >50% of the HCWs were not aware of ASP.²⁵ A nationwide study conducted in the KSA discovered the implementation of ASPs was ineffective and influencing factors were lack of awareness, teams of ASP, experience in the infectious diseases and technical resources.²⁷

After a careful search, only one study was found to assess the KAP of nursing students regarding the antibiotic use and AR during COVID-19,²⁸ and no studies studied HCWs’ KAP in general with regard to AR during COVID-19. However, most previous studies revealed a low level of knowledge of the HCWs towards AR whereas other studies reported good knowledge. While the low level of HCWs’ knowledge about AR before COVID-19 in the KSA has been reported,^{25,27,29–33} it is expected that the knowledge of the HCWs about AR during pandemic might be lower. Therefore, this study aimed to assess the HCWs’ KAP in relation to AR during COVID-19 period and identify influencing factors.

Materials and methods

Study design, participants and sampling methods

A cross-sectional design was used to assess the KAP of HCWs affiliated with Ministry of Health hospitals on the regional level in Najran, KSA. The Najran region is located south-west of the KSA and has a population of ∼435 000. The area is ∼365 000 km². The eastern border of the Najran region is the desert of the Empty Quarter. On the western border is the Asir region. It borders the Riyadh region to the north and the Republic of Yemen to the south.

The participants were doctors, dentists, nurses, pharmacists and staff in the following departments: public health, infection prevention and control (IPC), laboratory, radiology, physiotherapy, respiratory therapy and operation room. Administrative staff were not included. The participants were informed about the aim and purpose of the study. Moreover, they were informed about their right to withdraw from the study at any time. Their information was confidential and private.

The overall number of employees in the region was 9331 and HCWs represented ∼6000 of this number. The sample size was 362, and then increased to 20% for non-responsive participants. Therefore, the total sample size was 435 participants. The sample size was calculated using Raosoft software (http://www.raosoft.com/samplesize.html).

A method of proportionate stratified random sampling was used (see Table 1). In the Najran region, KSA, there are six governmental hospitals with a 50–100-bed capacity (Khobash General Hospital, Sharorah General Hospital, Habona General Hospital, Thar General Hospital, Bader Alganoob General Hospital, Yadamah General Hospital and Psychiatric Hospital). Two hospitals had capacities of 200 (New Najran General Hospital and Maternity and Children Hospital). One hospital had a 300-bed capacity (King Khalid Hospital).

Table 1.

A proportionate stratified random sampling method for recruiting HCWs

Hospital (governmental)	Bed capacity	Total HCWs	Sample (N)
Khobash General Hospital	50	300	14
Sharorah General Hospital	100	1500	70
Habona General Hospital	70	400	19
Thar General Hospital	50	280	13
Bader Alganoob General Hospital	50	231	11
Yadamah General Hospital	50	300	14
Psychiatric Hospital	100	400	19
New Najran General Hospital	200	1600	74
Maternity And Children Hospital	200	2000	93
King Khalid Hospital	300	2320	108
The total sample size			435

Data collection and study instrument

A validated questionnaire was used to assess the KAP of HCWs towards AR. The questionnaire was based on designs from previous related studies.^29,34–39 Content validity was conducted by three experts in the field independently and a few amendments were made on the basis of their suggestions. In addition, a pilot study was conducted on 30 HCWs, and a few modifications were made accordingly.

An online questionnaire in ‘Google Form’ was the method used to collect the participants’ data and this included four parts; the first part included socio-demographic and professional characteristics of the participants, the second included 11 items for evaluation of knowledge, the third included seven items for attitude and the fourth part had six items for practice. The data were collected between 5 September and 4 October 2022, and the participants spent between ∼10 and 15 minutes answering the questionnaire.

An overall score (for each on of KAP separately) was calculated on the basis of the responses of each participant to each item of KAP in the questionnaire. The overall knowledge score was 11, attitude was 7 and practice was 6. The 75th percentile was used as the cut-off point.⁴⁰ Thus, scores that were above the 75th percentile of the total score for KAP indicated good knowledge, positive attitude and good practice, while scores that were below the 75th percentile indicated poor knowledge, negative attitude and poor practice.

Statistical analysis

Data were presented as proportions (%) and median (IQR). Logistic regression analysis was used to identify associated variables with poor knowledge and negative attitude as well as poor practice. The included variables were age, gender, nationality, cadre, qualification and working place. In the logistic regression, univariate analysis was used first, and then significant variables were included in the multivariate analysis. SPSS v.27 was used for analysing the data.

Ethics

The ethical approval was obtained from the Human Research Ethics Committee of USM (JEPeM Code: USM/JEPeM/22040202).

Results

Of the 435 HCWs invited to participate in this study, the response rate was 406 (93.1%). Socio-demographic and professional characteristics of the participants are presented in Table 2. Median age was 37 years (IQR = 33–42 and 68.7% of the participants were male. More than 50% of the participants were Saudi and most of them were physicians (35%), whereas only 6.7% and 5.2% were dentists and IPC staff, respectively. Most of the participants had a bachelor degree (49.5%) and the fewest had a PhD (4.9%), Board (3.4%) and Fellowship (4.7). Roughly 42% of the participants worked at secondary care hospitals and 25% in tertiary care hospitals. Regarding the availability of the IPC department at the participants’ places of work, although 53.2% stated they had an ASP, 26.6% stated they did not and 20.2% said they did not know.

Table 2.

Socio-demographic and professional characteristics of the participants

Variable		N	%
Age, median (IQR)		37	(33–42)a
Gender	Female	127	31.3
	Male	279	68.7
Nationality	Saudi	212	52.2
	Non-Saudi	194	47.8
Cadre	Physician	101	24.9
	Dentist	27	6.7
	Pharmacist	33	8.1
	Nurse	142	35.0
	IPC	21	5.2
	Other	82	20.2
Qualification	Diploma	93	22.9
	Bachelor	201	49.5
	Master	59	14.5
	PhD	20	4.9
	Board	14	3.4
	Fellowship	19	4.7
Working Place	Primary Care	133	32.8
	Secondary Care	170	41.9
	Tertiary Care	103	25.4
Having ASP	Yes	216	53.2
	No	108	26.6
	Do not know	82	20.2

^aInterquartile range.

The median (IQR) knowledge score of the study group was 72.73% (27.27%–81.82%). Most of the participants showed good knowledge about eight questions with scores >64%. About 53% stated that antibiotics are used to treat common colds and other diseases associated with cough and fever and 58.1% stated antibiotics are used treat COVID-19 infection. However, 30.3% had insufficient knowledge regarding the frequent use of antibiotics during COVID-19 causing side effects (Figure 1).

Figure 1.

Responses to questions related to knowledge about antibiotic use and AR during the COVID-19 pandemic.

In terms of the participants’ attitudes, the median (IQR) attitude score was 71.43% (28.57%–71.43%). About 18% and 14% of the participants strongly disagreed and disagreed, respectively, that antibiotics are safe drugs and can be commonly used; 19.2% of the participants strongly agreed and 20.7% agreed that they overused antibiotics during COVID-19 at their healthcare institutions. About 46% of participants strongly agreed and 20% agreed to start an antibiotic course based on the microbiology report; 47% of the participants strongly disagreed and 11.6% disagreed they could access the antibiotics during COVID-19 pandemic without prescription. Only 17% of the participants strongly disagreed and 15% disagreed that the antibiotics would accelerate recovery from COVID-19 disease. Regarding the attitudes of the participants during COVID-19 as to whether inappropriate use of antibiotics can enhance AR, 41.9% strongly agreed it could and 17.5% simply agreed. Only 39.2% of the participants strongly agreed and 23.9% agreed to receive more education on using the antibiotics (Figure 2).

Figure 2.

Responses to questions related to attitude towards AR during the COVID-19 pandemic.

The median (IQR) practice score was 50% (0%–66.67%). Only 17.7% and 15.5% strongly disagreed and disagreed to take antibiotics when they got COVID-19 infection to prevent getting a more serious illness. Less than 56% of the participants strongly agreed and agreed that taking antibiotics without prescription would enhance AR. Only 18.5% strongly agreed and 15.5% agreed that when antibiotics are used properly, they will result in AR. Roughly 35% and 14% of the participants strongly disagreed and disagreed to share the leftover antibiotics with their families. About 13.8% and 14% of the participants strongly agreed and agreed they would keep antibiotic stock at their homes for emergency use. Nearly 55% and 17% strongly agreed and agreed to consult a physician during COVID-19 as to whether they needed antibiotics (Figure 3).

Figure 3.

Responses to questions related to practice regarding AR during the COVID-19 pandemic.

Univariate analysis logistic regression for factors associated with (good knowledge, positive attitude and good practice) is presented in Table 3. The significantly associated factors with good knowledge were age, nationality, cadre, qualification and working place. Nationality, cadre and qualification were statistically significantly associated with positive attitude. With regard to factors that significantly associated good practice, these were age, gender, nationality, cadre, qualification and working place.

Table 3.

Univariate analysis for factors associated with (good knowledge, positive attitude and good practice)

		Knowledge			Attitude			Practice
Factor		COR	(95% CI)	P	COR	(95% CI)	P	COR	(95% CI)	P
Age		1.046	(1.019–1.074)	0.001*	1.012	(0.986–1.038)	0.367	1.071	(1.042–1.101)	0.001*
Nationality	Non-Saudi	4.031	(2.627–6.184)	0.001*	2.296	(1.532–3.441)	0.001*	2.849	(1.894–4.285)	0.001*
	Saudi	1	1		1	1		1	1
Cadre	Physician	12.020	(5.734–25.199)	0.001*	3.686	(1.975–6.878)	0.001*	3.460	(1.856–6.449)	0.001*
	Dentist	2.917	(1.065–7.989)	0.037*	1.597	(0.666–3.833)	0.294	2.052	(0.835–5.034)	0.117
	Pharmacist	5.490	(2.194–13.736)	0.001*	1.065	(0.473–2.399)	0.880	1.283	(0.537–3.060)	0.575
	Nurse	2.056	(1.003–4.214)	0.049*	1.649	(0.053–2.852)	0.074	1.574	(0.873–2.837)	0.131
	IPC	6.417	(2.238–18.388)	0.001*	2.076	(0.777–5.548)	0.145	2.822	(1.056–7.538)	0.039*
	Other	Ref.	1		1	1		1	1
Qualification	Fellowship	14.625	(4.669–45.803)	0.001*	4.000	(1.235–12.959)	0.021*	5.532	(1.941–15.773)	0.001*
	Board	9.000	(2.657–30.479)	0.001*	6.400	(1.357–30.190)	0.019*	4.303	(1.347–13.747)	0.014
	PhD	38.250	(9.729–150.368)	0.001*	6.044	(1.659–22.024)	0.006*	9.682	(3.161–29.656)	0.001*
	Master	7.473	(3.381–16.514)	0.001*	2.080	(1.059–4.086)	0.034*	4.706	(2.323–9.535)	0.001*
	Bachelor	3.767	(1.925–7.372)	0.001*	1.190	(0.728–1.947)	0.488	2.004	(1.941–15.773)	0.014*
	Diploma	1	1		1	1		1	1
Working Place	Tertiary Care	2.642	(1.530–4.561)	0.001*	1.218	(0.725–2.048)	0.456	2.398	(1.410–4.078)	0.001*
	Secondary Care	1.867	(1.140–3.056)	0.013*	1.342	(0.848–2.124)	0.209	1.501	(0.934–2.412)	0.093
	Primary Care	1	1		1	1		1	1

^*Significant at P = 0.05.

COR: Crude odds ratio

Multivariate analysis for factors associated with good knowledge, positive attitude and good practice is presented in Table 4. The significantly associated factors with good knowledge were nationality, cadre and qualification. Age, nationality and qualification were the significant associated factors with positive attitude. The significantly associated factors with good practice were age, cadre, qualification and working place.

Table 4.

Multivariate analysis for factors associated with overall scores (good knowledge, positive attitude and good practice)

		Knowledge			Attitude			Practice
Factor		AOR	(95% CI)	P	AOR	(95% CI)	P	AOR	(95% CI)	P
Age		0.992	(0.957–1.027)	0.641	0.965	(0.934–0.996)	0.030*	1.051	(1.016–1.087)	0.004*
Nationality	Non-Saudi	3.656	(1.836–7.282)	0.001*	2.088	(1.161–3.754)	0.014*	1.790	(0.502–2.407)	0.812
	Saudi	1	1		1	1		1	1
Cadre	Physician	6.303	(2.554–15.556)	0.001*	2.129	(0.939–4.353)	0.262	1.801	(1.008–5.112)	0.048*
	Dentist	2.300	(0.741–7.137)	0.149	1.103	(0.413–2.941)	0.845	1.512	(0.562–4.067)	0.413
	Pharmacist	9.543	(3.367–27.050)	0.001*	1.048	(0.453–2.425)	0.913	1.555	(0.606–3.989)	0.359
	Nurse	1.645	(0.670–4.039)	0.277	1.361	(0.714–2.595)	0.349	1.649	(0.796–3.415)	0.178
	IPC	8.159	(2.546–26.144)	0.001*	2.342	(0.846–6.487)	0.102	2.912	(1.031–8.493)	0.047
	Other	Ref.	1		1	1		1	1
Qualification	Fellowship	2.703	(0.691–10.580)	0.153	2.110	(0.543–8.192)	0.281	1.829	(0.524–6.379)	0.344
	Board	5.740	(1.314–25.071)	0.020*	5.756	(1.085–30.529)	0.044*	2.703	(0.729–10.021)	0.137
	PhD	13.580	(2.630–70.113)	0.002*	3.986	(0.974–16.317)	0.055	4.565	(1.272–16.381)	0.020*
	Master	4.261	(1.662–10.928)	0.003*	1.622	(0.750–3.505)	0.219	3.725	(1.644–8.438)	0.002*
	Bachelor	1.960	(0.885–4.342)	0.097	0.704	(0.387–1.279)	0.249	1.628	(0.834–3.178)	0.153
	Diploma	1	1		1	1		1	1
Working Place	Tertiary Care	2.330	(1.212–4.478)	0.011*	1.075	(0.611–1.890)	0.802	1.971	(1.096–3.544)	0.024*
	Secondary Care	1.178	(0.652–2.128)	0.587	1.183	(0.720–1.944)	0.507	1.067	(0.629–1.811)	0.810
	Primary Care	1	1		1	1		1	1

^*Significant at P = 0.05.

AOR: Adjusted odds ratio.

Non-Saudi participants were 3.6 times more likely to have good knowledge compared to Saudi participants (AOR = 3.65, CI = 1.836–7.282, P = 0.001). Compared with other specialities, pharmacists and IPC staff were nine and eight times more likely to have good knowledge, respectively: (AOR = 9.543, CI = 3.367–27.050, P = 0.001) and (AOR = 8.159, CI = 2.546–26.144, P = 0.001), respectively. Participants who had a PhD degree were 13.5 times more likely to have good knowledge than those who had a diploma degree (AOR = 13.580, CI = 2.630–70.113, P = 0.002). Compared with participants who worked in primary care, HCWs who worked in tertiary care were 2.3 times more likely to have good knowledge (AOR = 2.330, CI = 1.212–4.478, P = 0.011).

As age increased by 1 year, the odds of having a positive attitude increased by 49% (AOR = 1.051, CI = 1.016–1.087, P = 0.004). Non-Saudi participants were twice as likely to have a positive attitude compared to Saudi participants (AOR = 3.65, CI = 1.836–7.282, P = 0.001). Participants who hold -the board degree were 5.7 times more likely to have a positive attitude than those who had a diploma degree (AOR = 5.756, CI = 1.085–30.529, P = 0.044).

As age increased by 1 year, the odds of showing good practice decreased by 4% (AOR = 0.965, CI = 0.934–0.996, P = 0.030). Being a member of IPC staff lead to participants being 2.9 times more likely to showing good practice than participants with other specialties (AOR = 2.912, CI = 1.031–8.493, P = 0.047). Compared with participants who had a diploma, staff who had a PhD and masters degree were 4.5 and 3.7 times more likely to demonstrate good practice, respectively (AOR = 4.565, CI = 1.272–16.381, P = 0.020) and (AOR = 3.725, CI = 1.644–8.438, P = 0.002), respectively. Compared with participants who work in primary care, those who work in tertiary care were 1.9 times more likely to show good practice (AOR = 1.971, CI = 1.096–3.544, P = 0.024).

Discussion

To the best of our knowledge, this is the first study conducted in the Arab countries that focuses on the assessment of the HCWs’ KAP towards AR during COVID-19 pandemic. The study participants showed poor knowledge and practice, however, their attitude was positive. Such findings reflected a lack of efficacious educational and training programmes. Furthermore, this study identified some HCWs who need improvement in their knowledge and practice towards AR, especially during the pandemic. This includes youths, Saudi HCWs, health practitioners (such as dentists, nurses, public health officer, laboratory personnel, radiology personnel, physiotherapy personnel, respiratory therapy personnel and operation room personnel), HCWs who hold higher-level qualifications (diploma and bachelor) and HCWs who work at primary and secondary healthcare centres.

Knowledge-related questions

In the current study, the median (IQR) score knowledge of the HCWs was 72.73% (27.27%–81.82%). Recently, a study in Jeddah, KSA, has reported the median (IQR) score knowledge among primary healthcare physicians about antibiotic use was 63.64 (45.45–81.82).⁴¹ In Pakistan, clinician’s knowledge about ASP and AR was relatively poor.⁴² In Najran, KSA, similar findings were also reported among HCWs regarding the COVID-19 pandemic.⁴³ In contrast, in Egypt, the mean (standard deviation) of physicians’ knowledge towards antibiotics was 8.65 (±1.69) out of 11.⁴⁴

In the current study, most of the participants showed good knowledge on eight questions related to knowledge questions at >64%. However, ∼53% stated that antibiotics are used to treat common colds and any disease related to cough and fever. This is congruent with a study conducted in Norway⁴⁵ and another study in Saudi Arabia.⁴⁶ COVID-19 is a viral infection and WHO strongly do not recommend using antibiotics as prophylaxis or therapy for mild or moderate COVID-19 unless there is a strong justification.⁴⁷ In the current study, 58.1% of the participants stated that antibiotics are used to treat COVID-19 infection. However, 24% of HCWs in Gambia and 6.5% of medical students in Zambia stated that antibiotics could cure viral infections.^33,39

Attitude-related questions

The attitude of the HCWs in the current study was positive, which was in line with two previous studies carried out in the KSA and Zambia.^39,46 However, the attitude of HCWs in Ethiopia was lax.⁴¹ A small percentage of the participants in the current study strongly agreed and agreed with the statement ‘The antibiotics are safe drugs; hence, during a pandemic, can they be commonly used.’, which is similar to the other studies.^38,48 About 19.2% of the participants in the current study strongly agreed and 15.5% disagreed that during the COVID-19 pandemic antibiotics were being overused at their healthcare institution. The findings in the study by Tegagn et al.³⁶ agreed with our findings.

During the COVID-19 pandemic, physicians had prescribed antibiotics for COVID-19 patients in cases where most of the patients did not have secondary bacterial infection or a positive bacterial culture.^4,5 Less than half of the current study’s participants strongly agreed and agreed to obtain culture and sensitivity reports before starting an antibiotic course. On the other hand, a study conducted by Chandan et al.³⁸ found ∼77% of the study participants strongly agreed and agreed to obtain culture and sensitivity reports before starting an antibiotic course. In our study, 24.4% of the participants agreed to access antibiotics during the COVID-19 pandemic with a physician’s prescription. On the contrary, 43% of the international students in Africa agreed to get a prescription before starting antibiotics.⁴⁹ In the present study, only 17% of the participants strongly disagreed and 15% disagreed that the antibiotics will accelerate the recovery of COVID disease. In contrast, another study reported that 50% of the respondents stated using antibiotics will speed up recovery from colds.³⁹ Also, 75.9% of the HCWs in Gambia agreed that antibiotics will not speed up the recovery from colds and coughs.³³ In line with previous studies that reported most of their healthcare providers (>90%) stated that the improper use of antibiotics can influence the AR,^33,44 60% of HCWs in the current study reported correctly. Although the HCWs in the current study showed a negative attitude, only 39.2% of the participants strongly agreed and 23.9% agreed to get more education on adequate use of antibiotics. This was different from high proportions of participants in the other studies who were highly recommended to get more education.^33,36,37

Practice-related questions

Responses of the participants in the current study to questions related to practice indicated a poor result. Interestingly, only 17.7% and 15.5% strongly disagreed and disagreed to take antibiotics when they get COVID-19 infection to prevent getting more serious illnesses, which agrees with a recent study in Saudi Arabia.²⁹ HOwever, a study in Colombia revealed ∼5% of medical students stated that when they have cold, they should take antibiotics to prevent occurring serious ailments.⁵⁰

About half of the participants in the current study strongly agreed and agreed that when they take antibiotics in the period of COVID-19 without prescription, they enhance the AR. Unfortunately, only 22.7% strongly disagreed and 21.2% disagreed that when antibiotics are used properly for the right indications and duration, this will result in bacterial resistance. Similarly, in Malaysia, ∼40% of public indicated poor practice towards the statement ‘Misuse of antibiotics will accelerate the AR process’.³⁷ On the contrary, >90% of physicians in Egypt reported that inappropriate antibiotic selection, antibiotic self-medication and inappropriate duration of antibiotic drugs contributed to AR.⁴⁴

Roughly 35% and 14% of the participants in the current study strongly disagreed and disagreed to hand over their leftover antibiotics to family members, and 27.8% agreed to keep an antibiotic stock at their home in case of emergency. Although the HCWs in the current study indicated overall poor practice, the majority (72%) stated they should consult physicians if they felt they needed antibiotics during COVID-19. This is in line with previous studies.^46–49

Factors associated with good knowledge, positive attitude and good practice

The current study identified the significantly associated factors with good knowledge, which were nationality, cadre, qualification and working place. A study conducted during COVID-19 in the KSA found the profession and educational level were the associated factors with HCWs’ knowledge about COVID-19.⁴³ On the other hand, a previous study reported that the higher knowledge among health professionals was associated with more working experience and fewer working hours.⁵¹ Furthermore, the current study identified the associated factors with positive attitude, including, age, nationality and qualification. In Ethiopia, educational status and level of experience were associated with the attitude of the HCWs on hospital-acquired infection.⁵² However, a study carried out during COVID-19 did not reveal an association between nursing students’ attitudes towards AR and demographic characteristics.²⁸ Regarding the associated factors with good practice, in the current study the related factors were age, cadre, qualification and working place. In contrast, a previous study stated that the practice score of nursing students regarding AR and antibiotic use was associated with IPC training. However, the study did not find an association with other variables such as gender and experience.²⁸

The current study has several strengths. First, this is the first study at the level of Arab countries focusing on the assessment of KAP of HCWs towards AR, particularly during the COVID-19 pandemic. Second, the study represents the KAP of HCWs towards AR during COVID-19 who worked in governmental hospitals in the entire governorate. Third, a proportionate sampling method was used to avoid misclassification bias. Finally, associated factors with the KAP of HCWs were identified throughout using univariate and multivariate analyses. Nevertheless, the study has a few limitations. First, generalizability of the findings to all the HCWs in the KSA is not possible because it covers only one city in the southern region of the kingdom. Moreover, there are about three private hospitals that were not included in the current study.

Conclusion

The current study showed the poor knowledge, positive attitude and poor practice of HCWs. The associated factors with KAP were age, nationality, cadre, qualification and work place. A lack of efficacious educational and training programmes contributes to exacerbate the problem of AR. Therefore, implementation of effective educational and training programmes is urgently needed. In addition, further prospective and clinical trial studies are highly recommended to better inform these programmes. Furthermore, HCWs who might get benefits from the interventional programmes were identified in this study.

Conflict of interest

The authors have no conflict of interest in the current study.

Funding

This study was conducted as part of main’s author PhD work.

Transparency declarations

None to declare