Medical education before graduation about antimicrobial resistance is one of the important sources that increase their knowledge about antibiotics. Subjects such as pathology courses, pharmacology, clinical pharmacy, and microbiology are opportune for antibiotic and antimicrobial resistance education. The medical curricula of various universities that increases student knowledge and backgrounds about AMR was not available to be assessed. However, this study sought to investigate medical students’ knowledge about antibiotics and antimicrobial resistance including the secondary aim to evaluate possible differences in their attitude and practice outcomes.
Our findings in this study showed that 329 (29.6%) and 484 (43.6%) of medical students appeared to have good and moderate knowledge about antibiotics respectively, while 297 (26.7%) of medical students in this study had poor knowledge. Studies in southeast Asia and Italy have also shown significantly higher knowledge about antibiotics among final-year allied health students (1,2). It has also been stated that poor knowledge may lead to inappropriate antibiotics consumption which can result in a corresponding increase in bacterial resistance antibiotics (3).
Our study finds that there was a difference between medical students in clinical science years (seniors) and those in their initial basic science (juniors) years when it comes to their knowledge about antibiotic resistance. The results of this study identified that senior students have significantly better knowledge scores when compared to juniors (P < 0.001), which concurs with the findings in a study among pharmacy students in Sri Lankan universities (4). Our results support that medical students from various areas, universities and backgrounds are aware about the growing global problem of antimicrobial resistance stated by the current evidence(3,5). A recent cross-sectional study in 29 European countries in 2018 discovered that medical students still need more education about the proper use of antibiotics for their future practice (6).
The majority (63.6%) held the misconception that antibiotics can be requested from healthcare providers during consultations. Patient request and coercion has proven to influence the prescription behaviour of healthcare providers, especially in the absence of continuing education and external responsibility. These factors greatly influence the dispensing behaviour among physicians, with malpractice being more common among healthcare providers expressing their refusal to communicate effectively with patients, in order to achieve time-effectiveness (10,21,32). In Tanzania, 25.5% also preferred use of non-prescription antibiotics for minor illnesses as opposed to consulting doctors. This has been cited as a common reason for antibiotic self-medication in Namibia (33,34).
Similar to a study conducted in UAE, a considerable proportion of final year medical students demonstrated a positive attitude to antibiotic use (35). Academic seniority was also significantly associated with attitude scores (P < 0.01), with first-to-third year students achieving lower scores. Antibiotic resistance is not given sufficient cover in medical curricula in Sudan, while liberal practice of antibiotic use may be motivated by the acquisition of tuition in pharmacology and infectious diseases during this period. These findings are consistent with a previous study in China, where third-year medical students achieved the lowest attitude scores. (36).
Our results in this study have shown that the prevalence of self-medication with antibiotics within the previous 12 months among medical students in Sudan is 60.8%, which is a very high rate. Such results are not uncommon in Sudan as similar trends have been observed in previous studies among undergraduate students and the general population in Khartoum State (10,21,32). In Africa and the Eastern Mediterranean regions, this trend is also not unique to Sudan. Several studies on self-medication with antibiotics in both regions have portrayed similar and higher prevalence rates. In the African region, a study in northeastern Tanzania has shown that the prevalence of self-medication with antibiotics is 58%, while in Namibia, a study conducted on antibiotic self-mediation among children with acute respiratory infections depicted a prevalence rate of 60%. In rural Nigeria, a considerably higher prevalence rate (82.2%) was observed. (33,34,37)
In the Eastern Mediterranean region, studies in UAE and Saudi Arabia reported prevalence rates of 52.1% and 78.8% respectively. (38,39)
Many significant predictors of self-medication among undergraduate medical students in Sudan were identified in this study. Females were significantly more likely to use non-prescription antibiotics than males in this study (p < 0.01). Previous studies in Khartoum State (10,21), also reported self-medication with antibiotics being higher among females. This was also a common finding in multiple studies across Africa. In studies conducted among university students in Ethiopia and Nigeria (37, 40–42), female gender was also a significant determinant of self-medication with antibiotics. This could be due to the practice of sharing various types of medications being higher among females, although this requires confirmation through further studies.
Monthly allowance was also found to be a predictor of antibiotic self-medication in this study (p = 0.011). In lower-middle-income and low-income countries, low income may force individuals to search ways for decreased expenditure associated with access to healthcare, often by avoiding consultations with primary care and specialist physicians (43). The development of health systems capable of providing healthcare to the population without financial hardship, in conjunction with a regulatory framework on antibiotic use would thus be crucial in combating the emergence of antibiotic-resistant strains resulting from the irrational use of antibiotics. (44)
The results of this study indicated that the most commonly used antibiotics to practice self-medication were azithromycin (29.9%) and amoxicillin/clavulanic acid (26.8%). Amoxicillin/clavulanic acid was also among the most popular antibiotics used for self-medication in Ethiopia (40) and Eritrea (45). Amoxicillin/clavulanic acid is widely prescribed by healthcare providers worldwide, inexpensive and is considered as first-line therapy in many lower-middle-income and low-income countries where infectious diseases are highly prevalent (46). In this study, azithromycin was the most popular antibiotic - a finding which was not observed in previously conducted studies in Sudan (10,21,32,46). This change may be due to the resistance of bacterial strains as a result of over-prescription and misuse amoxicillin/clavulanic acid. Amoxicillin/clavulanic acid is commonly sold in pharmacies as Amoclan in Sudan. Amoclan is effective in treatment of infections caused by Klebsiella and Escherichia coli. However, resistant strains have emerged as a result of its overuse (47,48). This may also be explained by clients and patients requesting more potent antibiotics from their pharmacies. The use of higher-potency antibiotics also suggests that pharmacists and physicians may inform their patients about infections resistant to certain antibiotics, while patients use this information independently after their consultations. Azithromycin was also commonly prescribed in Mozambique and India (49,50). 195 respondents used unknown antibiotics, with unknown dosage and course durations. Incomplete courses and indiscriminate drug use increase the risk of side effects rom polypharmacy and the emergence of antibiotic-resistant strains (10,51,52)
The most common symptoms treated with non-prescription antibiotics were acute respiratory tract symptoms (38.1%), cough (30.4%) and common cold (26.2%). These ailments do not usually require antibiotic treatment and the practice of non-prescription antibiotic use for their treatment is a global commonality (53–62). In accordance with the response of the World Health Organization to the global crisis of antimicrobial crisis, a universal protocol regarding antibiotic prescription is adopted by clinicians. Bacteria are the only class of organisms against which antibiotics have any effect, with infection by different strains of bacteria requiring treatment with different antibiotics. It is on these grounds that only a fully qualified healthcare provider is given the right to decide which antibiotic is used in particular bacterial infections, after thorough clinical assessment of each patient, in accordance which local and national guidelines. These policies promote patient safety and safer, more economical utilisation of antibiotics among both prescribers and patients (63–65). If the public were to be aware of these policies, the practice of self-medication with antibiotics would likely be discouraged. A one-health approach should therefore be applied in an effort to raise awareness and share information regarding the correct protocol of antibiotic use, which would lead to the making of more informed decisions regarding the use of non-prescription antibiotics.
Of the 675 respondents who practiced non-prescription antibiotic use, 47.5% sought these medications from community pharmacies, while 9.0% used leftover antibiotics. This pattern remains consistent in Sudan (10,21,32,46) and thus demonstrates laxity within its health system in prohibition of sales of antibiotics without valid prescriptions. Similar experiences also motivated 49.6% to use nonprescription antibiotics as a cost-effective option. This trend can be combated by enacting policies prohibiting the inappropriate sales in private pharmacies and maintaining supplies in hospital pharmacies and public health facilities. In low-income countries, low supplies of essential drugs in hospital pharmacies may drive patients to pay higher prices in private pharmacies (66). The enactment of policies prohibiting irrational sales of antibiotics can lead to considerably lower antibiotic self-mediation rates, thus proving beneficial in combating antimicrobial resistance (67,68). Leftover antibiotics are among the most frequently stored antibiotics in low-income countries, indicating frequent non-compliance with the course of anti-infective treatment in conjunction with an increased risk of sharing (69).
The authors acknowledge that this study is not without limitations. As this is a retrospective questionnaire-based study, the results of the study are entirely dependent on the responses given by the participants and are therefore influenced by recall bias. Also, the questionnaire itself was administered online due to high travel expenses amid a difficult political climate. Despite these barriers, given the applied sampling technique, the authors believe that the results give an appropriate portrayal of knowledge and attitude towards antibiotic use and antibiotic resistance, paired with an accurate estimate of self-medication with antibiotics among medical students in Sudan.