ORIGINAL KNOWLEDGE, ATTITUDE AND PRACTICE ON ANTIBIOTIC USE AND ITS RESISTANCE AMONG MEDICAL STUDENTS IN A TERTIARY CARE HOSPITAL

Background : Antimicrobial resistance is evolving as a major global public health problem. This study was aimed to assess the knowledge, attitude and practice on antibiotic use and its resistance among medical students in a tertiary care hospital. Methods: Questionnaire was administered to the students of an undergraduate medical college hospital to assess their knowledge, attitude and practice about rational use of antibiotics. Data was analyzed using SPSS version 20. Results: Two hundred fifty three undergraduate students completely filled the electronic question - naire. About 76.3% of the students believed that improper use of antibiotics/self-prescription can cause and promote antibiotic resistance. One third (33.2%) of students thought that use of antibi - otics will speed up recovery from flu and cold and skipping one or two doses does not contribute to the development of antibiotic resistance. Majority (93.3%) of the students had never attended a Continuing medical education about rational use of antibiotics in the past. The knowledge, attitude and practice domain scores were not significantly different between the students among various academic years. Conclusions: Our study showed that the majority of the students had good knowledge and at - titude about antibiotics and its resistance. Their practice was satisfactory towards rational use of antibiotics. Medical students need to be sensitized regarding antimicrobial resistance through various Continuing medical education and workshops highlighting its burden and impact. Proper guidelines and strict policy on sales of antibiotics without prescription should be implemented and monitored regularly.


INTRODUCTION
Antimicrobial resistance (AMR) is stated to be one of the greatest challenges to global public health. Excessive and irrational use of antibiotics leads to development of antimicrobial resistance over time. 1,2 As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others. 3 The irrational and injudicious use of high doses of antibiotics for therapy and suboptimal doses as growth promoters are leading causes of AMR in Nepal. 4 Nepal has only recently started its journey on the path to an integrated response to the challenge of antimicrobial resistance. In addition, most of the routinely used antibiotics are available over the counter, increasing the non-prescribed antibiotic usage. 5 Consequently, these reasons along with irrational use of antibiotics and unawareness among the consumers, Nepal is bound to have high AMR in absence of intervention. 6 Misuse and the overuse of the antibiotics is mostly addressed with the prescription system via health care professionals. However, the lack of data on the status of the understanding the antimicrobial resistance and the inadequate experience for it does not allow the implementers to guide the health care professional in a common grounds to address the antimicrobial resistance. 7 It is the high time that we include young medical students in continuous medical education on antibiotic resistance to take up advocacy and stewardship role in antimicrobial resistance in future. The objective of this study was to assess the knowledge, attitude and practice (KAP) on Antibiotic use and its resistance among Medical Students in a Tertiary Care Hospital.

METHODS
This was a cross-sectional study conducted among students from first, second, third and fourth years (253 out 350 students) of MBBS and BDS students of College of Medical Sciences from 10 th June to 9 th July2020. This study was questionnaire-based study, developed based on the literature review [8][9][10][11] of comparable studies done in the past. The questionnaire was pre-tested on ten percent of the sample size, and then modified according to the results and feedback. i.e. negatively phrased compared to other questions, reverse scoring was done for these questions before the final analysis.
The questionnaire was distributed to the participants after obtaining their informed consent with permission from principal of the institution. Only completely filled questionnaires were used for final analysis. Identity of the participants was kept confidential throughout the study periods. A structured questionnaire containing questions based on a five-point Likert scale was used. A few questions were true and false type also. Sample size was calculated using the formula: z 2 xpq/ e 2 /1+z 2 xpq/e 2 N N= Total students (350) e=0.05 margin of error z=1.96 (C.I) Confidence interval p=0.5 1.96 2 x0.5x0.5/ (0.05) 2 /1+ (1.96) 2 x (0.05x0.5)/ (0.05) 2 x/350 =93.44 Approval from the Institutional Ethical Committee (COMS-IRC 2019-031) was obtained. Participation were entirely voluntary and neither they were forced or coerced at any level with flexibility to withdraw from the study at any point of time. Only completely filled questionnaires were used for final analysis. Data collection was done using Google Forms and entered into SPSS-20/Microsoft Excel sheets. Data was described using mean and standard deviation for quantitative variables, and numbers and percentages for categorical variables. One-way Analysis of Variance (ANOVA) test was used to compare indi-vidual domain scores between different academic years. A pvalue of < 0.05 was considered as statistically significant.

RESULTS
Out of 350 students, 253 (72.28%) students completely filled the questionnaire. The response rate of our study was 72%.The mean age of the study participants was 21.4 ± 1.8 years. There were 121 (47.8%) males and 132 (52.2%) females. Demographic data are shown in Table 1. As shown in Table 2 and 3, 76.3% of the students believed that improper use of antibiotics/self-prescription can cause and promote antibiotic resistance. Surprisingly one third of students thought that use of antibiotics will speed up recovery from flu & cold and skipping one or two doses does not contribute to the development of antibiotic resistance. Most of the students also agreed that antimicrobial resistance is a major public health concern.  Table 4 represents practice of participants on antimicrobial resistance. Majority (93.3%) of the students had never attended a CME about rational use of antibiotics in the past. Almost half of the participants had advised others or taken antibiotics without consulting any physician. More than 90% of the students have completed the full course of antibiotics prescribed by the physician. More than two thirds of the participants have never taken antibiotics prophylactically and did not prefer using antibiotics for cough and sore throat.
The knowledge, attitude and practice domain scores were not significantly different between the students among various academic years ( Table 5). The second-year students scored lowest on knowledge domain as compared to other groups.

DISCUSSION
Antimicrobial resistance (AMR) is a major health issue globally. Awareness regarding AMR is key to stop its rising incidence. Knowledge on AMR is of utmost importance to rational use. Medical students at medical college are the foundation for becoming a qualified prescriber in the future. Medical students are exposed to theories on antimicrobials and its use since first year of medical school and learn P-drug concept includes the name of a drug, dosage form, dosage schedule and duration of treatment for a specified condition in the second year. However, it is not until internship and after being a medical license holder, they become qualified to prescribe medicine to patients. Therefore, this study was conducted to assess the knowledge, attitude and practice of AMR among undergraduate medical students who are headed towards becoming future health care professionals.
Majority of the students were well aware that improper use of antibiotics/self-prescription could cause and promote antibiotics resistance similar to the study conducted by Taj Uddin Shaik at el 8 in 2016 where most of the participants showed good level of knowledge among medical students about antimicrobial resistance. Surprisingly, however, only half of the participants considered antimicrobials as a major public health problem, unlike the study in India where approximately 90% of the students perceiving AMR as a major public health problem. 9,10 In our study, approximately one-third of the students agreed that use of antimicrobials will speed up recovery from flu and cold similar to the study done in India amongst the second year students, where 75% of them considered antibiot-ics to be wonder drugs that hasten recovery from illness, with more than half considering them to be safe drugs. 9 Almost half of students had ever advised others or taken antibiotics without prescription similar to the results of a study by Gupta et al 10 in 2018 which showed that 45% of medical students responded to having bought antibiotics without medical prescription. Regardless of the self-reported practices on antibiotics use, the majority of students completed a full course of antibiotics prescribed by the physician and never used antibiotics prophylactically. But interestingly, almost half of the participants responded that they save the remaining, leftover antibiotic for the next time when they get sick.
The knowledge, attitude and practice domain scores were not significantly different between the students of various academic years as opposed to the study by Zuzu et al 11 which had significant differences between the year of study and the level of knowledge, attitude and practices of the participants. 2 nd year students were the group to have least knowledge domain scores in our study.
AMR is a result of unnecessary and excessive use of antibiotics in humans as well as animals. 4 Overcrowding, availability of antibiotics without prescription, self-medication and lack of awareness further adds to the problem. AMR is an epidemic and a major public health problem that needs an integrated approach involving healthcare professionals, pharmaceutical companies and lawmakers. 12 Regular CMEs and workshop should be conducted for medical students and should be a part of their curriculum. 13,14 Clinical teaching using vignettes can make students better understand the burden and rationale of using antibiotics. Almost half of our participants had advised their friends and relatives to take antibiotics despite being unqualified. The left over antibiotic not always will be right antibiotic for the next illness, it may expire and hence become ineffective, or it will be only an incomplete course that promotes resistance 14 .This mandates a proper guideline and strict policy on sales of antibiotics without prescription. 15 Our study has few limitations. This includes convenience sampling, use of self-administered questionnaires rather than face to face interviews which may have caused recall bias along with small sample size. Hence, the study is not generalizable to other settings.

CONCLUSION
Medical students need to be sensitized regarding AMR through various CMEs and workshops highlighting its burden and impact. Education can play a major role in increasing awareness and developing positive attitude and safe practice. Hence, the medical curriculum should have proper guidelines on the rationale of antibiotic prescription.