Medical and pharmacy students’ knowledge, attitude and perception concerning antimicrobial use and resistance in Pakistan


  • Zikria Saleem Universiti Sains Malaysia; University of the Punjab, Pakistan & Rashid Latif College of Pharmacy
  • Mohamed Azmi Hassali Universiti Sains Malaysia
  • Furqan Hashmi Punjab University, Lahore
  • Faiza Azhar Punjab University, Lahore
  • Rabia Mubarak Punjab University, Lahore
  • Aysha Afzaal Punjab University, Lahore
  • Ujalla Munawar Punjab University, Lahore


Antimicrobial Use, Antimicrobial Resistance, Medical Students, Pharmacy Students


Background: Lack of adequate knowledge during undergraduate years may be responsible for prescribing or dispensing inappropriate antimicrobial agents which is one of the main reasons for antimicrobial resistance (AMR).

Objectives: The objective of the present study was to evaluate levels of medical and pharmacy students’ knowledge, attitude and perception concerning antimicrobial use and resistance.

Methods: A cross-sectional observational study was carried out in Lahore, Pakistan. A questionnaire was designed through a literature review. The study population included medical students and pharmacy students of the semi-final year (fourth) and final year (fifth). Data were then collected using a supervised, self-administered and pre-tested questionnaire containing 50 closed-ended questions. Six hundred and fifty students were invited to complete the questionnaire and the response rate was 69.2% (450 students).

Results: The majority of the students (79%) agreed that too many antimicrobial agents were prescribed in the hospitals nationally. The knowledge about antimicrobial use and resistance was significantly higher in pharmacy students than medical students (p<0.05). Pharmacy students were more inclined to strongly agree (94%) that they would like more education on the appropriate use of antimicrobial agents compared to medical students (p=0.001).

Conclusion: In order to reduce the growing problem of AMR, efforts should be undertaken to ensure that future pharmacists and doctors in Pakistan are well educated in practices of rational use of antimicrobial agents and their stewardship.

Author Biographies

Mohamed Azmi Hassali, Universiti Sains Malaysia

School of Pharmaceutical Sciences

Furqan Hashmi, Punjab University, Lahore

University College of Pharmacy

Faiza Azhar, Punjab University, Lahore

University College of Pharmacy

Rabia Mubarak, Punjab University, Lahore

University College of Pharmacy

Aysha Afzaal, Punjab University, Lahore

University College of Pharmacy

Ujalla Munawar, Punjab University, Lahore

University College of Pharmacy


Abbo, L.M., Cosgrove, S.E., Pottinger, P.S., Pereyra, M., Sinkowitz-Cochran, R., Srinivasan, Arjun, . . . Hooton, T. M. (2013). Medical students’ perceptions and knowledge about antimicrobial stewardship: how are we educating our future prescribers? Clinical Infectious Diseases, 57(5),


Afzal Khan, A., Banu, G. & Reshma, K. (2013). Antibiotic resistance and usage—a survey on the knowledge, attitude, perceptions and practices among the medical students of a Southern Indian teaching hospital. Journal of Clinical and Diagnostic Research: JCDR, 7(8), 1613

Buke, C., Hosgor-Limoncu, M., Ermertcan, S., Ciceklioglu, M., Tuncel, M., Köse, T. & Eren, S. (2005). Irrational use of antibiotics among university students. Journal of Infection, 51(2), 135-139

Carey, B. & Cryan, B. (2003). Antibiotic misuse in the community--a contributor to resistance? Irish Medical Journal, 96(2), 43-44, 46

Control & Prevention. (2002). CDC's campaign to prevent antimicrobial resistance in health-care settings. MMWR - Morbidity and mortality weekly report, 51(15), 343

Cosgrove, S.E. (2006). The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clinical Infectious Diseases, 42(Suppl 2), S82-S89. doi: 10.1086/499406

Cuff, P.A. (2013). Interprofessional education for collaboration: Learning how to improve health from interprofessional models across the continuum of education to practice: Workshop summary: National Academies Press.

Eng, J.V., Marcus, R., Hadler, J.L., Imhoff, B., Vugia, D.J., Cieslak, P.R., Zell, E., Deneen, V., McCombs, K.G., Zansky, S.M., Hawkins, M.A. & Besser, R.E. (2003). Consumer attitudes and use of antibiotics. Emerging Infectious

Diseases, 9(9), 1128

Feazel, L.M., Malhotra, A., Perencevich, E.N., Kaboli, P., Diekema, D.J. & Schweizer, M.L. (2014). Effect of antibiotic stewardship programmes on Clostridium difficile incidence: a systematic review and meta- analysis. Journal of Antimicrobial Chemotherapy, 69(7), 1748-1754

Fraimow, H.S. & Tsigrelis, C. (2011). Antimicrobial resistance in the intensive care unit: mechanisms, epidemiology, and management of specific resistant pathogens. Critical Care Clinics, 27(1), 163-205

Goossens, H., Ferech, M., Vander Stichele, R., Elseviers, M. & Group, ESAC Project. (2005). Outpatient antibiotic use in Europe and association with resistance: a cross- national database study. The Lancet, 365(9459), 579-587

Haltiwanger, K.A., Hayden, G.F., Weber, T., Evans, B.A., & Possner, A.B. (2001). Antibiotic-seeking behavior in college students: what do they really expect? Journal of American College Health, 50(1), 9-13

Hanberger, H., Arman, D., Gill, H., Jindrák, V., Kalenic, S., Kurcz, A., Licker, M., Naaber, P., Scicluna, E.A., Vanis, V & Walther, S.M. (2009). Surveillance of microbial resistance in European Intensive Care Units: a first report from the Care-ICU programme for improved infection control. Intensive Care Medicine, 35(1), 91-100

Harakeh, S., Almatrafi, M., Ungapen, H., Hammad, R., Olayan, F., Hakim, R., Ayoub, M., Bakhsh, N., Almasaudi, S.B., Barbour, E., Bahijri, S., Azhar, E., Damanhouri, G., Qari, Y., Kumosani, T., Harakeh, Z., Ahmad, M.S. & Cals, J.W.L. (2015). Perceptions of medical students towards antibiotic prescribing for upper respiratory tract infections in Saudi Arabia. BMJ Open Respiratory Research, 2(1), e000078

Hassali, M.A., Saleem, F., Alrasheedy, A.A., Ibrahim, Z.S., Khan, T.M. & Aljadhey, H. (2016). Leadership Attitudes and Beliefs of Pharmacy Students: A cross- sectional Study from a Malaysian University. Journal of Applied Pharmaceutical Science, 6(10), 189-194

Heddini, A., Cars, O., Qiang, S. & Tomson, G. (2009). Antibiotic resistance in China—a major future challenge. The Lancet, 373(9657), 30

Hoque, R., Mostafa, A. & Haque, M. (2016). Insight of Medical Students of Clinical Years to Antimicrobials Prescribing and Resistance in Private Medical School, Chittagong, Bangladesh. Journal of Young Pharmacists, 8(4), 447-455

Huang, Y., Gu, J., Zhang, M., Ren, Z., Yang, W., Chen, Y., Fu, Y., Chen, X., Cals, J.W.L. & Zhang, F. (2013). Knowledge, attitude and practice of antibiotics: a questionnaire study among 2500 Chinese students. BMC Medical Education, 13(1), 163

Ibia, E., Sheridan, M. & Schwartz, R. (2005). Knowledge of the principles of judicious antibiotic use for upper respiratory infections: a survey of senior medical students. Southern Medical Journal, 98(9), 889-895

Justo, J.A., Gauthier, T.P., Scheetz, M.H., Chahine, E.B., Bookstaver, P.B., Gallagher, J.C., Hermsen, E.D., DePestel, D.D., Ernst, E.J., Jacobs, D.M., Esterly, J.S., Suda, K.J., Olsen, K.M., Abbo, L.M. & MacDougall, C. (2014).

Knowledge and attitudes of doctor of pharmacy students regarding the appropriate use of antimicrobials. Clinical Infectious Diseases, 59(Suppl.3), S162-S169

Klein, E.Y., Van Boeckel, T.P., Martinez, E.M., Pant, S., Gandra, S., Levin, S.A., Goossens, H. & Laxminarayan, R. (2018). Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proceedings of the National Academy of Sciences, 115(15), E3463-E3470

Liu, Y.C., Huang, W.K., Huang, T.S. & Kunin, C.M. (2001). Inappropriate use of antibiotics and the risk for delayed admission and masked diagnosis of infectious diseases: a lesson from Taiwan. Archives of Internal Medicine, 161(19), 2366-2370

Leung, E., Weil, D.E., Raviglione, M. & Nakatani, H. (2011). The WHO policy package to combat antimicrobial resistance. Bulletin of the World Health Organization, 89, 390-2

Maragakis, L.L., Perencevich, E.N. & Cosgrove, S.E. (2008). Clinical and economic burden of antimicrobial resistance. Expert Review of Anti-Infective Therapy, 6(5), 751-763

Minen, M.T., Duquaine, D., Marx, M.A., & Weiss, D. (2010). A survey of knowledge, attitudes, and beliefs of medical students concerning antimicrobial use and resistance. Microbial Drug Resistance, 16(4), 285-289

Napolitano, F., Izzo, M.T., Di Giuseppe, G. & Angelillo, I.F. (2013). Public knowledge, attitudes, and experience regarding the use of antibiotics in Italy. PloS One, 8(12), e84177

Saleem, Z. & Hassali, M.A. (2018). Travellers take heed: Outbreak of extensively drug resistant (XDR) typhoid fever in Pakistan and a warning from the US CDC. Travel Med Infect Dis, 27, 127. doi: 10.1016/j.tmaid. 2018.10.013

Saleem, Z., Hassali, M.A. & Hashmi, F.K. (2018). Pakistan's national action plan for antimicrobial resistance: translating ideas into reality. The Lancet infectious diseases, 18(10), 1066-1067. doi:10.1016/ S1473-3099(18)30516-4

Suaifan, G.A., Shehadeh, M., Darwish, D.A., Al-Ije, H., Yousef, A.M.M. & Darwish, R.M. (2012). A cross- sectional study on knowledge, attitude and behavior related to antibiotic use and resistance among medical and non-medical university students in Jordan. African Journal of Pharmacy and Pharmacology, 6(10), 763-770

Thriemer, K., Katuala, Y., Batoko, B., Alworonga, J.P., Devlieger, H., Van Geet, C., Ngbonda, D. & Jacobs, J. (2013). Antibiotic prescribing in DR Congo: a knowledge, attitude and practice survey among medical doctors and students. PloS One, 8(2), e55495

Väänänen, M.H., Pietilä, K. & Airaksinen, M. (2006). Self-medication with antibiotics—does it really happen in Europe? Health Policy, 77(2), 166-171

WHO [World Health Organisation]. (2005). Containing antimicrobial resistance. Available at: management/anmicrobialresistance.pdf. Accessed 21st May, 2018

Wright, E.P. & Jain, P. (2004). Survey of antibiotic knowledge amongst final year medical students. Journal of Antimicrobial Chemotherapy, 53(3), 550-551

Yang, K., Wu, D., Tan, F., Shi, S., Guo, X., Min, Q., Zhang, X. & Cheng, H. (2016). Attitudes and perceptions regarding antimicrobial use and resistance among medical students in Central China. SpringerPlus, 5(1), 1779




How to Cite

Saleem, Z., Hassali, M. A., Hashmi, F., Azhar, F., Mubarak, R., Afzaal, A., & Munawar, U. (2019). Medical and pharmacy students’ knowledge, attitude and perception concerning antimicrobial use and resistance in Pakistan. Pharmacy Education, 19(1), p 199–205. Retrieved from



Research Article