Perspectives of Medical Students at Lorestan University of Medical Sciences on Antibiotic Resistance: Its Causes, Consequences, and Proposed Solutions

1. INTRODUCTION

The discovery and introduction of antibiotics in the 1940s revolutionized the treatment of infectious diseases, transforming previously fatal conditions into manageable infections and fundamentally altering the landscape of modern medicine [1, 2]. Antibiotics not only remain essential for treating bacterial infections but also serve as critical adjuncts in a wide range of medical interventions, particularly for immunocompromised populations such as cancer patients undergoing chemotherapy, premature infants, and individuals with HIV/AIDS [3, 4]. However, the misuse and overuse of antibiotics in recent decades have accelerated the rapid emergence of antibiotic-resistant bacteria, threatening the efficacy of once-reliable treatments. This growing resistance has resulted in increased treatment failure rates, prolonged hospital stays, secondary infections, higher mortality, and substantial economic burdens on healthcare systems worldwide [5, 6].

Antibiotic resistance (AR) is now recognized as a global health crisis, undermining the very foundation of modern medical care. The persistence of untreatable infections due to antibiotic resistance poses an urgent threat that transcends geographical and economic boundaries [7, 8]. In light of this, addressing AR has become a priority for healthcare providers, policymakers, and global health organizations. While the development of new antibiotic classes is crucial, it is equally important to implement strategies aimed at preserving the efficacy of existing antibiotics. Research has consistently demonstrated a direct correlation between antibiotic use and resistance levels, indicating that reducing unnecessary antibiotic prescriptions can slow the development of resistance [9, 10].

Medical professionals, particularly physicians, are on the frontline of this battle. However, ingrained prescribing habits can be difficult to change, highlighting the need for a proactive approach to educating future doctors about antibiotic stewardship. Medical students, as future healthcare providers, are vital stakeholders in combating AR. Their understanding of the causes and consequences of antibiotic misuse, along with their commitment to responsible prescribing, will play a pivotal role in shaping the trajectory of this global issue [11]. Studies from the UK and other regions have shown that targeted educational interventions for medical students can significantly improve prescribing behaviors and reduce unnecessary antibiotic use [12].

Despite formal training, evidence suggests that many medical students and early-career physicians still lack sufficient knowledge about appropriate antibiotic use and the mechanisms underlying antibiotic resistance [13]. Compounding this issue, some students rely heavily on outdated information from senior colleagues, emphasizing the need for an updated and comprehensive medical curriculum [14]. To better understand these educational gaps and develop effective solutions, this study aims to evaluate the knowledge and perceptions of medical students at Lorestan University of Medical Sciences regarding antibiotic resistance, its causes, and potential strategies for mitigating this growing public health threat.

2. MATERIALS AND METHODS

3. RESULTS

According to the results obtained from the total number of students participating in this study, 51.4% were women and 48.6% were men. Among the 319 participants, 50 students (15.6%) were in the Basic Sciences phase, 67 (21.0%) in the Physiopathology phase, 71 (22.2%) in the Stajer phase, 95 (29.7%) in the Internship phase, and 36 (11.2%) in the Residency phase. Overall, 21.0% of the students had participated in a meeting or workshop related to antibiotic resistance, while 79% had not. The opinions of medical students regarding the status of antibiotic resistance are presented in Tables 1-4.

4. DISCUSSION

This study provides a comprehensive insight into the perspectives of medical students at Lorestan University of Medical Sciences on antibiotic resistance-a growing global health threat. The findings indicate that although students are largely aware of the importance of this issue, significant gaps remain in formal education and practical experience. Only 21% had attended relevant workshops or courses, and many expressed concerns about the easy availability of antibiotics without a prescription. Participants identified several factors contributing to the spread of drug resistance, including self-medication, inappropriate prescribing by physicians, and the lack of adequate diagnostic tools, underscoring the need for educational, structural, and policy interventions. Notably, students recognized their role in combating drug resistance, demonstrating a readiness for active participation. These findings highlight a critical opportunity to leverage students’ awareness and motivation to strengthen antibiotic stewardship programs in Iran.

While our study findings indicated that physicians (72.1%) and pharmacists (48.9%) were identified as the primary agents responsible for controlling antibiotic resistance, it is also important to consider students’ perspectives on their own roles as future physicians. Interestingly, 41.6% of participants acknowledged their personal responsibility in controlling drug resistance, reflecting an emerging sense of professional awareness. This finding suggests that students recognize that their future prescribing practices will directly influence drug resistance patterns. Incorporating targeted educational interventions-such as clinical case-based learning, medication management workshops, and clinical simulations-can enhance students’ understanding of their professional responsibilities and better prepare them to play an active role in combating antibiotic resistance.

The findings of the study showed that 71% of students expressed concern about the inadequacy of research on antibiotic resistance, reflecting their growing awareness of global health challenges. This concern aligns with global trends; international research indicates that the development of new antibiotics has slowed over the past two decades due to high production costs, limited financial incentives, and regulatory challenges, while the threat of drug resistance continues to increase. Students’ awareness of this gap demonstrates a strong understanding of the importance of the issue and the need for scientific and educational action.

This concern can serve as a valuable incentive for student-led research and educational activities. Universities can encourage students to participate in small research projects, community awareness campaigns, and specialized scientific associations in the field of antibiotic stewardship. Additionally, incorporating research-based learning components into educational programs-such as optional research units or scientific mentoring programs-can enhance students’ scientific literacy, critical thinking, and professional responsibility in addressing antibiotic resistance at both national and global levels. Thus, these findings not only reflect students’ attitudes but also provide a basis for strengthening their active role in research, education, and community awareness in tackling the global challenge of antibiotic resistance.

Only about 54% of participants believed that antibiotic resistance would have a direct impact on their future careers, while the majority (46%) did not feel that it would. This difference likely reflects a limited understanding of drug resistance in everyday clinical challenges. Many students are still in the preclinical or early clinical stages of training and have not experienced treatment failure, prolonged patient stays, or limited drug options. Also, the current curriculum may not sufficiently emphasize the professional and economic dimensions of drug resistance in the healthcare system. Comparable international evidence supports this: for example, a Nigerian study found only about 40% of medical students had a positive perception of antibiotic resistance despite high self-rated knowledge [16]. Similarly, in a multi-country East African survey, only around one-third of final-year medical and pharmacy students achieved ‘good’ knowledge scores on antibiotic use and resistance [17]. Another Africa-wide study comparing South Africa and Nigeria also revealed substantial variation in knowledge and pointed to curriculum gaps [18]. This finding highlights the need for more context-based and clinical training (such as discussions of real patient cases and concrete examples of drug resistance complications) to help students better understand the connection between drug resistance and their future careers.

Currently, training related to antibiotic resistance at Lorestan University of Medical Sciences is provided in a scattered and limited manner, mainly through microbiology and pharmacology courses in the basic sciences curriculum and during parts of internships in internal medicine and infectious diseases. However, there is no dedicated unit or curriculum to systematically familiarize students with the concepts of antimicrobial stewardship and the public health aspects of drug resistance. The findings of the present study, especially the low rate of student participation in related workshops (21%) and their limited understanding of national policies to combat antibiotic resistance, indicate a serious need to review the educational content.

It seems that adding a dedicated unit or module on antimicrobial resistance and the rational use of antibiotics, holding interdisciplinary workshops involving medical, pharmacy, and nursing students, as well as using modern blended learning methods (online and clinical), which were also favoured by most participants in this study, could help improve the knowledge, attitudes, and behaviour of future physicians in this field. Such reforms could pave the way for training more informed and responsible physicians in the face of the global challenge of antibiotic resistance.

The results of this study were somewhat consistent with those of Sannathimmappa et al. in South Africa [13]. In the 2017 study by Sannathimmappa et al., the mean age of the students was 24 years, and 63% were female. Ninety-two percent of the students agreed that antibiotics are overused in South Africa, and 87% agreed that antibiotic resistance is a significant problem [13].

In the study by Alex IO et al. [19], conducted in Nigeria, respondents were predominantly male (62.5%) and in the age range of 20–29 years (68.9%), of whom 60.9% were in their final year. One hundred nineteen (64.7%) of the respondents had good knowledge about antibiotic use and antibiotic resistance; however, 39% incorrectly answered that bacteria cause colds. One hundred three (56%) of them had a history of antibiotic use, while 8.2% of respondents always consulted a doctor before starting antibiotics.

In this study, 51.4% of the 319 participating students were female and 48.5% were male. Of the 319 participating students, 50 (15.6%) were undergraduates, 67 (21%) were pathophysiology students, 71 (22.2%) were interns, 95 (29.7%) were clinical interns, and 36 (11.2%) were in residency.

In the study by Sannathimmappa et al., 38% were neutral or disagreed with the statement that poor hand hygiene by healthcare workers contributes to the spread of resistant bacteria [13]. In this study, 20% believed that the problem of antibiotic resistance was caused by the initial sample of patients, 18% believed that the problem was caused by hospitals, 44% believed that both were important, 14% indicated that they “did not know” the origin of antibiotic resistance, and 4% said that there was no problem.

In the study by Sannathimmappa et al., almost all students believed that good knowledge about antibiotics was important for physicians (287/289) and that inappropriate use of antibiotics contributed to resistance (283/289) [13].

In the Sannathimmappa et al. study, 63% of students rated their overall education on antibiotic use as helpful or very helpful. Most students reported wanting more education on appropriate antibiotic use (95%) and ABR in general (90%). In terms of curriculum, 91% of students attended a formal lecture on how to diagnose an infection, 79% on when to start antibiotics, 82% on when to take antibiotics, and 70% on when to use intrauterine antibiotics. They remembered intravenous injections as well as 89% of the basic principles of infection prevention and control. The most common sources for learning about antibiotic prescribing and antibiotic resistance were consultants (83%), registrars (85%), medical textbooks (87%), and using a tablet or smartphone (77%). Forty-seven percent of students reported learning from infectious disease physicians, and 30% from microbiologists. Less than one-third (32%) of students used medical journals as a source of learning. There was no statistically significant relationship between knowledge scores and sources used for learning [13]. In our study, 21% had attended a meeting or workshop related to antibiotic resistance, and 79% had not. Also, in this study, 138 medical students cited 45 existing standard guidelines, 60 from senior colleagues, 56 from laboratory reports on current bacterial resistance patterns, and 20 from pharmaceutical companies as the most important sources of knowledge for the appropriate use of antibiotics. Furthermore, according to the findings of this study, 204 cases were obtained through the medical education system, 109 cases through information available on the Internet, 232 cases through online courses on the correct use of antibiotics, and 221 cases through training for hospital staff in each hospital, 167 cases preferred to obtain information/training through national guidelines, and 24 cases through senior colleagues.

In a 2018 study by Dyar et al., it was shown that 37.3% of students wanted more education on the prudent use of antibiotics, and 26.8% wanted more education on both the prudent use of antibiotics and the general use of antibiotics. Thirty-one point two percent felt that they did not need more education, and 4.5% were unsure [20]. According to other reports, there is wide variation in students’ views on additional education regarding antibiotic resistance awareness around the world; for example, the proportion of students who wanted more education ranged from 20.3% in Sweden to 94.3% in Slovakia, with an average of 66% across countries [21].

In the present study, 204 students preferred to receive information or training through the medical education system, 109 through information available on the Internet, 232 through online courses on appropriate antibiotic use, 221 through hospital staff training in each hospital, 167 through national guidelines, and 24 through senior colleagues.

In the study by Sikkens et al., 71 students were in the intervention group and 285 in the control group. The participation rate in e-learning in the intervention group was 81%. The pass rate on the OSCE test was 86% in the control group, while this figure was 97% in the intervention group. The overall OSCE, knowledge, and Darwin selection scores were significantly higher in the intervention group [22].

In a study by Alshehri et al., examining the knowledge, awareness, and perceptions of antibiotic use, antibiotic resistance, and antibiotic stewardship among final-year medical and pharmacy students in Saudi Arabia, it was found that 44.7%, 47.7%, and 52.8%, respectively, had good knowledge about antibiotic use, antibiotic resistance, and antibiotic stewardship. Pharmacy students, however, showed higher knowledge about antibiotic stewardship and the proper use of antibiotics compared to medical students. In addition, the need for targeted educational strategies, standardized curricula, and advanced training was highlighted to further prepare future healthcare professionals to effectively combat antibiotic resistance [23].

This study aims to investigate the attitudes and knowledge of medical students at Lorestan University of Medical Sciences regarding antibiotic resistance, providing a comprehensive picture of their awareness, behaviour, and the educational resources available in this field. Findings indicate that although the general understanding of the risks of resistance is relatively high, gaps remain in formal education, learning resources, and enforcement of relevant laws, which affect students’ attitudes and performance. The high proportion of students in clinical settings, along with their willingness to learn through online courses, hospital training, and formal university education, indicates readiness to engage with structured educational programs. Furthermore, students have correctly identified the factors contributing to the spread of resistance, but the low involvement of policymakers and the general public in controlling this crisis points to systematic weaknesses that need to be addressed through educational, cultural, and legal interventions. Comparisons with other studies also suggest that the challenge of awareness and education regarding antibiotic resistance is a global phenomenon, requiring the alignment of educational strategies, particularly within medical curricula.

Although a cross-sectional design is suitable for examining student attitudes, it has inherent limitations. First, it is not possible to infer causal relationships from the data collected. Second, the study relies on self-reported data, which may be affected by recall bias or the tendency to provide socially desirable responses, potentially reducing the accuracy of the results. Finally, conducting the study at a single centre further limits generalizability. Future research could employ longitudinal or multi-centre designs to better examine changes in students' knowledge, attitudes, and behaviours over time and provide stronger evidence to support targeted interventions.

5. STUDY LIMITATIONS

This study was conducted at a single university (Lorestan University of Medical Sciences); therefore, the generalizability of the results to other universities and regions of the country is limited. The findings reflect the attitudes and knowledge of students in a specific educational and cultural context and may not fully represent the views of students at other medical universities in Iran or abroad. However, this limitation could provide an opportunity for conducting multicentred comparative studies across different universities and regions to determine whether similar patterns of awareness, attitudes, and educational needs regarding antibiotic resistance exist among other students. Such studies could offer a more comprehensive understanding of the status of antibiotic resistance education at the national level.

CONCLUSION

The findings of this study indicate that medical students are generally aware of the growing challenge of antibiotic resistance and have identified several areas requiring further attention. However, these results should be interpreted within the context of a study based on students’ perspectives and cannot, by themselves, serve as the sole basis for broad policy reforms. From the participants’ perspective, key areas for improvement include strengthening education, enhancing diagnostic capabilities, increasing public awareness, and reviewing regulations governing the sale of antibiotics. Nonetheless, more extensive research involving physicians, pharmacists, and policymakers is necessary to validate and prioritize these actions. The results also underscore the importance of promoting antibiotic resistance education within medical curricula. Implementing structured educational programs-such as workshops, online courses, and the provision of up-to-date clinical guidelines-can enhance students’ preparedness for the rational use of antibiotics. Furthermore, multicentre studies across multiple universities would provide a more comprehensive understanding of educational gaps and support evidence-based strategies to address antimicrobial resistance effectively.

REFERENCES