ORIGINAL RESEARCH

Survey on antimicrobial resistance knowledge and perceptions

in university students reveals concerning trends on antibiotic
use and procurement
Helena Ferreira Leal MSc1, Claudia Mamani BSc2, Caroline Quach MD, MSc, FRCPC1,3,
Emilie Bédard PhD4

BACKGROUND: The World Health Organization (WHO) has declared that antimicrobial resistance is one of the top ten global public
health threats humanity is facing. To tackle this problem, it is necessary to not only address it in the hospital setting, but even more so
in the community. In this context, understanding people’s knowledge, attitudes, and practices towards antimicrobial resistance is of
utmost importance. Accordingly, we investigated whether students from the Université de Montréal (Quebec, Canada) had perceptions
and behaviours that could foster bacterial resistance. METHODS: We conducted an observational, cross-sectional, prospective, and
descriptive study from November 30 to December 11, 2020. We applied an online questionnaire (Google Forms) adapted from the
WHO survey entitled ‘Antibiotic resistance: Multi-country public awareness survey.’ RESULTS: Overall, 106 participants were included
in this study. Most of them demonstrated reasonable understanding and behaviours related to antimicrobial resistance. Erroneous
response proportions ranged from 0.9% to 25.5%, except for the statement ‘Antibiotic resistance occurs when your body becomes
resistant to antibiotics, and they no longer work,’ where 63.2% of participants answered that it was true, even though it is false. Regar-
ding antibiotic use, 28.3% of participants said they already had used antibiotics without a doctor’s prescription. Of these, 55.2% were
Canadian students. CONCLUSIONS: This study indicates a possible misuse of antimicrobials in an area where antibiotics should not be
easily accessible without a prescription. It is necessary to investigate why these medications are being used without being prescribed.
Furthermore, we demonstrate a need to increase public awareness to better understand antimicrobial resistance’s theoretical basis.

KEYWORDS: antibiotic usage, antimicrobial resistance, eating and hygiene habits, perceptions, knowledge, university students

INTRODUCTION : Selon l’Organisation mondiale de la Santé (OMS), la résistance antimicrobienne (RAM) est l’une des dix menaces
sanitaires pour l’humanité. Pour faire face à ce problème, il est nécessaire de l’aborder non seulement dans le cadre hospitalier, mais
encore davantage au sein de la communauté. Dans ce contexte, il est primordial de comprendre les connaissances, les attitudes et les
pratiques de la population vis-à-vis de la résistance antimicrobienne. Ainsi, les chercheurs ont cherché à savoir si les perceptions et les
comportements de la communauté étudiante de l’Université de Montréal (Québec, Canada) pouvaient contribuer à la propagation
de la résistance bactérienne. MÉTHODES : Les chercheurs ont réalisé une étude observationnelle de type transversal, prospectif
et descriptif entre le 30 novembre et le 11 décembre 2020. Ils ont utilisé un questionnaire en ligne (formulaires Google) adapté du
sondage de l’OMS intitulé Antibiotic resistance: Multi-country public awareness survey. RÉSULTATS : Au total, 106 participants ont
été inclus dans l’étude. La plupart ont démontré avoir une compréhension et des comportements raisonnables au sujet de la RAM.
Les proportions de réponses erronées se situaient entre 0,9 % et 25,5 %, sauf pour la proposition « La résistance aux antibiotiques
survient lorsque votre corps devient résistant aux antibiotiques et qu’ils ne fonctionnent plus », pour laquelle 63,2 % des participants
ont répondu que c’était vrai, même si c’est faux. En ce qui concerne l’utilisation des antibiotiques, 28,3 % des participants ont déclaré
avoir déjà utilisé des antibiotiques sans prescription médicale, et 55,2 % d’entre eux étaient des étudiants canadiens. CONCLUSIONS :
La présente étude signale la possibilité que les antimicrobiens soient mal utilisés dans une région où les antibiotiques ne devraient pas
être facilement accessibles sans prescription. Une étude s’impose pour savoir pourquoi ces médicaments sont utilisés sans être prescrits.
De plus, les chercheurs démontrent la nécessité de sensibiliser le public aux fondements théoriques de la résistance antimicrobienne.

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Official Journal of the Association of Medical Microbiology and Infectious Disease Canada 7.3, 2022 doi:10.3138/jammi-2022-0008
 Students’ perceptions on AMR

MOTS-CLÉS : connaissances; étudiants universitaires; habitudes d’alimentation et d’hygiène; perceptions; résistance

a­ ntimicrobienne; utilisation des antibiotiques

1
Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Quebec, Canada; 2Department
of Pharmacology and Physiology, Faculty of Medicine, Université de Montréal, Quebec, Canada;3Centre Hospitalier Universitaire Sainte-Justine,
Quebec, Canada; 4Department of Civil, Geological and Mining Engineering, Polytechnique Montréal, Quebec, Canada

Correspondence: Emilie Bédard, Department of Civil Engineering, Polytechnique Montréal, C.P. 6079, succ. Centre-ville, Montréal,
Québec H3C 3A7 Canada. Telephone: 514-340-4711 ext. 5223. E-mail: e.bedard@polymtl.ca

Antimicrobials are critical in treating infections and have
contributed to the increase in the average life expectancy
observed over the last decades (1). However, these advances
are currently threatened by the emergence of antimicrobial-
resistant bacteria (2,3). Antimicrobial resistance (AMR) is
a phenomenon that evolves through natural selection, but
anthropogenic activities can accelerate its evolution (4). The
misuse and overuse of antibiotics contribute to the rapid spread
of resistant microorganisms worldwide (5). Most importantly,
resistant infections are associated with low treatment success
rates, excess morbidity, premature mortality, and increased
economic costs to society (3,6). To avoid the emergence of
AMR, we need to understand its theoretical basis, how it
emerges and spreads, and its impact on public health.
AMR can be intrinsic (peculiarities of the bacterial mor-
phology and metabolism) or acquired. The development of
resistance occurs randomly, through mutations in the bacte-
rial genome that allow them to survive against substances
that were previously able to kill or inhibit their growth. The
selective pressure generated by the overuse of antimicrobi-
als can accelerate the development of these mutations (4).
In addition to genomic mutations, which are transferred
vertically between bacterial cells, those microorganisms can
horizontally acquire mobile genetic elements such as plasmids,
transposons, and integrons, which encode resistance genes.
These genetic exchanges play a significant role in AMR’s
transmission (4,5).
Hospitals have been recognized as environments where
resistant bacteria emerge and multiply (2,7). Nevertheless,
resistant bacteria are also found in other settings. Most an-
timicrobial use happens outside health care institutions—in
the population, livestock farming, or crops—affecting com-
munity-dwelling individuals, animals, and their environment.
As a result, antibiotic resistance is now widely recognized
as a One Health problem, simultaneously endangering the
interconnected human-animal-environmental health (8,9).
In community settings, previous health care contact and
antibiotic exposure are widely described as risk factors for
resistance (5). However, behavioural factors might also cause
the spread of resistant organisms throughout a community. For
instance, eating and hygiene habits, domestic or occupational
contact with animals, unsafe water supplies, and travelling
and contact with family members can constitute routes for
human exposure to AMR (5,9,10).
One of the ways by which resistant bacteria can disseminate
through the community is via the food chain. In this context,
it is highly recommended that when handling food, people
adopt food safety and hygiene practices, a few of which are
washing hands before and after touching raw food; and washing
utensils during and after cooking (11). Another way by which
humans can acquire resistant bacteria is through interaction
with their pets (12). Thus, it is advisable to follow some safety
measures (eg, handwashing) after interacting with pets and
handling their food, excrements, and belongings.
Water, sanitation, and hygiene (WASH) measures, anti-
microbial stewardship, investments in the discovery of new
antibiotics, and educational campaigns are all critical tools
when fighting AMR (11,13). On the other hand, little is said
about the potential of vaccination. Vaccines that prevent
bacterial diseases, such as Haemophilus influenzae type B
(Hib) and Streptococcus pneumoniae conjugate vaccines, not
only lower antibiotic use, consequently reducing AMR, but
also prevent invasive infections caused by pneumococcal
serotypes that are usually antimicrobial resistant (14).
In this context, to prevent the dissemination of AMR, it
is necessary to address this problem not only in hospitals,
but also in the community (5,7). The general population
can contribute by improving their knowledge, attitudes, and
practices (KAP) toward AMR. Measures can be taken at an
individual level (11), a few of which are:
1. Having appropriate hygiene practices when eating and
cooking to limit cross-contamination
2. Avoiding the misuse of antimicrobials in pet welfare
3. Avoiding self-medication and limiting antibiotic use to
diagnosed bacterial infections
4. Following the medical prescription precisely, not saving
antibiotics for later, or sharing with someone else
5. Following recommended immunization schedules
Accordingly, the World Health Organization (WHO) has
emphasized the importance of raising awareness of health
risks posed by AMR and promoting good practices to limit the

7.3, 2022   Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada 221
H Ferreira Leal, C Mamani, C Quach, E Bédard
emergence of resistant bacteria (13). In Canada, The Public Health
Agency of Canada (PHAC) leads the international and domestic
response on AMR (15). The federal action plan recommends
activities to educate Canadian families, encouraging practices
that prevent the spread of resistant infections and germs, such
as handwashing. The plan also teaches about the theoretical
basis of resistance, explaining to the public why antibiotics are
not always necessary, particularly in the case of viral infections.
Furthermore, prescribers receive instructions to better explain
appropriate antimicrobial use to their patients (16).
While raising awareness of AMR is a priority in Canada,
recent local data shows that many are unfamiliar with or
unconcerned about the threat of drug resistance (17). AMR
ranked among their lowest concerns about personal overall
health and well-being, and 44% believed AMR was more of
a problem in developing countries (17).
In this context, studies aiming to assess people’s knowledge
and perceptions about AMR are essential to verify the impact
of awareness-raising campaigns. Hence, the main goal of this
investigation was to evaluate the level of knowledge and be-
haviours related to AMR by zooming on a subset of students
from the Université de Montréal. To our knowledge, this is
the first survey aiming to verify AMR-related perceptions
of students in a higher education environment in Canada.
In general, university students have a good level of knowl-
edge; therefore, they do not reflect the perceptions of the entire
population (18). However, they will soon become professionals
in key management and leadership positions and might play
a crucial role in fighting AMR. Especially students in the field
of natural sciences, as they might become future health care
providers. Thus, knowing if their perceptions and practices on
antibiotic usage are accurate is of great importance to adjust
our sensibilization strategy to ensure that future generations
will still benefit from these lifesaving drugs.
METHODS
We carried out an observational, cross-sectional, prospective,
and descriptive study. The survey was available on the Google
Forms platform from November 30, 2020 to December 11,
2020. The population was composed of students from the
Université de Montréal without age, gender, or study pro-
gram restrictions.
Data was collected using a questionnaire adapted from the
WHO survey (19) entitled ‘Antibiotic resistance: Multi-country
public awareness survey.’ The questionnaire comprised 42
questions, and participants were asked to self-complete the
survey. All questions were written in French, and participa-
tion was voluntary and anonymous.
The questions were designed to assess the students’ knowl-
edge of AMR and its theoretical basis and perceptions about
222 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada   7.3, 2022
the appropriate measures to tackle this health problem. We
also asked participants about lifestyle behaviours that could
foster AMR, including eating and hygiene habits, animal
contact, and antibiotic usage practices. All questions are
presented in the results section, in Figures 1 to 5.
The data were managed and analyzed using Epi Info version
3.5.1 (CDC, Atlanta, GA, USA), and graphics were made using
Microsoft Excel 2010. The Fisher’s exact and chi-square tests
were used to compare proportions for dichotomous variables.
Odds ratio (OR) and 95% CIs were calculated as measures
of association. Statistical significance was defined as p <0.05.
RESULTS
General characteristics of the study population
A total of 106 students were enrolled in this investigation.
Most of them were female (87, 82.1%), Canadians (77, 72.6%),
aged between 19 and 24 years old (62, 58.5%), undergraduate
students (66, 62.3%), living in urban areas (67, 63.2%), and
studying humanities and social sciences (45, 42.5%). The
characteristics of participants are shown in Table 1.
Lifestyle habits, practices, and levels of knowledge
Most respondents exhibited good eating and hygiene habits
(Figure 1), as well as good understanding of AMR’s transmis-
sion between humans and animals (Figure 2). The proportion
of incorrect responses ranged from 0.9% to 19.8%. The state-
ment for which the percentage of erroneous answers was the
highest was “I can exchange resistant bacteria with my pet,”
as 19.8% of participants indicated this statement was false
when it is true. In general, students were aware that AMR
has an impact outside the hospital (Figure 2).
Regarding the level of knowledge about the theoretical
basis of AMR (Figure 3), 63.2% of participants answered that
the statement “Antibiotic resistance occurs when your body
becomes resistant to antibiotics and they no longer work”
was true, even though it is false. Similarly, for the statement
“Bacteria that are resistant to antibiotics can be passed from
person to person,” 25.5% of participants answered false, an
incorrect response.
Concerning the awareness and understanding of how
to fight AMR (Figure 4), only 76.3% of students thought it
was important to ensure that children’s vaccinations were
up-to-date. Although most students (86.8%) agreed with the
statement “People should wash their hands regularly,” 13.2%
of them mentioned that they neither agreed nor disagreed
or strongly disagreed with this statement.
In addition, most participants (52.9%) said they neither
agree nor disagree or strongly disagreed with the statement
“Governments should subsidize the development of new
 Students’ perceptions on AMR

True False

It is necessary to wash your hands before cooking

After handling raw food (meat and vegetables), you

must wash your hands

I can use the same kitchen utensils for handling raw

and ready-to-eat foods

Kitchen utensils that have been used for raw food

should be washed before being used to prepare other
foods

It is necessary to wash fruits and vegetables before

eating them

We must wash our hands before eating

0% 25% 50% 75% 100%

Figure 1: Eating and personal hygiene habits

Notes: Statements are written on the left side of the graph; the colour blue corresponds to true and the colour red to false (n = 106)

True False

I can exchange resistant bacteria with my pet

The use of antibiotics in livestock and crops can

increase the presence of resistant bacteria in the
environment

The use of antibiotics in livestock and crops cannot

affect me directly

Resistant bacteria are only found in hospitals

0% 25% 50% 75% 100%

Figure 2: Antibiotic resistance associated to pets, livestock, and crops

Notes: Statements are written on the left side of the graph; the colour blue corresponds to true and the colour red to false (n = 106)

7.3, 2022   Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada 223
H Ferreira Leal, C Mamani, C Quach, E Bédard

True False

Antibiotic resistance occurs when your body becomes

resistant to antibiotics and they no longer work as well

Many infections are becoming increasingly resistant to

antibiotic treatment

If bacteria are resistant to antibiotics, it can be very difficult

or impossible to treat the infections they cause

Antibiotic resistance is an issue that could affect me or my

family

Antibiotic resistance is an issue in other countries but not

here (Canada)

Antibiotic resistance is only a problem for people who take

antibiotics regularly

Bacteria that are resistant to antibiotics can be spread from

person to person

Antibiotic-resistant infections could make medical

procedures like surgery, organ transplants, and cancer
treatment much more dangerous

0% 25% 50% 75% 100%

Figure 3: General knowledge about antibiotic resistance

Notes: Statements are written on the left side of the graph; the colour blue corresponds to true and the colour red to false (n = 106)

Strongly agree Neither agree nor disagree Strongly disagree

Farmers should give fewer antibiotics to food-

producing animals

People should not keep antibiotics and use them later

for other illnesses

Parents should make sure all of their children’s

vaccinations are up-to-date

People should wash their hands regularly

Doctors should only prescribe antibiotics when they

are needed

People should only use antibiotics when prescribed by

a doctor or nurse

Governments should finance the development of new

antibiotics

Pharmaceutical companies should develop new

antibiotics

0% 25% 50% 75% 100%

Figure 4: Levels of awareness and understanding of how to combat AMR

Notes: Statements are written on the left side of the graph; the colour blue corresponds to strongly agree, the colour yellow to neither
agree nor disagree, and the colour red to strongly disagree (n = 106)

224 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada   7.3, 2022

Strongly agree Neither agree nor disagree
Antibiotic resistance is one of the biggest problems
the world faces
Medical experts will solve the problem of antibiotic
resistance before it becomes too serious
Everyone needs to use antibiotics responsibly
People like me can't do much to stop antibiotic
resistance
I am worried about the impact that antibiotic
resistance will have on my health and that of my
family
I am not at risk of getting an antibiotic-resistant
infection, as long as I take my antibiotics correctly
0%
Figure 5: Participants’ perceptions on the magnitude of AMR and the impact it will have on them personally
Notes: Statements are written on the left side of the graph; the colour blue corresponds to strongly agree, the colour yellow to neither
agree nor disagree, and the colour red to strongly disagree (n = 106)
antibiotics.” Similarly, 52.9% of respondents neither agreed
nor disagreed or strongly disagreed with the statement
“Pharmaceutical companies should develop new antibiotics.”
Pertaining to participants’ views on the magnitude of
AMR and the impact it would have on them (Figure 5), only
27.4% of participants agreed with the statement, “Antibiotic
resistance is one of the world’s biggest problems.”
When asked about keywords related to AMR, participants
said they had heard the terms antibiotic resistance (82.1%),
superbugs (21.7%), antimicrobial resistance (27.4%), drug-
resistance (76.4%), and antibiotic-resistant bacteria (82.1%).
When asked about their sources of information most partici-
pants (52.8%) said they had heard about this phenomenon
through traditional media such as newspapers, television, or
radio. Only 8.5% of participants said they had been informed
through specific campaigns. Other sources of information
were the doctor or nurse (35.8%), the pharmacist (25.5%),
family member, friend, and social media (36.78%) or other
unspecified sources (34.9%), and 18.9% of participants could
not remember where they had heard about AMR.
Antibiotic usage
Only 4.5% of participants (5) said that they did not respect
the correct daily dosage when taking a course of antibiotics,
7.3, 2022   Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada
Students’ perceptions on AMR
Strongly disagree
25% 50% 75% 100%
of which three participants said they did it because they no
longer had symptoms (2.7%). However, when asked “Do you
stop using the medication once fever has gone down?,” 12.3%
(13) of participants said always, and 35.8% (38) sometimes,
for a total of 48%, a wide contrast with the 4.5% previously
obtained.
More importantly, 28.3% (30) of students said they had
used antibiotics without a prescription. Of these, 55.2%
(16) were Canadian students. However, it is noteworthy that
even though the number of Canadians was higher than that
of international students, proportionally, the use of antimi-
crobials without a prescription is more frequent among the
latter (16/81, 19.8% among Canadians versus 13/23, 56.5%
among international students).
When asked about the sources of these antimicrobials,
16.7% (5) of the participants said they got them from the
home medicine cabinet, 50% (15) from the pharmacy, 26.7%
(8) from family, neighbours, or friends, and 6.7% (2) from
other (unspecified) sources.
Comparison between groups
To verify if there were differences in KAP among different
student groups, we compared students in terms of their ori-
gin (Canadian versus international students), gender (male
225
H Ferreira Leal, C Mamani, C Quach, E Bédard

Table 1: Socio-demographic characteristics versus female), age (16–24 versus 25–64 years old), field of
study (natural sciences versus other domains), and level of
Characteristics No. (%)
education (undergraduate versus graduate). We selected the
Gender* statements that had proportions of error higher than 5.0%
Male 87 (82.1) (Table 2, p <0.05).
Female 13 (12.3) In general, incorrect responses were more common among
international students, male participants, and younger people.
Non-binary 3 (2.8)
Students in the natural sciences, including the health sciences,
Age, y had more accurate perceptions than students in other fields.
16–18 8 (7.5) However, 34.0% of these students did not find it important to
19–24 62 (58.5) ensure that children’s vaccinations are up-to-date, and 24.4%
25–34 23 (21.7) did not agree that people should wash their hands regularly.
35–44 11 (10.4)
DISCUSSION
45–64 2 (1.9)
Type of residence† AMR is as a problem that transcends the health care sphere
and affects the entire ecosystem (5,7–9). The food chain is
Urban 67 (63.2)
recognized as a transmission route for antimicrobial-resistant
Outskirts 35 (33) bacteria and resistance genes. Participants in the present in-
Rural 3 (2.8) vestigation demonstrated good cooking and eating practices,
University degree ‡ with a correct response rate above 90.0% for all questions.
Preparatory year 4 (3.8) However, it is notable that responses to the statements “After
handling raw food (meat and vegetables), you must wash your
Bachelor’s degree 66 (62.3)
hands” and “You must wash kitchen utensils already used
Master’s degree 15 (14.2) for raw food before preparing other foods” had an error rate
Doctorate 7 (6.6) higher than 5.0% (5.7% and 9.4% respectively).
Other 13 (12.3) Our findings differ from those recently reported by the Food
Field of study § Standards Agency in the UK (20), where only 69.0% of partici-
pants said that it was important to wash hands before preparing
Natural sciences 41 (38.7)
or cooking food. In the same report, only 62.0% of respondents
Humanities and social sciences 45 (42.5) stated that preparing different types of food on different surfaces
Arts and letters 11 (10.4) (chopping boards) could protect against antimicrobial resistance,
Continuing education 7 (6.6) thus demonstrating a reduced understanding of the spread of
Origin ¶ bacteria through the food chain. Although participants in our
Canadian (from Quebec) 77 (72.6)
study showed a high level of knowledge regarding this issue,
they are university students and might have better access to
International 23 (21.7)
information than the general population.
Canadian (outside Quebec) 4 (3.8) Regarding animal-to-human AMR transmission, almost
Notes: The socio-demographic characteristics of the 106 20.0% of respondents did not believe that resistant bacteria
participants included in the study are shown in Table 1 could be exchanged from their pet. These results contrast
* 3 participants did not want to specify their gender with those reported by Alexa et al in 2019 (21) where a
† 1 participant did not want to specify the type of residence questionnaire was administered to 1,252 respondents, mainly
‡ 1 participant did not want to specify their university degree from the European Union, from different age groups and
§ 2 participants did not want to specify their field of study educational and occupational backgrounds. Only 32.5%
¶ 2 participants did not want to specify their origin of respondents considered AMR transmission to humans
through direct contact with pets an important transmission
route. Conversely, the majority stated that giving antibiotics
to healthy animals to prevent illness (89.5%) or stimulate
growth (87.6%) could contribute to AMR. In our investiga-
tion, only 71.7% of participants agreed that “Farmers should
give fewer antibiotics to food-producing animals.”

226 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada   7.3, 2022
 Students’ perceptions on AMR

Table 2: Comparison between different studied groups

KAP Groups, no. (%) OR (95% CI)

Canadian; International;
n = 81 (76.4) n =23 (21.7)
Have you ever taken an antibiotic treatment without a 16 (19.8) 13 (56.5) 0.19 (0.07 to 0.51)
medical prescription? (Yes)
Bacteria that are resistant to antibiotics can be spread from 14 (17.3) 13 (56.5) 6.22 (2.27 to17.0)
person to person (False)
Female; n = 87 Male; n = 13
(82.1) (12.3)
I am worried about the impact that antibiotic resistance will 4 (4.6) 3 (23.1) 6.22 (1.21 to 31.91)
have on my health and that of my family (False)
People should only use antibiotics when prescribed by a 7 (8) 5 (38.5) 7.14 (1.84 to 27.79)
doctor or nurse (Neither agree nor disagree or strongly
disagree)
Age 16–24; Age 25–64;
n = 70 (66) n = 36 (34)
Antibiotic resistance is an issue that could affect me or my 2 (2.8) 5 (13.9) 5.48 (1 to 29.84)
family (False)
Antibiotic resistance is one of the biggest problems the 56 (80) 21 (58.3) 0.35 (0.14 to 0.85)
world faces (Neither agree nor disagree or strongly
disagree)
I am worried about the impact that antibiotic resistance will 44 (62.8) 14 (38.9) 0.38 (0.16 to 0.86)
have on my health and that of my family (False)
Natural sciences; Other fields of study;
n = 41 (38.7) n = 63 (59.4)
Stop using the medication once the fever has gone down 9 (21.9) 29 (46) 3.35 (1.33 to 8.4)
(Sometimes)
The use of antibiotics in livestock and crops can increase 1 (2.4) 11 (17.5) 8.46 (1.05 to 68.29)
the presence of resistant bacteria in the environment
(False)
Antibiotic resistance occurs when your body becomes 20 (48.8) 47 (74.6) 0.32 (0.14 to 0.74)
resistant to antibiotics and they no longer work as well
(True)
Parents should make sure all of their children’s vaccinations 14 (34.1) 10 (15.9) 0.36 (0.14 to 0.93)
are up-to-date (Neither agree or disagree and strongly
disagree)
People should wash their hands regularly (Neither agree 10 (24.4) 4 (6.3) 0.21 (0.06 to 0.72)
nor disagree or strongly disagree)
Antibiotic resistance is one of the biggest problems the 23 (56.1) 53 (84.1) 4.14 (1.66 to 10.35)
world faces (Neither agree nor disagree or strongly
disagree)

(Continued)

7.3, 2022   Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada 227
H Ferreira Leal, C Mamani, C Quach, E Bédard
KAP
People should only use antibiotics when prescribed by a
doctor or nurse (Neither agree nor disagree or strongly
disagree)
Antibiotic resistance is one of the biggest problems the
world faces (Neither agree nor disagree or strongly
disagree)
Notes: In order to identify whether there were differences in terms of KAP among distinct student profiles, participants were stratified
regarding their origin, gender, age, the field of study, and level of education; perceptions for which there was an error rate >5% were
included in the analysis; in Table 2, associations that had a p-value <0.05 are reported
KAP = Knowledge, attitudes, and practices; OR = Odds ratio
The misuse of antimicrobials not only has consequences
for the individuals who take them, but also affects society as
a whole and is a matter of public health (22). For this reason,
it is of outmost importance that the population understands
how antibiotics work and the impact of their misuse.
In our study, most participants demonstrated a good un-
derstanding of the theoretical basis of AMR. However, 63.2%
believed that AMR was a consequence of their body becom-
ing resistant to antibiotics. Similarly, 25.5% of respondents
did not think that AMR bacteria could be transmitted from
person to person. Interestingly, these two misconceptions
are somewhat related. If one thinks that it is the body that
becomes resistant to the antimicrobial and not the bacteria,
it is understandable that person-to-person transmission of
AMR is not thought to happen.
The survey conducted by the WHO in 12 countries, with
9,772 respondents, yielded similar results (19). In their study,
76.0% of respondents believed that AMR occurs when the
body becomes resistant. Furthermore, our results are consis-
tent with those from a study conducted by Shahpawee et al in
2020 at the University of Brunei, using a similar framework.
In their cohort, 79.0% of the student population also shared
this misconception (18).
Vaccines play a significant role in fighting AMR. Vaccination
helps decrease the development and spread of resistance at the
individual and collective levels. Vaccines are a prophylactic
strategy to prevent infections, averting a person from catching
an infection. Therefore, they reduce overall antibiotic utilization.
These effects may be amplified by herd immunity, extending
protection to unvaccinated persons in the population. In this
context, the transmission and circulation of certain types
of bacteria, including resistant strains, are prevented (14).
However, in our setting, 17.0% of participants neither agreed
228 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada   7.3, 2022
Groups, no. (%) OR (95% CI)
Bachelor’s degree; Graduate studies;
n = 70 (66) n = 22 (20.7)
5 (7.1) 7 (31.8) 6.06 (1.69 to 21.77)
57 (81.4) 10 (45.5) 0.19 (0.07 to 0.53)
nor disagreed or strongly disagreed (6.6%) with the statement
“Parents should make sure that their children’s vaccination is
up to date.” This is higher than the percentage found in the
general population by the WHO’s survey, in which only 13.0%
of the participants were uncertain or opposed to the same
statement (19). This is concerning, especially for students
who will have a career in health care.
Also, 13.2% of our respondents did not agree with the
statement “People should wash their hands regularly.” This
finding is even more surprising considering that this study
took place during the second wave of the coronavirus disease
pandemic (COVID-19) in Quebec when numerous aware-
ness campaigns on the importance of hand hygiene were
conducted (23). In the WHO survey, 9.0% of the participants
disagreed with this statement (19).
Hand washing is essential to decrease the risk of trans-
mission of pathogens in general, including those resistant to
antibiotics. This practice is even more crucial in the hospital
setting. The lack of adequate hand hygiene in this environment
increases the risk of health care-associated infections and
the spread of antibiotic-resistant bacteria, which endangers
patients’ lives (11,13).
When stratifying by groups, we can see that students in
the natural sciences, including the health sciences, had bet-
ter perceptions than students in other fields. Nevertheless, it
is concerning that 34% of these students did not think that
parents should make sure all their children’s vaccinations
are up-to-date, and 24.4% did not agree that washing hands
regularly was important for AMR prevention. These findings
are consistent with those from Dyar et al (24), which showed
that 24.0% of European medical students believed poor hand
hygiene was not at all important to control antibiotic-resistant
infections.

Only 27.4% of the students included in the present study
believed that antibiotic resistance is one of the biggest prob-
lems the world faces, while 45.3% were worried about the
impact that antibiotic resistance will have on their health, and
that of their family. This perception might be because this
questionnaire was applied during the COVID-19 pandemic.
Experiencing such a difficult period may alter priorities of
the individuals (when facing a significant health problem,
other issues may seem irrelevant).
Here we also explored levels of awareness of key terms
related to antibiotic resistance and information sources.
In our setting, only 8.5% of participants cited specific
campaigns as an information source. This proportion is
similar to that found in the WHO survey, in which 7.0%
stated that specific campaigns were their information source
(19). Thus, investing in innovative educational strategies
to raise awareness about AMR is necessary. This issue is
particularly relevant in the current times, where the dis-
semination of fake news through social media occurs (25).
Safe and reliable sources are needed to encourage better
practices and perceptions.
In addition, most people heard about terms related to AMR
through traditional media (TV, radio, newspapers). However,
recent data indicate that young adults and teenagers are dis-
engaging from these media outlets and spend much of their
time online with social media and entertainment services
(26). In order to reach this audience, official public health
organizations must explore the potential of other platforms.
One of the most surprising results of this research was
that 28.0% of participants said they had taken antibiotics
without a prescription. Most were Canadian students, which
is unexpected, as selling these drugs in Canada without a
prescription is not allowed (27). This proportion was higher
than those found in the WHO study (19) and by Shahpawee
et al (18), in which only 19% and 12% of respondents stated
that they took antibiotics without a doctor’s or nurse’s pre-
scription, respectively. However, although the percentage of
Canadians was greater than that of international students,
proportionally, antimicrobial use without a prescription is
more common among the latter.
As mentioned, selling antibiotics without a prescription
is not allowed in Canada, and there are strict regulations on
using these drugs. Patients cannot buy a whole blister pack
of antibiotics and are given only the amount needed for
the prescribed medical treatment. These measures prevent
the reuse and exchange of antimicrobials among friends
and family members and the unnecessary disposal of these
drugs into the environment. Even though over-the-counter
acquisition of antimicrobials is extremely well controlled, it
is possible to obtain antibiotics from other sources. Previous
7.3, 2022   Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada
Students’ perceptions on AMR
studies point to online purchasing as a potential unregulated
source of antibiotics (28,29).
Mainous et al carried out a web-based cross-sectional
study using two major search engines (Google and Yahoo)
to identify vendor websites selling antibiotics in the United
States. At the time, they found 138 unique vendors selling
antibiotics without a prescription (28).
More recently, in 2020, Zhang et al used a similar frame-
work to investigate the availability of over-the-counter animal
antibiotics and the intent for personal use (29). They found
24 websites selling antibiotics that require no prescription.
According to the reviews on these sites, 2.4% of consumers
bought antibiotics for self-medication purposes, demon-
strating the potential of the Internet as an illegal source for
obtaining antimicrobials.
In our study, 16.7% of participants reported obtaining
antibiotics from the home medicine cabinet and 26.7% from
a family member or friend. In both cases, the results indicate
reuse and exchange of antimicrobials between individuals.
Since the exact amount of antibiotics required to fulfill the
prescription is given to treat an infection, this suggests that
duration or dosage were not respected in previous antibiotic
therapies, allowing to store antibiotics for future use.
Also, 48.0% of participants stated that they always or
sometimes stop using antibiotics once symptoms disappear
(fever). This proportion is far more than the 4.5% who did
not respect the correct daily dosage, highlighting a discon-
nect between the respect of the dosage when symptoms are
present and stopping the medication because symptoms
have disappeared.
STRENGTHS AND LIMITATIONS
The present study has the major advantage of being prospec-
tive and using a standardized questionnaire designed by
the WHO (19). This instrument covered essential aspects,
namely antibiotic usage, general knowledge of AMR, and
lifestyle practices. Furthermore, our survey was anonymous
and voluntary, encouraging the respondents to give authentic
answers rather than socially desirable ones. However, this
investigation also has several limitations that should be ac-
knowledged. First, we used a convenience sample. Thus, the
results observed here cannot be extrapolated to the general
population or even to students at other universities. In addi-
tion, the small sample size results in a lack of statistical power.
Furthermore, we used self-reported data. Therefore, the study
is susceptible to information and recall bias. Moreover, most
of the respondents were female. We hypothesize that this may
have been due to how the survey was distributed (in groups
from the Université de Montréal on social networking sites).
Thus, the questionnaire may not have reached both genders
229
H Ferreira Leal, C Mamani, C Quach, E Bédard
in equal proportion. Also, female students may have been
more receptive to participating in the study, as previously
reported (30). Some studies show that women generally show
greater concern about their health status, which may lead to
increased knowledge about AMR, infection prevention, and
hygiene measures (31–33). This issue may have influenced our
results to some extent. Finally, there are limitations inherent
to the cross-sectional design that prevents the exploration of
causality and confounding factors.
CONCLUSION AND PERSPECTIVES
In summary, this investigation indicates a possible misuse
of over-the-counter antimicrobials in Canada. There is a
need for a better understanding of why antibiotics are used
without a prescription in this country where regulations
are, theoretically, strict. Also, we show the need to increase
awareness so people can better understand the theoretical
basis of AMR, especially the importance of taking the entire
course of treatment. In addition, specific campaigns seem to
have little impact, and a better way to target the population
should be explored.
ACKNOWLEDGEMENTS: The authors would like to thank
the students that took part in this study for their time and
effort. H Ferreira Leal is supported through a Merit Scholar-
ship Program for foreign students (PBEEE) from the Fonds
de recherche du Québec. C Quach is a chairholder for the
Canada Research Chair Program. E Bédard holds a NSERC
Discovery grant.
CONTRIBUTORS: Conceptualization, H Ferreira Leal,
C Mamani, C Quach, E Bédard; Investigation, H Ferreira
Leal, C Mamani; Data Analysis, H Ferreira Leal; Writing –
Original Draft, H Ferreira Leal, C Mamani; Writing – Review
& Editing, C Quach, E Bédard; Project Administration and
Supervision, E Bédard. All authors have read and approved
the final manuscript.
ETHICS APPROVAL: All procedures performed in this
study met institutional ethical standards and were approved
by the Comité d’éthique de la recherche en sciences et en santé
from the Université de Montréal (no20211261).
INFORMED CONSENT: N/A
REGISTRY AND THE REGISTRATION NO. OF THE
STUDY/TRIAL: N/A
230 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada   7.3, 2022
DATA ACCESSIBILITY: All data will not be made publicly
available. Researchers who require access to the study data
can contact the corresponding author for further information.
FUNDING: No funding was received for this work.
DISCLOSURES: H Ferreira Leal is supported through a Merit
Scholarship Program for foreign students (PBEEE) from the
Fonds de recherche du Québec. E Bédard holds a NSERC
Discovery Grant. The other authors have nothing to disclose.
PEER REVIEW: This manuscript has been peer reviewed.
ANIMAL STUDIES: N/A
REFERENCES
1. Ferri M, Ranucci E, Romagnoli P, Giaccone V. An-
timicrobial resistance: A global emerging threat
to public health systems. Crit Rev Food Sci Nutr.
2017;57(13):2857–76. https://doi.org/10.1080/
10408398.2015.1077192. Medline:26464037
2. Cars O, Chandy SJ, Mpundu M, Peralta AQ, Zorzet A,
So AD. Resetting the agenda for antibiotic resistance
through a health systems perspective. Lancet Glob
Health. 2021;9(7):e1022–7. https://doi.org/10.1016/
S2214-109X(21)00163-7.
3. Shrestha P, Cooper BS, Coast J, et al. Enumerating the
economic cost of antimicrobial resistance per antibi-
otic consumed to inform the evaluation of interven-
tions affecting their use. Antimicrob Resist Infect
Control. 2018;7(1):98. https://doi.org/10.1186/s13756-
018-0384-3. Medline:30116525
4. Davies J, Davies D. Origins and evolution of antibiotic
resistance. Microbiol Mol Biol Rev. 2010;74(3):417–
43. https://doi.org/10.1128/MMBR.00016-10.
Medline:20805405
5. Chatterjee A, Modarai M, Naylor NR, et al. Quantifying
drivers of antibiotic resistance in humans: A systematic
review. Lancet Infect Dis. 2018;18(12):e368–78. https://
doi.org/10.1016/S1473-3099(18)30296-2.
6. World Health Organization. Global priority list of an-
tibiotic-resistant bacteria to guide research, discovery,
and development of new antibiotics. 2017.
7. Rousham EK, Unicomb L, Islam, MA. Human, ani-
mal and environmental contributors to antibiotic
resistance in low-resource settings: Integrating behav-
ioural, epidemiological and One Health approaches.

Proc Biol Sci. 2018;285(1876):20180332. https://doi.
org/10.1098/rspb.2018.0332. Medline:29643217
8. World Health Organization. WHO, FAO, and OIE
unite in the fight against antimicrobial resistance.
2017.
9. London: Department of Health. Antimicrobial resistance
(AMR) systems map: Overview of the factors influencing
the development of AMR and the interactions between
them. 2014. Available from: https://assets.publishing.
service.gov.uk/government/uploads/system/uploads/­
attachment_data/file/387746/Microbial_Maps.pdf.
10. Aarestrup FM. The livestock reservoir for antimi-
crobial resistance: A personal view on changing
patterns of risks, effects of interventions and the
way forward. Philos Trans R Soc Lond B Biol Sci.
2015;370(1670):20140085. https://doi.org/10.1098/
rstb.2014.0085. Medline:25918442
11. Centers for disease control and prevention. Food Safety—
Antibiotic resistance, Food and Food Animals. 2021.
Available from: https://www.cdc.gov/foodsafety/chal-
lenges/antibiotic-resistance.html. (Accessed December
14, 2021).
12. Smith M, King C, Davis M, et al. Pet owner and vet
interactions: Exploring the drivers of AMR. Anti-
microb Resist Infect Control. 2018;7:46. https://doi.
org/10.1186/s13756-018-0341-1. Medline:29619213
13. World Health Organization. Global action plan on
antimicrobial resistance. 2015. Available from: https://
ahpsr.who.int/publications/i/item/global-action-plan-
on-antimicrobial-resistance. (Accessed December 14,
2021).
14. Jansen KU, Anderson AS. The role of vaccines in fight-
ing antimicrobial resistance (AMR). Hum Vaccin Im-
munother. 2018;14(9):2142–9. https://doi.org/10.1080/
21645515.2018.1476814. Medline:29787323
15. Public Health Agency of Canada Evaluation of the Co-
ordination of Antimicrobial Resistance (AMR) Activi-
ties. 2019.
16. Public Health Agency of Canada Federal Action Plan
on Antimicrobial Resistance and Use in Canada. 2015.
17. Santoli N. Survey reveals Canadians largely unaware of
threat of antimicrobial resistance. 2018: Mississauga,
Ontario.
18. Shahpawee NS, Chaw LL, Muharram SH, Goh HP,
Hussain Z, Ming LC. University students’ antibiotic use
and knowledge of antimicrobial resistance: What are
the common myths? Antibiotics (Basel). 2020;9(6):349.
https://doi.org/10.3390/antibiotics9060349.
Medline:32575716
7.3, 2022   Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada
Students’ perceptions on AMR
19. World Health Organization. Antibiotic resistance:
Multi-country public awareness survey. 2015.
20. Gillespie R, King M. AMR Consumer Awareness Sur-
vey. 2021, Food Standards Agency.
21. Oniciuc EAA, Likotrafiti E, Garre A, Ruiz L, Prieto M,
Alvarez-Ordóñez A. A European questionnaire-based
study on population awareness and risk perception
of antimicrobial resistance. FEMS Microbiol Lett.
2019;366(17):fnz221. https://doi.org/10.1093/femsle/
fnz221. Medline:31688910
22. Blaser MJ. Antibiotic use and its consequences for the
normal microbiome. Science. 2016;352(6285):544–
5. https://doi.org/10.1126/science.aad9358.
Medline:27126037
23. Gouvernement du Québec. Coronavirus disease (CO-
VID-19) in Québec. Available from: https://www.que-
bec.ca/en/health/health-issues/a-z/2019-coronavirus.
(Accessed December 14, 2021).
24. Dyar OJ, Pulcini C, Howard P, Nathwani D. European
medical students: A first multicentre study of knowl-
edge, attitudes and perceptions of antibiotic prescrib-
ing and antibiotic resistance. J Antimicrob Chemother.
2014;69(3):842–6. https://doi.org/10.1093/jac/dkt440.
Medline:24191307
25. Orso D, Federici N, Copetti R, Vetrugno L, Bove T.
Infodemic and the spread of fake news in the CO-
VID-19-era. Eur J Emerg Med. 2020;27(5):327–8.
https://doi.org/10.1097/MEJ.0000000000000713.
Medline:32332201
26. Galan L, Osserman J, Parker T, Taylor M. How young
people consume news and the implications for main-
stream media, O. University, Editor. 2019, Report com-
missioned by the Reuters Institute, authored by Flamingo.
27. Government of Canada. Guidance document: Deter-
mining prescription status for human and veterinary
drugs. 2013. Available from: https://www.canada.ca/
en/health-canada/services/drugs-health-products/
drug-products/prescription-drug-list/guidance-­
document.html. (Accessed December 14, 2021).
28. Mainous AG, Everett CJ, Post RE, Diaz VA, Hueston
WJ. Availability of antibiotics for purchase with-
out a prescription on the internet. Ann Fam Med.
2009;7(5):431–5. https://doi.org/10.1370/afm.999.
Medline:19752471
29. Zhang W, Williams A, Griffith N, Gaskins J, Book-
staver PB. Online availability of fish antibiotics and
documented intent for self-medication. PLoS One.
2020;15(9):e0238538. https://doi.org/10.1371/­journal.
pone.0238538. Medline:32881969
231
H Ferreira Leal, C Mamani, C Quach, E Bédard
30. Smith, G. Does gender influence online survey partici-
pation? A record-linkage analysis of university faculty
online survey response behavior. ERIC document
reproduction service no. ED 501717. 2008, San José
State University. p. 21.
31. Perelman J, Fernandes AA, Mateus C. Gender dis-
parities in health and healthcare: Results from
the Portuguese National Health Interview Survey.
Cad Saude Publica. 2012;28(12):2339–48. https://
doi.org/10.1590/S0102-311X2012001400012.
Medline:23288066
232 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada   7.3, 2022
32. Suen LKP., So, ZYY, Yeung SKW, Lo KYK, Lam SC.
Epidemiological investigation on hand hygiene knowl-
edge and behaviour: A cross-sectional study on gender
disparity. BMC Public Health. 2019;19(1):401. https://
doi.org/10.1186/s12889-019-6705-5. Medline:30975130
33. Galasso V, Pons V, Profeta P, Becher M, Br-
ouard S, Foucault M. Gender differences in CO-
VID-19 attitudes and behavior: Panel evidence
from eight countries. Proc Natl Acad Sci U S A.
2020;117(44):27285-91. https://doi.org/10.1073/
pnas.2012520117. Medline:33060298