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Jammi 2022 0008
Jammi 2022 0008
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
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: [email protected]
Antimicrobials are critical in treating infections and have contact with animals, unsafe water supplies, and travelling
contributed to the increase in the average life expectancy and contact with family members can constitute routes for
observed over the last decades (1). However, these advances human exposure to AMR (5,9,10).
are currently threatened by the emergence of antimicrobial- One of the ways by which resistant bacteria can disseminate
resistant bacteria (2,3). Antimicrobial resistance (AMR) is through the community is via the food chain. In this context,
a phenomenon that evolves through natural selection, but it is highly recommended that when handling food, people
anthropogenic activities can accelerate its evolution (4). The adopt food safety and hygiene practices, a few of which are
misuse and overuse of antibiotics contribute to the rapid spread washing hands before and after touching raw food; and washing
of resistant microorganisms worldwide (5). Most importantly, utensils during and after cooking (11). Another way by which
resistant infections are associated with low treatment success humans can acquire resistant bacteria is through interaction
rates, excess morbidity, premature mortality, and increased with their pets (12). Thus, it is advisable to follow some safety
economic costs to society (3,6). To avoid the emergence of measures (eg, handwashing) after interacting with pets and
AMR, we need to understand its theoretical basis, how it handling their food, excrements, and belongings.
emerges and spreads, and its impact on public health. Water, sanitation, and hygiene (WASH) measures, anti-
AMR can be intrinsic (peculiarities of the bacterial mor- microbial stewardship, investments in the discovery of new
phology and metabolism) or acquired. The development of antibiotics, and educational campaigns are all critical tools
resistance occurs randomly, through mutations in the bacte- when fighting AMR (11,13). On the other hand, little is said
rial genome that allow them to survive against substances about the potential of vaccination. Vaccines that prevent
that were previously able to kill or inhibit their growth. The bacterial diseases, such as Haemophilus influenzae type B
selective pressure generated by the overuse of antimicrobi- (Hib) and Streptococcus pneumoniae conjugate vaccines, not
als can accelerate the development of these mutations (4). only lower antibiotic use, consequently reducing AMR, but
In addition to genomic mutations, which are transferred also prevent invasive infections caused by pneumococcal
vertically between bacterial cells, those microorganisms can serotypes that are usually antimicrobial resistant (14).
horizontally acquire mobile genetic elements such as plasmids, In this context, to prevent the dissemination of AMR, it
transposons, and integrons, which encode resistance genes. is necessary to address this problem not only in hospitals,
These genetic exchanges play a significant role in AMR’s but also in the community (5,7). The general population
transmission (4,5). can contribute by improving their knowledge, attitudes, and
Hospitals have been recognized as environments where practices (KAP) toward AMR. Measures can be taken at an
resistant bacteria emerge and multiply (2,7). Nevertheless, individual level (11), a few of which are:
resistant bacteria are also found in other settings. Most an- 1. Having appropriate hygiene practices when eating and
timicrobial use happens outside health care institutions—in cooking to limit cross-contamination
the population, livestock farming, or crops—affecting com- 2. Avoiding the misuse of antimicrobials in pet welfare
munity-dwelling individuals, animals, and their environment. 3. Avoiding self-medication and limiting antibiotic use to
As a result, antibiotic resistance is now widely recognized diagnosed bacterial infections
as a One Health problem, simultaneously endangering the 4. Following the medical prescription precisely, not saving
interconnected human-animal-environmental health (8,9). antibiotics for later, or sharing with someone else
In community settings, previous health care contact and 5. Following recommended immunization schedules
antibiotic exposure are widely described as risk factors for
resistance (5). However, behavioural factors might also cause Accordingly, the World Health Organization (WHO) has
the spread of resistant organisms throughout a community. For emphasized the importance of raising awareness of health
instance, eating and hygiene habits, domestic or occupational 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 the appropriate measures to tackle this health problem. We
Agency of Canada (PHAC) leads the international and domestic also asked participants about lifestyle behaviours that could
response on AMR (15). The federal action plan recommends foster AMR, including eating and hygiene habits, animal
activities to educate Canadian families, encouraging practices contact, and antibiotic usage practices. All questions are
that prevent the spread of resistant infections and germs, such presented in the results section, in Figures 1 to 5.
as handwashing. The plan also teaches about the theoretical The data were managed and analyzed using Epi Info version
basis of resistance, explaining to the public why antibiotics are 3.5.1 (CDC, Atlanta, GA, USA), and graphics were made using
not always necessary, particularly in the case of viral infections. Microsoft Excel 2010. The Fisher’s exact and chi-square tests
Furthermore, prescribers receive instructions to better explain were used to compare proportions for dichotomous variables.
appropriate antimicrobial use to their patients (16). Odds ratio (OR) and 95% CIs were calculated as measures
While raising awareness of AMR is a priority in Canada, of association. Statistical significance was defined as p <0.05.
recent local data shows that many are unfamiliar with or
unconcerned about the threat of drug resistance (17). AMR RESULTS
ranked among their lowest concerns about personal overall
health and well-being, and 44% believed AMR was more of General characteristics of the study population
a problem in developing countries (17).
In this context, studies aiming to assess people’s knowledge A total of 106 students were enrolled in this investigation.
and perceptions about AMR are essential to verify the impact Most of them were female (87, 82.1%), Canadians (77, 72.6%),
of awareness-raising campaigns. Hence, the main goal of this aged between 19 and 24 years old (62, 58.5%), undergraduate
investigation was to evaluate the level of knowledge and be- students (66, 62.3%), living in urban areas (67, 63.2%), and
haviours related to AMR by zooming on a subset of students studying humanities and social sciences (45, 42.5%). The
from the Université de Montréal. To our knowledge, this is characteristics of participants are shown in Table 1.
the first survey aiming to verify AMR-related perceptions
Lifestyle habits, practices, and levels of knowledge
of students in a higher education environment in Canada.
In general, university students have a good level of knowl- Most respondents exhibited good eating and hygiene habits
edge; therefore, they do not reflect the perceptions of the entire (Figure 1), as well as good understanding of AMR’s transmis-
population (18). However, they will soon become professionals sion between humans and animals (Figure 2). The proportion
in key management and leadership positions and might play of incorrect responses ranged from 0.9% to 19.8%. The state-
a crucial role in fighting AMR. Especially students in the field ment for which the percentage of erroneous answers was the
of natural sciences, as they might become future health care highest was “I can exchange resistant bacteria with my pet,”
providers. Thus, knowing if their perceptions and practices on as 19.8% of participants indicated this statement was false
antibiotic usage are accurate is of great importance to adjust when it is true. In general, students were aware that AMR
our sensibilization strategy to ensure that future generations has an impact outside the hospital (Figure 2).
will still benefit from these lifesaving drugs. 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
METHODS becomes resistant to antibiotics and they no longer work”
We carried out an observational, cross-sectional, prospective, was true, even though it is false. Similarly, for the statement
and descriptive study. The survey was available on the Google “Bacteria that are resistant to antibiotics can be passed from
Forms platform from November 30, 2020 to December 11, person to person,” 25.5% of participants answered false, an
2020. The population was composed of students from the incorrect response.
Université de Montréal without age, gender, or study pro- Concerning the awareness and understanding of how
gram restrictions. to fight AMR (Figure 4), only 76.3% of students thought it
Data was collected using a questionnaire adapted from the was important to ensure that children’s vaccinations were
WHO survey (19) entitled ‘Antibiotic resistance: Multi-country up-to-date. Although most students (86.8%) agreed with the
public awareness survey.’ The questionnaire comprised 42 statement “People should wash their hands regularly,” 13.2%
questions, and participants were asked to self-complete the of them mentioned that they neither agreed nor disagreed
survey. All questions were written in French, and participa- or strongly disagreed with this statement.
tion was voluntary and anonymous. In addition, most participants (52.9%) said they neither
The questions were designed to assess the students’ knowl- agree nor disagree or strongly disagreed with the statement
edge of AMR and its theoretical basis and perceptions about “Governments should subsidize the development of new
222 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada 7.3, 2022
Students’ perceptions on AMR
True False
True False
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
224 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada 7.3, 2022
Students’ perceptions on AMR
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 of which three participants said they did it because they no
nor disagreed or strongly disagreed with the statement longer had symptoms (2.7%). However, when asked “Do you
“Pharmaceutical companies should develop new antibiotics.” stop using the medication once fever has gone down?,” 12.3%
Pertaining to participants’ views on the magnitude of (13) of participants said always, and 35.8% (38) sometimes,
AMR and the impact it would have on them (Figure 5), only for a total of 48%, a wide contrast with the 4.5% previously
27.4% of participants agreed with the statement, “Antibiotic obtained.
resistance is one of the world’s biggest problems.” More importantly, 28.3% (30) of students said they had
When asked about keywords related to AMR, participants used antibiotics without a prescription. Of these, 55.2%
said they had heard the terms antibiotic resistance (82.1%), (16) were Canadian students. However, it is noteworthy that
superbugs (21.7%), antimicrobial resistance (27.4%), drug- even though the number of Canadians was higher than that
resistance (76.4%), and antibiotic-resistant bacteria (82.1%). of international students, proportionally, the use of antimi-
When asked about their sources of information most partici- crobials without a prescription is more frequent among the
pants (52.8%) said they had heard about this phenomenon latter (16/81, 19.8% among Canadians versus 13/23, 56.5%
through traditional media such as newspapers, television, or among international students).
radio. Only 8.5% of participants said they had been informed When asked about the sources of these antimicrobials,
through specific campaigns. Other sources of information 16.7% (5) of the participants said they got them from the
were the doctor or nurse (35.8%), the pharmacist (25.5%), home medicine cabinet, 50% (15) from the pharmacy, 26.7%
family member, friend, and social media (36.78%) or other (8) from family, neighbours, or friends, and 6.7% (2) from
unspecified sources (34.9%), and 18.9% of participants could other (unspecified) sources.
not remember where they had heard about AMR.
Comparison between groups
Antibiotic usage To verify if there were differences in KAP among different
Only 4.5% of participants (5) said that they did not respect student groups, we compared students in terms of their ori-
the correct daily dosage when taking a course of antibiotics, gin (Canadian versus international students), gender (male
7.3, 2022 Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada 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
(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
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 nor disagreed or strongly disagreed (6.6%) with the statement
for the individuals who take them, but also affects society as “Parents should make sure that their children’s vaccination is
a whole and is a matter of public health (22). For this reason, up to date.” This is higher than the percentage found in the
it is of outmost importance that the population understands general population by the WHO’s survey, in which only 13.0%
how antibiotics work and the impact of their misuse. of the participants were uncertain or opposed to the same
In our study, most participants demonstrated a good un- statement (19). This is concerning, especially for students
derstanding of the theoretical basis of AMR. However, 63.2% who will have a career in health care.
believed that AMR was a consequence of their body becom- Also, 13.2% of our respondents did not agree with the
ing resistant to antibiotics. Similarly, 25.5% of respondents statement “People should wash their hands regularly.” This
did not think that AMR bacteria could be transmitted from finding is even more surprising considering that this study
person to person. Interestingly, these two misconceptions took place during the second wave of the coronavirus disease
are somewhat related. If one thinks that it is the body that pandemic (COVID-19) in Quebec when numerous aware-
becomes resistant to the antimicrobial and not the bacteria, ness campaigns on the importance of hand hygiene were
it is understandable that person-to-person transmission of conducted (23). In the WHO survey, 9.0% of the participants
AMR is not thought to happen. disagreed with this statement (19).
The survey conducted by the WHO in 12 countries, with Hand washing is essential to decrease the risk of trans-
9,772 respondents, yielded similar results (19). In their study, mission of pathogens in general, including those resistant to
76.0% of respondents believed that AMR occurs when the antibiotics. This practice is even more crucial in the hospital
body becomes resistant. Furthermore, our results are consis- setting. The lack of adequate hand hygiene in this environment
tent with those from a study conducted by Shahpawee et al in increases the risk of health care-associated infections and
2020 at the University of Brunei, using a similar framework. the spread of antibiotic-resistant bacteria, which endangers
In their cohort, 79.0% of the student population also shared patients’ lives (11,13).
this misconception (18). When stratifying by groups, we can see that students in
Vaccines play a significant role in fighting AMR. Vaccination the natural sciences, including the health sciences, had bet-
helps decrease the development and spread of resistance at the ter perceptions than students in other fields. Nevertheless, it
individual and collective levels. Vaccines are a prophylactic is concerning that 34% of these students did not think that
strategy to prevent infections, averting a person from catching parents should make sure all their children’s vaccinations
an infection. Therefore, they reduce overall antibiotic utilization. are up-to-date, and 24.4% did not agree that washing hands
These effects may be amplified by herd immunity, extending regularly was important for AMR prevention. These findings
protection to unvaccinated persons in the population. In this are consistent with those from Dyar et al (24), which showed
context, the transmission and circulation of certain types that 24.0% of European medical students believed poor hand
of bacteria, including resistant strains, are prevented (14). hygiene was not at all important to control antibiotic-resistant
However, in our setting, 17.0% of participants neither agreed infections.
228 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada 7.3, 2022
Students’ perceptions on AMR
Only 27.4% of the students included in the present study studies point to online purchasing as a potential unregulated
believed that antibiotic resistance is one of the biggest prob- source of antibiotics (28,29).
lems the world faces, while 45.3% were worried about the Mainous et al carried out a web-based cross-sectional
impact that antibiotic resistance will have on their health, and study using two major search engines (Google and Yahoo)
that of their family. This perception might be because this to identify vendor websites selling antibiotics in the United
questionnaire was applied during the COVID-19 pandemic. States. At the time, they found 138 unique vendors selling
Experiencing such a difficult period may alter priorities of antibiotics without a prescription (28).
the individuals (when facing a significant health problem, More recently, in 2020, Zhang et al used a similar frame-
other issues may seem irrelevant). work to investigate the availability of over-the-counter animal
Here we also explored levels of awareness of key terms antibiotics and the intent for personal use (29). They found
related to antibiotic resistance and information sources. 24 websites selling antibiotics that require no prescription.
In our setting, only 8.5% of participants cited specific According to the reviews on these sites, 2.4% of consumers
campaigns as an information source. This proportion is bought antibiotics for self-medication purposes, demon-
similar to that found in the WHO survey, in which 7.0% strating the potential of the Internet as an illegal source for
stated that specific campaigns were their information source obtaining antimicrobials.
(19). Thus, investing in innovative educational strategies In our study, 16.7% of participants reported obtaining
to raise awareness about AMR is necessary. This issue is antibiotics from the home medicine cabinet and 26.7% from
particularly relevant in the current times, where the dis- a family member or friend. In both cases, the results indicate
semination of fake news through social media occurs (25). reuse and exchange of antimicrobials between individuals.
Safe and reliable sources are needed to encourage better Since the exact amount of antibiotics required to fulfill the
practices and perceptions. prescription is given to treat an infection, this suggests that
In addition, most people heard about terms related to AMR duration or dosage were not respected in previous antibiotic
through traditional media (TV, radio, newspapers). However, therapies, allowing to store antibiotics for future use.
recent data indicate that young adults and teenagers are dis- Also, 48.0% of participants stated that they always or
engaging from these media outlets and spend much of their sometimes stop using antibiotics once symptoms disappear
time online with social media and entertainment services (fever). This proportion is far more than the 4.5% who did
(26). In order to reach this audience, official public health not respect the correct daily dosage, highlighting a discon-
organizations must explore the potential of other platforms. nect between the respect of the dosage when symptoms are
One of the most surprising results of this research was present and stopping the medication because symptoms
that 28.0% of participants said they had taken antibiotics have disappeared.
without a prescription. Most were Canadian students, which
is unexpected, as selling these drugs in Canada without a STRENGTHS AND LIMITATIONS
prescription is not allowed (27). This proportion was higher The present study has the major advantage of being prospec-
than those found in the WHO study (19) and by Shahpawee tive and using a standardized questionnaire designed by
et al (18), in which only 19% and 12% of respondents stated the WHO (19). This instrument covered essential aspects,
that they took antibiotics without a doctor’s or nurse’s pre- namely antibiotic usage, general knowledge of AMR, and
scription, respectively. However, although the percentage of lifestyle practices. Furthermore, our survey was anonymous
Canadians was greater than that of international students, and voluntary, encouraging the respondents to give authentic
proportionally, antimicrobial use without a prescription is answers rather than socially desirable ones. However, this
more common among the latter. investigation also has several limitations that should be ac-
As mentioned, selling antibiotics without a prescription knowledged. First, we used a convenience sample. Thus, the
is not allowed in Canada, and there are strict regulations on results observed here cannot be extrapolated to the general
using these drugs. Patients cannot buy a whole blister pack population or even to students at other universities. In addi-
of antibiotics and are given only the amount needed for tion, the small sample size results in a lack of statistical power.
the prescribed medical treatment. These measures prevent Furthermore, we used self-reported data. Therefore, the study
the reuse and exchange of antimicrobials among friends is susceptible to information and recall bias. Moreover, most
and family members and the unnecessary disposal of these of the respondents were female. We hypothesize that this may
drugs into the environment. Even though over-the-counter have been due to how the survey was distributed (in groups
acquisition of antimicrobials is extremely well controlled, it from the Université de Montréal on social networking sites).
is possible to obtain antibiotics from other sources. Previous Thus, the questionnaire may not have reached both genders
7.3, 2022 Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada 229
H Ferreira Leal, C Mamani, C Quach, E Bédard
in equal proportion. Also, female students may have been DATA ACCESSIBILITY: All data will not be made publicly
more receptive to participating in the study, as previously available. Researchers who require access to the study data
reported (30). Some studies show that women generally show can contact the corresponding author for further information.
greater concern about their health status, which may lead to
increased knowledge about AMR, infection prevention, and FUNDING: No funding was received for this work.
hygiene measures (31–33). This issue may have influenced our
results to some extent. Finally, there are limitations inherent DISCLOSURES: H Ferreira Leal is supported through a Merit
to the cross-sectional design that prevents the exploration of Scholarship Program for foreign students (PBEEE) from the
causality and confounding factors. Fonds de recherche du Québec. E Bédard holds a NSERC
Discovery Grant. The other authors have nothing to disclose.
CONCLUSION AND PERSPECTIVES
In summary, this investigation indicates a possible misuse PEER REVIEW: This manuscript has been peer reviewed.
of over-the-counter antimicrobials in Canada. There is a
need for a better understanding of why antibiotics are used ANIMAL STUDIES: N/A
without a prescription in this country where regulations
are, theoretically, strict. Also, we show the need to increase
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