Antibiotic resistance poses a significant global health challenge, threatening the efficacy of our most potent medications against bacterial infections. Understanding these dynamics is crucial for developing strategies to combat this growing threat and preserve the effectiveness of antibiotics for future generations. By exploring the factors contributing to resistance, this research seeks to contribute to the broader effort of mitigating the impact of antibiotic resistance on public health.[1] Antibiotics are cornerstone medications in modern healthcare, pivotal for treating bacterial infections and saving countless lives. However, the emergence of antibiotic resistance due to misuse and overuse threatens their effectiveness. Understanding the knowledge, attitudes, and practices (KAP) regarding antibiotics among different populations is crucial for designing effective interventions to promote their prudent use. This project aims to assess the KAP related to antibiotics among urban and rural population in Wayanad. By evaluating awareness levels, beliefs, and behaviours surrounding antibiotics, the study seeks to identify gaps and misconceptions that contribute to inappropriate antibiotic use. Moreover, it aims to explore the factors influencing these KAPs, such as educational background, cultural beliefs, and healthcare access Ultimately, this research strives to inform strategies that enhance antibiotic stewardship, thereby preserving the efficacy of antibiotics for current and future generations. By bridging the gap between knowledge, attitudes, and practices, we can work towards a sustainable approach to combating antibiotic resistance and safeguarding public health. The term antibiotic was coined from the word antibiosis which literally means against life. In the past, antibiotics were considered to be organic compounds produced by one microorganism which are toxic to other microorganisms. As a result of this notion, an antibiotic was originally ,broadly defined as a substance, produced by one microorganism or of biological origin which at low concentrations can inhibit the growth of ,or are lethal to other microorganisms. However, this definition has been modified in modern times ,to include antimicrobials that are also produced partly or wholly through synthetic means. Antibiotics are drugs that kill bacteria and stop them from spreading in our bodies. When antibiotics no longer work to kill bacteria, this is called antibiotic or antimicrobial resistance. This means that infections caused by certain types of bacteria can become difficult or impossible to treat with the antibiotics we have now. When antibiotics no longer work to kill bacteria, this is called antibiotic or antimicrobial resistance. This means that infections caused by certain types of bacteria can become difficult or impossible to treat with the antibiotics we have now .For example, there is growing evidence that urinary tract infections are becoming increasingly resistant to the antibiotics that, for generations, easily and quickly cured them. Some types of tuberculosis have become resistant to antibiotics and are becoming deadlier, just like they were before antibiotics were discovered.[2] The inappropriate utilization of antibiotics and inadequate knowledge plays a major role in the development of resistance. The discovery of antibiotics is often credited to Alexander Fleming in 1928 when he observed that a mold called Penicillium notatum inhibited the growth of bacteria. This serendipitous observation led to the development of penicillin, the first widely used antibiotic. There are several classes of antibiotics, each with its own mechanism of action and spectrum of activity against bacteria. Common classes include penicillins, cephalosporins, macrolides, tetracyclines, fluoroquinolones, and sulfonamides. Each class targets specific types of bacteria or inhibits particular bacterial functions. Antibiotics work in various ways to combat bacterial infections. Some target the bacterial cell wall, disrupting its integrity and leading to bacterial death. Others interfere with protein synthesis, DNA replication, or other essential bacterial processes, ultimately halting bacterial growth. One of the fundamental principles of antibiotics is selective toxicity, which means they can kill or inhibit bacteria while causing minimal harm to human cells. This selectivity is achieved by targeting structures or processes unique to bacteria, minimizing side effects on the host. Antibiotics should be used judiciously and only when necessary, as overuse or misuse can lead to the development of antibiotic-resistant bacteria. Antibiotic resistance occurs when bacteria evolve mechanisms to survive exposure to antibiotics, rendering the medications ineffective. To combat resistance, it's essential to use antibiotics only when prescribed by a healthcare professional and to complete the full course of treatment as directed. While antibiotics are generally safe when used appropriately, they can cause side effects in some individuals.[3] Common side effects may include diarrhea, nausea, vomiting, allergic reactions, and in rare cases, severe adverse effects such as antibiotic-associated colitis or anaphylaxis. Ongoing research is focused on developing new antibiotics, improving existing ones, and exploring alternative strategies to combat bacterial infections. This includes researching novel targets for antibacterial agents, investigating combination therapies, and exploring the use of bacteriophages (viruses that infect bacteria) and immunotherapies. Ongoing research is focused on developing new antibiotics, improving existing ones, and exploring alternative strategies to combat bacterial infections. Overuse and misuse of antibiotics have led to the emergence of antibiotic- resistant bacteria, posing a significant public health threat. Antibiotic resistance occurs when bacteria evolve mechanisms to survive exposure to antibiotics, rendering the medications ineffective. Therefore, it's crucial to use antibiotics judiciously and complete the full course of treatment as prescribed by a healthcare professional. While antibiotics are generally safe and well-tolerated, they can cause side effects in some individuals. Common side effects may include diarrhea, nausea, vomiting, allergic reactions, and in rare cases, severe adverse effects such as antibiotic-associated colitis or anaphylaxis. Antibiotics are currently the most commonly prescribed drugs in hospitals,world wide.The Centers for Disease Control and Prevention (CDC) estimates that more than 100 million antibiotic prescriptions are written each year in the ambulatory care setting.Antibiotics have been used effectively for the treatment of many diseases,which is why they were called miracle drugs.Unfortunately,widespread use and misuse worldwide have led to the emergence of super bugs and other drug-resistance bacteria.Microbial infections are most common types of infection which usually requires the use of antibiotics for treatment.Natural substances with selective antibacterial activity produced from microorganisms are the traditional definition given for antibiotics. Antibiotics represent a pivotal achievement in medicine, revolutionizing the treatment of bacterial infections and significantly reducing mortality rates worldwide. However, their efficacy is increasingly threatened by the rise of antibiotic resistance, primarily driven by the inappropriate use and misuse of these drugs. Understanding the Knowledge, Attitude, and Practice (KAP) regarding antibiotics among diverse populations is essential for combating this global health challenge effectively. Knowledge about antibiotics encompasses understanding their proper use, indications, side effects, and the consequences of misuse. It includes awareness of antibiotic resistance and its implications for public health. Attitudes towards antibiotics involve beliefs, perceptions, and cultural factors influencing their usage. Positive attitudes encourage appropriate antibiotic use, while misconceptions and overestimation of their effectiveness may lead to unnecessary prescriptions and non-compliance with treatment regimens.[4] Practices refer to the actual behaviors related to antibiotic use, encompassing adherence to prescribed courses, self- medication practices, and the sources from which antibiotics are obtained. This study aims to assess the KAP of antibiotics among [describe your target population], providing insights into current awareness levels, beliefs, and behaviors regarding antibiotic use. By identifying gaps and misconceptions in KAP, the research seeks to inform targeted educational interventions and policy initiatives aimed at promoting rational antibiotic use. Ultimately, enhancing KAP regarding antibiotics is crucial for preserving these invaluable medications' effectiveness and mitigating the global threat of antibiotic resistance.

In recent decades,the emergence and spread of bacterial resistance to antibioticsis growing prroblem.The increase of antibiotics resistance will endanger the therapeutic effectiveness,increase treatment failure and lead to longer and more severe illness episodes with higher cost and mortality rates.Additionally,antibiotic resistance threatens humanhealthcare progress,agricultural production and ultimately life expectancy.Among the the causes of antibiotics resistance,misuse and overuse of antibiotics directly involve emergence of antibiotic resistance, Which is occure due to lack of knowledge ,careless attitudes and incorrect beliefs of the public about antibiotics[3].Patients belief in the remarkable effectiveness of antibiotics and their universaly efficacious in all ailments has resulted     in overuse ,which is one of the significant factors of the exponential growth. Respiratory and gastrointestinal diseases are common but are also commonly incorrectly managed by using antibiotics, and physician needlessly write antibiotic prescriptions, increasing the chances of antibiotic resistance prevalence. A recent systematic review and meta-analysis has reported that antibiotics inappropriately by the general population as seen in behaviours such    as            purchasing antibiotics from    pharmacies     without a prescription, demanding antibitics from physicians, not following prescribed antibiotics and using antibiotics as a prophylaxis for non-indicated diseases. Many strategies have been proposed for the use of antibiotics such as a formulary  replacement  or  restriction,health  care  provider  education ,feedback activities,approval requirement froman infectious disease specialistfor the drug prescription and a more rational use of antimicrobial agent all over the world . Antimicrobials are probably one of the most successful forms of chemotherapy in the history of medicine.It is not necessary to reiterate here how many lives they saved and significantly they contributed to the control of infectious diseases that were the leading causes of human morbidity and mortality for most of human exixtaence.Country to the common belief that the exposure to antibiotics is confined to the modern “antibiotic era”,research has revealed that this is not the case.The traces of tetracycline have been found in human skeletal remains from ancient Sudanese Nubia dating back to 350-550 CE (Bassett et al., 1980; Nelson et al., 2010).The distribution of tetracycline in bones is only explicable after exposure to tetracycline in bones is only explicable afeter exposure to tetracycline containing materials in the diet of these ancient people.Another example of ancient antibiotic exposure is from a histological study of samples taken from the femoral midshafts of the late Roman period skeletons from the Dakhleh Oasis,Egypt. Antibiotics have been used for millennia to treat infections, although until the last century or so people did not know the infections were caused by bacteria. Various molds and plant extracts were used to treat infections by some of the earliest civilizations Ancient Egyptians used applied moldy bread to infected wounds. Nevertheless, until the 20th century, infections that we now consider straightforward to treat pneumonia and diarrhea – that are caused by bacteria, were the number one cause of human death in the developed world Chinese used moldy soya bean curd to treat carbuncle, boils and other infections. Greek physicians used wine, myrrh, and inorganic salts .In the middle ages honey was used to prevent infections following arrow wound. John Parkinson documented use of mold in his book called Theatrum botanicum in 1640. In those days there was no way of knowing that bacteria is the the causes of these infections. Later discover that bacteria are single cell microorganisms, first identified in the 1670 by Antony Van Leeuwenhoek following his invention of the microscope With the discovery of microbes in the later half 19 th century and that they are the cause of many diseases. Ehrlich toyed with the idea that if certain dyes could selectively stains microbes. They could also be toxic to these organisms. He tried methylene blue, trypan red …etc. Bacteria are ubiquitous, mostly free living organisms often consisting of one biological cell. They constitute a large domain of prokaryotic microorganisms. Typically a few micrometers in length.[5] Bacteria were among the first life forms to appear on earth and are present in most of its habitats. Bacteria have characteristic shapes such as cocci, rods, spirals, etc. And often occur in characteristic aggregates like pairs, chains,tetrads,clusters,etc.

These traits are usually typical for a genus and are diagnostically useful. Prokaryotes have a nucleoid or nuclear body rather than an enveloped nucleus and lack membrane bound cytoplasmic organelles. The plasma membrane in prokaryotes performs many of the functions carried out by membranous organelles in eukaryotes. Multiplication is by binary fission. Bacterial cells are generally protected from lysis induced by factors such as osmotic shock by having a cell wall made of peptidoglycan, also called murein . The entire peptidoglycan sack around each bacterial cell is in fact one giant, covalently bonded bag shaped molecule. Growth of the cell is requires that link of this sack be opened up long enough to inert new links in between them. Penicillin leads to the death of growing bacterial cells by specifically inhibiting the trans peptidase that catalyzes the cross linking of peptidoglycan, the final step in the cell wall synthesis. Which selectively suppress the growth or kill other microorganism. This definition excludes other natural substances which also inhibit microorganisms but are produced by higher forms like antibodies or even those produced by microbes but are needed in high concentrations such as ethanol,

lactic acid, H2O2.

History and development of antibiotics

The phenomenon of antibiosis was demonstrated by Louis Pasteur in 1877. Found that growth of anthrax bacilli in urine was inhibited by air born bacteria. In late 1900s, Robert Koch and Louis Pasteur proved that diseases can be by germs. Pasteur developed two approaches, the first approach was to use harmless bacteria to cure diseases caused by harmful bacteria. The second approach was to use chemicals to kill the bacteria giving rise to the process called chemotherapy. In 1904, Paul Ehrlich a German physician, explained the use of chemicals against infection is chemotherapy. Who spend much of his career to study histology, immunochemistry, won Nobel prize for immunology. Who understood the first step of chemotherapy must be binding of the chemical to the bacteria. Then noted that certain chemical dyes colored some bacterial cells but not others. He concluded that, according to this principle, it must be possible to create substances that can kill certain bacteria selectively without harming other cells. In 1909, he discovered that a chemical called arsphenamine was an effective treatment for syphilis. This became the first modern antibiotic, although Ehrlich himself referred to his discovery as 'chemotherapy' – the use of a chemical to treat a disease. The word 'antibiotics' was first used over 30 years later by the Ukrainian- American inventor and microbiologist Selman Waksman, who in his lifetime discovered over 20 antibiotics. Penicillin heralded the dawn of antibiotic age. Before its introduction there was no effective treatment for infections such as pneumonia, gonorrhea or rheumatic fever. Alexander Fleming Professor of Bacteriology at St. Mary’s Hospital in London. A bit disorderly in his work and accidentally discovered penicillin. Upon returning from a holiday in Suffolk on September 3, 1928, he noticed that a fungus, Penicillium notatum, had contaminated a culture plate of Staphylococcus bacteria, he had accidentally left uncovered. It was dotted with colonies, While working on staphylococci bacteria he observed green mold around which bacteria can’ t grow . The fungus had created bacteria free zones wherever it grew on the plate. Fleming isolated and grew the mold in pure culture. He found that P. notatum proved extremely effective even at very low concentrations, preventing Staphylococcus growth even when diluted 800 times, and was less toxic than the disinfectants used at the time. Antibiotics are compounds produced by bacteria and fungi which are capable of killing, or inhibiting, competing microbial species. This phenomenon has long been known; it may help explain why the ancient Egyptians had the practice of applying a poultice of moldy bread to infected wounds. Fleming found that his “mold juice “was capable of killing a wild range of harmful bacteria such as streptococcus, meningococcus and diphtheria bacillus. Methods of vaccination were studied and research was carried out to find effective antibiotics In 1935 Sulpha drugs or sulfonamides were introduced by the German physician Gerhard Domagk. He worked closely with two chemists, Fritz Mietzsch and Josef Klarer. They worked together on compounds related to synthetic dyes, testing their compounds related to synthetic dyes, testing their effects on infectious diseases. Their concerted work eventually led to the discovery of Prontosil (sulfamidochrysoidine), the first sulfa drug that showed an incredible antibacterial effect on diseased laboratory mice. Aminoglycoside antimicrobials were first discovered in the 1940s and originally isolated from actinomycetes. Streptomycin, isolated from Streptomyces griseus , was the first aminoglycoside introduced into clinical practice for the treatment of tuberculosis.[6] Selman Waksman won the Nobel Prize in 1952 for the discovery of streptomycin, along with Albert Schatz. Since then a number of aminoglycosides have been discovered as products from the Streptomyces group or Micromonospora group species or developed through chemical modifications using existing aminoglycoside scaffolds. Plazomicin is an aminoglycoside that was engineered to overcome aminoglycoside modifying enzymes, the most common aminoglycoside resistance mechanism in Enterobacteriaceae, and is the first aminoglycoside to be approved by the FDA in June 2018. Since the approval of amikacin in 1981, marking the beginning of a class rejuvenation. These group of soil microbes provide to be a treasure house of antibiotics and soon tetracycline, chloramphenicol, Erythromycin. In the past 50 years emphasized has shifted from searching new antibiotics producing organism to developing semisynthetic derivatives of older antibiotics with more desirable properties or differing spectrum of activity. Few novel synthetic antibiotics such as fluoroquinolone, oxazolidindiones have also be produced. Mupirocin is a monoxycarbolic acid antibiotic. It consists of a mixture of pseudomonic acid that are produced by the Gram-negative bacterium Pseudomonas fluorescens. It was isolated, purified and characterized by A.T Fuller and co-workers in 1971. First GlaxoSmithKline under the trade name Bactroban. Now it is a generic topical drug prescribed for human and veterinary use. It act as bactriostat in low concentration. [7] At Higher concentration it is a bactericide that is effective against gram-positive bacteria. In the late 1960s, as bacterial beta lactamases emerged and threatened the use of penicillin. By 1976 the first beta lactamase inhibitors were discovered, these olivanic acids were natural product produced by the gram- positive bacterium Streptomyces clavuligerus. Olivanic acids possess a carbapenem backbone, and act as broad spectrum beta lactams . Due to chemical instability and poor penetration into the bacterial cell, the olivanic acids were not further pursued. There after two superior beta lactamase inhibitors were discovered

ANTIBIOTIC RESISTANCE:

Antibiotic resistance is the inherited or acquired ability of microorganisms to survive or proliferate at concentrations of an antibiotics, that would otherwise kill or inhibit them. The more we use antibiotics, the more chance to become resistant to them. Horizontal and verticaltransmission can happen in the absence of antibiotic compounds being present. Wild spread environmental releases of biological antibiotic pollutants originate from dischargeof untreated human and animal excreta into the environment as well as from antibiotic manufacturing.[8] This occur when concomitant or barriers for these pollutants are lacking, suchas toilets without confining barriers or when west water is used to irrigate farmland and when during fertilization of crops with untreated animal manure or human waste , such releases transmit antibiotic resistant bacteria . The overuse and misuse of antibiotics in human health, animal health and agricultural; the global movement of people, animals, goods socio-economic and health system disparate in globally .This create condition for antibiotic resistance to accelerate and spread. At the same time, the pace of development of new antibiotics and antibiotics alternatives are not keeping up with the rise of antibiotic resistance giving health providers fewer effective options to treat infections in humans and animals.[9] The most serious concern with antibiotic resistance is that some bacteria have become resistant to almost all of the easily available antibiotics. These bacteria are able to serious disease and this is a major public health problem.Important examples are following;

• Methicillin-resistant staphylococcus aureus
• Vancomycin-resistant Enterococcus
• Multi-drug-resistant Mycobacterium tuberculosis
• Carbapenem-resistant Enterobacteriaceae gut bacteria Drug reistance follows the drug like a faithful shadow''
• Paul Erhlich 1854-1915

Causes of antibiotic resistance

• Antibiotic resistance happens when bacteria change and become resistant to the antibioticsused to treat the infections they cause
• Over-prescribing of antibiotics
• Patients not finishing their treatment
• Overuse of antibiotics in livestock and fish farming
• Poor infection control in hospitals and clinics
• Lack of hygiene and poor sanitation
• Lack of new antibiotics being developed

1. Natural or Biological causes:

Selective pressure

In the presence of antibiotics, bacteria are either killed or if they carry resistant genes, survive. These survivors will replicate, and their progeny will quickly become the dominant type throughout the microbial population.

2. Acquired resistance: Mutation :

 Most microbes reproduce by dividing every few hours, allowing them to evolve rapidlyand adapt quickly to new environmental conditions. During replication, mutations ariseand some of these mutations may help an individual microbe survive exposure to an antimicrobial.

Gene Transfer:

The resistance causing gene is passed from one organism to the other is called horizontaltransfer of resistance. Rapid spread of resistance can occur by this mechanism and highlevel resistance to several antibiotics can be acquired concurrently

Societal Pressures:

The use of antibiotics even when used appropriately, creates a pressure for resistant organisms. Therefore societal pressures that act to accelerate the increase of antimicrobial resistance.

Inappropriate use:

Healthcare providers must use incomplete or imperfect information to diagnose an infection and thus prescribe an antibiotics just in case or prescribe a broad -spectrum antibiotics when a specific antibiotic might be better. These situation contribute to selective pressure and accelerate antibiotic resistance.

Hospital use:

Critically ill patients are more susceptible to infection and thus often require the aid of antibiotics .The heavier use of antibiotics in these patients can worsen the problem by selectingfor antibiotic resistant organisms. The extensive use of antibiotics and close contact among sick patients creates a fertile environment for the spread of antibiotic resistant organisms.

Agricultural use

Scientist also believe that the practice of adding antibiotics to agricultural feed promotes drug resistance. More than half of the antibiotics produced are used for agricultural purposes.[10]

 Burdens of antibiotic resistance:

Causal association between antibiotic use and emergence of antibiotic resistance

• Antibiotic resistance :

more prevalent in HA infection than CA infection

• Health care associated infections are more likely to be caused by resistant strainsEspecially in those who have received prior antibiotics
• Hospitals that have the highest rates of antibiotic resistance also have the highestRates of antibiotic use
• Patient exposed to longer duration of antibiotics have an increased risk ofColonization with resistant organisms
• Mortality rate correlates with the presence of multi drug resistant organisms
• Association between development of antibiotic resistance in Staphylococus Aureus, Enterococci, gram negative bacilli and mortality
• Enterococcal infection have been associated with mortality rates exceeding 30%
• A meta-analysis of published studies have found that patient with methicillinResistant Staphylococcus aureus (MRSA) bacteremia had a increased risk of
• Mortality compared with methicillin susceptible Staphylococcus aureus (MSSA)

Killing of beneficial bacteria

Consensus about antibiotics focus on bacterial resistance but permanent changes to our protective flora have more serious consequences

Collateral damage

• Average child receives 10-20 courses of antibiotics before 18 years of age
• Antibiotic affect our resident microbiota and may not fully recover after a courseOf antibiotics
• Over use of antibiotics may be contributing to obesity, DM ,IBD, allergies andasthma

Why we need to improve antibiotic use

• Antibiotics are the only drug where use in one patient can impact the effectivenessIn another
• Improving antibiotics use improve patient outcome and saves money
• Antibiotic misuse adversely impact patient and society
• Inappropriate use of antibiotics in animals
• Improving antibiotic use is a public health imperative-WHO consider AMR anEmerging threat to global health

MULTIDRUG RESISTANCE

Multidrug resistance is a type of insensitivity developed by microorganisms to lethal dose of antibiotics. The statistics of infection caused by MDR bacteria show that the insensitiveness ofbacteria toward antibiotic has risen many fold in recent years. The ineffectiveness of antibiotics is not the only reason, but low bioavailability, inadequate access to spots of infection and the growth of MDR bacteria. The development of resistance to antibiotics by bacteria not only decrease the therapeutic efficacy of the drug but also increases the overall cost of treatment strategies. Currently surfacefunctionalized Nano carriers are widely used for overcoming MDR in bacteria against antibiotics.[11]

PRESENT SITUATION:

Tackling antibiotic resistance is a high priority for WHO. A global action plan on antibiotic resistance was endorsed at the World Health Assembly in 2015. The global action plan aims toensure prevention and treatment of infectious diseases with safe and effective medications. According to the world health organization diarrhea is the second major causes of mortality andleading cause of malnutrition among children under five years. The health burden of diarrheal diseases is severe in developing countries.The ''Global action plan on antibiotic resistance '' has five strategic objectives:

• To improve awareness and understanding of antibiotic resistance
• To strengthen surveillance and research
• To reduce the incidence of infection
• To optimize the use of antibiotic medicines
• To ensure sustainable investment in countering antibiotic resistance A political declaration endorsed by Heads of State at the United Nations General Assembly inNew York in September 2016 signaled the world's commitment to taking a broad, coordinatedapproach to address the root causes of antibiotic resistance across multiple sectors, especially human health, animal health and agriculture. WHO supporting Member States to develop national action plans on antibiotic resistance based on global action plan.[12]

WHO has been leading multiple initiatives to address antibiotic resistance:

World Antimicrobial Awareness Week (WAAW):

• Held annually since 2015, WAAW is a global campaign that aims to increase awareness of antibiotic resistance worldwide and to encourage best practices among the general public, health workers and policy makers to avoid the further emergence and spread of drug- resistant infections.
• The Global Antimicrobial Resistance Surveillance System(GLASS): The WHO-supported system supports a standardized approach to the collection, analysis and sharing of data related to antibiotic resistance at a global level to inform decision-making, drivelocal, national and regional action.

Interagency Coordination Group on Antimicrobial Resistance( IACG):

The United Nations Secretary-General has established IACG to improve coordination between international organizations and to ensure effective global action against this threat to health security. The clinical pipeline of new antibiotics is dry. In 2019 WHO identified 32 antibiotics in clinicaldevelopment that address the WHO list of priority pathogens, of which only six were classified a innovative. Furthermore, a lack of access to quality antibiotic remains a major issue. Antibiotic shortages are affecting countries of all levels of development and especially in health-care systems. New antibiotics are urgently needed-for such as to treat carbapenem- resistant gram-negative bacterial infections as identified in the WHO priority pathogen list. However, if people do not change the way antibiotics are used now, these new antibiotics will suffer the same fate as current ones and become ineffective. For common bacterial infections such as UTI , sepsis,STD, some form of diarrhea, high rate ofresistance against antibiotics frequently used to treat these infections have been observed world-wide indicating that we are running out of effective antibiotics. For example the rate of resistance to ciprofloxacin, an antibiotic commonly used to treat UTI varied from 8.4 to 92.9 for Escherichia coli and from 4.1 to 79.4 for Klebsiella pneumoniae in countries reporting to the Global Antimicrobial Resistance and Use Surveillance System GLASS. Klebsiella pneumonae are common intestinal bacteria that can cause life threatening infections.Resistance in K.pneumoniae to last resort treatment such as carbapenem antibiotics has spread to all regions of the world. K.pneumoniae is a major cause of hospital acquired infections such as pneumonia, bloodstream infections, and infections in newborn and ICU patients. In some countries, carbapenem antibiotics do not work in more than half of the patientstreated for K.pneumoniae infections due to resistance. Fluoroquinolone antibiotic resistance inE.coli for UTI is widespread.

PREVENTION AND CONTROL

The Global Action Plan on Antibiotic resistance, where one of five strategic objectives is to reduce the incidence of infection through effective sanitation, hygiene and infection preventionmeasures. At the national level, evidence based guidelines on infection control can form the basis for and facilitate the development and implementation of infection control programs at health care facilities. At the level of health care facilities, activities such as infection control programs, built environment, sufficient staffing and educational initiatives are of high importance. At the community level, preventing spread of infectious diseases, resistant bacteria and promoting a healthy lifestyle will reduce unnecessary use of antibiotics. Identify infected individuals in a timely manner with prompt and proper case management. Educate care providers, resident’s coverage for staff and residents. Most people are not aware of the precipice in new antimicrobial drugs because development, regulatory approval and commercialization of final products lag behind discovery by 15-20 years creating the false impression of new drugs. Coordination, leadership, and communication would do well to incorporate a broad range of stakeholders, especially social and behavioral sciences to change our current trajectory and avoid widespread, untreated infectious diseases.

 AIM AND OBJECTIVES

This KAP study is proposed to assess the knowledge, attitude, practices of antibiotics among urban and rural population of Wayanad and compare both of these population. For the assessment of KAP , a pre-structured questionnaire is providedto the respondents who are willing to answer.

The main objective of KAP survey is as follows;

To understand the current level of knowledge among urban and rural population of Wayanad regarding menstruation

Ten knowledge related questions were included in the questionnaire. These questions mainly focused on the respondent’s knowledge regarding menstruation. The questions included are antibiotics are effective for the treatment of bacterial infections, antibiotic resistance is the loss of activity of an antibiotics etc

To explore attitude of the urban and rural population of Wayanad towards menstruation .

6 attitude related questions are included in this section. The questions include mainly antibiotic resistance . This section is used to assess the attitude of society about antibiotic resistance.

To explore practices of the urban and rural population Wayanad during the time of menstruation

In this section 15 questions are included for assessing practices while consumption of antibiotics among the urban and rural population of Wayanad. The question included are antibiotics are prescribed by an authorized doctor , fail to complte the doses , ever faced any side effects etc. The rational use of antibiotics prevent antibiotic resistances.

METHODOLOGY

A research study is conducted in a systematic way with proper design and planning in order to reach to the conclusion. This study is conducted based on a pre- structured questionnaire to assess the knowledge, attitude and practices of the urban and rural population of wayanad.

Study design

A pre-structured questionnaire was selected and a prospective cross sectional study was carried out. All the respondents of age >18 years who are willing to answer were included in the study population The urban and rural population of wayanad was selected for the study. 120 participants from both urban and rural population are selected by using sampling technique.

Sample size calculation

Sample size calculation is important in a study because including the whole population will be a tedious process. The formula used to calculate the sample size is;

n=Z2P(1-P)/d2

Where;

n is the sample size

Z is confidence level statistic P is the prevalence expected d is the precision

Sampling

The participants were selected based on simple random sampling method from Wayanad.

Inclusion criteria-All respondents of age >18 years, who are willing toparticipate in the study.

Exclusion criteria- Respondents , who are not willing to participate in the study and male respondents are excluded from study.

 Questionnaire development

The questions included in the questionnaire were selected from previous KAP studies of this topic.

Questionnaire design

Questionnaire was divided into 4 sections which include demography, knowledge related, attitude related and practice related questions

Demographic section

Demographic section includes details of respondents include age and gender

Knowledge section

Knowledge section had 7 questions to assess the knowledge about antibiotics. The questions include antibiotics are effective for treatment of bacterial infection, viral infection ect.

Attitude section

6 attitude related questions are included in this section. The questions included mainly related with antibiotic resistance. This section is used to assess the attitude of society about antibiotic resistance.

Practice section

In this section 15 questions are included for assessing practices during consumption among the urban and rural population of Wayanad. The question included are do you fail to compete antibiotics, did you complete the course of antibiotics, do you face any side effects. The rational use of antibiotics prevent the emergence of antibiotic resistance.

Pilot Testing

Pilot study was conducted using the questionnaire in about 15 participants from each population

Data collection

Data’s were collected from urban and rural population of Wayanad through questionnaire.

 Study site

Study was conducted in urban and rural general population of Wayanad.

Study duration

The study was conducted for a period of 6 months (March- August 2024).

Scoring

For close ended question the answer ‘true’ score 1 and for answer ‘false’ score 2,’uncertain’score 3 and the questions with 4 or more options give 1 to 4 or 1to number of options score.

Knowledge section scoring

Knowledge section questions consist of 7 question. In these questions all questions are closed ended questions. For those question the answer ‘true’ score 1 and for answer ‘false’ score 2 and ‘uncertain’ score 3.

Attitude section scoring

Attitude section consist of 6 questions. All are close ended questions. For those question the answer ‘true’ score 1 and for answer ‘false’ score 2 and ‘uncertain’ score 3.

Practice section scoring

Practice section consist of 15 questions. From these questions 3 questions are close ended questions others are open ended question. For close ended question the answer ‘yes’ score 1 and for answer ‘no’ score 2 and the questions with 10 options give 1 to 10 score.

Statistical tools

All the data were made into a table and the data was analyzed by usingsoftware SPSS version 22.2. The frequency, cumulative frequency, percentage, chi square and P value was calculated .

Socio -Demographic variables

Table 1: Age distribution

Table 1 reveals the age group selected for this study. The age minimum age of 18 and maximum of 60 is selected for this study. Population selected for this study divided into urban and rural population. The mean age of rural population 31.07 and mean age group of urban population 30.17. The age less than 18 and more than 60 are not selected for this study.

Mother’s education distribution

Table 2 reveals the distribution of gender respondents. Population selected for this study divided in to urban and rural population. In rural areas , out of 60 population 39(65%) were females and 21(35%) were male and in urban areas, out of 60 population 34(56.7%) were females and 26(43.3%) were males. This data depicts that the female preponderance is more compared to males

The population selected for this study divided into urban and rural population based on location. 3 answers are given for this question that is true, false and uncertain. Over these 60 respondents of rural population 52(86.7%) considered as true,7(11.7%) considered as false,1(1.7%) and considered as uncertain. Over the 60 respondents of urban population 57(95.0%) considered as true,1(1.7%) considered as false and 2(3.3%) considered as uncertain. All the respondents have good knowledge.

K2: Antibiotics are effective for the treatment of viral infections?

In this question 3 answers are given that is true, false and uncertain. Over the 60 respondents of rural population 26(43.3%) consider as true, 31(51.7%) consider as false and 3(5.0%) considered as uncertain. Over the 60 respondents of urban population 15(25.0%) considered as true,36(60.0%) considered as false and 9(15.0%) considered as uncertain. All the respondents of urban population have good knowledge.

K3:Antibiotics are effective for the both bacterial and viral infections?

True, False ad uncertain are given as the option for this question. Over the 60 respondents of rural population 38(63.3%) considered as true,8(13.3%) considered as false and 14(23.3%)considered as uncertain as answer .60 respondents of urban population 17(28.3%) considered as true, 19(31.7%) considered as false and 24(40.0%) considered as uncertain as Answer. Urban population have good knowledge.

 K4:Antibiotic resistance is the loss of activity of an antibiotic?

Among 60 respondents of rural population 47(78.3%) consider true ,3(5.0%) considered as false and 10(16.7%) considered as uncertain as answer. Among 60 respondents of urban population 45(75.0%) considered as true ,5(8.3%) considered as false and 10(16.7%) considered as uncertain.

K5: Missing an antibiotic dose contributes to antibiotic resistance ?

Among 60 respondents of rural population 48(80.0%) considered as true, 4(6.7%) considered as false and 8(13.3%) considered as uncertain as answer. Over 60 respondents of urban population 47(78.3%) considered as true,5(8.3%) considered as false and 8(13.3%) considered as uncertain .

K6: Antibiotic resistance can be caused by the overuse of antibiotics

Over 171 respondents of rural population 38(63.3%)considered as true , 9(15.0%) considered as false and 13(21.7%) considered as uncertain as answer. In 171 respondents if urban population said that 54(90.0%) true, 1(1.7%) false and 5(8.3%) uncertain about antibiotic resistance . Urban population have good knowledge about

antibiotic resistance.

 K7: Consumption of antibiotics without physician’s prescription can contribute to antibiotic resistance?

Over 60 respondents of rural population 49(81.7%) considered as true , 3(5.0%) considered as false and 8(13.3%) considered as uncertain as answer. In 171 respondents of urban population53(88.3%) considered as true

,2(3.3%) considered as false and 5(8.3%) considered as uncertain as answer.

A1: Do you think antibiotic resistance is increasing?

3 options are given for this set of questions related to attitude towards antibiotics that is agree, disagree and uncertain .Among 60 respondents of rural population 51(85.0%) agree with this statement , 6(10.0%) disagree with this statement, 3(5.0%) chooses the answer uncertain.60 respondents of urban population 55(91.7%) chooses the answer agree, 1.7(7%) selected the answer disagree, 4(6.7%) uncertain with this attitude question.

A2:Do you think we should be more concern regarding antibiotic consumption.

The 60 respondents of rural population 52(86.7 %) chooses the answer agree, 7(11.7%) selected the answer disagree, 1(1.7%) selected the answer uncertain towards this attitude question. Over 60 respondents of urban population 56(93.3%) agree with their question, 1(1.7%) disagree and 3(5.0%) are uncertain about this statements

A3: Government should create more awareness of antibiotic resistance .

Over 60 respondents of rural population 58(96.7%) agree with this statement,2(3.3%) uncertain with this statement with this statement attitude towards antibiotics. Among 60 respondents of urban population 59(98.3%) agree with this statement, 1(1.7%) uncertain about this statement

A4:Enough knowledge should be generated to prevent antibiotic resistance.

Among 60 respondents of rural population 54(90.0%) agree with this attitude, 3(5.0%) disagree with this statement, 3(5.0%) uncertain about this statement. Over 60 participants of urban population 57(95.0%) agree with this statement and 2(3.3%) disagree with this statement and 1(1.7%) uncertain about this statement.

 A5:The uses of antibiotics in poultry and dairy industries should be strictly monitored.

Over 60 population of rural areas 53(88.3%) agree with this statement, 1(1.7%)dis agree with this statement, 6(10.0%) uncertain about the statement.

Among 60 respondents from urban population 50(83.3%) agree, 1(1.7%) disagree and 9(15.0%) uncertain about this statement.

A6: Do you think physicians often prescribe antibiotics unnecessarily.

In our country physicians also prescribes antibiotics unnecessarily. Over 60 respondents of rural population 29(48.3%) agree, 27(45.0%) disagree, 4(6.7%) don’t know , 72(42.1%) disagree and 26(15.2%) strongly disagree attitude towards this statement.

Table 7: Practice related questions

P1:How do you generally take antibiotics?