Antibiotic Knowledge, Awareness, Antimicrobial Stewardship, And Practice Among Pharmacy and Pharmacy Inclusive Student Populations: A Systematic Review of Global Evidence

Antimicrobial resistance (AMR) represents one of the most important threats to effective infectious disease management ^[1]. A global analysis estimated that bacterial AMR was directly responsible for approximately 1.27 million deaths in 2019 and was associated with approximately 4.95 million deaths overall ^[2]. Subsequent modelling has projected a continued increase in the burden of AMR, emphasizing the need for sustained preventive and stewardship measures ^[3]. The World Health Assembly has also identified AMR as a strategic global priority, reinforcing the need for coordinated action across health systems ^[4].

Inappropriate antibiotic use contributes substantially to the development and spread of resistance. Important drivers include unnecessary prescribing, self medication, access to antibiotics without a prescription, poor adherence to treatment, use of leftover medicines, use of expired products, limited access to appropriate clinical care economic constraints, and misunderstanding of when antibiotics are indicated ^[5,6]. These behaviours occur across different healthcare settings and are particularly relevant in low- and middle-income countries, where regulatory and access related factors may influence antibiotic use ^[7,8].

The problem extends beyond prescribing volume. Incorrect antibiotic selection, inadequate dosing, premature discontinuation, and use of antibiotics for conditions that do not require antibacterial therapy may also contribute to inappropriate exposure and resistance. Because behaviours and professional attitudes can develop during undergraduate education, pharmacy training provides an important opportunity to establish appropriate antibiotic use practices before students enter professional practice [^9].

Pharmacists occupy an important position in antimicrobial stewardship ^[10]. In many healthcare systems, community pharmacists are among the first healthcare professionals consulted by people seeking advice about symptoms or medicines ^[11]. This position allows pharmacists to support appropriate antibiotic selection, reinforce adherence, identify inappropriate requests, provide counselling, and contribute to antimicrobial stewardship activities. At the same time, pharmacists may face pressure to supply non-prescription antibiotics where regulation is weak and patient demand is high. Effective stewardship therefore requires more than factual knowledge; it also requires clinical reasoning, communication skills, confidence, and an understanding of stewardship principles.

Existing evidence suggests that pharmacy students may have reasonable knowledge of basic antibiotic and AMR concepts but less consistent competence in applying that knowledge to clinical or stewardship decisions ^[12,13]. Educational interventions have demonstrated that student knowledge and stewardship awareness can be improved. For example, social media based educational intervention among pharmacy, medical, and nursing learners and residents in Lebanon improved quiz scores ^[14], while pharmacist led educational interventions have improved KAP outcomes among healthcare workers ^[15]. The findings indicate that education can modify stewardship related knowledge and behaviour, although the content and delivery of such education vary between settings.

The pharmacy curriculum is therefore central to preparing future pharmacists for AMS responsibilities. Previous work has reported that AMS teaching within pharmacy education has been limited, inconsistently structured, and sometimes concentrated in elective courses rather than integrated throughout the core curriculum ^[16]. Differences in curricular exposure may partly explain the variation observed in students knowledge, attitudes, and practices.

Previous reviews have frequently focused on practising pharmacists, healthcare professionals, or the public rather than specifically examining students before professional qualification. A recent systematic review examined undergraduate AMS education across several health professions, but its focus was on educational interventions and included multiple professional groups ^[17]. A broader synthesis focused specifically on pharmacy and pharmacy inclusive students across WHO regions can therefore help identify geographical gaps, methodological limitations, and priorities for pharmacy education. 

2.Methods

2.1 Protocol and reporting

This systematic review was prepared in accordance with the preferred reporting items for systematic reviews and meta analyse (PRISMA) 2020 statement ^[18].

2.2 Eligibility criteria

Studies were considered eligible when they reported quantitative findings on antibiotic knowledge, AMR knowledge, awareness, attitudes, self reported antibiotic-use practices, AMS familiarity, training, confidence, or preparedness among pharmacy students or student populations that included pharmacy learners. Studies were eligible when pharmacy-specific findings were available or when the overall sample included pharmacy students and the relevant outcomes could not be separated. Eligible designs were cross-sectional surveys, mixed-methods studies containing clearly extractable quantitative findings, and educational pre-post surveys.

Studies were excluded when they involved an inappropriate population, did not report relevant antibiotic/AMR/AMS outcomes, were reviews, commentaries, protocols without eligible outcome data, conference abstracts, non-human studies, duplicate or retracted publications, or reports from which the required information could not be extracted. Only English language full text publications were ultimately eligible. Two potentially relevant studies published in Vietnamese and French were therefore excluded during the screening process.

2.3 Information sources

PubMed, Scopus, Web of Science, ResearchGate, and Google Scholar were searched from database inception. No date restriction was applied at the identification stage. Language and other eligibility criteria were applied during screening. The search dates, database specific strategies, and record counts were documented in the supplementary search strategy.

2.4 Search strategy

 The search strategy combined population, topic, and outcome concepts using Boolean operators. The PubMed strategy included terms related to pharmacy students and undergraduate pharmacy education together with terms for antibiotics, antimicrobials, antibacterials, knowledge, attitudes, practices, awareness, perceptions, and stewardship. Database-specific search strings were adapted as required for each platform.

2.5 Study selection

A total of 387 records were identified, of which 171 duplicate records were removed, leaving 216 unique records for title and abstract screening. Records were excluded when the population or outcomes were inappropriate or when publication and study design criteria were not met. Full texts were sought for 123 records; 11 reports could not be retrieved. Of the 112 full text reports assessed, 64 were excluded for prespecified reasons, resulting in 48 studies for the final narrative synthesis, Title abstract and full-text screening were undertaken independently by two reviewers, with disagreements resolved through discussion and, when necessary, adjudication by a third reviewer.

2.6 Data extraction

Data were extracted using a standardised electronic form. Extracted variable included bibliographic information, country, WHO region, World Bank income classification, sample size, sex distribution, study population, study design, response rate, assessment domain, reported results, questionnaire validation procedures, reliability information such as Cronbach’s alpha when available, and risk-of-bias information. One reviewer performed the initial extraction, and a second reviewer independently checked the extracted information against the original articles.

2.7 Risk-of-bias assessment

The Joanna Briggs institute critical appraisal checklist for analytical cross-sectional studies was used to assess methodological quality. The checklist evaluates eight domains relating to participant inclusion, study setting, exposure measurement, identification and management of confounding factors, outcome measurement, and statistical analysis. Each item was classified as Yes, No, unclear, or not applicable.

Because many included studies were descriptive KAP surveys, the absence of reported reliability coefficient was not automatically interpreted as evidence that the questionnaire was invalid or unreliable. Reliability and validity are related but distinct properties, Similarly, the absence of adjusted analyses was not considered a methodological failure when the primary purpose of a study was descriptive rather than analytical. Such characteristic was therefore reported descriptively. Where the source article did not provide enough information to determine whether a criterion was met, the item was classified as unclear.

A potential overlap was identified between two reports based on the same Sri Lankan participant cohort.  Both reports were retained because they provided different comparative contributions, but the shared participants were not counted twice in the overall participant total or treated as independent confirmation.

2.8 Data synthesis

Quantitative meta-analysis was not considered appropriate because the included studies used substantially different questionnaires, scoring systems, outcome definitions, participant groups, and thresholds for classifying knowledge or practice. The findings were therefore synthesised narratively by KAP/AMS domain and, where informative, by WHO region and methodological characteristics. The synthesis was guided by principles for reporting systematic reviews without meta-analysis (SWM).

3.RESULTS

3.1 Study selection

The database searches yielded 387 records. After removal of 171 duplicates, 216 unique records underwent title and abstract screening. Ninety-three records were excluded because of inappropriate populations or outcomes, ineligible publication types, duplicate status, non-English publication, non-human design, or an unrelated topic. Full texts were requested for 123 reports, of which 11 could not be retrieved. The remaining 112 reports underwent fulltext assessment, and 64 were excluded according to the predefined criteria. Forty-eight studies were therefore included in the final narrative synthesis. The study selection process is presented in the PRISMA 2020 flow diagram. (Figure 1).

 

 

 

 

 

 

 

 

DISCUSSION

This systematic review synthesised evidence from 48 studies conducted in 33 countries and all six WHO regions. Three major findings emerged. First, basic antibiotic and AMR knowledge was the most frequently studied domain and was generally stronger than applied clinical knowledge. Second, AMS specific familiarity was assessed much less often and was frequently weaker than general antibiotic knowledge. Third, positive attitudes and reasonable factual knowledge were not consistently accompanied by appropriate antibiotic-use practices.

The predominance of basic knowledge assessment suggests the pharmacy education has successfully introduced many fundamental antibiotic and AMR concepts. However, knowing that antibiotics are ineffective against viruses or the resistance is a global problem does not necessarily demonstrate the ability to make appropriate therapeutic decisions. The recurring difficulty with applied questions suggests that curricula should place greater emphasis on case-based learning, Clinical decision making, antimicrobial selection, dose optimisation, treatment duration, de-escalation, patient counselling, and interpretation of microbiological information.

The relatively limited assessment of AMS specific familiarity is also important. Only 17 studies assessed these domains, compared with 43 studies assessing general knowledge. In several studies, students had limited familiarity with the term AMS or with the practical responsibilities associated with stewardship. This suggests that antibiotic pharmacology and AMR education may not automatically provide sufficient preparation for stewardship practice.

The observed gap between attitudes and behaviour is another important finding. Several studies reported favourable attitudes toward rational antibiotic use while simultaneously documenting self medication, non prescription acquisition, incomplete courses, or other inappropriate practices ^{[19-24,38-40,52,53,57,58,65]}. Self reported behaviour may be affected by recall and social desirability bias, but the consistency of this pattern across settings indicates that educational interventions should address behavioural determinants in addition to factual knowledge

The findings have direct implications for pharmacy curricula. AMS education should be explicit, structured, and linked to real clinical situations. Core curriculum content could include principles of antimicrobial selection, local and international treatment guidelines, antimicrobial susceptibility testing, dose and duration optimization, IV to oral conversion, de-escalation, monitoring for effectiveness and toxicity, patient counselling, infection prevention, and communication with prescribers and other healthcare professionals. Practical training and simulated clinical cases may help students apply knowledge rather than simply recall facts.

The heterogeneity of the evidence base limits direct comparisons between studies. Most investigations were cross sectional and descriptive, questionnaires differed in content and scoring, and many studies did not report formal reliability statistics. The absence of a reported Cronbach's alpha should not be interpreted automatically as evidence of an invalid instrument; however, incomplete reporting makes it difficult to judge measurement quality and compare findings between settings.

The geographical distribution of evidence was also uneven. Only two study counts originated from the Region of the Americas, whereas the Eastern Mediterranean Region accounted for 22 study counts. The limited evidence from some regions reduces confidence in the generalisability of the findings and indicates a need for more research in underrepresented settings, including the Americas and parts of the Western Pacific region ^[66].

4.1 strengths of the review

The review included evidence from all six WHO regions and used five major information sources. The screening process followed PRISMA 2020 reporting principles ^[18], and methodological quality was assessed using the JBI critical appraisal framework. Data extraction was independently checked against articles, and an overlapping participant cohort was identified and excluded from the non duplicated participant count.

4.2 Limitations

Several limitations should be considered. Only English language publications were included, which resulted in the exclusion of potentially relevant studies from Vietnam and Senegal ^[67,68]. Thesis and dissertation databases were not searched. Most included studies were cross sectional, limiting causal interpretation. The substantial heterogeneity in instruments and outcome definitions prevented quantitative pooling. Some mixed professional studies did not report pharmacy specific findings separately, and a small number of study level data points require verification against the original articles before submission.

4.3 Implications for pharmacy education and research

The evidence supports three priorities. First, pharmacy programmes  should integrate AMS throughout the curriculum rather than treating it solely as an elective or isolated topic. Second, researchers should develop and validate standardised tools for assessing antibiotic Knowledge, AMR awareness, attitudes, behaviour, and AMS  competence in student populations. Third, future studies should move beyond descriptive surveys and evaluate education interventions using stronger designs, validated outcome measure, follow up assessment, and analytical methods capable of identifying factors associated with stewardship competence.

CONCLUSION

Across 48 studies from 33 countries and all six WHO regions, pharmacy and pharmacy inclusive students  generally demonstrated reasonable knowledge of basic antibiotic and AMR concepts and expressed favourable attitudes toward appropriate antibiotic use and AMS. In contrast, applied stewardship competence, AMS specific familiarity, and stewardship consistent practices were less consistently demonstrated. The evidence was geographically uneven and methodologically heterogeneous, which limits direct comparison and generalisation.

Pharmacy education should therefore provide structured and clinically applied AMS training that connects antibiotic knowledge with decision making, counselling, behaviour, and multidisciplinary practice. Future research should use validated assessment instruments, include underrepresented regions, report pharmacy specific findings clearly in mixed profession samples, and prioritise well designed education intervention studies with measurable follow up outcomes.

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