Research Open Access
Like 0



While several studies have assessed knowledge, attitudes and behaviours of the public, physicians and medical students in a number of EU/EEA countries with respect to antibiotic use and antibiotic resistance, there is a paucity of literature for other healthcare workers. This survey aimed to fill this gap.


A 43-item online questionnaire was developed, validated and pilot-tested through a modified Delphi consensus process involving 87 Project Advisory Group (PAG) members, including national representatives and members of European health professional groups. The survey was distributed by the PAG and via social media to healthcare workers in 30 EU/EEA countries.


Respondents (n = 18,365) from 30 EU/EEA countries participated. Knowledge of antibiotics and antibiotic use was higher (97%) than knowledge of development and spread of antibiotic resistance (75%). Sixty percent of respondents stated they had received information on avoiding unnecessary prescribing, administering or dispensing of antibiotics. Among respondents who prescribed, administered or dispensed antibiotics, 55% had provided advice on prudent antibiotic use or management of infections to patients, but only 17% had given resources (leaflets or pamphlets). For community and hospital prescribers, fear of patient deterioration or complications was the most frequent reason (43%) for prescribing antibiotics that were considered unnecessary. Community prescribers were almost twice as likely as hospital prescribers to prescribe antibiotics due to time constraints or to maintain patient relationships.


It is important to move from raising awareness about prudent antibiotic use and antibiotic resistance among healthcare workers to designing antimicrobial stewardship interventions aimed at changing relevant behaviours.


Article metrics loading...

Loading full text...

Full text loading...



  1. European Commission. A European One Health Action Plan against Antimicrobial Resistance (AMR). Brussels: European Commission; 2017. Available from: https://ec.europa.eu/health/sites/health/files/antimicrobial_resistance/docs/amr_2017_action-plan.pdf
  2. Cassini A, Högberg LD, Plachouras D, Quattrocchi A, Hoxha A, Simonsen GS, et al. Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis. Lancet Infect Dis. 2019;19(1):56-66.  https://doi.org/10.1016/S1473-3099(18)30605-4  PMID: 30409683 
  3. Earnshaw S, Mancarella G, Mendez A, Todorova B, Magiorakos AP, Possenti E, et al. European Antibiotic Awareness Day: a five-year perspective of Europe-wide actions to promote prudent use of antibiotics. Euro Surveill. 2014;19(41):20928.  https://doi.org/10.2807/1560-7917.ES2014.19.41.20928  PMID: 25345519 
  4. European Commission. Special Eurobarometer 478. Report. Antimicrobial Resistance. Brussels: European Commission; Nov 2018. Available from: https://ec.europa.eu/commfrontoffice/publicopinion/index.cfm/ResultDoc/download/DocumentKy/84386
  5. European Commission. Special Eurobarometer 445. Report. Antimicrobial Resistance. Brussels: European Commission; Jun 2016. Available from: https://ec.europa.eu/health/sites/health/files/antimicrobial_resistance/docs/eb445_amr_generalreport_en.pdf
  6. European Commission. Special Eurobarometer 407. Report. Antimicrobial Resistance. 2013. Brussels: Directorate-General for Communication; 3 Dec 2014. Available from: https://data.europa.eu/euodp/data/dataset/S1101_79_4_407
  7. European Commission. Special Eurobarometer 338. Antimicrobial Resistance. Report. Brussels: Directorate-General for Communication; Apr 2010. Available from: https://ec.europa.eu/health//sites/health/files/antimicrobial_resistance/docs/ebs_338_en.pdf
  8. Dyar OJ, Pulcini C, Howard P, Nathwani D, Nathwani D, Beovic B, et al. European medical students: a first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance. J Antimicrob Chemother. 2014;69(3):842-6.  https://doi.org/10.1093/jac/dkt440  PMID: 24191307 
  9. McCullough AR, Rathbone J, Parekh S, Hoffmann TC, Del Mar CB. Not in my backyard: a systematic review of clinicians’ knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother. 2015;70(9):2465-73.  https://doi.org/10.1093/jac/dkv164  PMID: 26093375 
  10. Simões AS, Alves DA, Gregório J, Couto I, Dias S, Póvoa P, et al. Fighting antibiotic resistance in Portuguese hospitals: Understanding antibiotic prescription behaviours to better design antibiotic stewardship programmes. J Glob Antimicrob Resist. 2018;13:226-30.  https://doi.org/10.1016/j.jgar.2018.01.013  PMID: 29409949 
  11. Gharbi M, Moore LS, Castro-Sánchez E, Spanoudaki E, Grady C, Holmes AH, et al. A needs assessment study for optimising prescribing practice in secondary care junior doctors: the Antibiotic Prescribing Education among Doctors (APED). BMC Infect Dis. 2016;16(1):456.  https://doi.org/10.1186/s12879-016-1800-z  PMID: 27576784 
  12. Fleming A, Bradley C, Cullinan S, Byrne S. Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation. BMJ Open. 2014;4(11):e006442.  https://doi.org/10.1136/bmjopen-2014-006442  PMID: 25377014 
  13. Gonzalez-Gonzalez C, López-Vázquez P, Vázquez-Lago JM, Piñeiro-Lamas M, Herdeiro MT, Arzamendi PC, et al. Effect of physicians’ attitudes and knowledge on the quality of antibiotic prescription: a cohort study. PLoS One. 2015;10(10):e0141820.  https://doi.org/10.1371/journal.pone.0141820  PMID: 26509966 
  14. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(2):101-14.  https://doi.org/10.1086/657912  PMID: 21460463 
  15. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37.  https://doi.org/10.1186/1748-5908-7-37  PMID: 22530986 
  16. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42.  https://doi.org/10.1186/1748-5908-6-42  PMID: 21513547 
  17. Eurostat. Healthcare personnel statistics - nursing and caring professionals. Luxembourg: Eurostat. [Accessed: 2 Aug 2019]. Available from: https://ec.europa.eu/eurostat/statistics-explained/index.php/Healthcare_personnel_statistics_-_nursing_and_caring_professionals
  18. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34.  https://doi.org/10.2196/jmir.6.3.e34  PMID: 15471760 
  19. Smith W. Does Gender Influence Online Survey Participation? A Record-Linkage Analysis of University Faculty Online Survey Response Behavior. San Jose, CA: San Jose State University. Jun 2008. Available from: https://files.eric.ed.gov/fulltext/ED501717.pdf
  20. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2005; (4):CD003539.  https://doi.org/10.1002/14651858.CD003539.pub2  PMID: 16235325 
  21. Little P, Stuart B, Francis N, Douglas E, Tonkin-Crine S, Anthierens S, et al. Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet. 2013;382(9899):1175-82.  https://doi.org/10.1016/S0140-6736(13)60994-0  PMID: 23915885 
  22. World Health Organization (WHO). WHO competency framework for health workers’ education and training on antimicrobial resistance. Geneva: WHO; 2018. Available from: https://www.who.int/hrh/resources/WHO-HIS-HWF-AMR-2018.1/en/
  23. Charani E, Edwards R, Sevdalis N, Alexandrou B, Sibley E, Mullett D, et al. Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review. Clin Infect Dis. 2011;53(7):651-62.  https://doi.org/10.1093/cid/cir445  PMID: 21890770 
  24. Public Health England (PHE). Behaviour Change and Antibiotic Prescribing in Healthcare Settings: Literature Review and Behavioural Analysis. London: PHE; Feb 2015. Available from: https://www.gov.uk/government/publications/antibiotic-prescribing-and-behaviour-change-in-healthcare-settings
  25. Cooke R, Sheeran P. Moderation of cognition-intention and cognition-behaviour relations: a meta-analysis of properties of variables from the theory of planned behaviour. Br J Soc Psychol. 2004;43(Pt 2):159-86.  https://doi.org/10.1348/0144666041501688  PMID: 15285829 
  26. Rhodes RE, Dickau L. Experimental evidence for the intention-behavior relationship in the physical activity domain: a meta-analysis. Health Psychol. 2012;31(6):724-7.  https://doi.org/10.1037/a0027290  PMID: 22390739 
  27. Newitt S, Anthierens S, Coenen S, Lo Fo Wong D, Salvi C, Puleston R, et al. Expansion of the ‘Antibiotic Guardian’ one health behavioural campaign across Europe to tackle antibiotic resistance: pilot phase and analysis of AMR knowledge. Eur J Public Health. 2018;28(3):437-9.  https://doi.org/10.1093/eurpub/ckx239  PMID: 29401283 
  28. Chaintarli K, Ingle SM, Bhattacharya A, Ashiru-Oredope D, Oliver I, Gobin M. Impact of a United Kingdom-wide campaign to tackle antimicrobial resistance on self-reported knowledge and behaviour change. BMC Public Health. 2016;16(1):393.  https://doi.org/10.1186/s12889-016-3057-2  PMID: 27177032 
  29. Public Health England (PHE). Antibiotic Guardian. London: PHE. [Accessed 20 Jan 2021]. Available from: https://antibioticguardian.com/
  30. Department of Primary Care and Public Health. Cardiff University. When should I worry? - Your guide to Coughs, Colds, Earache & Sore Throats. Cardiff: Cardiff University; 2016. Available from: http://www.whenshouldiworry.com/
  31. Royal College of General Practitioners (RCGP) and Public Health England. (PHE). TARGET Treating Your Infection (TYI) patient information leaflets. Leaflets to Share with Patients. London: RCGP. [Accessed: 29 Aug 2019]. Available from: https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/amr/target-antibiotics-toolkit/leaflets-to-share-with-patients.aspx
  32. European Centre for Disease Prevention and Control (ECDC). European Antibiotic Awareness Day. Patient brochure. Stockholm: ECDC. [Accessed: 29 Sep 2019]. Available from: https://antibiotic.ecdc.europa.eu/en/patient-brochure
  33. Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ. 2009;339(jul29 2):b2885.  https://doi.org/10.1136/bmj.b2885  PMID:19640941
  34. Jones LF, Hawking MKD, Owens R, Lecky D, Francis NA, Butler C, et al. An evaluation of the TARGET (Treat Antibiotics Responsibly; Guidance, Education, Tools) Antibiotics Toolkit to improve antimicrobial stewardship in primary care-is it fit for purpose? Fam Pract. 2018;35(4):461-7.  https://doi.org/10.1093/fampra/cmx131  PMID: 29300965 
  35. Hockenhull J, Turner AE, Reyher KK, Barrett DC, Jones L, Hinchliffe S, et al. Antimicrobial use in food-producing animals: a rapid evidence assessment of stakeholder practices and beliefs. Vet Rec. 2017;181(19):510.  https://doi.org/10.1136/vr.104304  PMID: 28847873 

Data & Media loading...

Supplementary data

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error