The study results revealed that the overall knowledge scores were excellent. However, 22% of the respondents believed that antibiotics are anti-inflammatory drugs. A similar study conducted in China revealed that approximately one-third of participants shared this misconception23. Therefore, it is important to address this issue in future educational programs to promote a better understanding of the role of antibiotics in bacterial infections rather than prescribing them for any inflammatory condition.
A study conducted in China revealed that 90% of pediatricians believe that antibiotics have limited effectiveness on influenza-like symptoms23, which is similar to our results. Additionally, 99.1% of the participants believed that the misuse of antibiotics can lead to bacterial resistance. However, a previous study conducted among pharmacists in Palestine revealed that almost half of them believed that antibiotic misuse was harmless24. Two studies conducted in Saudi Arabia and Ghana revealed that one-third of public residents had not heard of antibiotic resistance or whether it can lead to resistance25,26.
A study conducted in Ghana also revealed that public residents living in rural areas had less knowledge about the effectiveness of antibiotics on viral illness, although there was no significant difference in overall knowledge regarding the place of residence26. Our results also revealed that respondents who worked in villages had lower knowledge scores than did those who lived in cities did, although the difference was not statistically significant.
The majority of participants in a study conducted in Palestine agreed that antibiotic resistance is a significant public health issue in their country and is caused mainly by the misuse of antibiotics. Similarly, a study in Greece revealed that most participants were aware of the problem of antibiotic resistance in their country and globally27. Antibiotic resistance is also perceived as a significant issue by doctors at all levels, including juniors, seniors, and specialists, in France, Scotland, and Spain28,29. In Thailand, a study revealed that doctors-in-training had higher knowledge scores concerning antibiotic indications and infection control. They also had a greater perception that antibiotic resistance is a worldwide issue compared with that of final-year medical students30. Our study revealed that participants had a positive attitude toward antibiotic use, with an average score of 43.4. The majority of respondents did not approve of the use of antibiotics for common colds. Additionally, 88.8% of the participants agreed that broad-spectrum antibiotics should not be used for most acute URTIs because they are not effective against viral infections. This finding aligns with a study conducted in China, which revealed that only 22.7% of pediatricians preferred broad-spectrum antibiotics23, as did another study from Palestine, which revealed that 92.4% did not prescribe two or three antibiotics to control the disease31. Several studies have shown that the use of broad-spectrum antibiotics contributes significantly to the development of antibiotic resistance27,29.
A study conducted in Palestine revealed that despite the knowledge that antibiotics can cause resistance, parents still agreed to use antibiotics for their children’s URTIs in 79.7% of cases. However, nearly two-thirds of parents did not believe that most URTIs were of viral origin5. According to our research, 11% of the participants stated that they did not have sufficient time to explain the proper use of antibiotics to parents. While this percentage may seem small, it is vital that physicians take the time to educate parents about antibiotics, as they are considered the primary source of information for 61% of parents5. Raising awareness about the appropriate use of antibiotics can help prevent the misuse or overuse of these drugs. The duration of time available to explain antibiotics to parents was not influenced by the type of healthcare setting, as there was no significant difference observed between private and governmental hospitals. Although governmental departments had more patients visiting them, as many of them had medical insurance, this did not affect the duration of the explanation time. Furthermore, there was no correlation between the selection of broad-spectrum antibiotics or amoxicillin and the type of hospital setting, whether private or governmental.
In the practice section of our study, several reasons for prescribing antibiotics to children with URTIs were examined, including fever lasting for more than 5 days and yellow or greenish nasal discharge. Unfortunately, nearly half of the participants agreed to prescribe antibiotics in these situations, even though they were not justified according to the guidelines from the National Institute for Health and Care Excellence (NICE)32. Furthermore, approximately one-fifth of the participants considered factors such as uncertainty in diagnosis, history of recurrent URTIs, and attempts to avoid secondary bacterial infections as potential reasons for prescribing antibiotics. However, URTIs are self-limited and do not require antibiotics.
The majority of participants (80%) agreed on prescribing antibiotics for patients with otitis media, as well as for patients with tonsillitis (70%), in contrast to the findings of a Jordanian study, in which 16.9% of participants prescribed antibiotics for otitis media and 15% for tonislitis33. Another study in Palestine reported that antibiotics were prescribed for acute otitis media in 13.5% of cases and for tonsillitis in 56.9% of cases34. However, these conditions alone are not indications for antibiotics unless specific circumstances are present. For pharyngitis, antibiotics can only be used if they are confirmed by a positive rapid antigen test, which is not recommended for patients with acute pharyngitis with clinical features that strongly suggest a viral etiology (e.g., cough, rhinorrhea, hoarseness, and oral ulcers)18. On the other hand, bacterial sinusitis can be diagnosed and treated with antibiotics if symptoms worsen “double-sickening”, persist for more than 10 days, or if symptoms are severe since onset17,35,36. Finally, antibiotics are never an indication for the common cold36.
The results of our study regarding the practices of participants were not consistent with their level of knowledge, indicating that good knowledge does not necessarily translate into appropriate practice. This is partially supported by the weak correlation between knowledge and practice. Therefore, educational interventions and continuous surveillance are recommended to ensure that antibiotics are prescribed in a more professional manner. Our study highlights a persistent and troubling issue: antibiotics are still being overprescribed for URTIs. Comparing our findings with studies from Palestine and neighboring countries provides a clearer picture of how antibiotics are being prescribed in real-world settings for URTIs.
In Palestine, Maraqa et al. (2023) reported that antibiotics are still commonly used for URTIs in primary care, even though guidelines advise against them for viral infections. This aligns with our findings, where many patients were prescribed antibiotics for viral illnesses—cases where these medications simply do not work31. Similarly, AbuMohsen and Abusheikha (2022) highlighted a troubling pattern of unnecessary antibiotic prescriptions in the West Bank-Palestine, pointing to what may be a national challenge in following international guidelines34.
The issue is not limited to Palestine. In Jordan, Al-Alkhaldi et al. (2021) reported that antibiotics are often prescribed for mild URTIs. They noted that this overuse is partly driven by patient pressure and physicians’ reluctance to deny treatment—a dynamic that we also observed in our study33. Moreover, in Saudi Arabia, Al Munjem et al. (2022) reported frequent misuse of antibiotics for likely viral URTIs, underscoring the urgent need for better antibiotic stewardship37.
These findings collectively highlight a shared challenge across the region: the need to bridge the gap between clinical practice and established guidelines to ensure that antibiotics are used responsibly.
Limitations of the study
As with other self-administered studies, social desirability bias may result in differences in understanding the meaning of specific questions. Therefore, we cannot guarantee that all the participants provided true and honest answers. For example, participants may have responded on the basis of what they believe to be the appropriate behavior or what they think should be done in a particular scenario rather than reflecting their actual practice with patients. Importantly, this cross-sectional study assessed the knowledge, attitudes, and practices of participants at a single point in time without considering the time before or after the study was conducted. As a result, it may not capture changes in practice over time.
Conclusions and recommendations
While pediatricians generally have a good understanding of antibiotics and are positive about prescribing them, some still hold misconceptions, such as believing that antibiotics have anti-inflammatory effects and misuse them for treating URTIs. Factors such as time pressures, parental requests, and uncertainty about diagnoses also impact their prescribing behavior. To improve antibiotic use, it is not enough to provide more knowledge; we need to take a broader approach that includes raising public awareness, enforcing policies on over-the-counter antibiotic sales, and expanding stewardship programs. Pediatricians also need support in taking the time to explain treatments to parents. Given their close relationships with families, pediatricians are in a unique position to help reduce antibiotic misuse and promote better practices, and future research should involve general practitioners in primary care as well.
