Aiesh et al. BMC Pediatrics(2024) 24:582
https://doi.org/10.1186/s12887-024-05060-y

BMC Pediatrics

RESEARCH

Open Access

Assessing pediatric antibiotic knowledge
and practices among community pharmacists
in Palestine: implications for antibiotic use
and resistance
Banan M. Aiesh1,2, Salsabeel Saleh2, Nadine Matouk2, Marah Labadi2, Sanaa Kmail2, Zaina Baddad2, Amer A. Koni2,3,
Samah W. Al-Jabi2 and Sa’ed H. Zyoud2,4,5*Abstract
Background Antibiotics are widely used in the pediatric population, and their inappropriate use contributes toantibiotic resistance, which is a growing concern in developing countries. Therefore, this national cross-sectional study
aimed to assess community pharmacists’ knowledge, attitudes and practices regarding appropriate antibiotic use anddosing in pediatric patients and to explore the barriers to such use in Palestine.
Methods A questionnaire-based survey was conducted among community pharmacists on the West Bank, Palestine,from September 2022 to March 2023. The survey assessed the pharmacists’ sociodemographic characteristics;
knowledge, practices, and attitudes toward antibiotic use; and understanding of antibiotic dosing. The data wereanalyzed using descriptive statistics, and the factors affecting pharmacists’ knowledge were evaluated.
Results The study included 301 community pharmacists, with an average age of 30.06 years, who were primarily
female (75.1%). The majority of the pharmacists (80.1%) correctly believed that antibiotics are effective against
bacterial infections. However, 18.3% believed that antibiotics are effective against viruses. While 61.8% knew that
antibiotics kill germs, 32.0% were unaware that not all antibiotics require refrigeration. Furthermore, 67.8% were awarethat antibiotics do not speed up recovery from diarrhea. Over 99% of the participants recognized that antibiotic
resistance developed due to various resistant mechanisms. The majority (78.7%) believed that each infection neededa different antibiotic. Pharmacists demonstrated reasonable knowledge of antibiotic dosing in case scenarios.
Knowledge was positively correlated with years of experience (P = 0.001).
Conclusions This study revealed that community pharmacy professionals have a good understanding of antibiotic
usage in pediatric patients. The findings suggest that professional expertise and quality training improve healthcare
services. However, the results may not be universally applicable, as identifying knowledge gaps is necessary to help
with the development of focused interventions. Therefore, ongoing educational initiatives, awareness campaigns andantibiotic stewardship programs are recommended.

*Correspondence:
Sa’ed H. Zyoud
saedzyoud@yahoo.com
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
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Aiesh et al. BMC Pediatrics(2024) 24:582

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Keywords Community pharmacists, Knowledge, Attitude, Antibiotic resistance, Pediatrics

Background
Antibiotics are substances that specifically target bacteria, as they can inhibit growth and even kill bacteria;
hence, they are intended to treat and prevent bacterial
infections [1–3]. Antibiotics are among the most commonly prescribed medications, especially for childhood
illnesses, as in pediatric dentistry [4, 5]. However, themajor contributors to outpatient visits are acute diarrhea, acute upper or lower respiratory infection, and viral
infection with fever, indicating that only a small percentage of pediatric patients (< 20%) need antibiotic therapy[6]. On the other hand, the most common condition inpediatric patients who require antibiotic prescription isacute otitis media, as reported in the United States andCanada [7, 8]. While antibiotics are critical in healthcare, their usage in pediatric care, especially in developing countries, presents unique challenges. According toprevious studies, antibiotics are responsible for 27% of
medication-related pediatric medical errors and 19%of hazardous errors caused by systemic antibiotic use[9–11], especially those related to antibiotic dosing [5].
Antibiotic dosage is determined by taking into accounta number of factors, including age, weight, and coexisting disorders [12, 13]. Furthermore, the lack of clinical
trials on antibiotics for pediatric patients and the lackof new antibiotic pipelines have led to a paucity of highlevel evidence [14, 15]. Antibiotic resistance has reached
an alarming level worldwide, particularly in developing
countries [16, 17]. The inappropriate use of antibiotics,
particularly broad-spectrum antibiotics for these childhood diseases, has contributed largely to the evolutionof antibiotic resistance [6], and this is the most serious
problem worldwide [18]. Cultural, educational, behavioral, and socioeconomic factors are among the numerous factors that contribute to antibiotic resistance.
Therefore, the exacerbation of antibiotic resistance must
be clearly and deeply known by all members of the healthcare system, including pharmacists, and a plan must bepresented for an effective strategy to improve antibiotic
use and the creation of antibiotic supervision programs
to prevent further spread of antibiotic resistance.
While many studies on the appropriate use and dosage of antibiotics for children have been undertaken invarious regions of the world, relatively few studies havefocused on Palestinian community pharmacists to assess
this topic [5, 19–24]. This national study aimed to evaluate the knowledge of community pharmacists on thenorthern West Bank of Palestine on the appropriate use
and dosing of antibiotics for pediatric patients. Overall,this study highlights the importance of increasing awareness campaigns to promote appropriate antibiotic use

in pediatric patients. The results of this study may bevaluable for policymakers and healthcare providers indeveloping local guidelines and interventions to improve
appropriate antibiotic use.

Methods
Study design and settingThis was a cross-sectional questionnaire-based study thatwas conducted in Palestine from September 11, 2022, toMarch 27, 2023, targeting pharmacists working in community pharmacies. Participants were approached from 5
different cities, Nablus, Jenin, Tubas, Tulkarm, and Qalqilya, and from their respective villages and camps, which
represent northern Palestine. The data were gathered
through the use of a well-organized questionnaire distributed online. This online survey was administered via
the SurveyMonkey platform and subsequently disseminated across various digital channels, including WhatsApp, Facebook Messenger, Facebook, and email. Due tologistical limitations, we opted for online data collection
methods instead of in-person visits to specific districts.
Notably, many other studies have also supported theuse of a self-administered questionnaire survey methodfor data collection [6, 25, 26]. Approximately 10–15 min
were needed to complete the questionnaire. The study
protocol was approved by the Institutional Review Board(IRB) of An-Najah National University.
Sampling procedure

According to a previous study [27], there were 2350 pharmacists in Nablus, Jenin, Tubas, and Qalqilya. The Daniel
formula was used [28]; n = Z2*P (1-P)/d2, where n = thecalculated sample size for populations exceeding 10,000,
z = 1.96 (95% CI), d = 0.05 (absolute precision as a marginof error), and P = 0.5 expected prevalence or response distribution. The sample size was 385 participants. However,since our population was less than 10,000 (N = 2,350), we
adjusted this number using the adjusted sample equation;
adjusted sample = n/(1 + (n/N)). The sample size needed
was approximately 331, considering a 5% margin of error,a response of 50%, and a 95% confidence interval.
Questionnaire development

A thorough evaluation of relevant surveys was performed
to identify potentially relevant questions for the questionnaire utilized in our study [5, 21, 26, 29–37]. A comprehensive review of the questionnaire was performed
to validate the questions and ensure that the answers
were correct. The questionnaire was subsequently sentto specialists with extensive research experience, including an infectious disease medical doctor, an infectious

Aiesh et al. BMC Pediatrics(2024) 24:582

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disease clinical pharmacist, and an academic pharmacy
researcher. These experts conducted individual reviewsof the questionnaire and made comments and modifications. The initial version of the questionnaire wasadjusted based on their recommendations. Minor modifications were also made in the subsequent revisions until
the final version was obtained. The infectious disease
specialists provided correct answers. Finally, all specialists read the final edit and approved it.
Prior to the release of the survey, a pilot study of ten
questionnaires was performed to analyze and clarify thequestionnaire items. The questionnaire has four major
components:• 	 The first part contains questions regarding
sociodemographic characteristics (gender, age, yearsof working, etc.).
Table 1 Sociodemographic characteristics of the study sample
VariableAge category (years)
< 45
≥ 45
GenderMale
FemaleResidency
Refugee campVillage
City
Educational level
Pharmacy, bachelor’s degree
Doctor of pharmacy
Master’s degree in pharmacy
PhD in pharmacy
Graduation place
Palestine
Outside Palestine
Position in the pharmacy
Employee pharmacists
Employer pharmacists
Years of working<5≥5Household income per month< 2000 NIS
2000–4999 NIS≥ 5000 NIS
Hours of work per day
<8 h
8h
>8 h
NIS: new Israeli shekel

Frequency (%)
N = 301270 (89.7)
31 (10.3)
75 (24.9)
226 (75.1)
20 (6.6)
131 (43.5)
150 (49.8)
231(76.7)
47 (15.6)
21 (7.0)
2 (0.7)
264(87.7)37(12.3)
203 (67.4)
98 (32.6)
183 (60.8)
118 (39.2)
52(17.3)
201(66.8)48(15.9)109(36.2)
138(45.8)
54 (17.9)• 	 The second part included questions assessing
participants’ knowledge, practices, and attitudes
toward antibiotic use and antimicrobial resistance.
• 	 The third part was composed of questions regarding
a case scenario for antibiotic dosing and labeling of
instructions.
• 	 The fourth part concentrates on evaluating thebarriers and obstacles to the appropriate prescription
and use of antibiotics, as well as the effects ofsociodemographic factors on the knowledge ofcommunity pharmacists about appropriate antibiotic
use in pediatrics.
Inclusion and exclusion criteria

The study included pharmacists in the northern WestBank (Jenin, Nablus, Tulkarm, Qalqilya, Tubas, and theirvillages and camps), provided that they were registeredwith Palestine Pharmacists Syndicate and working community pharmacies aged 23 years and older. The study
excluded nonworking pharmacists and pharmacists
working in pharmaceutical fields other than community
pharmacies, such as hospital pharmacies, pharmaceuticalfactories, and medical representatives.
Statistical analysis

Data analysis was performed with IBM SPSS version 29.
Descriptive analysis was used to summarize the data,
including frequency and percentage for categorical variables and mean and median for continuous variables.
The total knowledge score for antibiotics was calculated
and ranged from zero to fifteen, where a score of zero
indicated that all questions were answered incorrectly
and a score of fifteen indicated that all questions wereanswered correctly. The pharmacists were then classified as knowledgeable or non-knowledgeable based on
their total score. Non-knowledgeable pharmacists were
those who answered fewer than eight questions correctly,
while knowledgeable pharmacists were those who scoredeight or more points. The Mann‒Whitney test was used
for binary variables, the Kruskal‒Wallis test was usedfor variables with more than two groups to analyze theknowledge score, and a p value less than 0.05 was considered to indicate statistical significance.

Results
Sociodemographic characteristics of the study sample

Among the 301 community pharmacists who completed the questionnaire, the average age was 30.06
years, and the vast majority of the pharmacists werefemales (75.1%). Approximately half of them lived in thecity (49.8%). In addition, 87.7% of them graduated from
Palestinian universities, and more than half worked as
pharmacy employees (67.4%). In addition, most of theAiesh et al. BMC Pediatrics(2024) 24:582

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Table 2 Knowledge of community pharmacists in Palestine about antibiotics
Questions#

AnswerCorrect
answerN (%)

Incorrect
answerN (%)

1. Antibiotics are effective against symptoms of a viral origin such as flu/common cold?
2. Antibiotics are effective for cough that lasts more than a week?
3. Antibiotics are safe drugs without adverse effects
4. Should all antibiotics be placed in the refrigerator after reconstitution
5. Is aluminum hydroxide + magnesium hydroxide an antibiotic
6. Are antibiotics useful for killing germs?
7. Does diarrhea improve faster with antibiotics
8. Misuse of antibiotics leads to resistance
9. Resistance to antibiotics occurs when bacteria develop mechanisms that protect themfrom the effects of antibiotics
10. If bacteria are resistant to antibiotics, it can be very difficult to treat the infections
11. Each infection needs a different antibiotic
12. Is amoxicillin/clavulanate used in acute otitis media?
13. Is trimethoprim/sulfamethoxazole used in lower urinary tract infection
14. Is azithromycin used in acute bacterial pharyngitis?
15. Is cefdinir used in acute bacterial sinusitis?

F
F
F
F
F
F
F
T
T

241(80.1)
181 (60.1)
269 (89.4)
264 (87.7)
278 (92.4)
102 (33.9)
204 (67.8)
298 (99)299(99.3)55(18.3)
100 (33.2)
29 (9.6)
64 (32.0)
4 (1.3)186 (61.8)
77 (25.6)2(0.7)
2 (0.7)Don’tknow theanswerN (%)
5 (1.7)20 (6.6)3 (1)8 (2.7)19 (6.3)
13 (4.3)
20 (6.6)
1 (0.3)
0

T
T
T
T
T
T

276(91.7)
237 (78.7)
279 (92.7)
280 (93)280 (93)244 (81.1)

22 (7.3)
61 (20.3)
17 (5.6)
12 (4)
20 (6.6)
29 (9.6)

3 (1)
3 (1)
5 (1.7)9 (3)1 (0.3)28 (9.3)#These questions were adapted from previous studies [5, 31–33, 37]

Table 3 Practices of community pharmacists in Palestine toward pediatric antibiotics
Statements #1(Weak)2 (Acceptable) 3(Good)

5 (Excellent)

79 (26.2)
28 (9.3)
69 (22.9)
87 (28.9)73(24.3)

4
(Very
good)
98 (32.6)
102 (33.9)
112 (37.2)
78 (25.9)82(27.2)

1. Easily adapt a pediatric antibiotics prescription.
2. Select the most appropriate dosage form for a given pediatric prescription.
3. Assess the suitability of a dose for pediatric antibiotic prescription.
4. Recalculate the dose written by the physician in the child’s antibiotic prescription.
5. Contact the doctor when inappropriateness in prescription is noted(dose/frequency is too high or too low).
6. I participate in antibiotic awareness campaigns to promote the optimal use ofantibiotics.

11 (3.7)
13 (4.3)
4 (1.3)
13 (4.3)
16 (5.3)

31 (10.3)9 (3)20 (6.6)
29 (9.6)
25 (8.3)

40 (13.3)

44 (14.6)89(29.6)

41(13.5)87(28.9)82 (27.2)
82 (27.2)
96 (31.9)
92 (30.6)
105(34.9)#These statements were adapted from previous studies [35, 36]participants had less than 5 years of experience (60.8%).
All the details can be found in Table 1.
Knowledge of community pharmacists in Palestine on
antibiotics

The pharmacists’ knowledge about antibiotics is shownin Table 2. The results showed that 18.3% of the pharmacists still believed that antibiotics were effective against
viruses. More than half of the pharmacists thought that
antibiotics were effective for coughs lasting more than aweek, and 61.8% answered that antibiotics were usefulfor killing germs. Only 67.8% knew that diarrhea did not
improve faster with antibiotics.
Antibiotic resistance, according to more than 99%of the pharmacists in our study, occurs when bacteria develop various resistance mechanisms against theeffects of antibiotics, and 92.1% of the pharmacists
agreed that it can be very difficult to treat the infections
they cause.

When azithromycin was used for acute bacterial pharyngitis, 93% of the pharmacists correctly answered thattrimethoprim/sulfamethoxazole can be used for lower
urinary tract infections. For the otitis and sinusitis scenarios, our findings showed that the majority of pharmacists (92.7% and 81.1%, respectively) correctly answered
the use of amoxicillin/clavulanate and cefdinir as therapeutic options.
Practices of community pharmacists in Palestine toward
pediatric antibiotics

A descriptive analysis of the practices of community
pharmacists toward pediatric antibiotics is shown in
Table 3. For example, adaptation to pediatric antibiotic
prescriptions was rated as very good for 32.6% of pharmacists and weak for 3.7%. Regarding the recalculationof the dose written by the physician in the prescriptionof antibiotics for children, 30.6% were excellent, and4.3% were weak. Furthermore, 34.9% of the patients were

Aiesh et al. BMC Pediatrics(2024) 24:582

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Table 4 Prescription scenario
In this prescription scenario, respondents were shown a prescription
for amoxicillin suspension 400 mg/5 mL, dose 800 mg, for a 20-kg
patient.

AnswerCorrect
answerN(%)

1. You have the above prescription; would you fill this prescription?

No, the dose is too high, I need more
information
Give 10 ml by mouth twice daily for 10 days
Give 10 ml (800 mg) by mouth twice daily for
10 days250 (83)

Incorrect
answerN(%)
51 (17)235 (78)

66 (22)

2. How would you label this prescription?

Table 5 Attitudes of pharmacists toward antibiotic use
statements #

Agree
N (%)

DisagreeN (%)

1- Dispense antibiotics without prescription due to the demand of parents.
2- Antibiotics are medicines of special importance.
3- I may be held responsible for the nonprescription dispensing of antibiotics, as this is a public health risk.
4- Inappropriate antibiotic therapy does not cause significant surplus health costs annually.
5- Education about antibiotics and antibiotic resistance should be more prominent during university training
6- I consider it important to become acquainted with the antibiotics of the current drug pool and those newly
licensed on the market.
7- For parents who request antibiotics for their children without prescription and are probably not in need of antibiotic therapy, I feel obligate to inform and educate them
8- There are several occasions when more time is needed to educate patients because doctors have not done thisproperly.
9- The counseling of community pharmacists is equally important as the physician’s recommendations
10- The personality and behavior of the patients significantly influence my dispensing practices.
11- In detail, the proper use of antibiotics when counseling the patient is described.
12- Proper use of antibiotics would be greater if pharmacists had time to carry out their duties.
pharmacological care duties
13- Appropriate patient education would effectively reduce the incidence of infectious diseases
14- During my work as a pharmacist, I have to make therapeutic decisions about acute infection but also have toprovide lifestyle advice to the patient.
15- I offer probiotics for patients purchasing a prescribed antibiotic.

61 (20.3)
289 (96)242(80.4)
58(19.3)295(98)288(95.7)

222 (73.8)
7 (2.3)46 (15.3)
231(76.6)4(1.3)
5(1.7)

I don‘t
know
N (%)
18(6)
5 (1.7)13(4.3)12(4)2(0.7)
8(2.7)

288(95.7)9(3)4 (1.3)297(98.7)

3 (1)1(0.3)

292(97)207(68.8)290(96.3)279(92.7)7(2.3)
87(28.9)7(2.3)
14(4.7)2(0.7)
7 (2.3)4(1.3)
8(2.7)

287(95.3)292(97)11(3.7)5(1.7)3(1)4(1.3)

143(47.5)

111(36.9)47(15.6)#

These statements were adapted from a previous study [33]excellent, and 5.3% of them were weak in contacting thedoctor when an inappropriate regimen (antibiotic dose/
frequency is too high or too low) was noted. According to
the analysis of the prescription scenario, 78% of the pharmacists gave instructions correctly, and 83% refused tofill prescriptions due to the wrong dosage (Table 4).
Attitudes of pharmacists toward antibiotic use

As noted in Tables 5 and 95.7% of the pharmacists considered themselves responsible for informing and educating parents who requested antibiotics for their children
without a prescription and who were probably not inneed of antibiotic therapy. Furthermore, 97% of themagreed that the medicine-related counseling of community pharmacists was just as important as the recommendations of the physician. However, there is somevariation, where 20.3% of pharmacists dispense antibiotics without prescriptions due to the demands of parents. Furthermore, 80.4% of the pharmacists believedthat nonprescription dispensing of antibiotics was apublic health risk, and 47.5% of them offered probiotics
for patients purchasing prescribed antibiotics.
Barriers that prevent the appropriate prescription and useof antibiotics

According to the pharmacists, there were many barriers
that could prevent appropriate antibiotic prescription
and use, such as parents’ behavior with respect to antibiotic use (91.7%), physician malpractice with respect toprescribing antibiotics (88.7%), and parents’ pressure toprescribe antibiotics (87.3%), as illustrated in Table 6.
The effects of sociodemographic factors on the knowledgeof community pharmacists about appropriate antibiotic
use in pediatrics

The analysis of sociodemographic factors affecting theknowledge of community pharmacists about antibiotics showed that age, position in the pharmacy, social
status, and years of work were independently associatedwith the knowledge of community pharmacists about

Aiesh et al. BMC Pediatrics(2024) 24:582

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Table 6 Barriers that prevent the appropriate prescription anduse of antibiotics

Table 7 Knowledge of community pharmacists according todemographic characteristics

statements #Variable

Patient pressure to prescribe antibiotic.

Yes
N (%)
263 (87.3)

Parents’ behavior with regard to antibiotic use.
Malpractice of the physician with respect to theprescribing of antibiotics.
Hard to clinically differentiate between viral andbacterial infections; yet, not requesting microbiological investigation
No clear understanding/follow-up of the clinicalguidelines.
Limited physician-pharmacist and physician‒patient communication related to antibiotic
prescription and use
Antibiotic prescribing regulations.

276 (91.7)
267 (88.7)

Data on antibiotic resistance patterns and availability of narrow spectrum antibiotic.
Workload and restricted time of consultation.

249 (82.8)

Pharmacists’ authority is limited

71 (23.6)

151 (50.2)

246 (81.7)
230 (76.4)

238 (79.1)

227 (75.4)

No
N (%)
37
(12.3)
24 (8)
33
(11)
2
(0.6)
54
(17.9)
70(23.3)
62(20.6)
52(17.3)
73(24.2)
230(76.4)∗

These statements were adapted from a previous study [26]antibiotics. Age was positively associated with pharmacist knowledge, as pharmacists aged 45 years and older
were more knowledgeable than those under 45 years (Pvalue = 0.013). Additionally, position in the pharmacy had
a positive association with pharmacists’ knowledge, andpharmacists who were employees were more knowledgeable than those who were employers (P value = 0.002).
Furthermore, years of work experience were positively
associated with pharmacist knowledge: pharmacists with
5 years of working experience were more knowledgeable
than those with less than 5 years of working experience(P value = 0.001). The details are shown in Table 7.

Discussion
The current study revealed that community pharmacists were highly knowledgeable about the appropriateprescription and use of antibiotics (98%). While pharmacists may not serve as prescribers in many countries,
knowledge about the appropriate selection of antibiotics is crucial. They play an important role in conducting
interventions or providing recommendations to clinicians regarding the appropriate choice of drugs. Several
studies have evaluated pharmacists’ beliefs that antibiotics are not effective at treating cold, flu, or cough. In
Jordan, 56.1% of pharmacists believed that antibiotics
would never treat cold, cough, or flu [38]; Zakaa El-din
et al. reported that 10.4% of the respondents thought that
antibiotics are helpful for sore throat and common colds[39], while in Catalonia, Spain, 34.8% of pharmacists

Age category (years)
< 45
≥ 45
GenderMale
FemaleResidency
Refugee campVillage
City
Educational level
Pharmacist
Doctor of pharmacy
Master’s degree in pharmacy
PhD in pharmacy
Graduation place
Palestine
Outside Palestine
Position in the pharmacy
Employee pharmacists
Employer pharmacists
Years of working<5≥5Household income per month< 2000 NIS
2000–4999 NIS≥ 5000 NIS
Hours of work per day
<8 h
8h
>8 h

Frequency Knowledge(%);
score;
N = 301Median[Q1-Q3]P
value*

270 (89.7)
31 (10.3)

12.5 [11–14]
13 [12–14]

0.013b75 (24.9)
226 (75.1)

12 [12–14]
13 [12–14]

0.689b20 (6.6)
131 (43.5)
150 (49.8)

12 [11.3–13]
13 [11–14]
13 [11–14]

0.412a231(76.7)
47 (15.6)
21 (7.0)
2 (0.7)

13 [11–14]
12 [11–14]
12 [11–13]
8.5 [6–11]

0.179a264(87.7)37(12.3)

13[11–14]
13 [12–14]

0.515 b203 (67.4)
98 (32.6)

12 [11–14]
13 [12–14]

0.002b183 (60.8)
118 (39.2)

12 [11–14]
13 [12–14]

0.001b52(17.3)
201(66.8)48(15.9)

12 [11-13.8]
13 [11–14]
12 [11–14]

0.127a109(36.2)
138(45.8)
54 (17.9)

12 [11–114]
13 [11–14]
12 [11–14]

0.239 a* Bold values denote statistical significancea Kruskal‒Wallis testb Mann‒Whitney U test

dispensed antibiotics for sore throat complaints [40]. In
our study, 80.1% of the pharmacists were against prescribing antibiotics for these indications. However, 61.8%of the pharmacists responded that antibiotics are effective at killing germs. This could be attributed to the factthat the term “germs” is generally used with antibiotics
rather than specific bacteria [37]. This demonstrates thecritical need for pharmacists to be more knowledgeable
about antibiotic indications, and they should feel obligated to make patients aware of their misuse and the consequences of their actions.
Almost all the pharmacists (99%) in our study
responded that the misuse of antibiotics led to antimicrobial resistance, whereas 79% of those in the Jordanian

Aiesh et al. BMC Pediatrics(2024) 24:582

study [38] and another Palestinian study (92.1%) reported
antimicrobial resistance [41]. The substantial increase inknowledge could be attributed to the fact that community pharmacists are well educated and have professional
skills and training that allow them to provide the best
health care services [34], as well as the fact that many
patients seek medical advice directly from community
pharmacies because they are faster and less expensive
than doctor clinic visits are and because they are considered reliable and easy to contact healthcare providers [39,42].
The level of practice in the current study was assessedby presenting one case scenario and six questions on thepractices of community pharmacists in Palestine regarding pediatric antibiotics. Approximately 61.5% of community pharmacists correctly calculated the dose ofamoxicillin, compared to 54% in Chicago [25]. The variability could be attributed to differences in study objectives and study populations (age groups, sample size), in
addition to the fact that more than 99.9% of community
pharmacies dispense amoxicillin and cephalexin over thecounter, so they are familiar with the dosing [43].
Regarding the evaluation of the practices of community
pharmacists in Palestine regarding pediatric antibiotics, 86.4% would consult physicians if they were uncertain about the appropriateness of antibiotic prescription.
This finding is in agreement with the results of a study in
Senegal (90.2%) [44] and greater than what was reported
in the Jordanian study (53.5%) [38] as well as the study
by Rehman et al. in Pakistan (32%) [45]. In Palestine, as
in some developing countries, patients can obtain antibiotics from pharmacies without a prescription [27, 39].
In fact, because some participants do not refer to physicians due to poor physician response, this may reflect thenecessity of strengthening interprofessional relationships
between healthcare teams, most likely starting with university curricula. Pharmacists and other health care practitioners should collaborate in multidisciplinary teams
to minimize antimicrobial irrationality and inappropriate use and hence antimicrobial resistance. Understanding how to develop relationships with caregivers canhelp change their attitudes and increase the acceptabilityof pharmacists who interfere with children’s antibiotic
prescriptions. Caregivers seeking symptom relief may
be more amenable to nonantibiotic options [46]. With
respect to dosing considerations, 85% of the pharmacists
recalculated the dose written by the physician before dispensing the antibiotic. Almost 93% of the pharmacists
correctly answered the question on utilizing azithromycin for acute bacterial pharyngitis. Similarly, the useof a trimethoprim/sulfamethoxazole dosage for treating lower urinary tract infections was identified for 93%
of the patients. Our knowledge rates were higher thanthose reported by Keewan et al. in their study in Jordan

Page 7 of 10[5], where the largest number of community pharmacists(55.8%) properly answered the case of azithromycin dosein acute bacterial pharyngitis, while 15.7% of the pharmacists correctly answered the dosing of trimethoprimsulfamethoxazole in lower urinary tract infection. To
ensure the accurate dispensing of antibiotics for pediatricpatients, double-checking could be implemented.
Approximately 98% of participants agreed that education about antibiotic use and antibiotic resistance should
be more prominent during university education years, asconcluded by studies in India [47], Trinidad and Tobago[48], and East Africa [49].
In our study, several factors exhibited statistically significant associations with pharmacist knowledge. These
factors include younger age, employment status within
a community pharmacy, and an accumulation of morethan five years of professional experience. A study carried out in the West Bank, Palestine, demonstrated
that women and those living in urban areas have higher
knowledge scores [41]. On the other hand, it was discovered that pharmacist education, professional title,
and years of experience had an impact on the pharmacist’s understanding of antimicrobial medications [50].
These findings highlight the importance of customizing
antimicrobial stewardship programs to meet pharmacist
requirements, taking into account sociodemographic differences. In addition, regarding the years spent working
in the pharmacy, this association could be because pharmacists spend much time in the pharmacy, which means
more time communicating with patients, prescriptions,and promotional representatives who scientificallyexplain their medications.
Several community pharmacists have reported barriers that can contribute to inappropriate antibiotic use inpediatrics. Among them, parental behavior and pressure
to prescribe antibiotics (91.7% and 87.3%, respectively)
were the barriers most frequently reported. This was followed by malpractice in antibiotic prescribing (88.7%).
These findings were consistent with a study conductedin Lebanon in which pharmacists first blamed parents(90.1%), second-level physicians (72.8%) and third-level
physicians (59.4%) for inappropriate antibiotic use andthe emergence of antimicrobial resistance [37]. Furthermore, in Qatar, patients and practitioners, mainly
physicians, play a role in shaping barriers to appropriate antibiotics [26]. In contrast, unfounded assumptions
about the efficacy of antibiotics by health professionals,
as well as an exaggeration of parents’ desire for medications, may be the key contributing cause of antibiotic
overprescription for the common cold in Korea [51].
This would support the need for antibiotic stewardship programs and effective behavior change programs
that are getting off to a good start to optimize antibiotic
prescription.

Aiesh et al. BMC Pediatrics(2024) 24:582

Strengths and limitations

The strengths of this study include the high number of
responses and the scenario design that community pharmacists are more likely to encounter; moreover, the study
succeeded in containing clear questions about practices
and attitudes toward antibiotic use. This is the first study
in the West Bank, Palestine, to discuss antibiotic use anddosing among pediatric patients. However, there are a
few limitations. For example, using the cross-sectional
design in this study prevented us from interpreting thecausality of significant associations. In addition, the current study is based on the real practice of pharmacists
with respect to antibiotic use, so the pharmacist might
check a reference or consult a colleague when answering the cases, which could lead to an overestimation ofpharmacist knowledge. Additionally, the research inquestion employed an online survey featuring a convenience sample. Consequently, there is potential for bias,
as the survey’s reach may be confined to individuals withinternet connectivity. Furthermore, the utilization of theconvenience-oriented snowball sampling method raises
concerns about the representativeness of this study’s
findings in relation to the entirety of Palestinian pharmacies. The smaller sample size and the use of online surveys may limit the generalizability of the study’s findings
to the entire population of pharmacists in the northernWest Bank of Palestine. However, the final sample size
remains statistically robust for analysis considering the
population size. Further research with a larger sample
size and a more representative recruitment strategy could
strengthen the generalizability of the results. The final
constraint pertains to the study’s design, which adopts across-sectional analysis. This design impedes the identification of causation and limits the generalizability of thestudy’s findings.

Conclusions
This study aimed to assess the level of knowledge possessed by community pharmacy professionals with regard
to the correct use of antibiotics by pediatric patients. The
investigation revealed that a significant proportion ofcommunity pharmacists demonstrated a commendable
understanding of the appropriate usage of antibiotics.
Furthermore, the outcomes indicated a positive correlation between pharmacists’ knowledge and their years ofprofessional experience and social status. This observation lends support to the proposition that the acquisitionof professional expertise and the quality of training contribute to the provision of enhanced healthcare services.
The findings derived from this investigation provide valuable insights into the proper use of antibiotics in pediatric care. Nevertheless, it is worth noting that the resultsof this study may not be readily generalizable to a broader
population. Consequently, it is advisable to implement

Page 8 of 10

ongoing educational programs, including interactive
workshops and lectures led by infectious disease specialists, under the coordination and support of the Palestinian Pharmacist Syndicate and awareness campaigns
aimed at enhancing the prescription and utilization of
antibiotics among community pharmacists. This recommendation is especially pertinent in light of the continuously evolving guidelines and evolving information
within this domain.
Future perspectives

This study emphasizes the need for continuous educational and awareness efforts to improve the understanding of proper antibiotic use and prescription guidelines
among children. Due to the high frequency of mistakes
in pharmaceuticals, especially related to dosage, providing effective treatments for children is crucial for
reducing this problem and improving patient safety
standards. Future research efforts may focus on developing and implementing educational programs specificallydesigned to enhance the knowledge and skills of community pharmacists in this field. Moreover, there is a significant advantage in educating parents and caregiverson the prudent use of antibiotics and the possible risks
associated with prescription inconsistencies. This can beachieved through the use of educational materials, suchas brochures distributed in pediatric clinics. In addition,community pharmacists should take the lead in ensuring that parents understand the instructions, risks, andproper use of antibiotics. Furthermore, future research
may aim to examine the impact of these treatments on
the prescription practices of pharmacists, patient healthoutcomes, and healthcare costs. In conclusion, the resultsof this study have the potential to impact policy choices
and inspire practical improvements in the quality ofcare for children while limiting the risk of prescription
mistakes.
Abbreviations
IRB	Institutional Review Board
NIS	New Israeli Shekel
PhD	Doctorate of Philosophy
SPSS	Statistical Package for the Social Sciences
Acknowledgements
Many thanks to the Clinical Research Centre of An-Najah National University
Hospital for constant support and wise advice.
Author contributions
SS, NM, ML, SK, and ZB performed data collection, reviewed the literatureand data analysis and wrote the draft manuscript. SA and AK participated indata analysis and wrote the draft manuscript. SZ and BA conceptualized anddesigned the study, coordinated, supervised, and analyzed the data, criticallyreviewed the manuscript to improve intellectual content, and assisted in the
final manuscript review. Then, all the authors reviewed and accepted the final
manuscript.
Funding
None.

Aiesh et al. BMC Pediatrics(2024) 24:582

Data availability
The data sets supporting the results of the present research are available fromthe corresponding authors upon request.

Page 9 of 108.
9.

Declarations
Ethics approval and consent to participate
The present study received approval from the Institutional Review Board (IRB)of An-Najah National University (Ref: Pharm D. Sep. 2022/34). In accordancewith the principles of informed consent, the act of survey completion wasconstrued as a manifestation of participants’ consent, given that the survey
was distributed via online platforms utilizing a SurveyMonkey® account.
Information concerning voluntary participation and the right to withdraw
from the study was provided within the invitation, prominently displayed on
the cover page. The cover page additionally elucidated the study’s objectives
and provided guidance on how to respond to the survey questions. The
data collected during the course of this study were exclusively utilized forresearch purposes and were diligently safeguarded to ensure anonymity andconfidentiality. Participants were not provided with any form of incentive tomotivate their survey participation. The IRB of An-Najah National University
deemed it appropriate to waive the necessity for written informed consent,
as the study was considered to pose minimal risk, and all procedures adheredrigorously to pertinent guidelines and regulations.
Consent to publish
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Department of Infection Prevention and Control, An-Najah National
University Hospital, Nablus 44839, Palestine2
Department of Clinical and Community Pharmacy, College of Medicine
and Health Sciences, An-Najah National University, Nablus
44839, Palestine
3
Division of Clinical Pharmacy, Department of Hematology and Oncology,
An-Najah National University Hospital, Nablus 44839, Palestine
4
Poison Control and Drug Information Center (PCDIC), College ofMedicine and Health Sciences, An-Najah National University,
Nablus 44839, Palestine
5
Clinical Research Center, An-Najah National University Hospital,
Nablus 44839, Palestine
Received: 21 October 2023 / Accepted: 5 September 2024

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