Antibiotics are medicines used to treat bacterial infections by killing bacteria or inhibiting their growth. ¹ They play an important role in treating bacterial infections, including life-threatening ones. ² However, microorganisms are becoming less susceptible to antibiotics, and by implication, infections are becoming difficult to treat due to antibiotic resistance. ³

Antibiotic misuse refers to the use of antibiotics in a manner inconsistent with appropriate clinical guidance, such as self-medication, non-prescription use, inappropriate use for viral infections, incorrect dosing, premature discontinuation, sharing antibiotics, or using leftover antibiotics. ⁴ The misuse of antibiotics has contributed to a constant surge in resistance, which is a global threat to human health. ^{4 , 7} Inappropriate antibiotic use is facilitated by non-prescription dispensing through community pharmacies and medicine vendors. ⁵ In many middle-income countries, antibiotics are available over the counter, exacerbating the problem. ^{5 , 6} Antimicrobial resistance (AMR) is a major consequence of antibiotic misuse, occurring when microbes are no longer inhibited or destroyed by antibiotics. ^{3 , 8} The continuous increase in antibiotic resistance rates is alarming, threatening the therapeutic effectiveness of antibiotics. ⁹ The misuse of antibiotics is a significant global health concern, particularly in low- and middle-income countries such as Nigeria. ⁶ In outpatient departments, patients frequently self-medicate, demand antibiotics unnecessarily, or fail to adhere to prescribed treatment regimens. ^{4 , 7} Factors such as lack of awareness, easy over-the-counter access to antibiotics, poor healthcare policies, the pressure on healthcare professionals to meet patient expectations, lack of funds for doctor consultations, long wait times at the hospital, high cost of laboratory tests, and unavailability of medical doctors contribute to this issue. ^{2 , 5 , 6} Various antibiotic misuse practices lead to antimicrobial resistance, prolonged hospital stays, increased healthcare costs, and higher morbidity and mortality rates. ^{8 , 10} Addressing this issue is crucial for sustaining the effectiveness of antibiotics in treating bacterial infections. ⁹ Given the global increase in antibiotic resistance, which is predominantly due to antibiotic misuse, this study aims to assess the knowledge, attitudes, practices, and factors associated with antibiotic misuse among outpatients in the University of Nigeria Teaching Hospital, Ituku Ozalla.

Antibiotic misuse is a growing global health threat, contributing to the rise of antimicrobial resistance (AMR), treatment failures, and increased mortality rates. The World Health Organization (WHO) has identified AMR as one of the top public health challenges of the 21st century, warning that without urgent action, common infections may become untreatable, leading to a potential post-antibiotic era. ¹¹ Overuse and inappropriate prescribing of antibiotics, particularly in outpatient settings, are major drivers of this crisis. WHO estimates that at least 50% of antibiotic use is unnecessary or improperly used, highlighting the need for stricter antibiotic stewardship programs worldwide. ¹² High-income countries have taken significant steps to regulate antibiotic prescriptions, yet misuse remains a concern. For instance, in the United States, despite guidelines promoting rational antibiotic use, nearly 20 to 30% of outpatient antibiotic prescriptions are deemed inappropriate. ¹³ Similarly, in the United Kingdom, studies have shown that antibiotics are often prescribed for viral infections where they offer no benefit. ¹⁴ In low- and middle-income countries (LMICs), the situation is even more alarming due to weak regulatory frameworks, easy access to antibiotics without prescriptions, and poor public awareness. ¹⁵ In India, for example, over-the-counter antibiotic sales contribute significantly to AMR, with self-medication being a prevalent practice. ¹⁶ In Nigeria, antibiotic misuse is widespread in both hospital and community settings, exacerbated by poor enforcement of prescription laws and limited awareness of AMR. Studies have reported high rates of self-medication with antibiotics, driven by factors such as cost, accessibility, and inadequate healthcare services. ¹⁷ In the outpatient departments of the University of Nigeria Teaching Hospital (UNTH), patterns of antibiotic misuse remain underexplored, raising concerns about irrational prescribing practices and patient self-medication habits. Understanding the extent and drivers of antibiotic misuse in this setting is crucial for designing targeted interventions to promote rational antibiotic use and curb the threat of AMR in Nigeria.

Of 400 eligible outpatients approached, 384 completed valid questionnaires, giving a response rate of 96.0%. Most participants were aged 18–45 years and predominantly female, as shown in Table 1. More than half of the respondents had at least a tertiary-level education.

Knowledge of antibiotic misuse was relatively high, with the majority correctly identifying misuse practices and recognizing their link to resistance. However, misconceptions remained, particularly regarding the use of antibiotics for viral infections (See Table 2).

As shown in Table 3, Overall, 69.8% of respondents correctly identified antibiotics as medicines used to treat bacterial infections. A minority falsely identified analgesics as antibiotics. The most common source of education on antibiotic resistance was healthcare professionals (35.2%).

Study respondents, as presented in Table 4, showed a favorable attitude towards antibiotic misuse, recognizing its potential local and global implications. 9 out of 10 participants affirm that bacteria can develop antibiotic resistance. The mean knowledge score among participants, calculated from combined responses across the antibiotic misuse, antibiotic resistance, and antibiotic knowledge domains (maximum score of 30), was 16.63 ± 1.50.

Regarding the belief that antibiotics are effective in treating viral infections such as the common cold or flu, over 30% agreed. More than half of the participants agreed that frequent antibiotic use can lead to antibiotic resistance. In response to whether respondents had ever taken antibiotics as a preventive treatment before experiencing any symptoms of an illness, 18.2% reported doing so often, 38.0% occasionally, and 40.1% never, as presented in Table 5. When asked if it is acceptable to buy or request the same antibiotics that previously worked for similar symptoms, 39.3% responded yes, 41.1% said no, and 16.4% were unsure. Lastly, 52.6% of respondents reported using leftover antibiotics from a previous illness without consulting a doctor.

A little over half of the respondents (52.6%) reported, as shown in Table 6, that they sometimes keep antibiotics at home as an emergency prescription for themselves or their children. When asked where they usually obtained antibiotics, 62.5% said they did so through a doctor’s prescription, though a similar proportion (55.7%) admitted to obtaining them from a pharmacy without a prescription. Only 32.3% of respondents said they always completed their full course even if they started feeling better. Encouragingly, 69.0% of participants expressed a definite willingness to avoid taking antibiotics unless necessary, to help prevent antibiotic resistance. An additional 19.8% said they might do so if advised by a doctor, but 3.1% still felt antibiotics should be taken whenever they felt the need.

As presented in Table 7, about two-thirds of respondents understood that antibiotics are effective only against bacterial infections and not viral illnesses. However, a notable fraction remained either misinformed or unsure. A significant proportion of participants admitted to having taken antibiotics without a prescription from a doctor at the clinic, with pharmacists being the most common source. When it came to adherence, 56% of participants said they sometimes stopped taking antibiotics before completing the full prescribed course once they felt better, and 6.5% always did so. The reuse of leftover antibiotics from a previous illness was common, with 44% admitting they sometimes did this.

Nearly a third of respondents admitted to skipping completion of an antibiotic course due to side effects, while 58.9% said they had never done so, see Table 8. When asked about the role of laboratory investigations in prescribing decisions, 42.2% said doctors only occasionally requested tests beforehand, while just below 20% said no tests were typically done. Finally, communication from pharmacists was shown to be inconsistent.

As presented in Table 9, Ampicillin and cloxacillin (Ampiclox) were the most frequently used antibiotics (50.5%), followed by metronidazole (46.1%). Pharmacists (50.8%) and doctors (47.6%) were the primary sources of consultation before antibiotic use. Most respondents (85.2%) purchased antibiotics from pharmacies, and a small proportion (11.2%) reported using herbal or traditional medicine alongside antibiotics. The leading reason for discontinuing antibiotics prematurely was feeling better (57.8). Over half occasionally self-medicate with antibiotics.

As shown in Table 10, one out of every three respondents have experienced side effects from antibiotics. Nearly half (48.7%) admitted to keeping leftover antibiotics for future use. Over-the-counter purchase of antibiotics was common, with 62.0% reporting they sometimes did this. In terms of frequency of use, 24.0% took antibiotics once every six months, while 8.9% used them more than once a month.

This study assessed knowledge, attitudes, practices, and factors influencing antibiotic misuse among outpatients at the University of Nigeria Teaching Hospital (UNTH), Enugu. Overall, the findings show that although participants had relatively good awareness of antibiotic misuse and antimicrobial resistance (AMR), this knowledge did not consistently translate into appropriate antibiotic use. This knowledge–practice gap reflects a broader challenge reported across many low- and middle-income countries, where easy access to antibiotics, socio-economic constraints, cultural beliefs, and weak enforcement of prescription regulations continue to promote misuse.

Most respondents demonstrated good knowledge of antibiotic misuse, with 69.5% correctly identifying misuse-related behaviours and 92.7% recognizing that misuse can contribute to antibiotic resistance. This level of awareness is higher than findings from Delta State, where only 57.8% of adults were aware of antibiotic resistance, ²⁰ and Kaduna State, where fewer than half of breastfeeding mothers had heard of antibiotic resistance. ²¹ The higher awareness in the present study may be related to the tertiary hospital setting, where patients are more likely to interact with healthcare professionals. However, misconceptions remained common, as about 40% of respondents believed antibiotics are effective against viral infections such as colds and flu. Similar misconceptions have been reported in Malaysia, ²⁴ Southwestern Nigeria, ^{18 , 19} Saudi Arabia, ²³ and India, ²⁵ suggesting that confusion between bacterial and viral infections remains widespread. Such beliefs may increase inappropriate patient demand for antibiotics and place pressure on healthcare providers to prescribe them unnecessarily. ²⁶ In addition, only half of the respondents had ever received information on proper antibiotic use, indicating that patient education remains inadequate even within a tertiary healthcare setting. This supports previous evidence that knowledge alone is insufficient and that continuous, structured education is needed to promote rational antibiotic use. ²⁷

Respondents’ attitudes also revealed inconsistencies between awareness and intended behaviour. More than half reported storing antibiotics for emergency use, while 52.6% admitted reusing leftover antibiotics without medical consultation. These findings are consistent with reports from Lebanon, ²⁸ Saudi Arabia, ²⁹ and India, ²⁵ where antibiotic storage and reuse are common. Although 69% of participants indicated willingness to avoid unnecessary antibiotics if advised by a doctor, 39.3% stated that they would request the same antibiotics if these had worked previously. This suggests that previous perceived effectiveness, convenience, and cost may strongly influence antibiotic-seeking behaviour despite awareness of appropriate use. Similar contradictions have been reported in Ogun State, where respondents who claimed to understand proper antibiotic use still engaged in self-medication for minor illnesses. ³⁰ Furthermore, 40% of participants admitted to reducing their antibiotic dose once symptoms improved, a practice also reported in Uganda ³¹ and Jordan. ³² Early discontinuation of antibiotics may be driven by perceived recovery, cost concerns, or fear of adverse effects, but it increases the risk of treatment failure and contributes to the survival of partially resistant organisms, thereby promoting AMR. ³³

Although awareness of AMR was relatively common, inappropriate antibiotic-use practices remained widespread, suggesting that knowledge alone is insufficient to change behaviour in settings where antibiotics are easily accessible without prescription. Self-medication was particularly high, with 61.7% reporting antibiotic use without a doctor’s prescription, and pharmacies were the most common source. This finding aligns with Nigerian studies reporting non-prescription antibiotic use ranging from 47% to 76%. ^{2 , 34 , 35} The persistence of this practice reflects weak enforcement of prescription regulations and the role of pharmacies and patent medicine vendors as informal sources of treatment. Only 32.3% of respondents reported always completing their antibiotic course, which is lower than findings from India ²⁵ and closer to reports from Uganda. ³¹ This difference may reflect variations in healthcare access, prescription control, stewardship activities, and patient counselling. Sharing and recommending antibiotics were also reported, with 25.5% of respondents sharing antibiotics and 34.1% recommending them to others. Similar practices have been documented in Kenya, ³⁶ Lebanon, ²⁸ and Nigeria, ³⁷ suggesting that social networks and communal approaches to medicine may reinforce antibiotic misuse and undermine professional medical advice.

Several structural and socio-economic factors influenced antibiotic misuse in this study. Long waiting times, high consultation and laboratory costs, and delays in test results encouraged some respondents to bypass formal healthcare services. Similar system-level barriers have been reported in Uganda ³⁸ and South Africa, ³⁹ where inefficient healthcare delivery contributed to self-treatment and empirical antibiotic use. The high rate of over-the-counter antibiotic purchase in this study further demonstrates how accessibility and convenience drive misuse. Economic pressures were also evident, as some respondents altered prescriptions to cheaper alternatives or reduced doses after feeling better. Comparable findings from Pakistan ⁴⁰ and China ²² show that affordability strongly shapes antibiotic-use behaviour. These findings indicate that interventions should address not only awareness but also the cost and accessibility of healthcare services.

Pharmacist-patient interaction was another important area of concern. Although pharmacies were a major source of antibiotics, only 57.6% of respondents reported receiving adequate instructions from pharmacists. Similar gaps in counselling have been reported in Ogun State ³⁰ and India. ²⁵ Inadequate counselling at the point of purchase may worsen misuse, particularly when antibiotics are obtained without prescriptions. Finally, although most respondents agreed that antibiotics should require prescriptions, their practices often contradicted this belief. This disconnect suggests that improving antibiotic use will require stronger enforcement of prescription-only policies, better pharmacy regulation, continuous patient education, and broader health-system reforms that reduce the financial and logistical barriers to seeking appropriate care.

Although most respondents demonstrated awareness of antibiotic resistance and recognized that antibiotic misuse contributes to AMR, inappropriate antibiotic-use practices were common. Non-prescription antibiotic use, early discontinuation of treatment, storage and reuse of leftover antibiotics, and over-the-counter access from pharmacies were prominent misuse behaviours. These findings suggest a substantial knowledge-practice gap among outpatients at UNTH. Interventions should combine patient education with stronger enforcement of prescription-only antibiotic sales, improved pharmacist counselling, reduced outpatient waiting times, and hospital-based antimicrobial stewardship activities.

This study titled “ Antibiotic Misuse Among Outpatients in University of Nigeria Teaching Hospital (UNTH)” received approval on 10/11/2025 with the approval no as Unth/nhrec/2025/04/4220, from the Research Ethics Committee of University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu.

All the participant are above 18 years and after being told about the study, they signed a written inform consent form.

All participant and authors consented to the publication of this paper.