ANTIMICROBIAL USE: A CROSS SECTIONAL STUDY AMONG HEALTHCARE WORKERS IN A LOWER-MIDDLE-INCOME COUNTRY (MOLDOVA)

DOI: https://doi.org/10.26758/16.1.29

(1) Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, alina.ferdohleb@usmf.md, https://orcid.org/0000-0003-1344-5466

(2) Hygiene Discipline, Department of Preventive Medicine, Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, elena.ciobanu@usmf.md, https://orcid.org/0000-0002-8969-922X

(3) Hygiene Discipline, Department of Preventive Medicine, Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, catalina.croitoru@usmf.md, https://orcid.org/0000-0002-7411-2393

(4) Microbiology and Immunology Discipline, Department of Preventive Medicine, Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, greta.balan@usmf.md, https://orcid.org/0000-0003-3704-3584

Address correspondence to: Alina Ferdohleb, Chair of Social Medicine and Management, Nicolae Testemitanu State University of Medicine and Pharmacy RM, MD 2025, bd. Ștefan cel Mare și Sfânt, 195-B, Chișinau, Republic of Moldova, Ph.: +37379402597; e-mail: alina.ferdohleb@usmf.md

Abstract

Objectives. This study aimed to assess the knowledge of health workers in the Republic of Moldova regarding antimicrobial administration and its environmental implications, including wastewater contamination, in order to identify educational gaps and support integrated One Health policies.

Material and methods. A cross-sectional survey was conducted between June and August 2022 among 1093 HCWs. Descriptive statistics and stratified analyses were performed using IBM SPSS v28.0.0.1(15).

Results. Baseline knowledge was high: 93.0% recognized that antibiotics are effective against bacteria, 86.8% correctly stated they are ineffective against viruses, and 80.8% acknowledged that misuse reduces efficacy. Regarding environmental aspects, 74.7% agreed that wastewater contributes to AMR dissemination, while 69.9% affirmed that climate change may affect pathogen resistance. Self-assessed adequate knowledge was reported by 65.8% of HCWs, and 91.9% reported understanding the concept of AMR. Prescribers and non-prescribers showed comparable knowledge levels, with no significant differences for key items (e.g., unjustified use; χ², p > 0.05). Higher self-assessment scores were observed among HCWs aged 41-60 and those with over 15 years of experience. Healthcare workers in therapeutic specialties and academic clinical roles demonstrated slightly elevated scores (mean Likert: 3.81-4.00).

Conclusions. Moldovan HCWs possess solid baseline knowledge on antimicrobial use and resistance. However, critical gaps remain regarding environmental links and the translation of knowledge into behavioural practices. Findings call for enhanced interdisciplinary education and integration of environmental risk communication into national AMR strategies, especially in LMIC settings. This supports the development of comprehensive, cross-sectoral stewardship initiatives bridging clinical and environmental health domains.

Keywords: antimicrobial resistance, healthcare workers, stewardship, One Health, LMICs

Suggested citation (APA):

Ferdohleb, A., Ciobanu, E., Croitoru, C., & Balan, G. (2026). Antimicrobial use: A cross sectional study among healthcare workers in a lower-middle-income country (Moldova). Anthropological Researches and Studies, 16, 452-470. https://doi.org/10.26758/16.1.29

Introduction

Antimicrobial resistance (AMR) is one of the most critical contemporary threats to global public health, undermining patient safety, treatment efficacy, and the sustainability of health systems (World Health Organization [WHO], 2015). International organizations emphasize that AMR is a multifactorial and cross-sectoral problem, framed within the One Health paradigm, as it simultaneously involves human, animal, and environmental health (Quadripartite, 2022 [FAO, UNEP, WHO, WOAH]). In the context of increasing bacterial resistance, global control strategies rely on reducing inappropriate antimicrobial use, integrated surveillance, and limiting environmental contamination with pharmaceutical residues.

The use of antimicrobials in medical practice inevitably leads to the excretion of active substances and metabolites through wastewater. Sub-inhibitory concentrations of antibiotics that reach wastewater treatment plants or urban effluents promote the selection of resistant bacteria and the persistence of resistance genes in aquatic ecosystems (United Nations Environment Programme [UNEP], 2023). This phenomenon is further amplified by co-exposure to biocides and heavy metals, which contribute to the horizontal transfer of resistance genes, facilitating their spread to both commensal and pathogenic bacteria. In the absence of tertiary treatment stages, hospital and urban effluents become major vectors for the propagation of antimicrobial resistance into surface waters and, indirectly, into the food chain, thereby confirming the systemic and circular nature of AMR (UNEP, 2023; WHO, 2015).

In low- and middle-income countries (LMICs), such as the Republic of Moldova, the ecological risk associated with AMR is exacerbated by structural vulnerabilities: partial coverage with wastewater treatment facilities, absence of advanced stages for neutralizing pharmaceutical pollutants, and inadequate management of sewage sludge and hospital effluents. These are compounded by organizational and educational challenges: limited access to up-to-date clinical guidelines, lack of coherent continuing education programs, and fragmented surveillance of antimicrobial use and resistance (UNEP, 2023; WHO, 2015). Under these conditions, integrated approaches from antimicrobial stewardship to low-cost ecological solutions such as constructed wetlands for the retention of pharmaceutical pollutants – are essential for reducing selective pressure on the environment (Quadripartite, 2022).

Healthcare workers’ knowledge represents a critical link in the prevention and control of antimicrobial resistance (AMR). The level of professional literacy concerning the prudent use of antibiotics, the clinical and ecological consequences of prescribing, and the mechanisms of resistance directly influences professional behaviours and, consequently, the risk of environmental contamination. Although most physicians are aware of the link between excessive antibiotic use and the rise of resistance, studies have revealed significant knowledge gaps, particularly regarding: human-to-human transmission and asymptomatic carriage of resistant bacteria; the role of the environment and wastewater in AMR dissemination; and the importance of proper disposal and neutralization of pharmaceutical waste (Abbo et al., 2013; McCullough et al., 2015; European Centre for Disease Prevention and Control [ECDC], 2019).

Assessing knowledge, attitudes, and practices (KAP) among medical personnel, including those without prescribing authority, is essential for identifying educational gaps and developing integrated training and stewardship programs. By correlating knowledge levels with clinical practices and environmental risks, One Health policies can be designed and tailored to the resources and infrastructural capacities specific to low- and middle-income countries (LMICs).

The present study aims to investigate the knowledge of healthcare workers in the Republic of Moldova regarding antimicrobial use and its impact on wastewater pollution, within the LMIC context. The ultimate goal is to support the development of educational interventions and integrated AMR control policies that encompass both clinical and environmental dimensions.

Material and methods

The present study constitutes an original descriptive cross-sectional research conducted within the framework of the international multilateral project “Phage treatment and wetland technology as intervention strategy to prevent dissemination of antibiotic resistance in surface waters (PhageLand)”. The applied research phase focused on analysing the cognitive dimensions related to antibiotic use and antimicrobial resistance (AMR).

For this purpose, the data collection instrument was developed based on the standardized questionnaire elaborated by the European Centre for Disease Prevention and Control (ECDC), entitled “Survey of healthcare workers’ knowledge, attitudes and behaviours on antibiotics, antibiotic use and antibiotic resistance in the EU/EEA” (ECDC, Stockholm, 2019). The adapted version retained approximately 33.5% of the original content of the ECDC tool, while undergoing cultural and contextual adjustments to reflect the characteristics of the Moldovan healthcare system and its national antimicrobial stewardship policies (Croitoru et al., 2022).

The sample size was estimated to ensure statistical relevance and representativeness for the healthcare worker population in the Republic of Moldova, applying Cochran’s formula for large populations:

𝑛=d[𝜋̃(1−𝜋̃)] * (𝑧𝛼/𝑤) ^ 2, where 𝑛 represents the required sample size, 𝜋̃ is the estimated proportion of the population with the attribute of interest, 𝑧𝛼 is the standard normal deviate corresponding to the desired confidence level, 𝑤 is the margin of error, and d is the design effect (usually set to 1 for simple random samples).   Based on this approach, the calculated sample size was 1,090 respondents. In total, 1,147 healthcare workers were invited to participate in the study, of whom 53 declined (by selecting the “I do not agree” option and withdrawing from the survey).

Ultimately, 1,093 fully completed questionnaires were collected and constituted the analysed database. The available values represent the proportions of correct responses within each group, not internal correctness rates; therefore, differences are interpreted descriptively rather than inferentially. Data were statistically processed using Microsoft Excel and IBM SPSS Statistics, version 28.0.0.1(15), under a licensed agreement. For the comparison of quantitative responses (Likert-scale items) and categorical data, both parametric and nonparametric statistical tests were applied, depending on the distribution.

Inclusion criteria comprised: holding a formal position as a healthcare worker, self-reported emotional stability, and provision of informed consent. Individuals who declined participation were excluded from the study. Data collection took place both online and face-to-face between June and August 2022.

Justification for Stratification by Age of Respondents

The stratification of respondents by age group was necessary to examine potential variations in knowledge, attitudes, and practices (KAP) regarding antibiotic use and antimicrobial resistance (AMR) in relation to professional experience and exposure to continuing medical education. Age is a relevant determinant of professional behavior, influencing both prescribing patterns and compliance with current public health recommendations (World Health Organization [WHO], 2015; European Centre for Disease Prevention and Control [ECDC], 2019). Previous studies have identified significant generational differences in access to information, attitudes toward antimicrobial policies, and openness to educational interventions (Dyar et al., 2014; Abbo et al., 2013). Therefore, including age as a variable was essential for the contextualized interpretation of the findings.

Justification for Stratification by Years of Professional Experience

Stratification by years of professional experience was applied to explore possible differences in the respondents’ KAP related to antibiotic use and AMR. Professional experience may influence familiarity with institutional policies and the willingness to adopt new, evidence-based practices (Pulcini et al., 2012; WHO, 2015). Literature shows that healthcare workers with fewer years of experience are often more open to modern educational interventions, whereas those with longer tenures may display greater resistance to change (Dyar et al., 2014; Abbo et al., 2013). This stratification was therefore essential for a nuanced interpretation of the results.

Justification for Stratification by Type of Healthcare Institution

To capture the institutional context, the questionnaire included the variable “type of healthcare institution” – public, private, or academic clinical base (from higher education medical institution). This classification allowed for differentiated analysis of KAP, accounting for the distinct organizational characteristics of each institutional type (WHO, 2021; ECDC, 2019). The division was justified by the assumption that internal policies, availability of clinical practice guidelines, and participation in continuing professional development may significantly influence professional behaviors (Gonzales et al., 2013; Pulcini et al., 2012).

Justification for Stratification by Antimicrobial Prescribing Authority

Stratification by respondents’ right to prescribe antimicrobials was conducted to identify potential differences in KAP between prescribers and non-prescribers. Healthcare personnel with prescribing authority play a pivotal role in initiating treatments and implementing antimicrobial stewardship strategies, which may significantly impact clinical behaviors (ECDC, 2019; WHO, 2015). Prior studies confirm that these differences warrant tailored educational approaches for the two professional categories (Pulcini et al., 2012; Abbo et al., 2013).

Participant Profile

The age of healthcare workers (HCWs) included in the study ranged from 23 to 79 years, with a mean of 42.53 ± 0.35 years (SD = 11.53; n = 1093; 95% CI [41.86, 43.18]). The gender distribution revealed a slight predominance of female participants (51.4%; n = 562; 95% CI [48.6, 54.4]) compared to males (48.6%; n = 531; 95% CI [45.6, 51.5]). Regarding area of residence, most respondents were from urban areas (60.8%; n = 664; 95% CI [57.8, 63.6]), while 39.2% resided in rural settings (n = 429; 95% CI [36.4, 42.2]).

Table 1

Participant Profile of Healthcare Workers Included in the Study (N = 1,093) (to see Table 1, please click here)

Professional Profile of Participants

With respect to medical specialty, 45.6% were engaged in therapeutic domains (n = 498; 95% CI [42.6, 48.5]), 15.1% in surgical specialties (n = 165; 95% CI [13.1, 17.3]), and 9.7% each in paediatrics (n = 106; 95% CI [8.1, 11.6]) and dental medicine (n = 106; 95% CI [8.1, 11.6]). Teaching staff and researchers accounted for 11.6% of the sample (n = 127; 95% CI [9.8, 13.6]), while personnel from specialized public health services (SPHS) comprised 14.5% (n = 158; 95% CI [12.5, 16.6]). Additional SPHS-related roles were reported by 1.9% of respondents (n = 21; 95% CI [1.2, 2.9]).

Regarding professional status, the largest group was composed of specialist physicians (27.1%; n = 296; 95% CI [24.5, 29.8]), followed by family doctors (22.9%; n = 250; 95% CI [20.5, 25.4]) and university faculty (23.5%; n = 257; 95% CI [21.1, 26.1]). Resident doctors made up 17.0% (n = 186; 95% CI [14.9, 19.3]). Lower proportions were observed among hygienists (0.6%; n = 7; 95% CI [0.3, 1.3]), epidemiologists (1.5%; n = 16; 95% CI [0.9, 2.3]), scientific researchers (3.2%; n = 35; 95% CI [2.3, 4.4]), pharmacists (2.6%; n = 28; 95% CI [1.7, 3.6]), laboratory doctors (0.8%; n = 9; 95% CI [0.4, 1.5]), and students employed in medical institutions (0.8%; n = 9; 95% CI [0.4, 1.5]).

As for the type of healthcare institution where the respondents were employed, 47.5% worked in public healthcare institutions (n = 519; 95% CI [44.5, 50.4]), 15.3% in private facilities (n = 167; 95% CI [13.2, 17.5]), and 37.2% within clinical teaching bases affiliated with the Nicolae Testemițanu State University of Medicine and Pharmacy (n = 407; 95% CI [34.4, 40.1]). This institutional structure allowed for differentiated analysis based on the organizational characteristics of each professional setting.

Table 2

Professional Characteristics of the Participants (N = 1,093) (to see Table 2, please click here)

Results

Responses were organized to reflect the level of knowledge regarding antibiotic (AB) use. When asked, “Do you have sufficient knowledge regarding antibiotic use?”, 65.8% of participants responded affirmatively (n = 719; 95% CI [62.9, 68.6]). In response to, “Do you know what information to provide on prudent antibiotic use?”, 81.2% answered affirmatively (n = 888; 95% CI [78.8, 83.5]). Concerning the question, “Do you know what antibiotic resistance is?”, 91.9% reported being familiar with the concept (n = 1005; 95% CI [90.2, 93.5]).

Table 3

Self-Assessment of Respondents Regarding Knowledge on Antibiotic Use and Antimicrobial Resistance (N = 1093) (to see Table 3, please click here)

The findings presented in Table 4 indicate that the majority of respondents (86.8%; n = 949; 95% CI [84.7, 88.7]) correctly answered the question “Are antibiotics effective against viruses?” (Correct answer: No). The stratified analysis by prescribing rights revealed a higher proportion of correct responses among those with prescribing rights – 63.0% (n = 593; 95% CI [59.9, 66.1]), compared to those without – 37.0% (n = 348; 95% CI [33.9, 40.1]). This discrepancy may be attributed to access to clinical guidelines, direct responsibility in antimicrobial prescribing, and more frequent participation in continuing medical education.

The age distribution of respondents highlighted a predominance of healthcare professionals in mid-career stages. The largest share was observed in the 31-40 age group (32.5%; n = 306; 95% CI [29.6, 35.6]), followed by those aged 41-50 years (25.4%; n = 239; 95% CI [22.7, 28.3]). Participants aged 51-60 years accounted for 18.6% (n = 175; 95% CI [16.2, 21.2]), those under 30 years for 15.7% (n = 148; 95% CI [13.5, 18.2]), and those over 61 years for only 7.8% (n = 73; 95% CI [6.2, 9.6]). This distribution suggests an active professional core with sufficient experience to reflect both clinical maturity and engagement in ongoing knowledge updating. The underrepresentation of older professionals may be associated with retirement or lower participation in survey-based research.

Work experience stratification revealed a relatively balanced distribution: 27.0% of participants had ≤5 years of professional experience (n = 254; 95% CI [24.2, 29.9]), 23.0% had 6-15 years (n = 216; 95% CI [20.4, 25.7]), 26.7% had 16-25 years (n = 251; 95% CI [23.9, 29.6]), and 23.4% had ≥26 years (n = 220; 95% CI [20.8, 26.2]). This confirms the representativeness of various stages in medical careers, from early practice to advanced professional experience.

Regarding the type of medical institution, 50.1% of respondents worked in public healthcare institutions (n = 471; 95% CI [46.9, 53.2]), 14.9% in private institutions (n = 140; 95% CI [12.7, 17.3]), and 35.1% in university-affiliated clinical settings (n = 330; 95% CI [32.1, 38.2]). No participant selected the category “Other,” reflecting a clearly defined professional environment.

From an occupational profile perspective, 42.4% of participants practiced in therapeutic specialties (n = 399; 95% CI [39.3, 45.6]), 17.2% in surgical fields (n = 162; 95% CI [14.9, 19.7]), 10.8% in pediatrics (n = 102; 95% CI [9.0, 12.9]), and 1.9% in dentistry and oral medicine (n = 18; 95% CI [1.2, 2.9]). Other professional categories included academic staff and researchers (11.6%; n = 109; 95% CI [9.7, 13.7]), public health service physicians (13.8%; n = 130; 95% CI [11.7, 16.1]), and pharmacists (2.2%; n = 21; 95% CI [1.4, 3.3]). This heterogeneous professional composition offers an appropriate framework for differentiated analysis of knowledge related to antibiotic use and antimicrobial resistance prevention.

The data summarized in Table 3 reflect healthcare workers’ self-assessed knowledge (N = 1093) on three key dimensions: (1) perceived level of general knowledge on antibiotic use, (2) ability to communicate relevant information to patients, and (3) understanding of the concept of antimicrobial resistance (AMR). The mean scores on the Likert scale (1-5) indicate an overall moderate to high perceived knowledge level, ranging from 3.72 to 3.87.

The highest mean was recorded for the item “I understand the concept of antibiotic resistance” (M = 3.87), followed by “I know what information to provide about antibiotic use” (M = 3.77) and “I have sufficient knowledge about the use of antibiotics” (M = 3.72). These results suggest a relatively high conceptual awareness of AMR among respondents, while also pointing to possible gaps between theoretical knowledge and the ability to effectively communicate information in clinical practice.

Table 4 synthesizes respondents’ answers to a set of key questions concerning the rational use of antibiotics and understanding of fundamental AMR mechanisms. The questions addressed basic knowledge relevant for clinical practice and public health, such as the effectiveness of antibiotics against different pathogens (viruses vs. bacteria), implications of inappropriate antibiotic use, associated risks (e.g., diarrhea, colitis, allergic reactions), and aspects related to the spread of resistant microorganisms and asymptomatic colonization in healthy individuals. Correct answers were coded as “No” for the question on the effectiveness of antibiotics against viruses, and “Yes” for all others, in accordance with international scientific consensus and One Health guidelines on AMR. These items were included to assess healthcare workers’ level of antimicrobial literacy and to inform priority directions for educational interventions and antibiotic stewardship policies.

Table 4

Respondents’ Knowledge Regarding Antibiotic Use and Antimicrobial Resistance (N = 1,093) (to see Table 4, please click here)

The level of basic knowledge was high: 93.0% correctly indicated that antibiotics are effective against bacteria; 86.8% correctly recognized their ineffectiveness against viruses; 80.8% associated unjustified use with reduced efficacy; 73.4% correctly acknowledged the existence of adverse effects (formulated as: “Yes, in some cases”); however, 31.4% incorrectly stated that all patients treated with antibiotics develop infections with resistant pathogens, suggesting an overgeneralization of the risk (in reality: “Yes, in some cases”).

Table 5

Respondents’ Knowledge Level Regarding the Use of Antibiotics and Antimicrobial Resistance, and Its Association with Participant Characteristics (N = 1,093) (to see Table 5, please click here)

The majority of respondents (93.0%; n = 1016; 95% CI [91.3, 94.4]) correctly identified that antibiotics are effective against bacterial infections. Only 4.1% (n = 45; 95% CI [3.1, 5.4]) provided an incorrect answer (“No”), while 2.9% (n = 32; 95% CI [2.0, 4.1]) reported “Don’t know.”

A substantial proportion of participants (68.2%) acknowledged the potential for human-to-human transmission of resistant microorganisms; 58.3% accurately recognized asymptomatic carriage in healthy individuals; and 80.8% confirmed the role of wastewater in the dissemination of antimicrobial resistance (AMR). These figures indicate a reasonably good understanding of the One Health paradigm, although there is room for improvement regarding awareness of asymptomatic colonization.

Affirmative responses predominantly originated from healthcare personnel with antimicrobial prescribing authority (63.8% of “Yes” for transmission; 60.6% for carriage; 62.3% for wastewater-related dissemination), suggesting a higher level of literacy among those with prescribing responsibilities. As with Table 4, the interpretation is descriptive, as the data reflect proportions of “Yes” responses within the full sample, not internal subgroup rates.

The majority of affirmative responses came from the 31–50 age group and those with ≤25 years of professional experience. Institutionally, public healthcare facilities and academic clinical bases accounted for the highest proportion of correct answers. Therapeutic specialties contributed the largest share of affirmative responses, followed by surgical specialties and public health professionals, reflecting greater clinical exposure and familiarity with relevant protocols.

Knowledge regarding the interconnections between clinical practice, the environment, and AMR appears relatively solid, particularly with regard to wastewater and interpersonal transmission. Educational interventions are recommended to strengthen understanding of asymptomatic colonization and to harmonize knowledge levels between prescribers and non-prescribers, especially among professionals in pharmacy, diagnostic imaging, microbiology, and laboratory medicine.

Discussions

Why does knowledge not always translate into behavior? Although the level of knowledge regarding the prudent use of antibiotics is generally high among healthcare professionals, prescribing behaviors remain influenced by a complex interplay of factors, including social norms and clinical hierarchies (“prescribing etiquette”), diagnostic uncertainty, time pressure, patient expectations, risk aversion, clinical defensiveness, and organizational constraints (e.g., access to guidelines, availability of rapid microbiological testing, audit and feedback mechanisms, and quality-oriented institutional culture) (Charani et al., 2013; ECDC, 2019). From a behavioral science perspective, the knowledge–action gap can be conceptualized through the COM-B model (Capability – Opportunity – Motivation – Behavior): while knowledge enhances capability, implementation depends equally on opportunity (resources, systems, leadership) and motivation (social norms, habits, incentives) (Michie et al., 2011).

In medical education, multicenter studies highlight that theoretical literacy alone is insufficient. Sustainable behavioral change requires the integration of clinical mentoring, structured audit and feedback, and embedded antimicrobial stewardship interventions (Dyar et al., 2018; Abbo et al., 2013).

The proportion of correct answers was significantly higher among respondents with the legal authority to prescribe antimicrobials (64.2%; n = 652) compared to those without such authority (35.8%; n = 364). Belonging to the prescribing category was positively associated with a better understanding of the efficacy of antibiotics against bacterial infections. This discrepancy can be plausibly explained by more frequent exposure to clinical guidelines and ongoing continuing medical education activities among prescribers.

In terms of age distribution, the highest proportion of correct responses was recorded among participants aged 31–40 years (33.0%), followed by those aged 41-50 years (24.2%) and 51-60 years (18.4%). Regarding professional experience, respondents with ≤5 years (28.2%) and 16-25 years (25.5%) of tenure contributed most frequently to correct responses.

Public medical institutions accounted for the highest share of correct answers (48.2%), followed by academic medical institutions (38.5%) and private sector institutions (13.3%).

From an occupational profile perspective, therapeutic specialties recorded the highest proportion of correct responses (43.4%), followed by surgical specialties (15.6%) and physicians working in specialized public health services (14.9%).

Relevant disparities were identified between professional subgroups. Pharmacists and surgeons reported the highest self-assessment scores (above 4.0), suggesting greater confidence in their competencies, likely related to the specific nature of their training and clinical responsibilities. In contrast, dental professionals, pediatric practitioners, and early-career personnel (<5 years of experience) reported significantly lower scores (ranging between 3.2 and 3.6), indicating a potential need for targeted educational interventions within these groups.

The age-based analysis revealed a clear trend of increasing self-assessment scores with age, peaking in the 41-50-year group, followed by a slight decline. Respondents aged 41-50 years registered the highest scores across all three assessed dimensions: “general knowledge regarding antibiotic use” (M = 3.94), “ability to provide information to patients” (M = 3.96), and “understanding of the AMR concept” (M = 4.13). These findings may reflect an optimal balance between accumulated clinical experience and active engagement in continuous learning. Conversely, respondents under 30 years reported the lowest scores (3.57-3.72), suggesting limited self-perception of competence in the area of antimicrobial resistance – likely due to insufficient clinical exposure and experience with prescribing or patient counseling scenarios.

Interestingly, a score decline was also observed among participants over 61 years (3.27-3.59), potentially attributable to lower participation in recent training initiatives or decreased confidence in knowledge updates – a phenomenon documented in international literature on knowledge obsolescence among senior medical professionals (WHO, 2022).

Years of professional experience mirrored age-related trends. Respondents with 6-15 years of experience reported the highest self-assessment scores: 3.95 for knowledge of antibiotics, 4.12 for the ability to inform patients, and 4.20 for understanding of AMR – suggesting strong professional confidence likely reinforced by active practice and access to recent training. In contrast, early-career professionals (<5 years) had the lowest scores (3.36–3.60), consistent with international findings emphasizing the need for early educational interventions to foster a robust culture of rational antibiotic use (Pulcini et al., 2021).

For professionals with over 25 years of experience, scores remained relatively stable (3.84-3.94), though slightly below the maximum observed in the 6-15 year group – possibly reflecting stagnation in ongoing professional development or decreased participation in recent educational activities.

Institutional affiliation also influenced self-assessment. Respondents from public healthcare institutions reported higher scores (3.82-4.00) compared to those in the private sector (3.40-3.45). This disparity may be attributed to differential access to continuing professional development, institutional protocols, or internal policies on antimicrobial stewardship. Studies from other LMICs confirm the essential role of public institutions in promoting AMR policies through systematic training and implementation of One Health programs (Holloway et al., 2019).

Participants affiliated with academic institutions (SUMPh) reported intermediate scores (3.71-3.88), possibly reflecting solid theoretical knowledge yet limited application in complex clinical contexts – particularly among faculty members not actively engaged in daily medical practice.

Differences between types of healthcare institutions highlight the role of organizational context: respondents from public and academic institutions scored higher than their counterparts from the private sector, possibly reflecting a more education- and stewardship-oriented institutional culture.

These findings support the hypothesis that knowledge self-assessment is influenced not only by professional experience and specialty but also by institutional environment and access to educational resources. They offer a strong empirical basis for designing tailored training programs based on self-identified needs.

Medical personnel with prescribing rights vs. those without prescribing rights. Correct answers were predominantly provided by respondents with the right to prescribe antimicrobial agents: 63.0% of all correct responses to the item regarding antibiotics and viruses; 64.2% for the item on bacterial efficacy; 62.3% for the unjustified use of antibiotics; 65.1% for adverse effects; and 60.3% for the risk of resistant infections. These figures suggest a concentration of correct knowledge among prescribers, likely due to greater access to clinical guidelines and continuing medical education.

Demographic and institutional profile. Correct responses were most frequent among participants aged 31-40 years (approximately 33-35%) and 41-50 years (approximately 24-28%), and among those with 16-25 years (≈25-26%) or ≤5 / 6-15 years (≈24-30%) of professional experience, indicating a peak in professional literacy within the active working-age population. Institutionally, public healthcare institutions accounted for approximately half of the correct responses (≈48-52%), followed by academic clinical settings (≈37-40%) and private facilities (≈11-13%). Regarding professional profiles, therapeutic specialties were predominant (≈42-46%), followed by surgical specialties (≈14-16%) and public health services (SSSP) (≈14-16%), reflecting both the structure of the sample and clinical exposure.

Knowledge foundations regarding antibiotics and antimicrobial resistance (AMR) are generally solid, with correct answers concentrated among professionals with prescribing rights and those in clinical specialties. However, some interpretative nuances persist – for instance, with regard to the item assessing universal risk (“all” vs. “some”), indicating a need to clarify concepts of probability and risk factors.

The knowledge level regarding the effectiveness of antibiotics against bacteria was very high among respondents. The differences identified by age group, years of professional experience, and specialty suggest that medical personnel with prescribing authority and those in therapeutic specialties possess the most robust understanding in this domain.

In the context of low- and middle-income countries (LMICs), such as the Republic of Moldova, infrastructural vulnerabilities – such as limited coverage with wastewater treatment plants, the absence of tertiary treatment stages for pharmaceutical residue removal, and heterogeneous management of hospital sludge and effluents combined with unequal institutional capacities including uneven AMR surveillance and antibiotic consumption monitoring, variable access to updated clinical guidelines, and discontinuous professional training may exacerbate both ecological risks and the difficulty of translating knowledge into practice (UNEP, 2023; WHO, 2015). From a One Health perspective, the clinical – waste – environment interface implies that prescribing decisions carry consequences beyond the individual patient, while untreated or inadequately treated wastewater may become potential “hotspots” for the selection and dissemination of antimicrobial resistance (UNEP, 2023). In this context, integrated interventions – such as hospital- and primary-care based antimicrobial stewardship programs, audit and feedback mechanisms, rapid diagnostic testing, cost-effective environmental solutions (e.g., constructed wetlands), and hospital effluent protocols are recommended within international action plans (Quadripartite, 2022). Therefore, aligning healthcare worker education with infrastructural measures is critical to convert knowledge into sustainable behavior and to reduce the antimicrobial and ARG (antibiotic resistance genes) burden within ecosystems.

Conclusions

The study results reveal a relatively high level of theoretical knowledge among healthcare workers regarding the use of antibiotics and the primary mechanisms of antimicrobial resistance (AMR). However, significant gaps persist concerning the awareness of the ecological dimension of the phenomenon. While the majority of respondents acknowledged the risk of human-to-human transmission and the possibility of asymptomatic carriage of resistant bacteria, only one-third correctly associated antibiotic administration with the emergence of resistant infections. Furthermore, approximately 40% of participants failed to recognize climate change and wastewater as relevant factors in the dissemination of AMR.

These findings underscore the necessity of strengthening the interdisciplinary training of healthcare professionals in alignment with the One Health approach. Additionally, there is a critical need for the systematic integration of environmental components into antibiotic stewardship policies. In the context of the Republic of Moldova and other low- and middle-income countries (LMICs), where wastewater treatment infrastructure remains underdeveloped and environmental AMR surveillance is in its infancy, the development of educational, legislative, and organizational interventions becomes imperative.

Mitigating AMR requires more than the mere accumulation of knowledge; it necessitates transforming this knowledge into sustainable behaviors and policies. These efforts must be tailored to the local context and aim to protect human health, veterinary health, and the surrounding environment.

Competing interests

The authors declare no competing interests.

Ethics Committee Approval

The study protocol was approved by the Research Ethics Committee of the “Nicolae Testemițanu” State University of Medicine and Pharmacy (approval no. 7 from 09.01.2022), as well as by the National Committee for Ethical Expertise of Clinical Studies under the Ministry of Health of the Republic of Moldova (approval no. 1245 from 26.01.2022) (Ciobanu et al 2022). 

Consent to participate

Informed consent was obtained from all participants prior to data collection. Consent was documented through an affirmative response to the introductory survey question (“Do you agree to participate in this study?”), which was mandatory for accessing the questionnaire. Participation was voluntary, and respondents were informed of their right to withdraw at any time without consequences. To ensure confidentiality and anonymity, no personally identifiable information was collected. All responses were anonymized at the point of data entry and analyzed in aggregated form. Access to the dataset was restricted to the research team, and data were stored on password-protected devices in accordance with applicable data protection regulations.

Acknowledgements

This study was conducted with the financial support of the European multinational project “Phage treatment and wetland technology as an intervention strategy to prevent dissemination of antibiotic resistance in surface waters (PhageLand)” with project number 22.80013.8007.1M. The authors are independent and take full responsibility for the integrity and accuracy of the data analysis.

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