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June 5, 2026Antibiotics0 citationsOpen Access

The Impact of Inappropriate Use Patterns on Sub-Lethal Antibiotic Exposure: A Multivariate Analysis on the Selection Risk of Resistant Mutants

AAAfet ArkutCyprus International University SUSaime UlucayliCyprus International University HSHatice SütçüCyprus International University

Key Points

This study aims to identify predictors of antibiotic non-adherence among university students using a behavioral-microbiological approach.
Conducted a cross-sectional KAP survey with 1044 students in Northern Cyprus.
Used a validated questionnaire to assess antimicrobial awareness.
Applied multivariate logistic regression to identify independent predictors of non-adherence.
Nursing students scored higher in knowledge (9 vs. 7), attitude (10 vs. 8), and practice (9 vs. 7) compared to non-healthcare students (p < 0.001).
Inappropriate attitude was the strongest predictor of non-adherence (AOR: 2.100; 95% CI: 1.586–2.780; p < 0.001).
Nursing education was a significant protective factor against non-adherence (AOR: 0.669; p = 0.005).

Abstract

Background: Antimicrobial resistance (AMR) is an evolutionary crisis accelerated by inappropriate antibiotic use. While awareness studies often focus on descriptive knowledge, evidence-based predictive models identifying how cognitive deficits trigger treatment non-adherence are lacking. This study analyzed predictors of antibiotic non-adherence among university students using a multivariate behavioral-microbiological approach. Methods: A cross-sectional KAP (Knowledge, Attitude, and Practice) survey was conducted with 1044 students (Nursing: n = 620; non-healthcare: n = 424) in Northern Cyprus. A validated questionnaire assessed antimicrobial awareness. Multivariate logistic regression identified independent predictors (Adjusted Odds Ratio AOR) of treatment non-adherence. Results: Nursing students achieved significantly higher median scores in knowledge (9 vs. 7), attitude (10 vs. 8), and practice (9 vs. 7) compared to non-healthcare students (p < 0.001). Within the nursing cohort, a significant linear progression in KAP scores occurred from the 1st to 4th academic years (p < 0.05). The strongest independent predictor of antimicrobial non-adherence was inappropriate attitude (AOR: 2.100; 95% CI: 1.586–2.780; p < 0.001), followed by inadequate knowledge (AOR: 1.536; 95% CI: 1.160–2.033; p = 0.003). Conversely, nursing education was a significant protective factor (AOR: 0.669; p = 0.005). Conclusions: Antibiotic non-adherence is a complex psychological behavior management issue rather than merely an information deficit. Incorrect attitudes primarily drive sub-lethal dose exposure, theoretically increasing the epidemiological risk associated with resistant mutant selection. Future antimicrobial stewardship (AMS) programs must transcend traditional educational models and incorporate behavioral economics principles, such as digital nudging, to modify inappropriate attitudes.

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