Knowledge and misconceptions about antibiotic use and antibiotic resistance among secondary school students in Riyadh, Saudi Arabia: implications for school- based antibiotic resistance education.

Background: Antibiotic resistance (AR) is a major global public health threat, and improving AR awareness among adolescents is a priority in efforts to combat it. However, adolescents remain an understudied population, particularly in Saudi Arabia. This study evaluated practices, knowledge, awareness, misconceptions, and attitudes regarding antibiotic use and AR among secondary school students in Riyadh, Saudi Arabia. Methods: A cross-sectional survey was conducted among 389 students from nine secondary schools (six public, two private, and one international) in Riyadh, between October 2024 and December 2024. A self-administered questionnaire assessed students' practices, knowledge, awareness, and attitudes regarding antibiotic use and AR. Associations with gender, school type, and participation in science or health clubs were examined using chi-square/Fisher's exact tests with false discovery rate adjustment and multivariable regression of composite knowledge scores. Results: Although most students reported positive attitudes toward responsible antibiotic use, substantial knowledge gaps were identified. Misconceptions were common regarding the treatment of viral infections, the biological basis of AR, and the role of antibiotic use in agriculture and food-producing animals. Correct responses to AR concept statements ranged from 8.7% to 42.2%. Students were more familiar with the terms antibiotic-resistant bacteria (49.4%), antibiotic resistance (44.5%), and drug resistance (40.6%) than with antimicrobial resistance (21.6%) or AMR (21.9%). Doctors were the most frequently reported source of information, whereas awareness campaigns were among the least frequently reported. After adjustment, club participation was not associated with the AR-concept score (β = 0.27, 95% CI -0.20 to 0.73), whereas female gender (β = 0.69, 95% CI 0.47 to 0.91) and private-school attendance (β = 0.30, 95% CI 0.06 to 0.54) were independently associated with higher knowledge of appropriate antibiotic use. Most students (61.7%) supported incorporating antibiotic use and AMR education into school curricula, primarily to increase awareness and knowledge and to protect individual and community health. Conclusions: Secondary school students in Riyadh demonstrated positive attitudes toward responsible antibiotic use but had important gaps in their understanding of AR. Strengthening school-based AR education, including appropriate antibiotic use, core AR concepts, and One Health concepts, could improve students' awareness and support national efforts to combat AR.