Assessment of Nursing Students’ Knowledge of Antibiotic Resistance in an Italian University Setting: A Survey of Knowledge, Attitudes, and Practices

Abstract

Nurses are healthcare professionals who can play a leading role in preventing antimicrobial resistance, given their direct assistance to patients. For this reason, in-depth university training is desirable. This study was conducted to detect possible weak points in the university training about an important public health topic represented by general knowledge about antibiotics and antibiotic resistance. We carried out a survey on Knowledge, Attitudes, and Practices of students attending the Nursing Sciences course at the University of Messina, Italy, by administering an online standardised questionnaire that included general and specific questions about antibiotics and antibiotic resistance. General and specific scores were calculated. Some gaps were found about the knowledge of antibiotics (mean score: 3.6/4) and, especially, antibiotic resistance (mean score: 3.2/5). As expected, most of the incorrect answers to both antibiotic and antibiotic-resistance knowledge were given by students in the first year, but some gaps were also found among students in the last year. Given the growing role nurses can play in combating antibiotic resistance, these findings point to a possible information gap in the study course and highlight the need to enhance the current university training programmes with activities designed to increase knowledge on these important public health issues.

1. Introduction

Antibiotic resistance (ABR) is a critical and growing global public health challenge, threatening the effectiveness of key drugs used to treat a wide range of bacterial infections [1,2]. In addition to occurring naturally in bacteria as an adaptive response to the environment, ABR has been exacerbated by several factors, including the excessive and inappropriate use of antibiotics in humans. This is often driven by patient demand, which puts doctors under pressure and leads to unnecessary antibiotic prescriptions [3]. This phenomenon can result in antibiotic misprescribing and/or overprescribing, further fuelling resistance [4,5,6]. This complex problem requires a deep understanding of the microbiological, epidemiological, and social dynamics involved [7,8].

Recent literature highlights an incremental trend in ABR across world regions; therefore, it is possible to outline emerging challenges and propose strategies to mitigate the spread of resistant strains and their consequences for human health [9]. According to current estimates, in just over 20 years, almost all bacteria will be resistant to most antibiotics currently used in medicine [10,11]. Moreover, it has been predicted that the number of deaths due to antimicrobial resistance could reach 10 million by 2050 [12,13]. This global concern represents a major challenge for current and future public health, and one possible way forward is the One Health approach [14]. It has been clearly demonstrated that the problem of ABR involves different settings [15,16] and, therefore, a multidisciplinary approach engaging many different professionals must be the cornerstone of this fight. Such an approach is crucial in the hospital environment, which has always played a key role in the emergence of new ABR strains, often responsible for Hospital-Acquired Infections (HAIs) [17]. Different approaches are needed to combat this phenomenon, such as standard and specific precautions and antimicrobial stewardship [18,19].

In line with a multidisciplinary approach to fighting ABR, different healthcare professions should join forces, each according to their tasks, skills, and expertise. Many international organisations working in the field of antimicrobial stewardship, such as the Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America (IDSA), and the Joint Commission International (JCI), nowadays emphasise the role of nurses in this area. Their guidelines suggest that nurses need to be involved in comprehensive educational programmes on ABR from the beginning of their studies [20,21,22].

Because of the distinctiveness of their work, characterised by a close and prolonged relationship with patients, nurses are especially involved in the general assessment of patients’ clinical conditions, early detection of infections, microbiological sampling procedures, and the early communication of this information to physicians. In addition, nurses are also responsible for monitoring the effectiveness and safety of antibiotic treatments. They must be capable of providing accurate information about medications and their correct use to patients and families, acting as one of the main sources of information alongside other ‘classic’ health professionals involved in care (e.g., general practitioners, specialised doctors, pharmacists) [23]. Moreover, nurses are often integrated into multidisciplinary teams dedicated to preventing HAIs, making a valuable contribution to ABR prevention. Therefore, expanding nurses’ contributions to antibiotic stewardship within a multidisciplinary approach could significantly improve antibiotic use in different health settings and realise their full potential [24,25,26]. In this context, nurses are a strategic category in the healthcare management of different critical issues, including ABR. The central role that nurses can play in antibiotic stewardship has been recently emphasised in the literature [27,28]. For this reason, it is appropriate to establish an adequate cultural background as early as the university course of study, expanding the knowledge of ABR among students of the healthcare professions, particularly those attending nursing courses. As an integral part of their training, students should gain in-depth knowledge of ABR and the importance of appropriate antibiotic use, including the correct intake and duration of treatment [29]. These concepts play a leading role in understanding the clinical implications of ABR for the management of infections and the impact on patient morbidity and mortality. Furthermore, continuous theoretical and practical training, as well as updating scientific society guidelines and recommendations on good healthcare practices, are essential to ensure students have the ‘preparedness’ necessary to face all possible healthcare challenges, including ABR, in their professional practice [30,31,32,33].

In light of these premises, this study aimed to evaluate a cohort of nursing students’ level of knowledge about antibiotics and ABR to highlight possible criticalities for action to improve this key aspect of healthcare worker training.

2. Materials and Methods

2.1. General Methodology

We carried out a Knowledge, Attitudes, and Practices (KAP) survey from September to October 2025 on the general knowledge of antibiotics and ABR among students attending the nursing science degree course at the University of Messina, Italy, in order to identify potential gaps that need to be addressed regarding a particularly important public health issue. Specifically, the main outcome of the study was to evaluate differences among the attended years and, then, to assess the improvement in knowledge over the course of the programme. The degree course consists of three years of theoretical coursework in core biological and clinical disciplines, combined with practical training at the University Hospital ‘G. Martino’ of Messina. Notably, in the university curriculum under study, most of the information concerning antibiotics and ABR is provided in courses, such as General and Clinical Microbiology, Hygiene and Public Health, Pharmacology, and Infectious Diseases, all included in the first two years of the degree course. In addition, students begin practical training in various departments from their first year, allowing them to gain hands-on experience with antibiotics and antibiotic treatment in daily practice. The study was conducted by administering an online, standardised, anonymous, and ad hoc questionnaire after obtaining informed consent. Specifically, the questionnaire was created and adapted to our needs from the World Health Organization (WHO) survey entitled ‘Antibiotic Resistance: Multi-Country Public Awareness Survey’ [34], a fundamental tool providing an overview of public awareness and behaviours related to antibiotics in many countries. The adaptation process accounted for the sample’s socio-demographic features. Since the survey recipients were students from all years of study, including first-year students, we used plain language, avoiding excessive technicalities. The questionnaire was sent to all students, as no exclusion criteria were applied, considering every attending student eligible. This approach was chosen to obtain a comprehensive overview of the situation. The questionnaire was distributed through Google Forms. The survey included questions focusing on participants’ general demographic data (age, gender, nationality, residence, year of attendance) and key aspects of antibiotics and ABR. Specifically, we formulated four questions on general knowledge of antibiotics and correct administration modalities, and five questions concerning the definition and causes of ABR. For each question, three possible answers were provided: one correct and two incorrect. The final section of the questionnaire included three questions about personal experience and attitudes towards antibiotic therapies. To quantify the responses, we calculated a general knowledge score based on the correct answers given to all the questions (n = 9). We then stratified this result to obtain two specific scores based on the correct answers concerning antibiotics and ABR knowledge, respectively. In calculating the general score (ranging from 0 to 9), values of ≤5, 6, and ≥7 were categorised as insufficient, sufficient, and good. In the specific score for general knowledge of antibiotics (ranging from 0 to 4), values ≤ 2 and ≥3 were considered insufficient and good, respectively. Finally, for the ABR knowledge score (ranging from 0 to 5), values ≤ 2, 3, and ≥4 were categorised as insufficient, sufficient, and good, respectively.

2.2. Statistical Analyses

All data obtained from the questionnaire were analysed using Prism 4.0 software (Boston, MA, USA). Descriptive statistics were used to calculate mean values, standard deviations, and percentages. Graphics were generated using Microsoft Excel 2010. Fisher’s exact test was applied to compare percentages and establish significant differences between variables in terms of p-values and Odds Ratio (OR) values. OR values were calculated by organising the data into a 2 × 2 table to provide a risk estimate in our experimental conditions. An a priori one-way ANOVA test was used to evaluate statistically significant differences among scores. Statistical significance was defined as p < 0.05.

3. Results

3.1. General Features of the Sample

The first step of the study was to obtain a comprehensive socio-demographic characterisation of the sample to evaluate all participants’ individual variables. The complete data are summarised in

Table 1. General features of the sample.

General Features	Results
Total sample of students attending the Nursing Science course	874 (first year: 320; second year: 293; third year: 261)
Percentage response rate (absolute number)	76.9% (672)
Average number of adherent students per year (M * ± SD §)	224 ± 24.5
Adherent students per year: absolute number (%)	First year: 253 (79.1% of first-year attendants; 37.6% of adherent sample) Second year: 226 (77.1% of second-year attendants; 33.6% of adherent sample) Third year: 193 (73.9% of third-year attendants; 28.7% of adherent sample)
Average age (M * ± SD §) of the adherent sample	21.9 ± 3.6 (min. 18–max: 47)
Percentage of adherent students’ gender (absolute number)	M **: 30.7% (206) W §§: 69.3% (466)
Nationality of the adherent sample	Italians: 99% (51.8% coming from the city of Messina and its provincial territory; 41.8% coming from other Sicilian provinces; 6.3% coming from the neighbouring region of Calabria) Foreigners: 1%

* = Mean value; ^§ = standard deviation; ** = men; ^§§ = women.

.

The clear prevalence of female students among respondents was due to the fact that, in our context, 78% of the students attending the nursing science course are women.

3.2. Overall Knowledge Score

Regarding the overall knowledge score, the mean value was 6.9 ± 1.4 out of a possible 9 points. When stratifying this result by year of attendance, the values were 6.4 ± 1.4, 7.1 ± 1.4, and 7.3 ± 1.2 for the first-, second-, and third-years, respectively, with a statistically significant difference among them (F = 27.80332, p < 0.001, η² = 0.08). To evaluate differences in the overall knowledge score across years of attendance and assess potential improvement over the course of study, we compared the values recorded in the three years according to the ranges described in Section 2 (Figure 1).

Figure 1 shows a clear improvement, with important percentage differences between first- and third-years.

Specifically, there was a substantial decrease (−58.9%) in ‘insufficient’ scores and a parallel increase (+57.7%) in ‘good’ scores. When combining the ‘sufficient’ and ‘good’ results for the first- and third-years (77.1% and 90.6%, respectively), a highly significant difference between the two years was found (OR = 0.3424, 95% CI: [0.1520, 0.7713], p = 0.0073).

3.3. General Knowledge of Antibiotics

This type of knowledge was investigated through four questions concerning the general knowledge of these drugs and the correct modalities of their intake. The questions and the corresponding percentages of answers are shown in

Table 2. Questions about general knowledge of antibiotics and percentage of relative correct and incorrect answers divided according to year of attendance.

	Correct Answer			Incorrect Answer			Incorrect Answer
(a) Antibiotics are taken in case of...	Bacterial infections			Viral infections			All types of infection
	TOT 530 (79.1%)			TOT 88 (12.9%)			TOT 54 (8.0%)
	I year 178 (33.6%)	II year 188 (35.5%)	III year 164 (30.9%)	I year 57 (64.8%)	II year 22 (25.0%)	III year 9 (10.2%)	I year 19 (35.2%)	II year 15 (27.8%)	III year 20 (37.0%)
(b) You can use the antibiotics prescribed to a friend or family member to treat the same disease	False			True			I do not know
	TOT 622 (92.5%)			TOT 24 (3.6%)			TOT 26 (3.9%)
	I year 229 (36.8%)	II year 212 (34.1%)	III year 181 (29.1%)	I year 11 (45.8%)	II year 5 (20.8%)	III year 8 (33.4%)	I year 13 (50.0%)	II year 9 (34.6%)	III year 4 (15.4%)
(c) You can use the same antibiotics that helped you to recover from a previous disease in the past	False			True			I do not know
	TOT 621 (92.4%)			TOT 26 (3.9%)			TOT 25 (3.7%)
	I year 227 (36.5%)	II year 211 (34.0%)	III year 183 (29.5%)	I year 13 (50%)	II year 9 (34.6%)	III year 4 (15.4%)	I year 13 (52.0%)	II year 6 (24.0%)	III year 6 (24.0%)
(d) When do you think it is better to stop an antibiotic treatment?	After taking all the prescribed pills			When I feel better			I do not know
	TOT 615 (91.5%)			TOT 44 (6.5%)			TOT 13 (1.9%)
	I year 219 (35.6%)	II year 211 (34.3%)	III year 185 (30.1%)	I year 25 (56.8%)	II year 13 (29.5%)	III year 6 (13.6%)	I year 9 (69.2%)	II year 2 (15.4%)	III year 2 (15.4%)

.

The table indicates that 142 (20.9%) of students (combining both incorrect answers) were unaware of the correct use of antibiotics, especially concerning the type of diseases they are intended for. When stratifying the sample by year of attendance, the highest percentage of correct answers to question (a) was given by students attending the third year, representing a significant percentage increase (+150.6%, OR = 0.0657 [95% CI: [0.0308, 0.1400], p < 0.001) compared to first-year students (Figure 2A). Similarly, regarding questions (b), (c), and (d), remarkable percentage increases in correct answers were found between the students attending the first and the third year, specifically +50.1% (OR = 0.2628 [95% CI: [0.1388, 0.4975], p < 0.001), +69.2% (OR = 0.1813 [95% CI: [0.0930, 0.3532], p < 0.001), and +100.0% (OR = 0.1268 [95% CI: [0.0641, 0.2507], p < 0.001), respectively (Figure 2B). Overall, Figure 2 shows that first-year students consistently provided the lowest percentage of correct answers, particularly for questions (a) and (d) (on the correct use of antibiotics and the correct duration of therapy).

In addition to the above results, we evaluated the number of correct answers given by individual students. The analysis showed that 67.4% of the entire sample gave all four correct answers, 23.4% gave three correct answers, 6.8% gave two correct answers, 2.2% gave only one correct answer, and, finally, 0.2% gave no correct answers. The relationship between the number of correct answers and the year of attendance is shown in Figure 3.

The figure shows that the number of correct answers was strictly related to the year of study. While all correct answers were distributed with similar percentages across the three years, the other percentages showed that the frequency of incorrect answers was inversely proportional to the year attended, with the extreme result of ‘no correct answers’ observed only in the first year. In detail, we found the following percentage decreases (with statistically significant differences) between the first and third years: −46.5% (OR = 2.7352 [95% CI: [1.5088, 4.9585], p = 0.0012), −68.0% (OR = 0.1788 [95% CI: [0.0936, 0.3415], p < 0.00001), −89.9% (OR = 0.0398 [95% CI: [0.0170, 0.0933], p < 0.00001), and −100% for three, two, one, and no correct answers, respectively. Furthermore, we investigated which of the four questions was most frequently answered correctly. Specifically, 79.0%, 92.9%, 92.4%, and 91.5% of students gave correct answers to questions (a), (b), (c), and (d), respectively, identifying question (a) as the most critical topic.

Finally, concerning the general knowledge of antibiotics, the mean score was 3.6 ± 0.7 out of a possible 4 points. Stratifying this result by year of attendance, the values were 3.4 ± 0.8, 3.7 ± 0.6, and 3.7 ± 0.5 for the first, second, and third years, respectively, with a statistically significant difference among them (F = 13.54685; p < 0.00001). As previously mentioned, considering ‘insufficient’ values in the range 0–2 and ‘good’ values in the range 3–4, insufficient values were detected in 11.9%, 9.2%, and 7.8% of students across the three years. This demonstrates a decreasing trend parallel to academic progress, with a moderate percentage decrease (−34.4%) in ‘insufficient’ scores and a slight percentage increase (+4.7%) in ‘good’ scores between the first and third years, without statistically significant differences.

3.4. General Knowledge of ABR

This second aspect was investigated through five questions regarding the definition of ABR, its dissemination, and the role that individuals play in its development. In detail, the questions and the percentages of correct and incorrect answers are shown in

Table 3. Questions about ABR knowledge and relative answers.

	Correct Answer			Incorrect Answer			Incorrect Answer			Incorrect Answer
(a) ABR is when our body becomes resistant to antibiotics	False			True			I do not know			//
	TOT 170 (25.3%)			TOT 495 (73.6%)			TOT 7 (1.1%)
	I year 53 (31.2%)	II year 77 (45.3%)	III year 40 (23.5%)	I year 197 (39.8%)	II year 146 (29.5%)	III year 152 (30.7%)	I year 4 (57.1%)	II year 2 (28.6%)	III year 1 (14.3%)
(b) Antibiotic-resistant bacteria can be acquired by…	All the following answers			Contact with someone affected by an infection caused by antibiotic-resistant bacteria			Contact with items contaminated by antibiotic-resistant bacteria			Contact with animals or foods contaminated by antibiotic-resistant bacteria
	TOT 416 (61.9%)			TOT 86 (12.8%)			TOT 40 (6.0%)			TOT 130 (19.3%)
	I year 121 (29.1%)	II year 159 (38.2%)	III year 136 (32.7%)	I year 43 (50.0%)	II year 20 (23.3%)	III year 23 (26.7%)	I year 18 (45.0%)	II year 10 (25.0%)	III year 12 (30.0%)	I year 71 (54.6%)	II year 37 (28.5%)	III year 22 (16.9%)
(c) What can happen when you get an infection caused by antibiotic-resistant bacteria?	All the following answers			The disease can last for a longer period of time			You might need of a hospital admission			You might need to intake more antibiotics
	TOT 399 (59.4%)			TOT 91 (13.6%)			TOT 116 (17.2%)			TOT 66 (9.9%)
	I year 123 (30.8%)	II year 133 (33.4%)	III year 143 (35.8%)	I year 47 (51.6%)	II year 29 (31.9%)	III year 15 (16.5)	I year 58 (50.0%)	II year 39 (33.6%)	III year 19 (16.4%)	I year 27 (40.9%)	II year 24 (36.4%)	III year 15 (22.7%)
(d) ABR is a widespread reality. There is nothing I can do to counteract it	False			True			I do not know			//
	TOT 620 (92.3%)			TOT 47 (7.0%)			TOT 5 (0.7%)
	I year 234 (37.7%)	II year 209 (33.7%)	III year 177 (28.5%)	I year 18 (38.3%)	II year 16 (34.0%)	III year 13 (27.7%)	I year 3 (60.0%)	II year 1 (20.0%)	III year 1 (20.0%)
(e) I can contribute to reduce ABR if	I undergo all the suggested vaccinations			I always take antibiotics every time I have fever			I share antibiotic treatment with someone else			//
	TOT 584 (86.9%)			TOT 77 (11.5%)			TOT 11 (1.6%)
	I year 218 (37.3%)	II year 190 (32.5%)	III year 176 (30.1%)	I year 28 (36.4%)	II year 32 (41.5%)	III year 17 (22.1%)	I year 7 (63.6%)	II year 4 (36.4%)	III year 0 (0.0%)

.

The table shows that a very low percentage of students answered question (a) correctly, indicating a lack of awareness of the definition of ABR. Notably, 60.0%, 70.5% and 69.5% of students attending the first, second, and third years, respectively, gave incorrect answers, without significant differences among the years.

A better understanding of ABR’s modes of transmission (question b), the consequences of contracting an antibiotic-resistant bacterial infection (question c), and, most importantly, the potential to take personal action to combat it (question d–e) was observed; however, no significant differences were found across years of attendance.

Furthermore, we evaluated the number of correct answers given by individual students. The analysis showed that 10.6%, 38.6%, 36.3%, 17.3%, 6.5%, and 1.3% of the entire sample gave five, four, three, two, one, and no correct answers, respectively. The relationship between the number of correct answers and the year of study is shown in Figure 4.

The figure shows that, for this type of knowledge, the number of correct answers was also closely related to the year of attendance. Specifically, first-year students comprised only a little more than a tenth of the sample providing five correct answers, showing a statistically significant difference compared to third-years (OR = 0.1370 [95% CI: [0.0685, 0.2741], p < 0.00001). The result of four correct answers was equally distributed among the three years. For the findings of three, two, and one correct answer, we observed the following significant percentage variations between the first- and third-years: −39.0% (OR = 2.1051 [95% CI: [1.1687, 3.7917], p = 0.012681), −75.8% (OR = 0.1122 [95% CI: [0.0566, 0.2224], p < 0.00001), and −72.3% (OR = 0.1808 [95% CI: [0.0903, 0.3620], p < 0.00001). Finally, no difference was found across years of attendance regarding the result of no correct answers.

Additionally, we highlighted the most frequently missed question among the five provided. In the entire sample, 72.2%, 38.1%, 40.8%, 3.0%, and 13.1% gave incorrect answers to questions (a), (b), (c), (d), and (e), respectively.

Finally, concerning ABR knowledge, the mean score was 3.2 ± 1.1 out of a possible 5 points. When stratifying this result by year of attendance, the values were 2.9 ± 1.0, 3.4 ± 1.2, and 3.5 ± 1.0 for the first, second, and third years, respectively, with a statistically significant difference among them (F = 18.99722; p < 0.00001). Using the parameters reported in Section 2, the percentage for each of the three years is shown in Figure 5.

The figure shows statistically significant differences between the first- and third-years, with a substantial decrease of −68.2% (OR = 4.3613 [95% CI: [2.1324, 8.9200], p = 0.000033) for ‘insufficient’ scores and a substantial increase of +103.9% (OR = 0.2974 [95% CI: [0.1656, 0.5341], p = 0.000055) for ‘good’ scores.

3.5. Past Experiences with Antibiotics

The last section of the questionnaire focused on past personal experiences with antibiotics, specifically regarding past therapeutic treatments, the individuals who recommended them, and the sources from which the antibiotics were obtained. The results are shown in

Table 4. Questions about personal past experiences with antibiotics.

(a) Have you ever taken antibiotics?
Yes	TOT 644 (95.8%)
	I year 238 (37.0%)	II year 217 (33.7%)	III year 189 (29.3%)
No	TOT 13 (1.9%)
	I year 7 (53.8%)	II year 4 (30.8%)	III year 2 (15.4%)
I do not remember	TOT 15 (2.2%)
	I year 8 (53.3%)	II year 5 (33.4%)	III year 2 (13.3%)
(b) Who recommended them to you?
Doctor	TOT 647 (96.3%)
	I year 236 (36.5%)	II year 220 (34.0%)	III year 191 (29.5%)
Chemist	TOT 5 (0.8%)
	I year 3 (60.0%)	II year 1 (20.0%)	III year 1 (20.0%)
Relative/Friend	TOT 14 (2.0%)
	I year 6 (42.9%)	II year 5 (35.7%)	III year 3 (21.4%)
Nobody	TOT 2 (0.3%)
	I year 1 (50.0%)	II year 0 (0.0%)	III year 1 (50.0%)
I do not remember	TOT 4 (0.6%)
	I year 3 (75.0%)	II year 0 (0.0%)	III year 1 (25.0%)
(c) Where did you find antibiotics?
Purchase in pharmacy	TOT 622 (92.6%)
	I year 239 (38.4%)	II year 209 (33.6%)	III year 174 (28.0%)
Relative/Friend	TOT 2 (0.3%)
	I year 1 (50.0%)	II year 1 (50.0%)	III year 0 (0.0%)
Internet	TOT 4 (0.5%)
	I year 3 (75.0%)	II year 1 (25.0%)	III year 0 (0.0%)
At home, after previous use	TOT 34 (5.1%)
	I year 4 (11.8%)	II year 12 (35.3%)	III year 18 (52.9%)
I do not remember	TOT 10 (1.5%)
	I year 4 (40.0%)	II year 1 (10.0%)	III year 5 (50.0%)

.

The table makes it clear that almost the entire sample had previously received at least one antibiotic treatment and that the most frequently reported sources of prescription and purchase were doctors and pharmacies, respectively. However, a small percentage of the sample (3.1%) declared that a doctor did not provide the recommendation, and 5.9% declared that the antibiotics were obtained from a source other than a pharmacy. Particularly interesting is the finding ‘at home, after previous use’, since it may imply improper use.

4. Discussion

ABR represents one of the most critical public health challenges worldwide, as previously highlighted. To address this critical concern, prevent the circulation of antibiotic-resistant microorganisms, and block the spread of difficult-to-treat infections, a multidisciplinary approach is essential [35]. In this context, close cooperation between different professionals, each according to their own expertise, can be decisive. Previous studies have investigated nurses’ potential to influence this phenomenon, in some cases through direct intervention as antibiotic prescribers [36,37,38,39]. Nurses are in daily contact with patients and often represent the first source of information on health-related issues. Moreover, they act as a key information source for patients with doubts about the correct use of antibiotics and the behaviours necessary to best preserve one’s health. In this regard, as stated by Hamdy et al. in 2019 [40], nurses can act as a bridge between doctors and patients or their families to fill communication gaps, explaining the correct use and potential risks of antimicrobials [41]. These claims are corroborated by recent scientific evidence focusing on patients’ trust in nurses and the reasons for this attitude [42,43]. Factors such as more time spent with patients, a stronger focus on care, easier accessibility, and higher perceived empathy often make the nurse–patient relationship more impactful than the doctor–patient one.

However, nurses often perceive their own knowledge and university preparation regarding antimicrobial use as insufficient, expressing a desire to enhance their training and a motivation to play a role in antimicrobial stewardship—a cornerstone of ABR prevention [44]. For these reasons, advanced scientific expertise in many fields of healthcare, including ABR, is necessary. For this reason, in-depth university training is recommended. To this end, the nursing programme has undergone several significant changes over time, transforming it from what was previously classified as an apprenticeship into a full-fledged bachelor’s degree programme. According to some scientific evidence, in the United Kingdom this has resulted in a decline in the practical and interpersonal skills of the nursing profession [45]. One of the possible reason was that the academic environment can represent a barrier to some who cannot cover fees or who would have difficulty earning a college degree. Current nursing education focuses on different elements covering all healthcare aspects in order to front challenges, such as an aging population whose physical and mental health is declining, to take on new professional roles, to adapt to new technologies, and collaborate with professionals from other sectors [46].

In light of what was said above, our study aimed to evaluate the effectiveness of a nursing science degree course in an Italian provincial territory, assessing the general knowledge of antibiotics and ABR in a large cohort of students. The KAP survey methodology allowed us to collect crucial information on these topics and identify critical gaps to address to improve the skills of these future healthcare professionals. The study’s major outcome was the identification of several critical issues regarding knowledge of both antibiotics and, especially, ABR.

Firstly, the overall knowledge score was only slightly above sufficient, although significant differences emerged among the years of study, with first-year students scoring much lower than third-years. This result demonstrates the curriculum’s effectiveness, as expected. However, approximately 15% and 10% of second- and third-year students, respectively, still proved ‘insufficient’. This finding indicates room for improvement in both theoretical and practical training. Nevertheless, when dividing this overall knowledge into the specific knowledge of the two single components of antibiotics and ABR, we noticed distinct differences. Concerning specific knowledge of antibiotics and their correct use, the score was notably high, resulting in a value very close to the maximum. However, in this regard, a certain percentage of students remained unaware of the actual therapeutic functions of these drugs—this question received the highest number of incorrect responses. This critical issue was significantly related to the year of attendance, primarily affecting first-year students. However, even though the percentage of incorrect responses decreased in subsequent years, it must be deemed markedly high for this straightforward, fundamental information that all students should possess. In addition, a certain percentage of students remained unaware of the correct use of these drugs, an essential point to minimise ABR’s development and spread. A major concern is the belief that treatment can be started independently of medical advice or stopped before the cycle is completed. This is a key finding, as self-treatment and lack of therapeutic adherence are strictly associated with ABR’s spread [47,48,49,50,51]. Notably, while about half of the students giving incorrect answers belonged to the first year (50.8%), this dropped to 15.7% in the final year. This trend was confirmed by the results for individual students: almost half of the first-year students made at least one mistake (three correct answers), and only students in this group made four mistakes.

More concerning were the results regarding general knowledge of ABR, where the average score was only ‘sufficient’. Also in this case, we detected an increasing trend by year of attendance. However, we must emphasise the unexpected finding that a very high percentage of the sample did not know what ABR actually is. Unlike other statistics, this gap is only partially addressed by subsequent years of study, as approximately one-third of second and third-year students still provided incorrect responses. This result is particularly critical and must be promptly addressed through targeted interventions, such as workshops, conferences, and real-world case scenarios. We can assume that bidirectional health education interventions, consisting of the preliminary administration of a dedicated questionnaire followed by a face-to-face lecture and, finally, the administration of the same questionnaire, could be very useful for evaluating the interventions’ efficacy. This widespread and well-tested methodology would allow useful feedback from the class and could then help teachers to improve the quality of the information provided and students to increase their knowledge.

In addition, it was highlighted that a certain number of students were unaware of ABR transmission modes and the severity of infections caused by resistant bacteria, as shown by the answers to questions (b) and (c) related to ABR knowledge. Moreover, concerning the number of correct answers by individual students, we did not observe the same findings as for general knowledge of antibiotics, as a consistently high percentage of students who did not give correct answers belonged to the second and third years. Specifically, more than one-third of students who got no correct answers belonged to the second and third years, in line with the percentage among first-year students. Fortunately, as highlighted by the answers to the last two questions about ABR knowledge, almost the entire sample is aware that each of us can play a key role, both negatively and positively, in the spread of ABR and that vaccination can play a leading role in managing this critical phenomenon.

Although there is little evidence in the global scientific literature regarding this issue, our data perfectly overlap with previous findings. A Spanish study by Rábano-Blanco et al. (2019) [44] showed that while students are well aware of general aspects of antibiotics, they exhibit poor expertise in ABR, often accompanied by the perception that they have received scarce education on this topic during their degree course. Interestingly, however, the authors found that knowledge and expertise improved over the years of study and training. De Vita et al. (2024) [52] performed an Italian multicentre study including both students and nurses, detecting a low knowledge level in more than a third of the sample. The same authors found that living in southern Italy, the same location as our study, seemed to be associated with a low knowledge level; however, they stated that this result should be considered as a bias, as most of the enrolled participants worked or studied in southern Italy. In a cross-sectional study focusing especially on antimicrobial stewardship knowledge and enrolling nursing students [53], some participants declared satisfaction with the preparation on ABR in the university’s curriculum, and that additional course content on this topic was not required. Furthermore, nursing students are taught about ABR as early as their first year of study and during their internship, which aligns with what we found at our university. Despite this, the authors found that ABR knowledge was poor.

5. Conclusions

Our study demonstrated an overall improvement in general knowledge of antibiotics and ABR throughout the study course, as expected. This finding indicates that significant attention is paid to these pivotal topics. However, certain criticalities were detected in a subset of students, including those in their final year. This gap was especially evident regarding specific aspects of ABR. These results suggest that greater emphasis must be placed on this crucial topic throughout the entire nursing curriculum, considering the vital, increasingly prominent role this category of healthcare workers plays in managing antibiotic treatments and fighting ABR across all healthcare settings. To address this, we propose several strategies to enhance knowledge and expertise. These include integrating additional university activities specifically focused on these topics, such as online and face-to-face workshops, conferences, or dedicated internships, which should supplement standard learning activities throughout all years of study, as supported by previous evidence [54]. Moreover, we can assume that regular detection of the acquired knowledge of ABR and other important topics during the normal course of classes, e.g., at the end of a semester, using in itinere verifications or interactive modules, could be a precious tool for improving nurses’ general preparedness. We assume that the routine administration of dedicated questionnaires, similar to the one used in this research, could assist faculty boards in evaluating their teaching methods and effectively filling the gaps identified among students.

Limits of the Study

This research began as a study of a local context characterised by a unique structure of the academic programme; however, we believe it can also be applied to other university settings. There could be some biases in the methodology used—for example, a measurement bias, as considering that this was an online survey, students may have consulted external sources (books, Google) before responding, leading to an overestimation of their actual knowledge, or a social desirability bias where participants tend to answer what is professionally “correct” rather than what they actually do. Furthermore, some confounding factors, e.g., prior work experience and previous degrees, could also be present. Finally, to fully understand the level of knowledge regarding a topic as complex as ABR, we believe it is necessary to use equally complex tools, such as comprehensive and systematic questionnaires that, however, could pose an additional limitation in terms of low response rates.