OBJECTIVES: To assess the healthcare workers' (HCWs) knowledge, attitude and practice (KAP) in relation to AR during the era of COVID-19, and identify the associated factors with good knowledge, positive attitude and good practice.

METHODS: A cross-sectional design was used to assess the KAP of HCWs in Najran, Kingdom of Saudi Arabia (KSA). A validated questionnaire was used to collect participants' data, which consisted of the following information; socio-demographics, knowledge, attitude and items for practice. Data were presented as percentages and median (IQR). Mann-Whitney and Kruskal Wallis tests were used to compare them. Logistic regression was used to identify the associated factors linked to KAP.

RESULTS: The study included 406 HCWs. Their median (IQR) knowledge score was 72.73% (27.27%-81.82%), attitude score was 71.43% (28.57%-71.43%) and practice score was 50% (0%-66.67%). About 58.1% of the HCWs stated that antibiotics could be used to treat COVID-19 infection; 19.2% of the participants strongly agreed and 20.7% agreed that during the COVID-19 pandemic, antibiotics were overused at their healthcare institutions. Only 18.5% strongly agreed and 15.5% agreed when asked whether antibiotics used properly for the right indication and duration can still result in AR. The significantly associated factors with good knowledge were nationality, cadre and qualification. A positive attitude was significantly associated with age, nationality and qualification. Good practice was significantly associated with age, cadre, qualification and working place.

METHODOLOGY: A retrospective cross-sectional study was employed to identify patients with positive AR bacteria between March 2019 and March 2022. The bacterial isolates and patients' data were identified from laboratory and medical records departments retrospectively. Binary logistic regression analysis was performed to identify the factors associated with AR and deaths. Multinominal logistic regression was applied to confirm the factors associated with AR classification.

RESULTS: AR Gram-negative bacteria decreased during and after the pandemic. However, S. aureus showed a negligible increase in resistance rate after pandemic, while E. faecium, recorded a higher-than-average resistance rate during the pandemic. The prevalence of pan drug resistance (PDR) during the pandemic (85.7%) was higher than before (0%) and after (14.3%), p = 0.001. The length of stay and time were significant predictors for AR classification. The odds of multi drug resistance (MDR) development to PDR during the pandemic were 6 times higher than before and after (OR = 6.133, CI =, p = 0.020). Age, nationality, COVID-19 infection, smoking, liver disease, and type and number of bacteria were associated with death of patients with positive AR.