Antibiotic use and antibiotic resistance awareness: A survey of ruminant and poultry Farming practices in Tunisia

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The overuse and/ misuse of antibiotics in food-producing animals is a potentially key factor contributing to the transmission of AMR among humans. This study was set up to describe the antibiotic use patterns of ruminant and poultry farmers in Tunisia, to understand the reasons for their antibiotic use decisions and to assess their awareness of the risk of antibiotic misuse in the development of resistance. A structured, anonymous questionnaire consisting of 12 questions divided into four main sections was conducted face-to-face by 11 veterinarians with 110 chicken and ruminant farmers across three Governorates—Sousse, Mahdia, and Monastir—in the Sahel region of Tunisia. Statistical analysis was performed on the collected data. Findings revealed a significant proportion of farmers (90%) lacked a livestock register to ensure traceability of animal care and medication. Alarmingly, 92.7% of the farmers administered antibiotics through self-medication without veterinary prescriptions. Digestive diseases (88.2%) were the most commonly treated, followed by foot diseases (60%), mammary diseases (60%), and respiratory diseases (41.8%). The analysis revealed that high treatment costs (p = 0.005) and the ease of obtaining antibiotics from local pharmacies (p = 0.016) significantly contributed to the prevalence of self-medication practices. Inappropriate use of antibiotics was widespread, with 62.7% of farmers not adhering to the prescribed treatment duration and 82.7% stopping treatment prematurely after symptoms had disappeared. In addition, 61.8% of farmers did not respect the withdrawal period for antibiotics. Critically, 94.5% of respondents were unaware of the dangers of inappropriate antibiotic use and only 5.5% of farmers had received training in good husbandry practices. These findings highlight the urgent need to improve farmers' antibiotic knowledge and practices. Implementing strong training programs, enforcing veterinary surveillance, and promoting responsible antibiotic use are essential to reduce the risk of AMR and protect both animal and public health in Tunisia. Antibiotic resistance Survey Farmers Antibiotics use Livestock Awareness level of antibiotic resistance Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The phenomenon of antibiotic resistance (AMR) has now become a serious concern and a major threat to global public health, with considerable mortality and morbidity rates. A recent study estimates that by 2050 the number of deaths attributable to AMR will reach 1.91 million while the number of deaths associated with AMR will reach the 8.22 million ( 1 ). Nowadays, humans and animals share most classes of antibiotics, as well as antibiotic resistance bacteria and antibiotic resistance genes. The widespread use of antibiotic classes, including those of high clinical value, in human and veterinary medicine is a key factor contributing to the emergence of antibiotic resistance ( 2 ). In addition, the overuse and abuse of antibiotics and their use in animals (food producers and pets) has also led to the selection and transmission of resistant bacteria. Antibiotics are administered to food-producing animals for a number of reasons, including therapeutic, metaphylactic and prophylactic purposes, but they are also used as growth promoters ( 3 ). AMR is potentially transmissible to humans via the food chain, through contact with resistant bacteria or via transfer mechanisms between bacteria. Appropriate use of antibiotics is therefore crucial in order to limit the selection of resistant bacteria, to preserve the efficacy of the antibiotic and to limit the presence of residues in animal food products. In Tunisia, the failure to comply with the guides to good practice for the use of antibiotics established by international organizations in livestock farming, the abusive and uncontrolled use of antibiotics, and the absence of national networks for monitoring AMR in animals, are all factors that have led to the emergence of AMR. Furthermore, no concrete data on the use of antibiotics in livestock farming in Tunisia was available. This gap was filled by a survey of livestock farmers and veterinary doctors. The aim of this survey is to understand better the determinants of antibiotic use practices in poultry and ruminant farming, as well as the reasoning of breeders in decision-making. The study also aims to assess farmers' awareness of the use of antibiotics and the issue of antibiotic resistance in general. Materials and Methods 1. Ethics, Consent, and Permissions The study was approved by the Ethical Committee of Animal Experimentation, National School of Veterinary Medicine, Tunisia, under the number of acceptance CEEA-ENMV 93/25 . 2. Survey areas The survey was conducted among 110 chicken and ruminant farmers in 3 major governorates in Tunisia's Sahel region in the east of the country: Monastir, Sousse and Mahdia and in a number of delegations within these 3 governorates (Fig. 1 ). These governorates have both large-scale livestock (including cattle, goats, and sheep) and small-scale livestock, including poultry. Sousse Governorate According to the regional Delegation of Agriculture of Sousse, the region produced in 2019, 6750 heads of cattle, with the delegation of Kalaâ Kebira having the greatest potential. The number of sheep stands at 185,000 head, of which 40,000 (21.6%) come from the Enfidha delegation. Goat numbers are estimated at 17,000 head. The M'Saken delegation has the greatest potential for small livestock. It has 46,600 head of poultry, representing 34.15% of the total ( 4 ) Monastir Governorate Livestock production in the governorate of Monastir remains modest compared with other governorates in the Centre-East. In 2017, the livestock population consisted mainly of 80,000 sheep, 12,000 cattle, 2,700 goats, 5,000 beehives, and around 1.3 million poultry units. The distribution of livestock by delegation in 2017 shows a wide spatial disparity. The three delegations of Jammel, Zeramdine and Moknine alone account for 51,000 head of sheep, representing 63.7% of the total ( 5 ). Mahdia Governorate The governorate is best known for its cattle farming, which makes it the country's second-largest milk-producing area. In 2022, the livestock population consisted mainly of 27,500 cattle, 280,000 goats and 15,000 sheep distributed over 11 delegations ( 6 ). 1. Design and implementation of the survey An anonymous individual interview with 110 farmers was carried out face-to-face by 11 veterinary doctors between 01/09/2024 and 15/09/2024 using a survey available in a paper-based format. The questionnaire was prepared on the basis of readings that enabled us to identify the most relevant questions ( 7 – 9 ). Additional material includes the French-language questionnaire used and an English-language translation (Supplementary material 1 and 2). Participants’ responses were anonymous and confidentiality was assured. According to the Comité d'Ethique en Expérimentation Animale-(CEEA), Ecole Nationale Médecine Vétérinaire à Tunis (Committee on Ethics in Animal Experimentation-CEEA, National School of Veterinary Medicine, Tunis), this study does not require an ethical approval. The survey was composed by a total of 12 questions and 4 main sections: Section 1 : Farm identification (two closed questions), Section 2 : Health monitoring (two closed questions), Section 3 : Information on their use of antibiotics (two open questions with multiple answers and 4 closed questions) and Section 4: Farmers' awareness of antibiotics and antibiotic resistance (two closed questions). The questionnaire sections are detailed below. 2.1. Information on livestock farms In this first part, general information about the farmers and their farms was collected in order to study its possible impact on the use and perception of antibiotic use. 2.2. Health monitoring In the second part of the survey, farmers were asked how often they consulted a veterinary surgeon and whether they kept a livestock register. 2.3. Uses and practices In this section, farmers are asked to describe their treatment habits (method of use, frequent pathologies for which they self-medicate with antibiotics (reasons for treatment), whether or not they comply with treatment and withdrawal times, and the reasons why farmers administer antibiotics to their livestock without consulting a veterinary doctor. 2.4. Assessing farmers' awareness of antimicrobial resistance In this section, farmers are asked whether or not they are aware of the risk of extensive and inappropriate use of antibiotics on farms and their impact on human health. They are also asked whether they have received any training on antibiotic resistance. 3. Statical analysis Statistical analyses of this study were carried out using SPSS software 2012. Answers to open questions were coded into categorical variables and analyzed. Data were explored primarily through descriptive analyses and correlation tests, aimed at examining the relationships between self-medication with antibiotics and the reasons motivating this behavior. To explore the links between the practice of self-medicating with antibiotics and participants' motivations, the Chi2 test of independence was carried out. This test is used to assess the existence of a significant association between two qualitative variables. In this study, it was used to determine whether certain specific reasons (breeder “Knowledge”, cost of medical consultations, or nearby pharmacy) were significantly linked to the decision to self-medicate antibiotics in livestock. p < 0.05 was considered as statistically significant. Graphs were generated by EXCEL 2019 software. Results 1. Type of breeding and health monitoring A survey was carried out among 110 farmers. The first section of the survey provided general information about the farms. The results showed that the majority of farms was extensive (70.9%, 78/110), whereas it was intensive in 32 cases (29.1%, 32/110). Extensive farms are characterized by low stocking densities and diversity of animal species (sheep, cattle, goats, etc. ), in contrast to intensive farms, also known as industrial farms, which are animal production systems designed to maximize yields through high animal density in a relatively small area. The breeding were poultry farms (19.1%, 21/110) and ruminant farms (80.9%, 89/110).In the second part, the farmers were asked whether they kept a livestock register, which guarantees the traceability of animal care and medication. The answer was negative (No) in 99 cases (90%, 99/110). 2. Antibiotic use practices In this section, farmers were asked about their antibiotic use practices on poultry and ruminant farms. According to the farmers' responses, antibiotics were frequently used on these types of farms without a veterinary prescription, and were self-medicated (92.7%, 102/110) according to the farmers (Fig. 2 ). According to farmers, antibiotics are frequently self-medicated for the most common diseases, of which digestive disease is the most frequent (88.2%), followed by foot disease (60%), mammary disease (60%, 66/110) and respiratory disease (41.8%, 46/110). More than half of farmers do not comply with antibiotic treatment measures, in particular by not following the treatment times recommended by the veterinarian (62.7%, 69/110) and by changing the length of time they take antibiotics after the symptoms of the disease have disappeared (82.7%, 91/110), which contributes to the problem of antibiotic resistance in animals. Another critical point highlighted in the survey was the failure to respect the withdrawal period (61.8%, 68/110), (the time taken between the last administration of veterinary medication and the presence of residues in foodstuffs below the maximum residue limits MRLs) (Fig. 3 ). With regard to veterinary interventions, the great majority of first-line antibiotic treatments were carried out without a medical prescription and the animal was not consulted by the veterinarian (self-medication). According to the farmers interviewed, the reasons for administering antibiotics without consulting a veterinarian were the high cost of medical treatment (65.6%, 67/102), direct sale without a medical prescription (‘local pharmacy’) (57.8%, 59/102) and self-medication on the pretext that the farmers knew the pathologies and their treatments (23.5%, 24/102) (Fig. 4 ). These results revealed that high medical treatment costs (p = 0.005) and local pharmacy (p = 0.016) are significantly associated with antibiotic self-medication. Knowledgeable breeder was not significantly associated with antibiotic self-medication (p = 0.112). 3. Farmers' awareness of antibiotic use and antibiotic resistance In this section, farmers are asked whether they are aware of the risk associated with the misuse and abuse of antibiotics on farms. They are also asked if they have received any training on the issue of antibiotic resistance. The results obtained show that 94.5% (104/110) of the farmers have no knowledge of the risk of inappropriate antibiotic use on their farms, and only 6 farmers (5.5%, 6/110) have attended a training course on good husbandry practices (Fig. 5 ). Discussion Several factors play a role in the increasing development of antibiotic resistance, thereby threatening animal and human health and becoming a national and global issue. The excessive and inappropriate use of antibiotics for both prophylactic and therapeutic uses in food-producing livestock has been highlighted as one of the most important factors. Farmers' knowledge, attitudes, and behaviors regarding the use of antibiotics in animals play a key role in the development and spread of antibiotic resistance. However, previous reports have indicated that much of the farming community does not have sufficient information on the antibiotic use and antibiotic resistance issue ( 10 – 12 ). According to a study survey, antibiotics should be given to all sick animals, according to over 70% of respondents, and 63% thought that antibiotics had no side effects in animals ( 12 ). Another study showed that 32% of respondents felt that antibiotics were effective against internal and external parasites in animals, while 61% considered them to be antipyretic and analgesics ( 13 ). These results suggest that farmers are largely unaware of the proper use of antibiotics, which poses a serious problem. In our survey, face-to-face contact with farmers was used to collect questionnaire responses, in order to improve the response rate, unlike in other studies where responses were collected by post ( 14 , 15 ). Respondent anonymity was guaranteed to encourage farmers to answer without misrepresenting their practices. In our study, 90% of breeders did not have a sanitary register, whereas a similar study carried out in France in 2006 revealed that 85% of breeders completed their sanitary registers to contribute to the traceability of their farms ( 14 ). The absence of health records in this study may reflect either gaps in legislation, lack of implementation or poor support for farmers to adopt such practices. It may also indicate gaps in awareness or training on the benefits of record keeping for farm management and traceability. These findings highlight the need for targeted interventions, including education on the benefits of traceability, strengthening veterinary support systems and possibly introducing simplified procedures to improve record keeping compliance. In this study, we reported an alarming finding: (92.7%, 102/110) of farmers administered antibiotics by self-medication without veterinary prescription. In comparison with other similar studies, this prevalence is higher than in other studies such as Pakistan: 22% ( 16 ), Indonesia: 33.3% ( 17 ) and Turkey: 48% ( 13 ). The high cost of medical treatment (65.6%, 67/102) and the ‘nearby pharmacy’ (57.8%, 59/102), significantly contributed to the prevalence of self-medication practices. On the one hand, livestock farmers, particularly small producers, have limited budgets and live in a critical economic and financial situation. They find that professional veterinary services are financially inaccessible. They therefore opt for cheaper and illegal solutions, such as buying antibiotics directly from local pharmacies without a prescription. While these farmers cut costs in the short term, the reality is that this behaviour often leads to antibiotic misuse, treatment failures and longer-term expenses. Pharmacies also play an important role in this bad practice. In many low- and middle-income countries, including Tunisia, antibiotics are often sold over the counter without a prescription. Driven by market demand and poor surveillance, local pharmacies may prioritize sales over appropriate use, encouraging farmers to adopt this habit, thereby indirectly contributing to the development and emergence of resistance in farm animals, and subsequent transmission to humans. With such behaviour and the lack of protection and sanctions provided by governments, the ethics and morality of such a practice become questionable. The classification of diseases for which farmers resort to self-medication, highlighting digestive, foot, mammary and respiratory diseases, reveals significant trends in animal health management. These diseases are a priority not only because they directly affect production, but also because of the potential costs associated with veterinary treatment and associated production losses. A similar study reached the same conclusions, suggesting that these results are probably generalizable, illustrating a common management of pathologies on farms ( 14 ). It has also been observed that breeders do not apply the instructions contained in prescriptions, such as changing the duration of treatment as soon as the animal is improved, due to a lack of awareness among breeders of the problem of antibiotic resistance ( 18 ) as well as the ease with which antibiotics can be obtained from local pharmacies without a veterinary prescription, in the form of multi-dose bottles of antibiotics which can then be used for several animals. This is a concern because misuse in animals can accelerate the dissemination of resistant bacteria, which can then affect humans through direct contact, environmental pathways or the food chain. A multifaceted approach is needed to solve this challenge. Raising awareness among farmers of the risks associated with antibiotic misuse, insisting on the importance of completing prescribed treatments and pointing out the wider impact of antibiotic resistance could improve regulatory compliance. In addition, increased regulation and policing of the sale of antibiotics on prescription would limit access to these medicines and ensure that their use is in line with veterinary recommendations. These measures would contribute to more sustainable livestock management practices and form part of global efforts to combat antibiotic resistance in human and veterinary medicine. One of the most important limitations of this study is the absence of socio-demographic data on the breeders questioned, such as age and sex as well as socio-economic and cultural level, which could be important factors influencing habits, degree of awareness, and knowledge about the use of antibiotics and the risk of developing resistance. Indeed, previous studies found a significant relationship between knowledge of antibiotic use and level of education and other demographic factors such as region of residence, gender, and age ( 13 , 19 , 20 ). However, other studies have found no statistically significant association between these parameters (gender and age) ( 21 ). In Tunisia, people involved in livestock farming generally live in rural areas, have a low level of education, and are relatively old. Livestock farming is generally seen as a necessity rather than a professional activity. This could partly explain the lack of awareness of the risk of inappropriate use of antibiotics and resistance and the reasons for self-medication (high cost of treatment). Another limitation of this study is the lack of quantitative data on antibiotic use, such as information on the antibiotic molecules self-medicated by farmers and the quantity and dose of antibiotics used. Such data would provide a clearer understanding of the extent and intensity of antibiotic misuse, enabling a more accurate assessment of the potential risk for antimicrobial resistance development in livestock. In addition, the study was carried out on a sample of 110 farmers in three governorates in the Tunisian Sahel. Although relevant to this region, the results may not be generalizable to the whole country or other regions with different economic and social contexts. Conclusion This survey is the first of its type in Tunisia to describe antibiotic use practices on livestock farms and to assess farmers' awareness of the risks associated with the misuse of antibiotics in the development of resistance. The results highlight some worrying deficiencies, in particular the lack of structured surveillance systems to monitor the use of antibiotics in the livestock sector, which encourages uncontrolled practices and thus contributes to the emergence and spread of antibiotic resistance. The lack of a national monitoring network considerably exacerbates the situation, as it prevents the systematic collection of data on antibiotic use. This limits the ability to assess the true scale of the problem and to put in place appropriate strategies to control it. Further, more extensive and in-depth studies are needed to assess the situation at national level and explore certain specific aspects, in particular the use of antibiotic molecules and farmers' antibiotic therapy practices. Such studies could help to fill critical gaps and develop an effective surveillance system enabling strict control measures to be established in order to tackle antibiotic resistance, which is a growing challenge for animal and human health. Declarations Ethics approval and consent to participate : The study was approved by the Ethical Committee of Animal Experimentation, National School of Veterinary Medicine, Tunisia, under the number of acceptance CEEA-ENMV 93/25. All the participants, vets and farmers, gave their verbal informed consent to participate in this survey. Consent for publication : Not Applicable Availability of data and materials : Not Applicable Competing interests : Authors declare that they have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper Funding : This work was funded by the International Center for Antimicrobial Resistance Solutions (ICARS)- Project ID: 200005 ; ENVIRE Project - 13th JPIAMR transnational co-funded call for research projects within the ERA-NET JPIAMR-ACTION: “One Health interventions to prevent or reduce the development and transmission of antimicrobial resistance (AMR)” Authors' contributions : I.H, M.S and A.BB made the survey, analyse the results and wrote the manuscript. WM conceived the idea, monitored the work and revised the manuscript. All authors reviewed the manuscript. 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Supplementary Files QuestionnaireFr.pdf QuestionnaireEn.pdf Cite Share Download PDF Status: Published Journal Publication published 26 Nov, 2025 Read the published version in BMC Veterinary Research → Version 1 posted Editorial decision: Revision requested 29 Apr, 2025 Reviews received at journal 10 Apr, 2025 Reviews received at journal 04 Apr, 2025 Reviewers agreed at journal 30 Mar, 2025 Reviewers agreed at journal 28 Mar, 2025 Reviewers agreed at journal 27 Mar, 2025 Reviewers agreed at journal 27 Mar, 2025 Reviewers invited by journal 27 Mar, 2025 Editor assigned by journal 27 Mar, 2025 Editor invited by journal 25 Mar, 2025 Submission checks completed at journal 21 Mar, 2025 First submitted to journal 21 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Mansour","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYHCCBAlknhyIOPCAFC3GYC0JBKxB0ZLYADYGj3KD4w0Pb3zcYcOg23728IePbffS54cdfgi0xU5OtwGHljMHki1nnkljMDuTlyY5s604d+PtNAOglmRjswPYtZjdSEiT5m07zGB2IMeMmbctIXfj7ASQlgOJ23Bpuf8gTfpv238Gs/NvjD8DtaQbzk7/gF/LDYY0aca2A0BGjgHQuoQEeekc/LbYn0lItuxtS+Yxu/HGTHLGuQTDDdI5BQcSDHD7RbL9TOKNn212cmbnc4w/fChLkJefnb75w4cKoAgOLQwMPAlgEs43AKs0wKUcBNjRDJNvwKd6FIyCUTAKRiIAAKhBZVPX5d6/AAAAAElFTkSuQmCC","orcid":"","institution":"University of Sousse","correspondingAuthor":true,"prefix":"","firstName":"Wejdene","middleName":"","lastName":"Mansour","suffix":""}],"badges":[],"createdAt":"2024-12-29 19:53:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5731443/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5731443/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12917-025-05126-8","type":"published","date":"2025-11-26T15:57:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79568325,"identity":"4d272fa5-2df9-4ab7-8563-b51367374659","added_by":"auto","created_at":"2025-03-31 09:54:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1002917,"visible":true,"origin":"","legend":"\u003cp\u003eGeographical maps of the 3 regions where the survey was carried out and their demographic informations\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5731443/v1/71e8c096baa7652b77846a69.png"},{"id":79568321,"identity":"cb33472d-0690-4cee-adeb-15c68bf56d41","added_by":"auto","created_at":"2025-03-31 09:54:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26098,"visible":true,"origin":"","legend":"\u003cp\u003eSelf-medication with antibiotics for treatment\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5731443/v1/41b0c2ec2f42cbd900783f62.png"},{"id":79568323,"identity":"35096a07-8c81-44ff-8071-e5b8da7eb69a","added_by":"auto","created_at":"2025-03-31 09:54:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":102003,"visible":true,"origin":"","legend":"\u003cp\u003eAntibiotic use practices\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5731443/v1/109c898915815ff8260b1813.png"},{"id":79568326,"identity":"278add3b-9128-4dd1-a743-0296154c5276","added_by":"auto","created_at":"2025-03-31 09:54:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":140370,"visible":true,"origin":"","legend":"\u003cp\u003eReasons of administering antibiotics without consulting a veterinarian\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5731443/v1/c1a1e46ba5a79228254f08e5.png"},{"id":79568324,"identity":"27df5897-2331-44c7-a633-139911d3ca43","added_by":"auto","created_at":"2025-03-31 09:54:01","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":69354,"visible":true,"origin":"","legend":"\u003cp\u003eFarmers's awarness of antibiotic use and antibiotic resistance\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5731443/v1/127960961e33b5e7abe26ba5.png"},{"id":97179354,"identity":"5f433390-10a4-4a3c-8f91-48f91b738e4b","added_by":"auto","created_at":"2025-12-01 16:14:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2034071,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5731443/v1/84ccae87-9c4e-4eba-a387-30a45c35b6db.pdf"},{"id":79568825,"identity":"7ff60d0b-dd3d-448e-af5a-b162fa66b2eb","added_by":"auto","created_at":"2025-03-31 10:02:01","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":424109,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnaireFr.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5731443/v1/d0a65ee44bd4ee7ba6797a3d.pdf"},{"id":79568823,"identity":"916723ec-161d-4eb2-90ef-c90c8137d4d9","added_by":"auto","created_at":"2025-03-31 10:02:01","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":409988,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnaireEn.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5731443/v1/77d6a2ad7fda72f45d4faa8e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Antibiotic use and antibiotic resistance awareness: A survey of ruminant and poultry Farming practices in Tunisia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe phenomenon of antibiotic resistance (AMR) has now become a serious concern and a major threat to global public health, with considerable mortality and morbidity rates. A recent study estimates that by 2050 the number of deaths attributable to AMR will reach 1.91\u0026nbsp;million while the number of deaths associated with AMR will reach the 8.22\u0026nbsp;million (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNowadays, humans and animals share most classes of antibiotics, as well as antibiotic resistance bacteria and antibiotic resistance genes. The widespread use of antibiotic classes, including those of high clinical value, in human and veterinary medicine is a key factor contributing to the emergence of antibiotic resistance (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In addition, the overuse and abuse of antibiotics and their use in animals (food producers and pets) has also led to the selection and transmission of resistant bacteria. Antibiotics are administered to food-producing animals for a number of reasons, including therapeutic, metaphylactic and prophylactic purposes, but they are also used as growth promoters (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). AMR is potentially transmissible to humans via the food chain, through contact with resistant bacteria or via transfer mechanisms between bacteria. Appropriate use of antibiotics is therefore crucial in order to limit the selection of resistant bacteria, to preserve the efficacy of the antibiotic and to limit the presence of residues in animal food products. In Tunisia, the failure to comply with the guides to good practice for the use of antibiotics established by international organizations in livestock farming, the abusive and uncontrolled use of antibiotics, and the absence of national networks for monitoring AMR in animals, are all factors that have led to the emergence of AMR. Furthermore, no concrete data on the use of antibiotics in livestock farming in Tunisia was available. This gap was filled by a survey of livestock farmers and veterinary doctors. The aim of this survey is to understand better the determinants of antibiotic use practices in poultry and ruminant farming, as well as the reasoning of breeders in decision-making. The study also aims to assess farmers' awareness of the use of antibiotics and the issue of antibiotic resistance in general.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1. Ethics, Consent, and Permissions\u003c/h2\u003e \u003cp\u003eThe study was approved by the Ethical Committee of Animal Experimentation, National School of Veterinary Medicine, Tunisia, under the number of acceptance \u003cb\u003eCEEA-ENMV 93/25\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2. Survey areas\u003c/h3\u003e\n\u003cp\u003eThe survey was conducted among 110 chicken and ruminant farmers in 3 major governorates in Tunisia's Sahel region in the east of the country: Monastir, Sousse and Mahdia and in a number of delegations within these 3 governorates (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These governorates have both large-scale livestock (including cattle, goats, and sheep) and small-scale livestock, including poultry.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSousse Governorate\u003c/strong\u003e \u003cp\u003eAccording to the regional Delegation of Agriculture of Sousse, the region produced in 2019, 6750 heads of cattle, with the delegation of Kala\u0026acirc; Kebira having the greatest potential. The number of sheep stands at 185,000 head, of which 40,000 (21.6%) come from the Enfidha delegation. Goat numbers are estimated at 17,000 head. The M'Saken delegation has the greatest potential for small livestock. It has 46,600 head of poultry, representing 34.15% of the total (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMonastir Governorate\u003c/strong\u003e \u003cp\u003eLivestock production in the governorate of Monastir remains modest compared with other governorates in the Centre-East. In 2017, the livestock population consisted mainly of 80,000 sheep, 12,000 cattle, 2,700 goats, 5,000 beehives, and around 1.3\u0026nbsp;million poultry units. The distribution of livestock by delegation in 2017 shows a wide spatial disparity. The three delegations of Jammel, Zeramdine and Moknine alone account for 51,000 head of sheep, representing 63.7% of the total (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMahdia Governorate\u003c/strong\u003e \u003cp\u003eThe governorate is best known for its cattle farming, which makes it the country's second-largest milk-producing area. In 2022, the livestock population consisted mainly of 27,500 cattle, 280,000 goats and 15,000 sheep distributed over 11 delegations (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003e1. Design and implementation of the survey\u003c/h3\u003e\n\u003cp\u003eAn anonymous individual interview with 110 farmers was carried out face-to-face by 11 veterinary doctors between 01/09/2024 and 15/09/2024 using a survey available in a paper-based format. The questionnaire was prepared on the basis of readings that enabled us to identify the most relevant questions (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Additional material includes the French-language questionnaire used and an English-language translation (Supplementary material 1 and 2).\u003c/p\u003e \u003cp\u003e Participants\u0026rsquo; responses were anonymous and confidentiality was assured. According to the Comit\u0026eacute; d'Ethique en Exp\u0026eacute;rimentation Animale-(CEEA), Ecole Nationale M\u0026eacute;decine V\u0026eacute;t\u0026eacute;rinaire \u0026agrave; Tunis (Committee on Ethics in Animal Experimentation-CEEA, National School of Veterinary Medicine, Tunis), this study does not require an ethical approval.\u003c/p\u003e \u003cp\u003eThe survey was composed by a total of 12 questions and 4 main sections: Section \u003cspan refid=\"Sec12\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Farm identification (two closed questions), Section \u003cspan refid=\"Sec13\" class=\"InternalRef\"\u003e2\u003c/span\u003e: Health monitoring (two closed questions), Section \u003cspan refid=\"Sec14\" class=\"InternalRef\"\u003e3\u003c/span\u003e: Information on their use of antibiotics (two open questions with multiple answers and 4 closed questions) and Section 4: Farmers' awareness of antibiotics and antibiotic resistance (two closed questions). The questionnaire sections are detailed below.\u003c/p\u003e\n\u003ch3\u003e2.1. Information on livestock farms\u003c/h3\u003e\n\u003cp\u003eIn this first part, general information about the farmers and their farms was collected in order to study its possible impact on the use and perception of antibiotic use.\u003c/p\u003e\n\u003ch3\u003e2.2. Health monitoring\u003c/h3\u003e\n\u003cp\u003eIn the second part of the survey, farmers were asked how often they consulted a veterinary surgeon and whether they kept a livestock register.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Uses and practices\u003c/h2\u003e \u003cp\u003e In this section, farmers are asked to describe their treatment habits (method of use, frequent pathologies for which they self-medicate with antibiotics (reasons for treatment), whether or not they comply with treatment and withdrawal times, and the reasons why farmers administer antibiotics to their livestock without consulting a veterinary doctor.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2.4. Assessing farmers' awareness of antimicrobial resistance\u003c/h3\u003e\n\u003cp\u003eIn this section, farmers are asked whether or not they are aware of the risk of extensive and inappropriate use of antibiotics on farms and their impact on human health. They are also asked whether they have received any training on antibiotic resistance.\u003c/p\u003e\n\u003ch3\u003e3. Statical analysis\u003c/h3\u003e\n\u003cp\u003eStatistical analyses of this study were carried out using SPSS software 2012. Answers to open questions were coded into categorical variables and analyzed. Data were explored primarily through descriptive analyses and correlation tests, aimed at examining the relationships between self-medication with antibiotics and the reasons motivating this behavior. To explore the links between the practice of self-medicating with antibiotics and participants' motivations, the Chi2 test of independence was carried out. This test is used to assess the existence of a significant association between two qualitative variables. In this study, it was used to determine whether certain specific reasons (breeder \u0026ldquo;Knowledge\u0026rdquo;, cost of medical consultations, or nearby pharmacy) were significantly linked to the decision to self-medicate antibiotics in livestock. p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered as statistically significant.\u003c/p\u003e \u003cp\u003eGraphs were generated by EXCEL 2019 software.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e1. Type of breeding and health monitoring\u003c/h2\u003e \u003cp\u003eA survey was carried out among 110 farmers. The first section of the survey provided general information about the farms. The results showed that the majority of farms was extensive (70.9%, 78/110), whereas it was intensive in 32 cases (29.1%, 32/110). Extensive farms are characterized by low stocking densities and diversity of animal species (sheep, cattle, goats, etc. ), in contrast to intensive farms, also known as industrial farms, which are animal production systems designed to maximize yields through high animal density in a relatively small area. The breeding were poultry farms (19.1%, 21/110) and ruminant farms (80.9%, 89/110).In the second part, the farmers were asked whether they kept a livestock register, which guarantees the traceability of animal care and medication. The answer was negative (No) in 99 cases (90%, 99/110).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2. Antibiotic use practices\u003c/h2\u003e \u003cp\u003eIn this section, farmers were asked about their antibiotic use practices on poultry and ruminant farms. According to the farmers' responses, antibiotics were frequently used on these types of farms without a veterinary prescription, and were self-medicated (92.7%, 102/110) according to the farmers (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAccording to farmers, antibiotics are frequently self-medicated for the most common diseases, of which digestive disease is the most frequent (88.2%), followed by foot disease (60%), mammary disease (60%, 66/110) and respiratory disease (41.8%, 46/110).\u003c/p\u003e \u003cp\u003e More than half of farmers do not comply with antibiotic treatment measures, in particular by not following the treatment times recommended by the veterinarian (62.7%, 69/110) and by changing the length of time they take antibiotics after the symptoms of the disease have disappeared (82.7%, 91/110), which contributes to the problem of antibiotic resistance in animals. Another critical point highlighted in the survey was the failure to respect the withdrawal period (61.8%, 68/110), (the time taken between the last administration of veterinary medication and the presence of residues in foodstuffs below the maximum residue limits MRLs) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWith regard to veterinary interventions, the great majority of first-line antibiotic treatments were carried out without a medical prescription and the animal was not consulted by the veterinarian (self-medication). According to the farmers interviewed, the reasons for administering antibiotics without consulting a veterinarian were the high cost of medical treatment (65.6%, 67/102), direct sale without a medical prescription (\u0026lsquo;local pharmacy\u0026rsquo;) (57.8%, 59/102) and self-medication on the pretext that the farmers knew the pathologies and their treatments (23.5%, 24/102) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThese results revealed that high medical treatment costs (p\u0026thinsp;=\u0026thinsp;0.005) and local pharmacy (p\u0026thinsp;=\u0026thinsp;0.016) are significantly associated with antibiotic self-medication. Knowledgeable breeder was not significantly associated with antibiotic self-medication (p\u0026thinsp;=\u0026thinsp;0.112).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3. Farmers' awareness of antibiotic use and antibiotic resistance\u003c/h2\u003e \u003cp\u003eIn this section, farmers are asked whether they are aware of the risk associated with the misuse and abuse of antibiotics on farms. They are also asked if they have received any training on the issue of antibiotic resistance. The results obtained show that 94.5% (104/110) of the farmers have no knowledge of the risk of inappropriate antibiotic use on their farms, and only 6 farmers (5.5%, 6/110) have attended a training course on good husbandry practices (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSeveral factors play a role in the increasing development of antibiotic resistance, thereby threatening animal and human health and becoming a national and global issue. The excessive and inappropriate use of antibiotics for both prophylactic and therapeutic uses in food-producing livestock has been highlighted as one of the most important factors. Farmers' knowledge, attitudes, and behaviors regarding the use of antibiotics in animals play a key role in the development and spread of antibiotic resistance. However, previous reports have indicated that much of the farming community does not have sufficient information on the antibiotic use and antibiotic resistance issue (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). According to a study survey, antibiotics should be given to all sick animals, according to over 70% of respondents, and 63% thought that antibiotics had no side effects in animals (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Another study showed that 32% of respondents felt that antibiotics were effective against internal and external parasites in animals, while 61% considered them to be antipyretic and analgesics (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These results suggest that farmers are largely unaware of the proper use of antibiotics, which poses a serious problem.\u003c/p\u003e \u003cp\u003eIn our survey, face-to-face contact with farmers was used to collect questionnaire responses, in order to improve the response rate, unlike in other studies where responses were collected by post (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Respondent anonymity was guaranteed to encourage farmers to answer without misrepresenting their practices.\u003c/p\u003e \u003cp\u003eIn our study, 90% of breeders did not have a sanitary register, whereas a similar study carried out in France in 2006 revealed that 85% of breeders completed their sanitary registers to contribute to the traceability of their farms (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The absence of health records in this study may reflect either gaps in legislation, lack of implementation or poor support for farmers to adopt such practices. It may also indicate gaps in awareness or training on the benefits of record keeping for farm management and traceability.\u003c/p\u003e \u003cp\u003e These findings highlight the need for targeted interventions, including education on the benefits of traceability, strengthening veterinary support systems and possibly introducing simplified procedures to improve record keeping compliance.\u003c/p\u003e \u003cp\u003eIn this study, we reported an alarming finding: (92.7%, 102/110) of farmers administered antibiotics by self-medication without veterinary prescription. In comparison with other similar studies, this prevalence is higher than in other studies such as Pakistan: 22% (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), Indonesia: 33.3% (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and Turkey: 48% (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The high cost of medical treatment (65.6%, 67/102) and the \u0026lsquo;nearby pharmacy\u0026rsquo; (57.8%, 59/102), significantly contributed to the prevalence of self-medication practices.\u003c/p\u003e \u003cp\u003eOn the one hand, livestock farmers, particularly small producers, have limited budgets and live in a critical economic and financial situation. They find that professional veterinary services are financially inaccessible. They therefore opt for cheaper and illegal solutions, such as buying antibiotics directly from local pharmacies without a prescription. While these farmers cut costs in the short term, the reality is that this behaviour often leads to antibiotic misuse, treatment failures and longer-term expenses. Pharmacies also play an important role in this bad practice. In many low- and middle-income countries, including Tunisia, antibiotics are often sold over the counter without a prescription. Driven by market demand and poor surveillance, local pharmacies may prioritize sales over appropriate use, encouraging farmers to adopt this habit, thereby indirectly contributing to the development and emergence of resistance in farm animals, and subsequent transmission to humans. With such behaviour and the lack of protection and sanctions provided by governments, the ethics and morality of such a practice become questionable.\u003c/p\u003e \u003cp\u003eThe classification of diseases for which farmers resort to self-medication, highlighting digestive, foot, mammary and respiratory diseases, reveals significant trends in animal health management. These diseases are a priority not only because they directly affect production, but also because of the potential costs associated with veterinary treatment and associated production losses. A similar study reached the same conclusions, suggesting that these results are probably generalizable, illustrating a common management of pathologies on farms (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt has also been observed that breeders do not apply the instructions contained in prescriptions, such as changing the duration of treatment as soon as the animal is improved, due to a lack of awareness among breeders of the problem of antibiotic resistance (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) as well as the ease with which antibiotics can be obtained from local pharmacies without a veterinary prescription, in the form of multi-dose bottles of antibiotics which can then be used for several animals. This is a concern because misuse in animals can accelerate the dissemination of resistant bacteria, which can then affect humans through direct contact, environmental pathways or the food chain.\u003c/p\u003e \u003cp\u003eA multifaceted approach is needed to solve this challenge. Raising awareness among farmers of the risks associated with antibiotic misuse, insisting on the importance of completing prescribed treatments and pointing out the wider impact of antibiotic resistance could improve regulatory compliance. In addition, increased regulation and policing of the sale of antibiotics on prescription would limit access to these medicines and ensure that their use is in line with veterinary recommendations. These measures would contribute to more sustainable livestock management practices and form part of global efforts to combat antibiotic resistance in human and veterinary medicine.\u003c/p\u003e \u003cp\u003eOne of the most important limitations of this study is the absence of socio-demographic data on the breeders questioned, such as age and sex as well as socio-economic and cultural level, which could be important factors influencing habits, degree of awareness, and knowledge about the use of antibiotics and the risk of developing resistance. Indeed, previous studies found a significant relationship between knowledge of antibiotic use and level of education and other demographic factors such as region of residence, gender, and age (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, other studies have found no statistically significant association between these parameters (gender and age) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In Tunisia, people involved in livestock farming generally live in rural areas, have a low level of education, and are relatively old. Livestock farming is generally seen as a necessity rather than a professional activity. This could partly explain the lack of awareness of the risk of inappropriate use of antibiotics and resistance and the reasons for self-medication (high cost of treatment).\u003c/p\u003e \u003cp\u003eAnother limitation of this study is the lack of quantitative data on antibiotic use, such as information on the antibiotic molecules self-medicated by farmers and the quantity and dose of antibiotics used. Such data would provide a clearer understanding of the extent and intensity of antibiotic misuse, enabling a more accurate assessment of the potential risk for antimicrobial resistance development in livestock. In addition, the study was carried out on a sample of 110 farmers in three governorates in the Tunisian Sahel. Although relevant to this region, the results may not be generalizable to the whole country or other regions with different economic and social contexts.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis survey is the first of its type in Tunisia to describe antibiotic use practices on livestock farms and to assess farmers' awareness of the risks associated with the misuse of antibiotics in the development of resistance. The results highlight some worrying deficiencies, in particular the lack of structured surveillance systems to monitor the use of antibiotics in the livestock sector, which encourages uncontrolled practices and thus contributes to the emergence and spread of antibiotic resistance.\u003c/p\u003e \u003cp\u003eThe lack of a national monitoring network considerably exacerbates the situation, as it prevents the systematic collection of data on antibiotic use. This limits the ability to assess the true scale of the problem and to put in place appropriate strategies to control it. Further, more extensive and in-depth studies are needed to assess the situation at national level and explore certain specific aspects, in particular the use of antibiotic molecules and farmers' antibiotic therapy practices. Such studies could help to fill critical gaps and develop an effective surveillance system enabling strict control measures to be established in order to tackle antibiotic resistance, which is a growing challenge for animal and human health.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: The study was approved by the Ethical Committee of Animal Experimentation, National School of Veterinary Medicine, Tunisia, under the number of acceptance\u0026nbsp;\u003cstrong\u003eCEEA-ENMV 93/25.\u0026nbsp;\u003c/strong\u003eAll the participants, vets and farmers, gave their verbal informed consent to participate in this survey.\u003cbr\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: \u0026nbsp;Not Applicable\u003cbr\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: Not Applicable\u003cbr\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: Authors declare that they have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper\u003cbr\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This work was funded by the International Center for Antimicrobial Resistance Solutions (ICARS)- Project ID: \u003cstrong\u003e200005\u003c/strong\u003e; ENVIRE Project - 13th JPIAMR transnational co-funded call for research projects within the ERA-NET JPIAMR-ACTION: \u0026ldquo;One Health interventions to prevent or reduce the development and transmission of antimicrobial resistance (AMR)\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: I.H, \u0026nbsp;M.S and A.BB made the survey, analyse the results and wrote the manuscript. WM conceived the idea, monitored the work and revised the manuscript. All authors reviewed the manuscript.\u003cbr\u003e\u0026nbsp;Acknowledgements\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Dr Maha Dardouri (Hail University, Saudi Arabia) for her support in preparing and validating the questionnaire and also all the veterinarians and farmers for giving their time to participate in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNaghavi M, Vollset SE, Ikuta KS, Swetschinski LR, Gray AP, Wool EE, et al. Global burden of bacterial antimicrobial resistance 1990\u0026ndash;2021: a systematic analysis with forecasts to 2050. The Lancet. 28 sept 2024;404(10459):1199‑226. \u003c/li\u003e\n\u003cli\u003eCaneschi A, Bardhi A, Barbarossa A, Zaghini A. The Use of Antibiotics and Antimicrobial Resistance in Veterinary Medicine, a Complex Phenomenon: A Narrative Review. Antibiotics. 1 mars 2023;12(3):487. \u003c/li\u003e\n\u003cli\u003eEuropean regulations on the use of antibiotics in veterinary medicine. Eur J Pharm Sci. 1 oct 2023;189:106473. \u003c/li\u003e\n\u003cli\u003eCRDA Sousse - Producteurs - CKAN [Internet]. [cit\u0026eacute; 17 d\u0026eacute;c 2024]. Disponible sur: https://catalog.agridata.tn/fr/organization/crda-sousse?organization=crda-sousse\u0026amp;page=3\u003c/li\u003e\n\u003cli\u003eCRDA MONASTIR - Producteurs - CKAN [Internet]. [cit\u0026eacute; 17 d\u0026eacute;c 2024]. Disponible sur: https://catalog.agridata.tn/fr/organization/crda-monastir\u003c/li\u003e\n\u003cli\u003eR\u0026eacute;partition du cheptel -Gouvernorat de Mahdia - Jeu de donn\u0026eacute;es - CKAN [Internet]. [cit\u0026eacute; 17 d\u0026eacute;c 2024]. 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Utilisation des antibiotiques par les \u0026eacute;leveurs en fili\u0026egrave;re bovine en France. In 2010 [cit\u0026eacute; 17 d\u0026eacute;c 2024]. Disponible sur: https://www.semanticscholar.org/paper/Utilisation-des-antibiotiques-par-les-%C3%A9leveurs-en-Cazeau-Chazel/e0ba49a45db87be77bbf6d8074019e4273cc5647\u003c/li\u003e\n\u003cli\u003eGodycki-Cwirko M, Cals JWL, Francis N, Verheij T, Butler CC, Goossens H, et al. Public Beliefs on Antibiotics and Symptoms of Respiratory Tract Infections among Rural and Urban Population in Poland: A Questionnaire Study. PLoS ONE. 2 oct 2014;9(10):e109248. \u003c/li\u003e\n\u003cli\u003eHoffmann K, Ristl R, Heschl L, Stelzer D, Maier M. Antibiotics and their effects: what do patients know and what is their source of information? Eur J Public Health. juin 2014;24(3):502‑7. \u003c/li\u003e\n\u003cli\u003eYou JHS, Yau B, Choi KC, Chau CTS, Huang QR, Lee SS. Public knowledge, attitudes and behavior on antibiotic use: a telephone survey in Hong Kong. Infection. mars 2008;36(2):153‑7. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-veterinary-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Veterinary Research](http://bmcvetres.biomedcentral.com/)","snPcode":"12917","submissionUrl":"https://submission.nature.com/new-submission/12917/3?","title":"BMC Veterinary Research","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antibiotic resistance, Survey, Farmers, Antibiotics use, Livestock, Awareness level of antibiotic resistance","lastPublishedDoi":"10.21203/rs.3.rs-5731443/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5731443/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAntibiotic resistance (AMR) has become a major threat to human public health. The overuse and/ misuse of antibiotics in food-producing animals is a potentially key factor contributing to the transmission of AMR among humans. This study was set up to describe the antibiotic use patterns of ruminant and poultry farmers in Tunisia, to understand the reasons for their antibiotic use decisions and to assess their awareness of the risk of antibiotic misuse in the development of resistance. A structured, anonymous questionnaire consisting of 12 questions divided into four main sections was conducted face-to-face by 11 veterinarians with 110 chicken and ruminant farmers across three Governorates\u0026mdash;Sousse, Mahdia, and Monastir\u0026mdash;in the Sahel region of Tunisia. Statistical analysis was performed on the collected data. Findings revealed a significant proportion of farmers (90%) lacked a livestock register to ensure traceability of animal care and medication. Alarmingly, 92.7% of the farmers administered antibiotics through self-medication without veterinary prescriptions. Digestive diseases (88.2%) were the most commonly treated, followed by foot diseases (60%), mammary diseases (60%), and respiratory diseases (41.8%). The analysis revealed that high treatment costs (p\u0026thinsp;=\u0026thinsp;0.005) and the ease of obtaining antibiotics from local pharmacies (p\u0026thinsp;=\u0026thinsp;0.016) significantly contributed to the prevalence of self-medication practices. Inappropriate use of antibiotics was widespread, with 62.7% of farmers not adhering to the prescribed treatment duration and 82.7% stopping treatment prematurely after symptoms had disappeared. In addition, 61.8% of farmers did not respect the withdrawal period for antibiotics. Critically, 94.5% of respondents were unaware of the dangers of inappropriate antibiotic use and only 5.5% of farmers had received training in good husbandry practices. These findings highlight the urgent need to improve farmers' antibiotic knowledge and practices. Implementing strong training programs, enforcing veterinary surveillance, and promoting responsible antibiotic use are essential to reduce the risk of AMR and protect both animal and public health in Tunisia.\u003c/p\u003e","manuscriptTitle":"Antibiotic use and antibiotic resistance awareness: A survey of ruminant and poultry Farming practices in Tunisia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-31 09:53:57","doi":"10.21203/rs.3.rs-5731443/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-29T09:32:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-10T20:16:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-04T21:37:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152537851440163759539898188924161432010","date":"2025-03-30T13:46:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31416751721772465898568682840221045945","date":"2025-03-28T06:22:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235142579552899973348794794159778248779","date":"2025-03-27T22:51:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220234052420305723020074619144245013572","date":"2025-03-27T22:50:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-27T22:39:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-27T22:34:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-25T13:32:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-21T14:20:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Veterinary Research","date":"2025-03-21T14:19:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-veterinary-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Veterinary Research](http://bmcvetres.biomedcentral.com/)","snPcode":"12917","submissionUrl":"https://submission.nature.com/new-submission/12917/3?","title":"BMC Veterinary Research","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e0ba6cd1-6a27-45e2-b7d4-948a4a783b62","owner":[],"postedDate":"March 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:10:51+00:00","versionOfRecord":{"articleIdentity":"rs-5731443","link":"https://doi.org/10.1186/s12917-025-05126-8","journal":{"identity":"bmc-veterinary-research","isVorOnly":false,"title":"BMC Veterinary Research"},"publishedOn":"2025-11-26 15:57:17","publishedOnDateReadable":"November 26th, 2025"},"versionCreatedAt":"2025-03-31 09:53:57","video":"","vorDoi":"10.1186/s12917-025-05126-8","vorDoiUrl":"https://doi.org/10.1186/s12917-025-05126-8","workflowStages":[]},"version":"v1","identity":"rs-5731443","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5731443","identity":"rs-5731443","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}