Introduction  

In the endless battle of survival, bacteria have been known to possess a nifty armor, helping them to always be on top of the survivors’ list. Microbial communities are very versatile and can propagate in almost all environmental conditions, as well as easily adapt if new changes occur. This adaptation is mainly attributed to multiple mechanisms such as continuous gene expression regulation and metabolic regulation for planktonic bacterial cells [1, 2]. Another well-known mechanism is biofilm formation. A biofilm is a community consisting of sessile bacteria affixed on a surface or to each other irreversibly. This community is submerged in a matrix of Extracellular Polymeric Substances (EPSs) self-produced by the bacteria. This matrix is a highly self-organized complex three-dimensional structure of polymers  in relations to their composition and complex architecture [3]. Members of the biofilm community display an enhanced biological properties, mechanical properties, and phenotypic properties [3-5].

Biofilm formation in healthcare systems is a serious concern; it results in higher morbidity and mortality rates; it is associated with a major impact as an economic burden on the healthcare system. Around 80% of chronic and recurrent infections are due to biofilm-forming bacteria [6]. 50-70% of all nosocomial infections are implant-associated due to biofilm-forming bacteria [7, 8]. Biofilms has significant impact  in the treatment of biofilms associated infections as it  is proving difficult and costly to health care systems [9]. Biofilm bacteria are highly resistant to conventional antimicrobials and are associated with persistent infections [10]. They use Quorum sensing to control every process from proliferation rate and sporulation, maturation of the biofilm, motility, the secretion and use of enzymes, EPS production, horizontal gene transfer, and most importantly; antibiotic resistance and virulence [11]. Moreover wet and dry biofilms are associated with healthcare-associated infections and they may serve as a persistent environmental source of pathogens [12]. Environmental biofilms have also played an important role in the emergence and spread of antibiotic resistance, they must be considered synonymously with antimicrobial resistance due to their innate phenotypic antibiotic tolerance and their excellence in transferring resistance genes [13].

Pharmacists are a vital member of the healthcare team and have a big role in how patients use their medications due to the regular patient counseling about proper drug use and healthcare instructions. Pharmacist education and training havea great impact on the behavior of consumers as well as other members of the healthcare team. Well-educated and trained pharmacists must be able to improve the understanding of antibiotics and their use, raise awareness of the proper use of antibiotics, and aid in the prevention of antibiotic resistance in patients counseled during their visit to the community pharmacy or hospital.  Many studies have highlighted that educating and training undergraduate students has a significant impact on their professional attitude and behavior and proper pharmaceutical practice students portray as future pharmacists and part of the healthcare team [14].

Jordan is a small developing country in the Middle East with inadequate supplies of water and natural resources. It is nearly self-sufficient in health services and health education [15]. Currently, little is known about how pharmacy students in low-income countries perceive knowledge about biofilms and their impact on the health system. To date, no study has been conducted in Jordan to determine undergraduate pharmacy students' knowledge about biofilms. Thus, this regionally novel study aims to assess the knowledge and awareness about biofilms among pharmacy/PharmD students in universities in Jordan.

Materials and Methods

Study design and setting

A descriptive cross-sectional study was conducted between February 1^st and April 1^st, 2022, to assess and evaluate knowledge about biofilms among undergraduate pharmacy/PharmD students in universities in Jordan. Respondents from multiple pharmacy schools in both public and private universities in Jordan have been sampled to fill the survey.

Inclusion and exclusion criteria

All students enrolled in undergraduate pharmacy/PharmDbachelor’s degree programs at both public and private universities in Jordan during the study period; irrespective of their age, gender, ethnicity, religion, or social class were eligible to take part in the study. Only participants willing to take part in the study voluntarily were enrolled. All non-pharmacy/non-Pharm D students, in addition to all postgraduate students, were excluded from the study. All pharmacy/PharmD students who have not been enrolled in or are not currently receiving an academic course of pharmaceutical microbiology/related course (i.e. biotechnology, immunology, or advanced microbiology) were excluded from the study.

Data collection

The data collection form was designed after an extensive literature review. Data were collected using a pre-tested standard questionnaire that included 27 questions divided into three sections. A self-administered web-based questionnaire (Appendix 2) was used to collect data to assess the knowledge and awareness about biofilms among pharmacy/PharmD students in universities in Jordan. The Questionnaire consists of a section on socio-demographic data, a section on general knowledge, and awareness of biofilms, and finally a section on the role of biofilms in infections and their behavior. The main methods for participant invitations are Facebook, messages through WhatsApp groups, e-mails, and postings in pharmacy-focused forums. The expected time to complete the questionnaire is 5-10 minutes. No financial inducements were offered to participants.

Informed consent form

An informed consent form (Appendix 1) is required to be signed voluntarily before participating in the questionnaire. The study was described to participants and its importance was clarified in written words. Informed consent must be signed before participating in the questionnaire. Those who signed the informed consent electronically by clicking the agree button were included in the study, while the others were not. Participants were also informed that participation is voluntary, and they can withdraw from the study at any time, as well as being informed that the provided data are treated confidentially with their privacy protected.  

Data analysis

SPSS software, V.26 (IBM) was used to analyze the data. Continuous variables were reported as means and standard deviations and categorical variables were reported as frequencies and percentages. The normality of the data was checked using Kolmogorov-Smirnov and Shapiro Wilk tests. The one-way analysis of variance test was used to compare the mean scores between different demographic groups. Tukey post hoc test was conducted to identify the source of significant variation within each group. Significant predictors of knowledge about microbial biofilm were determined via regression analysis and the level of significance was predetermined as 5%.

Descriptive statistical analyses, such as frequencies and percentages, were used to represent the respondents’ demographic information. Student t-test was used for data analysis, to compare the responses of pharmacy students from public and private universities. A statistical significance level of p<0.05 was used in all analyses.

Ethical approval

The study protocol was approved by the institutional review board (IRB) committee at King Abdullah University Hospital (KAUH), Irbid, Jordan, after supplying the committee with the requested documents to ensure the protection of human rights, confidentiality, and privacy. (Reference number is 39/136/2020).

State the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results.

Results and Discussion

Participants’ characteristics

The sample consists of 1,058 undergraduate pharmacy/PharmD students from all pharmacy schools in Jordan (n=14). Of those, 83.2% (n=880) were female students. The majority of the students were in their 3rd and 4th year of study with 41.1% (n=435) and 25.2% (n=267), respectively. More than half (57.6%) of the students’ ages ranged between 20 and 21 years. As shown in Table 1, the majority of participants (90.6%) were from public schools of pharmacy, and (91.8%) majored in Pharmacy.

A high number of participating students (80.7%) have been enrolled in or are currently receiving an academic course in pharmaceutical microbiology and around half (48.0%) have been enrolled in or are currently receiving a related course i.e. biotechnology, immunology, or advanced microbiology.

*Biotechnology, immunology, or advanced microbiology

The study found that less than half of the participants (43.4%) reported themselves to have sufficient knowledge about microbial biofilms, with the majority (83.9%)agreeing their knowledge was exclusively from their undergraduate microbiology-related courses. A considerable percentage of students (65.3%) displayed their willingness to improve their knowledge about microbial biofilms and three-quarters of the students (74.8%) exhibited a greater sense of the importance of microbial biofilm-related research (Figure 1).

Perception towards “Microbial biofilms”

Students’ knowledge about “Microbial biofilms”

Table 2 shows the knowledge of students about microbial biofilms. A significant percentage of students (71.2%) knew the definition of biofilms as an organized community of microorganisms, enveloped in an extracellular polymeric substance (EPS). Whereas, only 12.7% of the students knew that the discovery of biofilms is not new. Regarding the microbial effect of biofilms on surfaces, less than half of the participants (44.0%) knew that biofilms can initiate and colonize on both living and non-living surfaces. Approximately half of the participants (52.9%) knew that biofilms can delay wound healing. Finally, regarding the removal of biofilms, the majority of students (73.8%) falsely reported that biofilms are easily eradicated by antimicrobials compared to planktonic infections.

Effect of students’ characteristics on their knowledge about microbial biofilm

Table 3 presents the effect of the students’ demographics on their knowledge of microbial biofilm scores. Students’ scores significantly changed with students’ age, academic year, and previous or current enrollment in pharmaceutical microbiology courses (P<0.001). Tukey’s HSD posthoc test confirmed that those aged 18-19 years in their first or second academic year have different scores than other participants.

*P<0.05

Simple linear regression analysis showed that students’ age, academic year, and previous or current enrollment in pharmaceutical microbiology courses were significantly associated with students’ knowledge scores with a p-value less than 0.01. Multiple linear regression analysis to predict student knowledge from student age, academic year, and previous or current enrollment in pharmaceutical microbiology courses showed that these variables statistically significantly predicted student knowledge score, F(3, 1058) = 20.123, p < 0.001, R2 = 0.054. However, only academic year and previous or current enrollment in pharmaceutical microbiology course variables added statistically significantly to the prediction (p = 0.011 and p <0.001, respectively) (Table 4).

B: The unstandardized beta; SE: The standard error for the unstandardized beta; β: The standardized beta; P-value: The probability value