MRSA Knowledge, Infection-Prevention Practices, and Antibiotic Use Without Clinician Consultation Among Hajj Pilgrims Arriving in Madinah, Saudi Arabia: A Cross-Sectional Study

Abstract

Background: Hajj is an international mass gathering in which infection prevention and antimicrobial stewardship intersect. Methicillin-resistant Staphylococcus aureus (MRSA) was selected as the organism-specific focus because it is a clinically important antimicrobial-resistant pathogen associated with skin and soft-tissue infections, wound care, and transmission through close contact and sharing of personal items. Hajj studies have also documented MRSA-related carriage and broader antimicrobial-resistance concerns among pilgrims and other mass-gathering populations. However, the relation between general infection awareness, MRSA-specific knowledge, and self-reported antibiotic-use behaviour remains less well described. This study assessed these three domains among Hajj pilgrims arriving in Madinah, Saudi Arabia. Methods: A questionnaire-based cross-sectional study was conducted during Hajj 1446H (2025). The study dataset comprised 342 completed questionnaires. Item-level descriptive analyses were used because no validated composite scoring algorithm was documented in the available study records. The primary exploratory outcome was an undated, self-reported history of taking antibiotics without consulting a doctor. Modified Poisson regression with robust variance estimated adjusted prevalence ratios (aPRs), with sex, age group, education, healthcare employment, and MRSA awareness entered simultaneously as prespecified covariates. Results: Among 342 respondents, 213 (62.3%) were male, 155 (45.3%) were aged 46–60 years, 181 (52.9%) reported postgraduate education, and 51 (14.9%) worked in healthcare. General awareness of crowding-related bacterial-infection risk was high (256/342, 74.9%), whereas MRSA-specific knowledge was lower: 110 (32.2%) had heard of MRSA, 137 (40.1%) identified personal-item sharing as a transmission route, and 124 (36.3%) recognised that MRSA can cause serious or fatal infection. Handwashing ≥ 3 times/day was reported by 310 respondents (90.6%), and 327 (95.6%) reported not sharing personal items. However, 143 respondents (41.8%) reported taking antibiotics without consulting a doctor. In the adjusted model, the prevalence of this outcome was higher among participants aged > 60 years than among those aged < 46 years (aPR 1.86, 95% CI 1.35–2.56) and among those who had not heard of MRSA (aPR 3.60, 95% CI 2.10–6.18) or did not know whether they had heard of MRSA (aPR 3.40, 95% CI 1.84–6.30), compared with those who had heard of MRSA. Conclusions: Among pilgrims arriving in Madinah, general infection-prevention awareness and self-reported hygiene practices coexisted with limited MRSA-specific knowledge, and a substantial proportion of respondents reported taking antibiotics without consulting a doctor. The observed associations are cross-sectional and non-causal; they neither establish the timing or appropriateness of antibiotic use nor demonstrate that an education intervention would change behaviour. They identify a hypothesis for prospective evaluation of multilingual Hajj education linking MRSA transmission, wound care, and antibiotic stewardship.