Use of Probiotics with Antibiotics: Knowledge, Attitudes, and Practices in Community Pharmacy

Antibiotic-associated diarrhea (AAD) is a common consequence of gut microbiota disruption following broad-spectrum antibiotic use. Certain probiotics may reduce the incidence of AAD. However, their effectiveness also depends on appropriate counseling by community pharmacy professionals and implementation of evidence-based practice.

To assess the knowledge, attitudes, and practices (KAP) of community pharmacy professionals in North Macedonia regarding concomitant antibiotic-probiotic use and to identify factors associated with these domains.

An anonymous content-validated online questionnaire was distributed to a convenience sample of community pharmacists and pharmacy technicians in North Macedonia (April-May 2026). Data were analyzed using descriptive statistics, chi-square tests, factor analysis, and regression models in Jamovi (version 2.6) and R software (version 4.4). A p-value <0.05 was considered statistically significant.

Among 285 respondents (mean age 41.8 ± 9.6 years), 54.7% were classified in the high category of the survey-based knowledge index according to the prespecified survey key. Recognition of probiotic efficacy was high (95.8%), but alignment with the prespecified survey key regarding proper administration with food and risk identification was lower (34.6% and 66.8%, respectively). Attitudes toward probiotic use were highly positive, and recommendation practices were frequently reported (84.5%), although counseling practices varied. More positive attitudes were associated with higher recommendation behavior (β = 0.512, p < 0.001) and female gender was also associated with higher scores (p = 0.008). Recent continuous professional education was associated with higher counseling-related practice scores (p < 0.001), while greater variability in counseling behavior was observed across community pharmacy professionals.

Community pharmacy professionals in North Macedonia demonstrated favorable attitudes and frequent self-reported recommendation practices regarding probiotic use alongside antibiotics. However, important gaps remain in clinical knowledge and counseling consistency. Targeted continuing professional education and development of standardized national guidelines may be considered, but their effects on observed practice and patient outcomes require prospective evaluation.