BackgroundAntibiotic resistance is an increasing problem worldwide. Inappropriate use of antibiotics, including suboptimal use, abuse, and dispensing errors substantially contributes to this problem. Dispensing antibiotics without medical prescription is a major contributing factor to antibiotic resistance. Pharmacists as health-care providers are, in many studies, considered accountable for this malpractice. However, in Palestine, little research has been carried out into their involvement in antibiotic resistance. Therefore, we aimed to study Palestinian pharmacists' knowledge, attitudes, and practices in relation to antibiotic resistance. MethodsA descriptive cross-sectional survey of Palestinian pharmacists was conducted in 2017. A convenience sample of 162 pharmacists was included in this study. The convenience sample was selected from the four main cities (Hebron, Ramallah, Nablus, and Bethlehem) of the West Bank. Subjects were selected based on their availability and accessibility, and there were no specific inclusion criteria. A self-administered questionnaire was developed as a data collection instrument. The questionnaire included five sections: demographic characteristics, practices, attitudes, knowledge, and potential interventions. Responses were given using a Likert scale and frequencies were recorded. There were also questions to which participants could respond with either “agree” or “disagree”. Descriptive statistics, frequencies, percentages, and correlation tests were used to summarise and analyse the data. FindingsOf 162 questionnaires distributed, 155 (96·7%) were returned. Of the participants, 40·0% (62 of 155) had experience of 10 years or longer. Results indicated a significant association between pharmacists' experience and antibiotic practices. According to responses regarding practices, 77·0% (119 of 155) of pharmacists encountered unnecessary antibiotic prescriptions made by doctors. Furthermore, 82·6% (128 of 155) of pharmacists reported that patients demanded antibiotics without prescription, and 60·8% (94 of 155) of pharmacists reported dispensing antibiotics upon patient demand. In terms of knowledge, 53·2% (82 of 155) of pharmacists agreed with the statement that unnecessary dispensing of antibiotics is harmless, whereas 77·7% (120 of 155) thought that over-the-counter antibiotic purchases contribute to antibiotic resistance, and 89·2% (138 of 155) agreed that there is a need for antibiotic dispensing guidelines. Results of the knowledge scale reported that 35·5% (55 of 155) of pharmacists have a low level of knowledge regarding antibiotic use. Pharmacists were asked for potential interventions to which they would consent; 78·1% (120 of 155) agreed that restricting the use of antibiotics may help to contain antibiotic resistance, and 58·1% (90 of 155) responded that they would become participants in educational programmes regarding antibiotic resistance. InterpretationThis is the first study in Palestine to assess pharmacists' knowledge, attitudes, and practices in relation to antibiotic use and its relationship to microbial resistance. Our study indicated that patients demanding antibiotics without medical prescription is relatively common and is ascribed to patients' lack of information and knowledge regarding the relationship between antibiotic use and microbial resistance. Antibiotic dispensing is a problem in Palestine. The percentage of over-the-counter antibiotic purchases was found to be high compared to prescribed antibiotics, and there was a lack of information and knowledge about antibiotic resistance in the pharmacy community. An intervention programme for community pharmacists could be designed to improve the dispensing of antibiotics and to minimise resistance. Furthermore, the study highlights the need for intensive training and educational programmes to enhance community pharmacists' knowledge of antibiotic resistance. FundingAl-Quds Public Health Society, Jerusalem, Palestine.