E-Learning versus Face-to-Face Methodology for Learning Antimicrobial Resistance and Prescription Practice in a Tertiary Hospital of a Middle-Income Country.

Background: Antimicrobial resistance is a growing health problem worldwide. One strategy to face this problem in a reasonable way is training health personnel for the rational use of antimicrobials. There are some difficulties associated with medical staff to receiving training with E-learning education, but there is a lack of studies and insufficient evidence of the effectiveness of this method compared to face-to-face learning. Methods: An educational intervention on antimicrobial resistance (AMR) and antimicrobial prescription practice (APP) was designed and implemented using two approaches: face-to-face and E-learning among physicians of the intensive care unit (ICU) and internal medicine ward (IMW) at Eugenio Espejo Hospital in Quito. Modalities of interventions were compared to propose a strategy of continuous professional development (CPD) for all hospital staff. An interventional study was proposed using a quasi-experimental approach that included 91 physicians, of which 49 belong to the IMW and 42 to the ICU. All of them received training on AMR­half in a face-to-face mode and the other half in an asynchronous E-learning mode. They then all participated on APP training but with switched groups; those who previously participated in the face-to-face experience participated in an E-learning module and vice-versa. We evaluated self-perception about basic knowledge, attitudes and referred practices towards AMR and APP before and after the intervention. A review of medical records was conducted before and after training by checking antimicrobial prescriptions for all patients in the ICU and IMW with bacteremia, urinary tract infection (UTI), pneumonia, and skin and soft tissue infection. The study received IRB clearance, and we used SPSS for statistical analysis. Results: No statistically significant difference was observed between the E-learning and the face-to-face methodology for AMR and APP. Both methodologies improved knowledge, attitudes and referred practices. In the case of E-learning, there was a self-perception of improved attitudes (p < 0.05) and practices (p < 0.001) for both AMR and APP. In face-to-face, there was a perception of improvement only in attitudes (p < 0.001) for APP. In clinical practice, the use of antimicrobials significantly improved in all domains after training, including empirical and targeted treatment of bacteremia and pneumonia (p < 0.001) and targeted treatment of UTI (p < 0.05). For the empirical treatment of pneumonia, the mean number of antibiotics was reduced from 1.87 before to 1.05 after the intervention (p = 0.003), whereas in the targeted management of bacteremia, the number of antibiotics was reduced from 2.19 to 1.53 (p = 0.010). Conclusions: There was no statistically significant difference between the effect of E-learning and face-to-face strategy in terms of teaching AMR and APP. Adequate self-reported attitudes and practices in E-learning exceed those of the face-to-face approach. The empiric and targeted use of antimicrobials improved in all reviewed cases, and we observed an overall decrease in antibiotic use. Satisfaction with training was high for both methods, and participants valued the flexibility and accessibility of E-learning.

MUCORMICOSE EM PACIENTES PÓS COVID-19: RELATO DE TRÊS CASOS

Introdução A mucormicose é uma infecção angioinvasiva causada por fungos filamentosos ubíquos que acomete especialmente pacientes imunocomprometidos. Diabetes mellitus, neoplasias hematológicas, uso prolongado de glicocorticoides, imunossupressão por transplante de órgãos e síndrome da imunodeficiência adquirida são fatores de risco. Tal entidade ganhou especial atenção nos últimos dois anos devido ao aumento de casos em pacientes com COVID-19 tratados com corticoterapia. Objetivo Relatar três casos de mucormicose em pacientes internados em hospital terciário com histórico de COVID-19 que receberam corticoterapia endovenosa em altas doses. Método Caso 1: homem, 69 anos, diabético. Quatorze dias após alta hospitalar apresentou dor e mobilidade dentária. Imagem radiológica evidenciou abscessos em seio maxilar direito e erosões ósseas. Submetido a maxilectomia e remoção de arco zigomático e de partes moles acometidas. Biópsia com hifas compatíveis com Mucor spp. Feito dose acumulada de 8350 mg de anfotericina B lipossomal com boa evolução clínica. Caso 2: homem, 70 anos, apresentou múltiplos abscessos em calota craniana e órbita à esquerda após 20 dias do início de corticoterapia. Realizada a exenteração orbitária, ressecção de parede lateral de órbita e de múltiplos ossos da face, crânio e partes moles adjacentes. Além da biópsia compatível, houve crescimento de Mucor spp em cultura. Feito dose acumulada de anfotericina complexo lipídico de 14900 mg, com boa evolução clínica. Caso 3: homem, 44 anos, diabético, apresentou quadro de sinusite 11 dias após início da corticoterapia. Imagem radiológica mostrou extenso acometimento de ossos frontais e zigomáticos e abscessos em seios frontais e etmoidais. Submetido a maxilectomia esquerda ampliada para parede lateral de órbita e osso zigomático, palatectomia esquerda e drenagem de abscessos. Biópsia foi compatível e houve crescimento de Rhizopus spp em cultura. Feito dose acumulada de anfotericina complexo lipídico de 11600 mg, também com boa evolução. Resultados A mucormicose é uma doença rara, porém emergente e com altas taxas de mortalidade. Os casos descritos evoluíram bem clinicamente apesar da extrema gravidade e seguem com quadro estável. Pode-se atribuir como fatores determinantes a associação da abordagem cirúrgica extensa e precoce aliada ao início de terapia antifúngica. Conclusão Assim, é necessário a suspeição diagnóstica precoce, devido ao grande benefício da terapia medicamentosa e desbridamento cirúrgico em fases iniciais da doença.

Prevalence of virological and serological markers of SARS-CoV-2 infection in the population of Ribeirão Preto, Southeast Brazil: an epidemiological survey.

INTRODUCTION: This epidemiological household survey aimed to estimate the prevalence of the current and past SARS-CoV-2 infections in Ribeirão Preto, a municipality of southeast Brazil. METHODS: The survey was conducted in two phases using a clustered sampling scheme. The first phase spanned May 1-3 and involved 709 participants. The second phase spanned June 11-14, 2020, and involved 646 participants. RESULTS: During the first phase, RT-PCR performed on nasopharyngeal swabs was positive at 0.14%. The serological tests were positive in 1.27% of the patients during the first phase and 2.79% during the second phase. People living in households with more than five members had a prevalence of 10.83% (95%CI: 1.58-74.27) higher than those living alone or with someone other. Considering the proportion of the positive serological test results with sex and age adjustments, approximately 2.37% (95%CI: 1.32-3.42) of the population had been cumulatively infected by mid-June 2020, which is equivalent to 16,670 people (95%CI: 9,267-24,074). Considering that 68 deaths from the disease in the residents of the city had been confirmed as at the date of the second phase of the survey, the infection fatality rate was estimated to be 0.41% (95%CI: 0.28-0.73). Our results suggest that approximately 88% of the cases of SARS-CoV-2 infection at the time of the survey were not reported to the local epidemiological surveillance service. CONCLUSIONS: The findings of this study provide in-depth knowledge of the COVID-19 pandemic in Brazil and are helpful for the preventive and decision-making policies of public managers.

Ocular findings among patients surviving COVID-19.

To describe the medium-term ophthalmological findings in patients recovering from COVID-19. Patients recovered from the acute phase of COVID-19 underwent a complete ophthalmological evaluation, including presenting and best-corrected visual acuity (BCVA), refractometry, biomicroscopy, tonometry, break-up time and Schirmer tests, indirect ophthalmoscopy, color fundus picture, and retinal architecture evaluation using optical coherence tomography. Socio-demographic data and personal medical history were also collected. According to the severity of systemic manifestations, patients were classified into mild-to-moderate, severe, and critical. Sixty-four patients (128 eyes) were evaluated 82 ± 36.4 days after the onset of COVID's symptoms. The mean ± SD duration of hospitalization was 15.0 ± 10.7 days. Seven patients (10.9%) had mild-to-moderate, 33 (51.5%) severe, and 24 (37.5%) critical disease. Median [interquartile ranges (IQR)] presenting visual acuity was 0.1 (0-0.2) and BCVA 0 (0-0.1). Anterior segment biomicroscopy was unremarkable, except for dry eye disease, verified in 10.9% of them. The mean ± SD intraocular pressure (IOP) in critical group (14.16 ± 1.88 mmHg) was significantly higher than in severe group (12.51 ± 2.40 mmHg), both in the right (p 0.02) and left eyes (p 0.038). Among all, 15.6% had diabetic retinopathy, and two patients presented with discrete white-yellowish dots in the posterior pole, leading to hyporreflective changes at retinal pigment epithelium level, outer segment, and ellipsoid layers. The present study identified higher IOP among critical cases, when compared to severe cases, and discrete outer retina changes 80 days after COVID-19 infection. No sign of uveitis was found.

Pre- and post-COVID-19 evaluation of antimicrobial susceptibility for healthcare-associated infections in the intensive care unit of a tertiary hospital.

INTRODUCTION: Antimicrobial resistance has worsened since the onset of COVID-19. METHODS: This study involved patients admitted to the adult intensive care unit (ICU) of a tertiary hospital. Pre- and post-COVID-19 data were analyzed. The healthcare-related infections (HCRIs) reported between January 2018 and January 2020 and during the pandemic between February and July 2020 were compared. RESULTS: Antimicrobial resistance increased during the pandemic, especially for Klebsiella pneumoniae isolates, with a rate increase from 5% to 50% for Polymyxin B. CONCLUSIONS: The susceptibilities of the main pathogens associated with HCRIs in the ICU changed and should be considered in managing severe COVID-19.