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.

The impact of COVID-19 on antimicrobial prescription and drug resistance in fungi and bacteria.

Secondary infections are one of the complications in COVID-19 patients. We aimed to analyze the antimicrobial prescriptions and their influence on drug resistance in fungi and bacteria isolated from severely ill COVID-19 patients. Seventy-nine severely ill COVID-19 hospitalized patients with secondary bacterial or fungal infections were included. We analyzed the prescribed antimicrobial regimen for these patients and the resistance profiles of bacterial and fungal isolates. In addition, the association between drug resistance and patients' outcome was analyzed using correlation tests. The most prescribed antibacterial were ceftriaxone (90.7% of patients), vancomycin (86.0%), polymyxin B (74.4%), azithromycin (69.8%), and meropenem (67.4%). Micafungin and fluconazole were used by 22.2 and 11.1% of patients, respectively. Multidrug-resistant (MDR) infections were a common complication in severely ill COVID-19 patients in our cohort since resistant bacteria strains were isolated from 76.7% of the patients. Oxacillin resistance was observed in most Gram-positive bacteria, whereas carbapenem and cephalosporin resistance was detected in most Gram-negative strains. Azole resistance was identified among C. glabrata and C. tropicalis isolates. Patients who used more antimicrobials stayed hospitalized longer than the others. The patient's age and the number of antibacterial agents used were associated with the resistance phenotype. The susceptibility profile of isolates obtained from severely ill COVID-19 patients highlighted the importance of taking microbial resistance into account when managing these patients. The continuous surveillance of resistant/MDR infection and the rational use of antimicrobials are of utmost importance, especially for long-term hospitalized patients with COVID-19.

Cambios en la prescripción de antimicrobianos utilizados en un hospital infantil / Changes in the antimicrobials prescription used in a pediatric hospital

Se realizó un estudio descriptivo y transversal de 32 niños, tratados con antimicrobianos, quienes se encontraban ingresados en el Hospital Infantil Norte Docente "Dr. Juan de la Cruz Martínez Maceira" de Santiago de Cuba, desde julio hasta diciembre del 2013, con vistas a identificar los cambios en la prescripción de estos antimicrobianos. Se halló que la mayoría de estas prescripciones se realizaron en los pacientes de 4-5 años de edad que presentaron infecciones respiratorias, y el agente causal mayormente aislado fue el neumococo. Entre los antibacterianos que fueron cambiados primaron: penicilinas, cefalosporinas y macrólidos, los cuales se sustituyeron debido a la inadecuada evolución de los afectados, así como a los resultados del antibiograma. Otras variables, tales como edad, localización de la infección, así como tipo y duración del tratamiento no influyeron en la decisión del cambio.

A descriptive and cross-sectional study of 32 children, treated with antimicrobials who were admitted in "Dr. Juan de la Cruz Martínez Maceira" Northern Teaching Children Hospital in Santiago de Cuba, was carried out from July to December, 2013, aimed at identifying the changes in the prescription of these antimicrobials. It was found that most of these prescriptions were carried out in the 4-5 years patients that presented breathing infections, and the most isolated causal agent was the pneumococcus. Among the antibacterial drugs that were changed prevailed: penicillins, cephalosporins and macrolids, which were substituted due to the inadequate clinical course of those affected, as well as to the results of the antibiogram. Other variables, such as age, localization of the infection, as well as type and duration of the treatment didn't influence in the decision of the change.

Prescripción de antimicrobianos en pacientes con enfermedad pulmonar obstructiva crónica / Prescription of antimicrobials in patients with chronic obstructive pulmonary disease

OBJETIVO: caracterizar la prescripción de antimicrobianos en pacientes con diagnóstico de enfermedad pulmonar obstructiva crónica descompensada. MÉTODOS: estudio descriptivo, de corte transversal, que incluyó a 131 pacientes con enfermedad pulmonar obstructiva crónica descompensada, a quienes se les prescribió algún antimicrobiano en salas de medicina interna del Hospital Clinicoquirúrgico Joaquín Albarrán, La Habana, Cuba, entre mayo del 2011 y abril del 2012. Se identificaron las principales causas de exacerbación, se describió la prescripción de antimicrobianos y se determinó su relación con la severidad de la descompensación y con la estadía hospitalaria. Se analizaron los resultados obtenidos a través de programa estadístico SPSS. RESULTADOS: el 65 por ciento de los pacientes presentaron una descompensación infecciosa. La prescripción de antimicrobianos se realizó de forma empírica en el 92 por ciento de los casos, e inadecuada en el 49 por ciento de ellos. Se demostró la existencia de una relación estadísticamente significativa entre la severidad de la descompensación y la prescripción de antimicrobianos. CONCLUSIONES: se prescribió antimicrobianos de manera inadecuada en cinco de cada diez pacientes con diagnóstico de enfermedad pulmonar obstructiva crónica descompensada, mayormente en aquellos casos sin haberse constatado diagnóstico positivo de infección respiratoria. A medida que disminuye la severidad de la descompensación, incrementa la incidencia de prescripción inadecuada(AU)

OBJECTIVE: to characterize the prescription of antimicrobials in patients with decompensated chronic obstructive pulmonary disease. METHODS: descriptive and cross-sectional study that covered 131 patients with chronic obstructive pulmonary disease, who were prescribed some kind of antimicrobials in the internal medicine wards of Joaquin Albarran clinical and surgical hospital located in Havana, Cuba in the period of May 2011 through April 2012. The main causes of exacerbation were identified, the antimicrobial prescription was described and the association of severe decompensation and length of stay at hospital was determined. The statistical SPSS software analyzed the results. RESULTS: sixty five percent of patients presented with infectious decompensation. Antimicrobial prescription was mostly empirical in 92 percent of cases and inadequate in 49 percent. It was proven that the association of decompensation severity and antimicrobial prescription was statistically significant. CONCLUSIONS: antimicrobials were inadequately prescribed in five out of ten patients diagnosed with decompensated chronic obstructive pulmonary disease, mostly in those cases without proven positive diagnosis of respiratory infection. As the decompensation severity decreases, the incidence of inadequate prescription increases(AU)