Evaluation of the impact of a nationwide massive online open course on the appropriate use of antimicrobials

Evaluation of the impact of a nationwide massive online open course on the appropriate use of... Abstract Objectives To evaluate the impact of a massive online open course (MOOC) design on the appropriate use of antimicrobial agents, to determine specific study areas with better learning outcomes and to identify weak points. Methods A pre- and post-intervention study in the context of a training course on infectious diseases aimed at health professionals. We designed a questionnaire with 30 questions related to the management of infectious diseases in different clinical situations. Participants had to answer the questions based on their competencies and training for these situations. We analysed the scores obtained before and after the course and the resulting progress. In addition, an open response section was provided to enable a qualitative evaluation. Results Two thousand one hundred and forty-eight health professionals were enrolled in the course. The questionnaire was completed before and after the course by 606 participants, mainly physicians (81.2%) and pharmacists (15.4%). The mean overall scores for the pre- and post-course questionnaires were 6.2 (SD 1.38) and 7.9 (SD 0.88), respectively (overall score increase = 1.8, SD 1.21, P < 0.001). A significant increase in self-assessment was detected (P < 0.001) for all the questions. Qualitative assessments were provided by 218 participants with 225 comments, most of which were very positive. Conclusions The course with a MOOC design showed a great teaching capacity in the infectious diseases area for all the clinical situations analysed, notably in the management of severe infections with higher mortality. For future editions of this training activity, the need to include other infectious diseases, especially infections in primary care, was highlighted. Introduction Antimicrobial resistance constitutes an increasing threat to global public health, which has been recently described by WHO as a global crisis.1 The appropriate use of antimicrobial agents is essential in preventing the development and spread of resistance,2 but requires the development of continuous specific training for health professionals.3 E-learning methodology has proved to be a very useful teaching tool in the professional field in terms of its effectiveness, cost-effectiveness and interactivity,4 and it could play a significant role in increasing awareness and improving antimicrobial prescription.5 Massive online open courses (MOOCs) are a recent popular trend in e-learning methodology and have the potential to provide continuing professional development opportunities to healthcare professionals.6 A monitoring and evaluation process is necessary to determine whether the teaching methodology used achieves the objectives of the activity.7 Antimicrobial stewardship programmes are not an exception. One of the most commonly used forms of assessment are formative tests carried out after the activity and based on multiple-choice questions focusing on aspects of decision making.8 Also, pre- and post-intervention tests enable participants to obtain further feedback on their behaviour and focus their learning on certain aspects of the course for a more in-depth uptake of the taught content.9 Additionally, perceived experience as well as favourable or unfavourable issues not previously identified can be obtained through narrative feedback.10 The main objective of this study was to evaluate the impact of a course with an e-learning (MOOC) design on the baseline knowledge of the participants about the appropriate use of antimicrobial agents. The secondary objectives were to determine the specific areas of study in which better learning outcomes were achieved and to identify weak points to improve future editions of the course. Methods Methodology of the training course This was a training course with an e-learning (MOOC) design performed at a national level by and for physicians and hospital pharmacists on the prescription of antimicrobials in the hospital setting, entitled ‘Workshop to improve the use of antimicrobials in major syndromes of serious infectious diseases’. Its main objective was to improve knowledge on the appropriate use of antimicrobials for the main clinical syndromes of infectious diseases. The course was delivered in Spanish, lasted 4 months and access was free for all interested health professionals. The characteristics and detailed methodology are available at http://www2.iavante.es/es/detalle-curso/2289. The course was promoted in the context of the Spanish Institutional Programme for the Prevention and Control of Healthcare Associated Infections and Appropriate Use of Antimicrobials (known by its Spanish acronym PIRASOA) and supported by the Foundation for Progress and Health-IAVANTE Line. Study design This was a before-and-after study of a course aimed at training in infectious diseases. We designed a questionnaire with 30 questions related to the management of infectious diseases in different clinical situations (2 questions for each of the 15 topics covered). Participants had to answer the questions based on their competencies, abilities and preparedness to approach each situation. Each question was rated using a Likert scale from 1 to 10, where a score of 1 meant bad, minimum or nothing and 10 referred to excellent, maximum or all. In addition, a satisfaction survey including an open response section offered participants the possibility of giving a qualitative evaluation of the teaching activity. The questionnaire was provided online to all enrolled participants before and after the course. Completion was voluntary and the questions were addressed through self-assessment of their competence and decision-making capacity in the different clinical situations (the post-test was completed 4 months after the pre-test). We considered the questionnaires of all the participants who had completed both the initial and the final test. Variables For every question asked, we analysed the scores of the participants at the beginning and at the end of the course and the resulting progress. We reviewed the items showing more notable progress and the aspects with higher final score. Finally, a descriptive analysis of the qualitative evaluation of the participants was performed. Statistical analysis Frequency measures were used for the analysis of qualitative variables. For quantitative variables, data were presented as mean value and standard deviation. For the comparative analysis between pre- and post-tests, we used a Student’s t-test for paired samples or independent samples, as appropriate, and the Kolmogorov–Smirnov test for the analysis of normality. The threshold for statistical significance was established at a P value of <0.05 (P values reported have not been adjusted for multiple comparisons). This analysis was carried out with the IBM-SPSS Statistics V24 software. Ethics The study was considered to be part of the evaluation of the course, so ethics committee approval was not required, and it was conducted in compliance with the relevant legislation on data protection. Results and discussion Of the 2148 professionals who started the course (mean age 39.2 years; 63.0% women), 1632 were medical doctors, of whom 492 replied to the survey (30.1% response rate), and 387 were pharmacists, of whom 93 replied (24.1% response rate). The initial questionnaire was completed by 1226 professionals and 834 completed the final questionnaire. Of these, 606 (49.4%) completed both questionnaires and were included in the study for analysis. Not all participants completed both questionnaires because their completion was not mandatory. The characteristics of these participants are detailed in Table 1. Table 1. Baseline characteristics of participants who completed the pre- and post-questionnaires Gender, n (%)  male 212 (35.0)  female 394 (65.0) Age (years)a, mean (SD) 39.8 (8.23) Most common healthcare specialties, n (%)  family and community medicine 118 (19.5)  internal medicine 108 (17.8)  intensive care medicine 79 (13.0)  hospital and primary care pharmacy 69 (11.4)  anaesthesiology and resuscitation 39 (6.4)  clinical microbiology and parasitology 38 (6.3)  general and digestive surgery 27 (4.5)  obstetrics and gynaecology 14 (2.3)  haematology and haemotherapy 13 (2.2)  paediatrics and its specific areas 11 (1.8)  nephrology 9 (1.5)  preventive medicine and public health 8 (1.3)  nursing 8 (1.3) Gender, n (%)  male 212 (35.0)  female 394 (65.0) Age (years)a, mean (SD) 39.8 (8.23) Most common healthcare specialties, n (%)  family and community medicine 118 (19.5)  internal medicine 108 (17.8)  intensive care medicine 79 (13.0)  hospital and primary care pharmacy 69 (11.4)  anaesthesiology and resuscitation 39 (6.4)  clinical microbiology and parasitology 38 (6.3)  general and digestive surgery 27 (4.5)  obstetrics and gynaecology 14 (2.3)  haematology and haemotherapy 13 (2.2)  paediatrics and its specific areas 11 (1.8)  nephrology 9 (1.5)  preventive medicine and public health 8 (1.3)  nursing 8 (1.3) a 109 participants did not provide age data. Table 1. Baseline characteristics of participants who completed the pre- and post-questionnaires Gender, n (%)  male 212 (35.0)  female 394 (65.0) Age (years)a, mean (SD) 39.8 (8.23) Most common healthcare specialties, n (%)  family and community medicine 118 (19.5)  internal medicine 108 (17.8)  intensive care medicine 79 (13.0)  hospital and primary care pharmacy 69 (11.4)  anaesthesiology and resuscitation 39 (6.4)  clinical microbiology and parasitology 38 (6.3)  general and digestive surgery 27 (4.5)  obstetrics and gynaecology 14 (2.3)  haematology and haemotherapy 13 (2.2)  paediatrics and its specific areas 11 (1.8)  nephrology 9 (1.5)  preventive medicine and public health 8 (1.3)  nursing 8 (1.3) Gender, n (%)  male 212 (35.0)  female 394 (65.0) Age (years)a, mean (SD) 39.8 (8.23) Most common healthcare specialties, n (%)  family and community medicine 118 (19.5)  internal medicine 108 (17.8)  intensive care medicine 79 (13.0)  hospital and primary care pharmacy 69 (11.4)  anaesthesiology and resuscitation 39 (6.4)  clinical microbiology and parasitology 38 (6.3)  general and digestive surgery 27 (4.5)  obstetrics and gynaecology 14 (2.3)  haematology and haemotherapy 13 (2.2)  paediatrics and its specific areas 11 (1.8)  nephrology 9 (1.5)  preventive medicine and public health 8 (1.3)  nursing 8 (1.3) a 109 participants did not provide age data. The mean overall scores in the pre- and post-tests were 6.2 (SD 1.38) and 7.9 (SD 0.88), respectively, with an average increase of 1.8 (SD 1.21) (P < 0.001). We observed a greater increase in participants who were practitioners in training (2.0; SD 0.09) than in those who had finished their training (1.7; SD 1.22) (P = 0.003). Table 2 shows the results obtained for each question and the comparative analysis between the beginning and the end of the course for the 606 paired completed questionnaires. For all the questions, there was a significant increase in the self-assessment results after the course compared with the initial assessment (P < 0.001), which reflects a very positive impact on the management of serious infections, and it follows that an e-learning tool may be helpful in improving the prescription of antimicrobials.11 In fact, the score increased by at least 2 points for 11 questions and between 1 and 2 points for 16 questions. Table 2. Comparison of the results of the questionnaire before and after the completion of the e-learning course Question Initial answer Final answer Variation (%) Student’s t-test P mean SD mean SD Overall score for the questionnaire 6.2 1.38 7.9 0.88 29.1 −36.51 <0.001 Q1. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials worldwide? 9.1 1.22 9.4 0.94 3.2 −6.04 <0.001 Q2. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials at the national level? 9.0 1.28 9.3 0.96 2.9 −4.56 <0.001 Q3. How do you rate the response given to the problem of bacterial resistance to antimicrobials worldwide? 6.1 1.77 7.0 1.61 14.4 −12.05 <0.001 Q4. How do you rate the response given to the problem of bacterial resistance to antimicrobials at the national level? 5.9 1.80 6.9 1.62 16.9 −13.81 <0.001 Q5. How do you rate the response given to the problem of bacterial resistance to antimicrobials in Andalusia? 6.2 1.95 7.3 1.56 17.8 −14.61 <0.001 Q6. How confident do you feel when you prescribe an antimicrobial, evaluating potential side effects and drug–drug interactions? 6.3 1.63 7.5 1.28 18.1 −16.99 <0.001 Q7. In patients who require hospitalization for community-acquired pneumonia, do you know how to recognize in which situations the combined treatment of a β-lactam with macrolides or quinolones is necessary? 6.1 2.25 8.2 1.23 32.9 −23.83 <0.001 Q8. How confident do you feel when you prescribe amoxicillin to a healthy, non-smoking patient with typical community-acquired pneumonia (acute onset, cold sores and lobar condensation without associated effusion)? 6.2 2.29 8.1 1.46 30.4 −19.07 <0.001 Q9. If a patient hospitalized for community-acquired pneumonia progresses favourably with the prescribed treatment, could you identify the criteria necessary to switch the antibiotic to the oral route? 6.4 2.08 8.4 1.15 30.6 −24.90 <0.001 Q10. In patients with an infection of the skin and soft tissues, do you know the indications for empirical treatment for MRSA? 6.1 2.25 8.1 1.19 31.8 −22.87 <0.001 Q11. In a patient with a serious infection of the skin and soft tissues, do you feel prepared to recognize the diagnostic criteria of necrotizing fasciitis? 5.9 2.25 8.0 1.37 34.5 −25.29 <0.001 Q12. Do you feel well trained to evaluate the result of a culture taken from a pressure ulcer? 5.9 2.15 7.8 1.40 32.4 −23.99 <0.001 Q13. How confident are you when you evaluate an antimicrobial susceptibility test? 6.8 1.78 7.9 1.34 16.8 −17.53 <0.001 Q14. With an antimicrobial susceptibility test of an Escherichia coli isolate, do you know whether or not it is a potential strain producing ESBLs? 6.2 2.35 8.0 1.41 29.0 −21.28 <0.001 Q15. In patients with nosocomial fever, is your diagnostic and therapeutic assessment systematized? 5.9 2.15 8.0 1.33 35.5 −25.49 <0.001 Q16. How prepared do you feel to start the diagnostic workup and therapeutic care of a patient with septic shock? 6.4 2.24 8.2 1.42 28.4 −24.74 <0.001 Q17. Are you trained to establish the diagnostic value of a positive urine culture in a catheterized patient with no focal nosocomial fever? 6.2 1.99 8.1 1.25 29.0 −24.52 <0.001 Q18. Do you know the criteria for monitoring plasma levels of vancomycin? 5.1 2.59 7.8 1.59 52.1 −28.44 <0.001 Q19. How confident do you feel when recommending the duration of antibiotic treatment for a patient with complicated intra-abdominal infection? 5.5 2.13 7.7 1.34 39.7 −27.49 <0.001 Q20. How do you rate your level of training to assist a patient with febrile neutropenia after chemotherapy for lung cancer? 5.0 2.38 7.5 1.53 48.3 −27.77 <0.001 Q21. Do you feel confident to recognize the criteria of empirical antifungal treatment in patients with febrile neutropenia after chemotherapy? 4.8 2.20 7.6 1.41 56.4 −31.76 <0.001 Q22. For a patient with suspected ventilator-associated pneumonia, how confident do you feel to evaluate the diagnostic criteria? 5.4 2.36 7.7 1.49 43.5 −27.10 <0.001 Q23. For the same patient, how confident do you feel to establish the appropriate empirical treatment? 5.5 2.37 7.8 1.39 41.1 −26.43 <0.001 Q24. How confident do you feel for a patient with S. aureus bacteraemia? 6.3 2.07 8.1 1.18 28.2 −23.94 <0.001 Q25. Regarding treatment of ESBL-producing Enterobacteriaceae infections, do you feel trained enough to decide when the treatment of choice is a carbapenem and when it is not? 5.6 2.32 8.0 1.27 41.9 −27.88 <0.001 Q26. In a patient with candidaemia, do you feel confident enough to decide when treatment with fluconazole is indicated or when it is not? 5.4 2.25 8.0 1.29 48.0 −29.77 <0.001 Q27. How confident do you feel choosing empirical antimicrobial treatment for a patient with a serious infection? 6.2 1.98 8.0 1.13 30.7 −25.86 <0.001 Q28. And targeted antimicrobial treatment? 6.4 2.04 8.2 1.17 29.1 −24.03 <0.001 Q29. How confident do you feel to decide when to switch the antimicrobial treatment from the intravenous to the oral route in general? 6.3 1.99 8.2 1.09 29.0 −25.57 <0.001 Q30. How confident do you feel to decide when to stop the antimicrobial treatment? 6.3 1.79 8.0 1.09 26.6 −24.05 <0.001 Question Initial answer Final answer Variation (%) Student’s t-test P mean SD mean SD Overall score for the questionnaire 6.2 1.38 7.9 0.88 29.1 −36.51 <0.001 Q1. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials worldwide? 9.1 1.22 9.4 0.94 3.2 −6.04 <0.001 Q2. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials at the national level? 9.0 1.28 9.3 0.96 2.9 −4.56 <0.001 Q3. How do you rate the response given to the problem of bacterial resistance to antimicrobials worldwide? 6.1 1.77 7.0 1.61 14.4 −12.05 <0.001 Q4. How do you rate the response given to the problem of bacterial resistance to antimicrobials at the national level? 5.9 1.80 6.9 1.62 16.9 −13.81 <0.001 Q5. How do you rate the response given to the problem of bacterial resistance to antimicrobials in Andalusia? 6.2 1.95 7.3 1.56 17.8 −14.61 <0.001 Q6. How confident do you feel when you prescribe an antimicrobial, evaluating potential side effects and drug–drug interactions? 6.3 1.63 7.5 1.28 18.1 −16.99 <0.001 Q7. In patients who require hospitalization for community-acquired pneumonia, do you know how to recognize in which situations the combined treatment of a β-lactam with macrolides or quinolones is necessary? 6.1 2.25 8.2 1.23 32.9 −23.83 <0.001 Q8. How confident do you feel when you prescribe amoxicillin to a healthy, non-smoking patient with typical community-acquired pneumonia (acute onset, cold sores and lobar condensation without associated effusion)? 6.2 2.29 8.1 1.46 30.4 −19.07 <0.001 Q9. If a patient hospitalized for community-acquired pneumonia progresses favourably with the prescribed treatment, could you identify the criteria necessary to switch the antibiotic to the oral route? 6.4 2.08 8.4 1.15 30.6 −24.90 <0.001 Q10. In patients with an infection of the skin and soft tissues, do you know the indications for empirical treatment for MRSA? 6.1 2.25 8.1 1.19 31.8 −22.87 <0.001 Q11. In a patient with a serious infection of the skin and soft tissues, do you feel prepared to recognize the diagnostic criteria of necrotizing fasciitis? 5.9 2.25 8.0 1.37 34.5 −25.29 <0.001 Q12. Do you feel well trained to evaluate the result of a culture taken from a pressure ulcer? 5.9 2.15 7.8 1.40 32.4 −23.99 <0.001 Q13. How confident are you when you evaluate an antimicrobial susceptibility test? 6.8 1.78 7.9 1.34 16.8 −17.53 <0.001 Q14. With an antimicrobial susceptibility test of an Escherichia coli isolate, do you know whether or not it is a potential strain producing ESBLs? 6.2 2.35 8.0 1.41 29.0 −21.28 <0.001 Q15. In patients with nosocomial fever, is your diagnostic and therapeutic assessment systematized? 5.9 2.15 8.0 1.33 35.5 −25.49 <0.001 Q16. How prepared do you feel to start the diagnostic workup and therapeutic care of a patient with septic shock? 6.4 2.24 8.2 1.42 28.4 −24.74 <0.001 Q17. Are you trained to establish the diagnostic value of a positive urine culture in a catheterized patient with no focal nosocomial fever? 6.2 1.99 8.1 1.25 29.0 −24.52 <0.001 Q18. Do you know the criteria for monitoring plasma levels of vancomycin? 5.1 2.59 7.8 1.59 52.1 −28.44 <0.001 Q19. How confident do you feel when recommending the duration of antibiotic treatment for a patient with complicated intra-abdominal infection? 5.5 2.13 7.7 1.34 39.7 −27.49 <0.001 Q20. How do you rate your level of training to assist a patient with febrile neutropenia after chemotherapy for lung cancer? 5.0 2.38 7.5 1.53 48.3 −27.77 <0.001 Q21. Do you feel confident to recognize the criteria of empirical antifungal treatment in patients with febrile neutropenia after chemotherapy? 4.8 2.20 7.6 1.41 56.4 −31.76 <0.001 Q22. For a patient with suspected ventilator-associated pneumonia, how confident do you feel to evaluate the diagnostic criteria? 5.4 2.36 7.7 1.49 43.5 −27.10 <0.001 Q23. For the same patient, how confident do you feel to establish the appropriate empirical treatment? 5.5 2.37 7.8 1.39 41.1 −26.43 <0.001 Q24. How confident do you feel for a patient with S. aureus bacteraemia? 6.3 2.07 8.1 1.18 28.2 −23.94 <0.001 Q25. Regarding treatment of ESBL-producing Enterobacteriaceae infections, do you feel trained enough to decide when the treatment of choice is a carbapenem and when it is not? 5.6 2.32 8.0 1.27 41.9 −27.88 <0.001 Q26. In a patient with candidaemia, do you feel confident enough to decide when treatment with fluconazole is indicated or when it is not? 5.4 2.25 8.0 1.29 48.0 −29.77 <0.001 Q27. How confident do you feel choosing empirical antimicrobial treatment for a patient with a serious infection? 6.2 1.98 8.0 1.13 30.7 −25.86 <0.001 Q28. And targeted antimicrobial treatment? 6.4 2.04 8.2 1.17 29.1 −24.03 <0.001 Q29. How confident do you feel to decide when to switch the antimicrobial treatment from the intravenous to the oral route in general? 6.3 1.99 8.2 1.09 29.0 −25.57 <0.001 Q30. How confident do you feel to decide when to stop the antimicrobial treatment? 6.3 1.79 8.0 1.09 26.6 −24.05 <0.001 Table 2. Comparison of the results of the questionnaire before and after the completion of the e-learning course Question Initial answer Final answer Variation (%) Student’s t-test P mean SD mean SD Overall score for the questionnaire 6.2 1.38 7.9 0.88 29.1 −36.51 <0.001 Q1. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials worldwide? 9.1 1.22 9.4 0.94 3.2 −6.04 <0.001 Q2. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials at the national level? 9.0 1.28 9.3 0.96 2.9 −4.56 <0.001 Q3. How do you rate the response given to the problem of bacterial resistance to antimicrobials worldwide? 6.1 1.77 7.0 1.61 14.4 −12.05 <0.001 Q4. How do you rate the response given to the problem of bacterial resistance to antimicrobials at the national level? 5.9 1.80 6.9 1.62 16.9 −13.81 <0.001 Q5. How do you rate the response given to the problem of bacterial resistance to antimicrobials in Andalusia? 6.2 1.95 7.3 1.56 17.8 −14.61 <0.001 Q6. How confident do you feel when you prescribe an antimicrobial, evaluating potential side effects and drug–drug interactions? 6.3 1.63 7.5 1.28 18.1 −16.99 <0.001 Q7. In patients who require hospitalization for community-acquired pneumonia, do you know how to recognize in which situations the combined treatment of a β-lactam with macrolides or quinolones is necessary? 6.1 2.25 8.2 1.23 32.9 −23.83 <0.001 Q8. How confident do you feel when you prescribe amoxicillin to a healthy, non-smoking patient with typical community-acquired pneumonia (acute onset, cold sores and lobar condensation without associated effusion)? 6.2 2.29 8.1 1.46 30.4 −19.07 <0.001 Q9. If a patient hospitalized for community-acquired pneumonia progresses favourably with the prescribed treatment, could you identify the criteria necessary to switch the antibiotic to the oral route? 6.4 2.08 8.4 1.15 30.6 −24.90 <0.001 Q10. In patients with an infection of the skin and soft tissues, do you know the indications for empirical treatment for MRSA? 6.1 2.25 8.1 1.19 31.8 −22.87 <0.001 Q11. In a patient with a serious infection of the skin and soft tissues, do you feel prepared to recognize the diagnostic criteria of necrotizing fasciitis? 5.9 2.25 8.0 1.37 34.5 −25.29 <0.001 Q12. Do you feel well trained to evaluate the result of a culture taken from a pressure ulcer? 5.9 2.15 7.8 1.40 32.4 −23.99 <0.001 Q13. How confident are you when you evaluate an antimicrobial susceptibility test? 6.8 1.78 7.9 1.34 16.8 −17.53 <0.001 Q14. With an antimicrobial susceptibility test of an Escherichia coli isolate, do you know whether or not it is a potential strain producing ESBLs? 6.2 2.35 8.0 1.41 29.0 −21.28 <0.001 Q15. In patients with nosocomial fever, is your diagnostic and therapeutic assessment systematized? 5.9 2.15 8.0 1.33 35.5 −25.49 <0.001 Q16. How prepared do you feel to start the diagnostic workup and therapeutic care of a patient with septic shock? 6.4 2.24 8.2 1.42 28.4 −24.74 <0.001 Q17. Are you trained to establish the diagnostic value of a positive urine culture in a catheterized patient with no focal nosocomial fever? 6.2 1.99 8.1 1.25 29.0 −24.52 <0.001 Q18. Do you know the criteria for monitoring plasma levels of vancomycin? 5.1 2.59 7.8 1.59 52.1 −28.44 <0.001 Q19. How confident do you feel when recommending the duration of antibiotic treatment for a patient with complicated intra-abdominal infection? 5.5 2.13 7.7 1.34 39.7 −27.49 <0.001 Q20. How do you rate your level of training to assist a patient with febrile neutropenia after chemotherapy for lung cancer? 5.0 2.38 7.5 1.53 48.3 −27.77 <0.001 Q21. Do you feel confident to recognize the criteria of empirical antifungal treatment in patients with febrile neutropenia after chemotherapy? 4.8 2.20 7.6 1.41 56.4 −31.76 <0.001 Q22. For a patient with suspected ventilator-associated pneumonia, how confident do you feel to evaluate the diagnostic criteria? 5.4 2.36 7.7 1.49 43.5 −27.10 <0.001 Q23. For the same patient, how confident do you feel to establish the appropriate empirical treatment? 5.5 2.37 7.8 1.39 41.1 −26.43 <0.001 Q24. How confident do you feel for a patient with S. aureus bacteraemia? 6.3 2.07 8.1 1.18 28.2 −23.94 <0.001 Q25. Regarding treatment of ESBL-producing Enterobacteriaceae infections, do you feel trained enough to decide when the treatment of choice is a carbapenem and when it is not? 5.6 2.32 8.0 1.27 41.9 −27.88 <0.001 Q26. In a patient with candidaemia, do you feel confident enough to decide when treatment with fluconazole is indicated or when it is not? 5.4 2.25 8.0 1.29 48.0 −29.77 <0.001 Q27. How confident do you feel choosing empirical antimicrobial treatment for a patient with a serious infection? 6.2 1.98 8.0 1.13 30.7 −25.86 <0.001 Q28. And targeted antimicrobial treatment? 6.4 2.04 8.2 1.17 29.1 −24.03 <0.001 Q29. How confident do you feel to decide when to switch the antimicrobial treatment from the intravenous to the oral route in general? 6.3 1.99 8.2 1.09 29.0 −25.57 <0.001 Q30. How confident do you feel to decide when to stop the antimicrobial treatment? 6.3 1.79 8.0 1.09 26.6 −24.05 <0.001 Question Initial answer Final answer Variation (%) Student’s t-test P mean SD mean SD Overall score for the questionnaire 6.2 1.38 7.9 0.88 29.1 −36.51 <0.001 Q1. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials worldwide? 9.1 1.22 9.4 0.94 3.2 −6.04 <0.001 Q2. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials at the national level? 9.0 1.28 9.3 0.96 2.9 −4.56 <0.001 Q3. How do you rate the response given to the problem of bacterial resistance to antimicrobials worldwide? 6.1 1.77 7.0 1.61 14.4 −12.05 <0.001 Q4. How do you rate the response given to the problem of bacterial resistance to antimicrobials at the national level? 5.9 1.80 6.9 1.62 16.9 −13.81 <0.001 Q5. How do you rate the response given to the problem of bacterial resistance to antimicrobials in Andalusia? 6.2 1.95 7.3 1.56 17.8 −14.61 <0.001 Q6. How confident do you feel when you prescribe an antimicrobial, evaluating potential side effects and drug–drug interactions? 6.3 1.63 7.5 1.28 18.1 −16.99 <0.001 Q7. In patients who require hospitalization for community-acquired pneumonia, do you know how to recognize in which situations the combined treatment of a β-lactam with macrolides or quinolones is necessary? 6.1 2.25 8.2 1.23 32.9 −23.83 <0.001 Q8. How confident do you feel when you prescribe amoxicillin to a healthy, non-smoking patient with typical community-acquired pneumonia (acute onset, cold sores and lobar condensation without associated effusion)? 6.2 2.29 8.1 1.46 30.4 −19.07 <0.001 Q9. If a patient hospitalized for community-acquired pneumonia progresses favourably with the prescribed treatment, could you identify the criteria necessary to switch the antibiotic to the oral route? 6.4 2.08 8.4 1.15 30.6 −24.90 <0.001 Q10. In patients with an infection of the skin and soft tissues, do you know the indications for empirical treatment for MRSA? 6.1 2.25 8.1 1.19 31.8 −22.87 <0.001 Q11. In a patient with a serious infection of the skin and soft tissues, do you feel prepared to recognize the diagnostic criteria of necrotizing fasciitis? 5.9 2.25 8.0 1.37 34.5 −25.29 <0.001 Q12. Do you feel well trained to evaluate the result of a culture taken from a pressure ulcer? 5.9 2.15 7.8 1.40 32.4 −23.99 <0.001 Q13. How confident are you when you evaluate an antimicrobial susceptibility test? 6.8 1.78 7.9 1.34 16.8 −17.53 <0.001 Q14. With an antimicrobial susceptibility test of an Escherichia coli isolate, do you know whether or not it is a potential strain producing ESBLs? 6.2 2.35 8.0 1.41 29.0 −21.28 <0.001 Q15. In patients with nosocomial fever, is your diagnostic and therapeutic assessment systematized? 5.9 2.15 8.0 1.33 35.5 −25.49 <0.001 Q16. How prepared do you feel to start the diagnostic workup and therapeutic care of a patient with septic shock? 6.4 2.24 8.2 1.42 28.4 −24.74 <0.001 Q17. Are you trained to establish the diagnostic value of a positive urine culture in a catheterized patient with no focal nosocomial fever? 6.2 1.99 8.1 1.25 29.0 −24.52 <0.001 Q18. Do you know the criteria for monitoring plasma levels of vancomycin? 5.1 2.59 7.8 1.59 52.1 −28.44 <0.001 Q19. How confident do you feel when recommending the duration of antibiotic treatment for a patient with complicated intra-abdominal infection? 5.5 2.13 7.7 1.34 39.7 −27.49 <0.001 Q20. How do you rate your level of training to assist a patient with febrile neutropenia after chemotherapy for lung cancer? 5.0 2.38 7.5 1.53 48.3 −27.77 <0.001 Q21. Do you feel confident to recognize the criteria of empirical antifungal treatment in patients with febrile neutropenia after chemotherapy? 4.8 2.20 7.6 1.41 56.4 −31.76 <0.001 Q22. For a patient with suspected ventilator-associated pneumonia, how confident do you feel to evaluate the diagnostic criteria? 5.4 2.36 7.7 1.49 43.5 −27.10 <0.001 Q23. For the same patient, how confident do you feel to establish the appropriate empirical treatment? 5.5 2.37 7.8 1.39 41.1 −26.43 <0.001 Q24. How confident do you feel for a patient with S. aureus bacteraemia? 6.3 2.07 8.1 1.18 28.2 −23.94 <0.001 Q25. Regarding treatment of ESBL-producing Enterobacteriaceae infections, do you feel trained enough to decide when the treatment of choice is a carbapenem and when it is not? 5.6 2.32 8.0 1.27 41.9 −27.88 <0.001 Q26. In a patient with candidaemia, do you feel confident enough to decide when treatment with fluconazole is indicated or when it is not? 5.4 2.25 8.0 1.29 48.0 −29.77 <0.001 Q27. How confident do you feel choosing empirical antimicrobial treatment for a patient with a serious infection? 6.2 1.98 8.0 1.13 30.7 −25.86 <0.001 Q28. And targeted antimicrobial treatment? 6.4 2.04 8.2 1.17 29.1 −24.03 <0.001 Q29. How confident do you feel to decide when to switch the antimicrobial treatment from the intravenous to the oral route in general? 6.3 1.99 8.2 1.09 29.0 −25.57 <0.001 Q30. How confident do you feel to decide when to stop the antimicrobial treatment? 6.3 1.79 8.0 1.09 26.6 −24.05 <0.001 Some areas of study had a greater improvement (>40%), such as knowledge of criteria for monitoring plasma levels of vancomycin (52.1%), which should be considered a strategic point, because the use of suboptimal dosing regimens of antibiotics can substantially contribute to the development of bacterial resistance.12 Other areas were antifungal treatment of post-chemotherapy febrile neutropenia, treatment of febrile neutropenia in lung cancer patients, treatment of candidaemia and ESBL-producing Enterobacteriaceae infections, and training in criteria for the diagnosis and empirical treatment of ventilator-associated pneumonia (56.4%, 48.3%, 48.0%, 41.9%, 43.5% and 41.1%, respectively). These patients have an increased risk of mortality and could therefore benefit more from adequate management with antimicrobial treatment.13–16 The items with the best final score (>8 points) were: evaluation of the importance of bacterial resistance at global and national levels; attitude towards sequential therapy; combined therapy for inpatients and treatment with amoxicillin in community-acquired pneumonia for outpatients; comprehensive treatment of septic shock; sense of confidence for switching from intravenous to oral treatment; management of Staphylococcus aureus bacteraemia and of MRSA skin and soft tissue infections; and interpretation of a positive urine culture in catheterized patients. A qualitative assessment after the course was provided by 218 participants, with 225 comments (Table S1, available as Supplementary data at JAC Online). The most common ones were very favourable and highlight the positive aspects of the course (teaching capacity and methodology used). This reflects the importance given by health professionals to e-learning courses for their professional development, particularly in the management and control of infectious diseases.17,18 Despite this, some comments showed aspects that could be changed, such as a more structured theoretical content and a summary with key ideas or technical problems with the platform. These largely coincide with published studies that compare e-learning and traditional methods.19 Furthermore, other comments suggest expansion of the areas of knowledge to other ones, such as primary care, because the course was aimed at addressing serious infections in hospital settings. However, most participants were specialists in family and community medicine, and this aspect may well have confused the picture, but it shows the interest of these professionals in further training in infectious diseases. General practitioners were invited to participate in the course because it was of the open access type, and in Andalusia many general practitioners work in the emergency departments of hospitals and the course covered issues of interest to them, although it could be a limitation of the study. As limitations of the study, we should mention that only about half of the participants completed the pre- and post-questionnaires, so they may have been completed only by better trained participants. Additionally, the inherent limitations of pre-/post-intervention studies, such as history, maturation, test effects and the regression to the mean effect, must be considered,20 although the short period of time that elapsed between the pre- and post-tests may have minimized these effects. Finally, the fact that scores were based on self-assessment may have led to greater before–after differences. For future activities, this subjectivity should be avoided by requesting participants to complete a baseline knowledge test. Nevertheless, the self-assessments performed provided valuable information on the perception of health professionals of their own knowledge, clinical decision-making capacity and self-confidence. Conclusions Our course with an e-learning (MOOC) design has shown considerable teaching capacity in the infectious diseases area for all the clinical situations analysed, with a greater scope for improvement detected in pharmacokinetic monitoring of antibiotics and management of post-chemotherapy febrile neutropenia, candidaemia and ventilator-associated pneumonia. The degree of learning after the course was high, most notably in knowledge regarding community-acquired pneumonia, septic shock, S. aureus infections and switching to oral antibiotics. For future editions of this training activity, the need to include other infectious diseases, especially infections in primary care, was highlighted. Acknowledgements We thank the teaching team of the course: Manuela Aguilar Guisado, Rocío Álvarez Marín, Juan José Castón Osorio, Elisa Cordero Matía, Juan Enrique Corzo Delgado, Alfonso del Arco Jiménez, Ángel Estella García, José Garnacho Montero, María Victoria Gil Navarro, Belén Gutiérrez Gutiérrez, Carmen Hidalgo Tenorio, Patricia Jiménez Aguilar, José Antonio Lepe Jiménez, Luis Eduardo López Cortés, Andrés Martín Aspas, José Molina Gil-Bermejo, Clara Natera Kindelan, Enrique Nuño Álvarez, Carmen María Pinto Nieto, José María Reguera Iglesias, Pilar Retamar Gentil, María Dolores Rojo Martín, Alberto Romero Palacios, Rafael Sierra Camerino, Lucía Valiente de Santis and Salvador Vergara López. Funding The e-learning course was supported by Merck Sharp & Dohme Corp. through an unrestricted grant. Transparency declarations None to declare. Supplementary data Table S1 is available as Supplementary data at JAC Online. References 1 WHO . Antimicrobial Resistance. Fact Sheet. http://www.who.int/mediacentre/factsheets/fs194/en/. 2 Zilberberg MD , Nathanson BH , Sulham K et al. Carbapenem resistance, inappropriate empiric treatment and outcomes among patients hospitalized with Enterobacteriaceae urinary tract infection, pneumonia and sepsis . BMC Infect Dis 2017 ; 17 : 279 . Google Scholar CrossRef Search ADS PubMed 3 Gutiérrez F , Masiá M. Teaching infectious diseases in the medical degree within the European higher education area . Enferm Infecc Microbiol Clin 2016 ; 34 : 372 – 83 . Google Scholar CrossRef Search ADS PubMed 4 Sinclair PM , Kable A , Levett-Jones T et al. The effectiveness of Internet-based e-learning on clinician behaviour and patient outcomes: a systematic review . Int J Nurs Stud 2016 ; 57 : 70 – 81 . Google Scholar CrossRef Search ADS PubMed 5 Rocha-Pereira N , Lafferty N , Nathwani D. Educating healthcare professionals in antimicrobial stewardship: can online-learning solutions help? J Antimicrob Chemother 2015 ; 70 : 3175 – 7 . Google Scholar CrossRef Search ADS PubMed 6 Liyanagunawardena TR , Williams SA. Massive open online courses on health and medicine: review . J Med Internet Res 2014 ; 16 : e191. Google Scholar CrossRef Search ADS PubMed 7 Moro J , Tejedor JM , Zancajo JL. La calidad de la formación especializada a través de la encuesta de opinión de residentes . Rev Calidad Asistencial 2006 ; 21 : 82 – 6 . Google Scholar CrossRef Search ADS 8 Nicol DJ , Macfarlane-Dick D. Formative assessment and self-regulated learning: a model and seven principles of good feedback practice . Stud High Educ 2006 ; 31 : 199 – 218 . Google Scholar CrossRef Search ADS 9 Luetsch K , Burrows J. Certainty rating in pre-and post-tests of study modules in an online clinical pharmacy course—a pilot study to evaluate teaching and learning . BMC Med Educ 2016 ; 16 : 267. Google Scholar CrossRef Search ADS PubMed 10 Cook DA , Ellaway RH. Evaluating technology-enhanced learning: a comprehensive framework . Med Teach 2015 ; 37 : 961 – 70 . Google Scholar CrossRef Search ADS PubMed 11 van Buul LW , Sikkens JJ , van Agtmael MA et al. Participatory action research in antimicrobial stewardship: a novel approach to improving antimicrobial prescribing in hospitals and long-term care facilities . J Antimicrob Chemother 2014 ; 69 : 1734 – 41 . Google Scholar CrossRef Search ADS PubMed 12 Monogue ML , Kuti JL , Nicolau DP. Optimizing antibiotic dosing strategies for the treatment of Gram-negative infections in the era of resistance . Expert Rev Clin Pharmacol 2016 ; 9 : 459 – 76 . Google Scholar CrossRef Search ADS PubMed 13 Pagano L , Busca A , Candoni A et al. ; SEIFEM (Sorveglianza Epidemiologica Infezioni Fungine nelle Emopatie Maligne) Group . Risk stratification for invasive fungal infections in patients with hematological malignancies: SEIFEM recommendations . Blood Rev 2017 ; 31 : 17 – 29 . Google Scholar CrossRef Search ADS PubMed 14 Freifeld AG , Bow EJ , Sepkowitz KA et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America . Clin Infect Dis 2011 ; 52 : e56 – 93 . Google Scholar CrossRef Search ADS PubMed 15 Leavitt A , Chmelnitsky I , Colodner R et al. Ertapenem resistance among extended-spectrum-β-lactamase-producing Klebsiella pneumoniae isolates . J Clin Microbiol 2009 ; 47 : 969 – 74 . Google Scholar CrossRef Search ADS PubMed 16 Fujitani S , Sun H-Y , Yu VL et al. Pneumonia due to Pseudomonas aeruginosa: part I: epidemiology, clinical diagnosis, and source . Chest 2011 ; 139 : 909 – 19 . Google Scholar CrossRef Search ADS PubMed 17 Carter RR , Sun J , Jump RL. A survey and analysis of the American public’s perceptions and knowledge about antibiotic resistance . Open Forum Infect Dis 2016 ; 3 : ofw112. Google Scholar CrossRef Search ADS PubMed 18 Atack L , Luke R. Improving infection control competency through an online learning course . Nurs Times 2009 ; 105 : 30 – 2 . Google Scholar PubMed 19 Cook DA , Steinert Y. Online learning for faculty development: a review of the literature . Med Teach 2013 ; 35 : 930 – 7 . Google Scholar CrossRef Search ADS PubMed 20 Marsden E , Torgerson CJ. Single group, pre- and post-test research designs: some methodological concerns . Oxford Rev Educ 2012 ; 38 : 583 – 616 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Antimicrobial Chemotherapy Oxford University Press

Evaluation of the impact of a nationwide massive online open course on the appropriate use of antimicrobials

Journal of Antimicrobial Chemotherapy , Volume Advance Article (8) – Apr 25, 2018

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com.
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0305-7453
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1460-2091
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10.1093/jac/dky149
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Abstract

Abstract Objectives To evaluate the impact of a massive online open course (MOOC) design on the appropriate use of antimicrobial agents, to determine specific study areas with better learning outcomes and to identify weak points. Methods A pre- and post-intervention study in the context of a training course on infectious diseases aimed at health professionals. We designed a questionnaire with 30 questions related to the management of infectious diseases in different clinical situations. Participants had to answer the questions based on their competencies and training for these situations. We analysed the scores obtained before and after the course and the resulting progress. In addition, an open response section was provided to enable a qualitative evaluation. Results Two thousand one hundred and forty-eight health professionals were enrolled in the course. The questionnaire was completed before and after the course by 606 participants, mainly physicians (81.2%) and pharmacists (15.4%). The mean overall scores for the pre- and post-course questionnaires were 6.2 (SD 1.38) and 7.9 (SD 0.88), respectively (overall score increase = 1.8, SD 1.21, P < 0.001). A significant increase in self-assessment was detected (P < 0.001) for all the questions. Qualitative assessments were provided by 218 participants with 225 comments, most of which were very positive. Conclusions The course with a MOOC design showed a great teaching capacity in the infectious diseases area for all the clinical situations analysed, notably in the management of severe infections with higher mortality. For future editions of this training activity, the need to include other infectious diseases, especially infections in primary care, was highlighted. Introduction Antimicrobial resistance constitutes an increasing threat to global public health, which has been recently described by WHO as a global crisis.1 The appropriate use of antimicrobial agents is essential in preventing the development and spread of resistance,2 but requires the development of continuous specific training for health professionals.3 E-learning methodology has proved to be a very useful teaching tool in the professional field in terms of its effectiveness, cost-effectiveness and interactivity,4 and it could play a significant role in increasing awareness and improving antimicrobial prescription.5 Massive online open courses (MOOCs) are a recent popular trend in e-learning methodology and have the potential to provide continuing professional development opportunities to healthcare professionals.6 A monitoring and evaluation process is necessary to determine whether the teaching methodology used achieves the objectives of the activity.7 Antimicrobial stewardship programmes are not an exception. One of the most commonly used forms of assessment are formative tests carried out after the activity and based on multiple-choice questions focusing on aspects of decision making.8 Also, pre- and post-intervention tests enable participants to obtain further feedback on their behaviour and focus their learning on certain aspects of the course for a more in-depth uptake of the taught content.9 Additionally, perceived experience as well as favourable or unfavourable issues not previously identified can be obtained through narrative feedback.10 The main objective of this study was to evaluate the impact of a course with an e-learning (MOOC) design on the baseline knowledge of the participants about the appropriate use of antimicrobial agents. The secondary objectives were to determine the specific areas of study in which better learning outcomes were achieved and to identify weak points to improve future editions of the course. Methods Methodology of the training course This was a training course with an e-learning (MOOC) design performed at a national level by and for physicians and hospital pharmacists on the prescription of antimicrobials in the hospital setting, entitled ‘Workshop to improve the use of antimicrobials in major syndromes of serious infectious diseases’. Its main objective was to improve knowledge on the appropriate use of antimicrobials for the main clinical syndromes of infectious diseases. The course was delivered in Spanish, lasted 4 months and access was free for all interested health professionals. The characteristics and detailed methodology are available at http://www2.iavante.es/es/detalle-curso/2289. The course was promoted in the context of the Spanish Institutional Programme for the Prevention and Control of Healthcare Associated Infections and Appropriate Use of Antimicrobials (known by its Spanish acronym PIRASOA) and supported by the Foundation for Progress and Health-IAVANTE Line. Study design This was a before-and-after study of a course aimed at training in infectious diseases. We designed a questionnaire with 30 questions related to the management of infectious diseases in different clinical situations (2 questions for each of the 15 topics covered). Participants had to answer the questions based on their competencies, abilities and preparedness to approach each situation. Each question was rated using a Likert scale from 1 to 10, where a score of 1 meant bad, minimum or nothing and 10 referred to excellent, maximum or all. In addition, a satisfaction survey including an open response section offered participants the possibility of giving a qualitative evaluation of the teaching activity. The questionnaire was provided online to all enrolled participants before and after the course. Completion was voluntary and the questions were addressed through self-assessment of their competence and decision-making capacity in the different clinical situations (the post-test was completed 4 months after the pre-test). We considered the questionnaires of all the participants who had completed both the initial and the final test. Variables For every question asked, we analysed the scores of the participants at the beginning and at the end of the course and the resulting progress. We reviewed the items showing more notable progress and the aspects with higher final score. Finally, a descriptive analysis of the qualitative evaluation of the participants was performed. Statistical analysis Frequency measures were used for the analysis of qualitative variables. For quantitative variables, data were presented as mean value and standard deviation. For the comparative analysis between pre- and post-tests, we used a Student’s t-test for paired samples or independent samples, as appropriate, and the Kolmogorov–Smirnov test for the analysis of normality. The threshold for statistical significance was established at a P value of <0.05 (P values reported have not been adjusted for multiple comparisons). This analysis was carried out with the IBM-SPSS Statistics V24 software. Ethics The study was considered to be part of the evaluation of the course, so ethics committee approval was not required, and it was conducted in compliance with the relevant legislation on data protection. Results and discussion Of the 2148 professionals who started the course (mean age 39.2 years; 63.0% women), 1632 were medical doctors, of whom 492 replied to the survey (30.1% response rate), and 387 were pharmacists, of whom 93 replied (24.1% response rate). The initial questionnaire was completed by 1226 professionals and 834 completed the final questionnaire. Of these, 606 (49.4%) completed both questionnaires and were included in the study for analysis. Not all participants completed both questionnaires because their completion was not mandatory. The characteristics of these participants are detailed in Table 1. Table 1. Baseline characteristics of participants who completed the pre- and post-questionnaires Gender, n (%)  male 212 (35.0)  female 394 (65.0) Age (years)a, mean (SD) 39.8 (8.23) Most common healthcare specialties, n (%)  family and community medicine 118 (19.5)  internal medicine 108 (17.8)  intensive care medicine 79 (13.0)  hospital and primary care pharmacy 69 (11.4)  anaesthesiology and resuscitation 39 (6.4)  clinical microbiology and parasitology 38 (6.3)  general and digestive surgery 27 (4.5)  obstetrics and gynaecology 14 (2.3)  haematology and haemotherapy 13 (2.2)  paediatrics and its specific areas 11 (1.8)  nephrology 9 (1.5)  preventive medicine and public health 8 (1.3)  nursing 8 (1.3) Gender, n (%)  male 212 (35.0)  female 394 (65.0) Age (years)a, mean (SD) 39.8 (8.23) Most common healthcare specialties, n (%)  family and community medicine 118 (19.5)  internal medicine 108 (17.8)  intensive care medicine 79 (13.0)  hospital and primary care pharmacy 69 (11.4)  anaesthesiology and resuscitation 39 (6.4)  clinical microbiology and parasitology 38 (6.3)  general and digestive surgery 27 (4.5)  obstetrics and gynaecology 14 (2.3)  haematology and haemotherapy 13 (2.2)  paediatrics and its specific areas 11 (1.8)  nephrology 9 (1.5)  preventive medicine and public health 8 (1.3)  nursing 8 (1.3) a 109 participants did not provide age data. Table 1. Baseline characteristics of participants who completed the pre- and post-questionnaires Gender, n (%)  male 212 (35.0)  female 394 (65.0) Age (years)a, mean (SD) 39.8 (8.23) Most common healthcare specialties, n (%)  family and community medicine 118 (19.5)  internal medicine 108 (17.8)  intensive care medicine 79 (13.0)  hospital and primary care pharmacy 69 (11.4)  anaesthesiology and resuscitation 39 (6.4)  clinical microbiology and parasitology 38 (6.3)  general and digestive surgery 27 (4.5)  obstetrics and gynaecology 14 (2.3)  haematology and haemotherapy 13 (2.2)  paediatrics and its specific areas 11 (1.8)  nephrology 9 (1.5)  preventive medicine and public health 8 (1.3)  nursing 8 (1.3) Gender, n (%)  male 212 (35.0)  female 394 (65.0) Age (years)a, mean (SD) 39.8 (8.23) Most common healthcare specialties, n (%)  family and community medicine 118 (19.5)  internal medicine 108 (17.8)  intensive care medicine 79 (13.0)  hospital and primary care pharmacy 69 (11.4)  anaesthesiology and resuscitation 39 (6.4)  clinical microbiology and parasitology 38 (6.3)  general and digestive surgery 27 (4.5)  obstetrics and gynaecology 14 (2.3)  haematology and haemotherapy 13 (2.2)  paediatrics and its specific areas 11 (1.8)  nephrology 9 (1.5)  preventive medicine and public health 8 (1.3)  nursing 8 (1.3) a 109 participants did not provide age data. The mean overall scores in the pre- and post-tests were 6.2 (SD 1.38) and 7.9 (SD 0.88), respectively, with an average increase of 1.8 (SD 1.21) (P < 0.001). We observed a greater increase in participants who were practitioners in training (2.0; SD 0.09) than in those who had finished their training (1.7; SD 1.22) (P = 0.003). Table 2 shows the results obtained for each question and the comparative analysis between the beginning and the end of the course for the 606 paired completed questionnaires. For all the questions, there was a significant increase in the self-assessment results after the course compared with the initial assessment (P < 0.001), which reflects a very positive impact on the management of serious infections, and it follows that an e-learning tool may be helpful in improving the prescription of antimicrobials.11 In fact, the score increased by at least 2 points for 11 questions and between 1 and 2 points for 16 questions. Table 2. Comparison of the results of the questionnaire before and after the completion of the e-learning course Question Initial answer Final answer Variation (%) Student’s t-test P mean SD mean SD Overall score for the questionnaire 6.2 1.38 7.9 0.88 29.1 −36.51 <0.001 Q1. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials worldwide? 9.1 1.22 9.4 0.94 3.2 −6.04 <0.001 Q2. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials at the national level? 9.0 1.28 9.3 0.96 2.9 −4.56 <0.001 Q3. How do you rate the response given to the problem of bacterial resistance to antimicrobials worldwide? 6.1 1.77 7.0 1.61 14.4 −12.05 <0.001 Q4. How do you rate the response given to the problem of bacterial resistance to antimicrobials at the national level? 5.9 1.80 6.9 1.62 16.9 −13.81 <0.001 Q5. How do you rate the response given to the problem of bacterial resistance to antimicrobials in Andalusia? 6.2 1.95 7.3 1.56 17.8 −14.61 <0.001 Q6. How confident do you feel when you prescribe an antimicrobial, evaluating potential side effects and drug–drug interactions? 6.3 1.63 7.5 1.28 18.1 −16.99 <0.001 Q7. In patients who require hospitalization for community-acquired pneumonia, do you know how to recognize in which situations the combined treatment of a β-lactam with macrolides or quinolones is necessary? 6.1 2.25 8.2 1.23 32.9 −23.83 <0.001 Q8. How confident do you feel when you prescribe amoxicillin to a healthy, non-smoking patient with typical community-acquired pneumonia (acute onset, cold sores and lobar condensation without associated effusion)? 6.2 2.29 8.1 1.46 30.4 −19.07 <0.001 Q9. If a patient hospitalized for community-acquired pneumonia progresses favourably with the prescribed treatment, could you identify the criteria necessary to switch the antibiotic to the oral route? 6.4 2.08 8.4 1.15 30.6 −24.90 <0.001 Q10. In patients with an infection of the skin and soft tissues, do you know the indications for empirical treatment for MRSA? 6.1 2.25 8.1 1.19 31.8 −22.87 <0.001 Q11. In a patient with a serious infection of the skin and soft tissues, do you feel prepared to recognize the diagnostic criteria of necrotizing fasciitis? 5.9 2.25 8.0 1.37 34.5 −25.29 <0.001 Q12. Do you feel well trained to evaluate the result of a culture taken from a pressure ulcer? 5.9 2.15 7.8 1.40 32.4 −23.99 <0.001 Q13. How confident are you when you evaluate an antimicrobial susceptibility test? 6.8 1.78 7.9 1.34 16.8 −17.53 <0.001 Q14. With an antimicrobial susceptibility test of an Escherichia coli isolate, do you know whether or not it is a potential strain producing ESBLs? 6.2 2.35 8.0 1.41 29.0 −21.28 <0.001 Q15. In patients with nosocomial fever, is your diagnostic and therapeutic assessment systematized? 5.9 2.15 8.0 1.33 35.5 −25.49 <0.001 Q16. How prepared do you feel to start the diagnostic workup and therapeutic care of a patient with septic shock? 6.4 2.24 8.2 1.42 28.4 −24.74 <0.001 Q17. Are you trained to establish the diagnostic value of a positive urine culture in a catheterized patient with no focal nosocomial fever? 6.2 1.99 8.1 1.25 29.0 −24.52 <0.001 Q18. Do you know the criteria for monitoring plasma levels of vancomycin? 5.1 2.59 7.8 1.59 52.1 −28.44 <0.001 Q19. How confident do you feel when recommending the duration of antibiotic treatment for a patient with complicated intra-abdominal infection? 5.5 2.13 7.7 1.34 39.7 −27.49 <0.001 Q20. How do you rate your level of training to assist a patient with febrile neutropenia after chemotherapy for lung cancer? 5.0 2.38 7.5 1.53 48.3 −27.77 <0.001 Q21. Do you feel confident to recognize the criteria of empirical antifungal treatment in patients with febrile neutropenia after chemotherapy? 4.8 2.20 7.6 1.41 56.4 −31.76 <0.001 Q22. For a patient with suspected ventilator-associated pneumonia, how confident do you feel to evaluate the diagnostic criteria? 5.4 2.36 7.7 1.49 43.5 −27.10 <0.001 Q23. For the same patient, how confident do you feel to establish the appropriate empirical treatment? 5.5 2.37 7.8 1.39 41.1 −26.43 <0.001 Q24. How confident do you feel for a patient with S. aureus bacteraemia? 6.3 2.07 8.1 1.18 28.2 −23.94 <0.001 Q25. Regarding treatment of ESBL-producing Enterobacteriaceae infections, do you feel trained enough to decide when the treatment of choice is a carbapenem and when it is not? 5.6 2.32 8.0 1.27 41.9 −27.88 <0.001 Q26. In a patient with candidaemia, do you feel confident enough to decide when treatment with fluconazole is indicated or when it is not? 5.4 2.25 8.0 1.29 48.0 −29.77 <0.001 Q27. How confident do you feel choosing empirical antimicrobial treatment for a patient with a serious infection? 6.2 1.98 8.0 1.13 30.7 −25.86 <0.001 Q28. And targeted antimicrobial treatment? 6.4 2.04 8.2 1.17 29.1 −24.03 <0.001 Q29. How confident do you feel to decide when to switch the antimicrobial treatment from the intravenous to the oral route in general? 6.3 1.99 8.2 1.09 29.0 −25.57 <0.001 Q30. How confident do you feel to decide when to stop the antimicrobial treatment? 6.3 1.79 8.0 1.09 26.6 −24.05 <0.001 Question Initial answer Final answer Variation (%) Student’s t-test P mean SD mean SD Overall score for the questionnaire 6.2 1.38 7.9 0.88 29.1 −36.51 <0.001 Q1. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials worldwide? 9.1 1.22 9.4 0.94 3.2 −6.04 <0.001 Q2. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials at the national level? 9.0 1.28 9.3 0.96 2.9 −4.56 <0.001 Q3. How do you rate the response given to the problem of bacterial resistance to antimicrobials worldwide? 6.1 1.77 7.0 1.61 14.4 −12.05 <0.001 Q4. How do you rate the response given to the problem of bacterial resistance to antimicrobials at the national level? 5.9 1.80 6.9 1.62 16.9 −13.81 <0.001 Q5. How do you rate the response given to the problem of bacterial resistance to antimicrobials in Andalusia? 6.2 1.95 7.3 1.56 17.8 −14.61 <0.001 Q6. How confident do you feel when you prescribe an antimicrobial, evaluating potential side effects and drug–drug interactions? 6.3 1.63 7.5 1.28 18.1 −16.99 <0.001 Q7. In patients who require hospitalization for community-acquired pneumonia, do you know how to recognize in which situations the combined treatment of a β-lactam with macrolides or quinolones is necessary? 6.1 2.25 8.2 1.23 32.9 −23.83 <0.001 Q8. How confident do you feel when you prescribe amoxicillin to a healthy, non-smoking patient with typical community-acquired pneumonia (acute onset, cold sores and lobar condensation without associated effusion)? 6.2 2.29 8.1 1.46 30.4 −19.07 <0.001 Q9. If a patient hospitalized for community-acquired pneumonia progresses favourably with the prescribed treatment, could you identify the criteria necessary to switch the antibiotic to the oral route? 6.4 2.08 8.4 1.15 30.6 −24.90 <0.001 Q10. In patients with an infection of the skin and soft tissues, do you know the indications for empirical treatment for MRSA? 6.1 2.25 8.1 1.19 31.8 −22.87 <0.001 Q11. In a patient with a serious infection of the skin and soft tissues, do you feel prepared to recognize the diagnostic criteria of necrotizing fasciitis? 5.9 2.25 8.0 1.37 34.5 −25.29 <0.001 Q12. Do you feel well trained to evaluate the result of a culture taken from a pressure ulcer? 5.9 2.15 7.8 1.40 32.4 −23.99 <0.001 Q13. How confident are you when you evaluate an antimicrobial susceptibility test? 6.8 1.78 7.9 1.34 16.8 −17.53 <0.001 Q14. With an antimicrobial susceptibility test of an Escherichia coli isolate, do you know whether or not it is a potential strain producing ESBLs? 6.2 2.35 8.0 1.41 29.0 −21.28 <0.001 Q15. In patients with nosocomial fever, is your diagnostic and therapeutic assessment systematized? 5.9 2.15 8.0 1.33 35.5 −25.49 <0.001 Q16. How prepared do you feel to start the diagnostic workup and therapeutic care of a patient with septic shock? 6.4 2.24 8.2 1.42 28.4 −24.74 <0.001 Q17. Are you trained to establish the diagnostic value of a positive urine culture in a catheterized patient with no focal nosocomial fever? 6.2 1.99 8.1 1.25 29.0 −24.52 <0.001 Q18. Do you know the criteria for monitoring plasma levels of vancomycin? 5.1 2.59 7.8 1.59 52.1 −28.44 <0.001 Q19. How confident do you feel when recommending the duration of antibiotic treatment for a patient with complicated intra-abdominal infection? 5.5 2.13 7.7 1.34 39.7 −27.49 <0.001 Q20. How do you rate your level of training to assist a patient with febrile neutropenia after chemotherapy for lung cancer? 5.0 2.38 7.5 1.53 48.3 −27.77 <0.001 Q21. Do you feel confident to recognize the criteria of empirical antifungal treatment in patients with febrile neutropenia after chemotherapy? 4.8 2.20 7.6 1.41 56.4 −31.76 <0.001 Q22. For a patient with suspected ventilator-associated pneumonia, how confident do you feel to evaluate the diagnostic criteria? 5.4 2.36 7.7 1.49 43.5 −27.10 <0.001 Q23. For the same patient, how confident do you feel to establish the appropriate empirical treatment? 5.5 2.37 7.8 1.39 41.1 −26.43 <0.001 Q24. How confident do you feel for a patient with S. aureus bacteraemia? 6.3 2.07 8.1 1.18 28.2 −23.94 <0.001 Q25. Regarding treatment of ESBL-producing Enterobacteriaceae infections, do you feel trained enough to decide when the treatment of choice is a carbapenem and when it is not? 5.6 2.32 8.0 1.27 41.9 −27.88 <0.001 Q26. In a patient with candidaemia, do you feel confident enough to decide when treatment with fluconazole is indicated or when it is not? 5.4 2.25 8.0 1.29 48.0 −29.77 <0.001 Q27. How confident do you feel choosing empirical antimicrobial treatment for a patient with a serious infection? 6.2 1.98 8.0 1.13 30.7 −25.86 <0.001 Q28. And targeted antimicrobial treatment? 6.4 2.04 8.2 1.17 29.1 −24.03 <0.001 Q29. How confident do you feel to decide when to switch the antimicrobial treatment from the intravenous to the oral route in general? 6.3 1.99 8.2 1.09 29.0 −25.57 <0.001 Q30. How confident do you feel to decide when to stop the antimicrobial treatment? 6.3 1.79 8.0 1.09 26.6 −24.05 <0.001 Table 2. Comparison of the results of the questionnaire before and after the completion of the e-learning course Question Initial answer Final answer Variation (%) Student’s t-test P mean SD mean SD Overall score for the questionnaire 6.2 1.38 7.9 0.88 29.1 −36.51 <0.001 Q1. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials worldwide? 9.1 1.22 9.4 0.94 3.2 −6.04 <0.001 Q2. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials at the national level? 9.0 1.28 9.3 0.96 2.9 −4.56 <0.001 Q3. How do you rate the response given to the problem of bacterial resistance to antimicrobials worldwide? 6.1 1.77 7.0 1.61 14.4 −12.05 <0.001 Q4. How do you rate the response given to the problem of bacterial resistance to antimicrobials at the national level? 5.9 1.80 6.9 1.62 16.9 −13.81 <0.001 Q5. How do you rate the response given to the problem of bacterial resistance to antimicrobials in Andalusia? 6.2 1.95 7.3 1.56 17.8 −14.61 <0.001 Q6. How confident do you feel when you prescribe an antimicrobial, evaluating potential side effects and drug–drug interactions? 6.3 1.63 7.5 1.28 18.1 −16.99 <0.001 Q7. In patients who require hospitalization for community-acquired pneumonia, do you know how to recognize in which situations the combined treatment of a β-lactam with macrolides or quinolones is necessary? 6.1 2.25 8.2 1.23 32.9 −23.83 <0.001 Q8. How confident do you feel when you prescribe amoxicillin to a healthy, non-smoking patient with typical community-acquired pneumonia (acute onset, cold sores and lobar condensation without associated effusion)? 6.2 2.29 8.1 1.46 30.4 −19.07 <0.001 Q9. If a patient hospitalized for community-acquired pneumonia progresses favourably with the prescribed treatment, could you identify the criteria necessary to switch the antibiotic to the oral route? 6.4 2.08 8.4 1.15 30.6 −24.90 <0.001 Q10. In patients with an infection of the skin and soft tissues, do you know the indications for empirical treatment for MRSA? 6.1 2.25 8.1 1.19 31.8 −22.87 <0.001 Q11. In a patient with a serious infection of the skin and soft tissues, do you feel prepared to recognize the diagnostic criteria of necrotizing fasciitis? 5.9 2.25 8.0 1.37 34.5 −25.29 <0.001 Q12. Do you feel well trained to evaluate the result of a culture taken from a pressure ulcer? 5.9 2.15 7.8 1.40 32.4 −23.99 <0.001 Q13. How confident are you when you evaluate an antimicrobial susceptibility test? 6.8 1.78 7.9 1.34 16.8 −17.53 <0.001 Q14. With an antimicrobial susceptibility test of an Escherichia coli isolate, do you know whether or not it is a potential strain producing ESBLs? 6.2 2.35 8.0 1.41 29.0 −21.28 <0.001 Q15. In patients with nosocomial fever, is your diagnostic and therapeutic assessment systematized? 5.9 2.15 8.0 1.33 35.5 −25.49 <0.001 Q16. How prepared do you feel to start the diagnostic workup and therapeutic care of a patient with septic shock? 6.4 2.24 8.2 1.42 28.4 −24.74 <0.001 Q17. Are you trained to establish the diagnostic value of a positive urine culture in a catheterized patient with no focal nosocomial fever? 6.2 1.99 8.1 1.25 29.0 −24.52 <0.001 Q18. Do you know the criteria for monitoring plasma levels of vancomycin? 5.1 2.59 7.8 1.59 52.1 −28.44 <0.001 Q19. How confident do you feel when recommending the duration of antibiotic treatment for a patient with complicated intra-abdominal infection? 5.5 2.13 7.7 1.34 39.7 −27.49 <0.001 Q20. How do you rate your level of training to assist a patient with febrile neutropenia after chemotherapy for lung cancer? 5.0 2.38 7.5 1.53 48.3 −27.77 <0.001 Q21. Do you feel confident to recognize the criteria of empirical antifungal treatment in patients with febrile neutropenia after chemotherapy? 4.8 2.20 7.6 1.41 56.4 −31.76 <0.001 Q22. For a patient with suspected ventilator-associated pneumonia, how confident do you feel to evaluate the diagnostic criteria? 5.4 2.36 7.7 1.49 43.5 −27.10 <0.001 Q23. For the same patient, how confident do you feel to establish the appropriate empirical treatment? 5.5 2.37 7.8 1.39 41.1 −26.43 <0.001 Q24. How confident do you feel for a patient with S. aureus bacteraemia? 6.3 2.07 8.1 1.18 28.2 −23.94 <0.001 Q25. Regarding treatment of ESBL-producing Enterobacteriaceae infections, do you feel trained enough to decide when the treatment of choice is a carbapenem and when it is not? 5.6 2.32 8.0 1.27 41.9 −27.88 <0.001 Q26. In a patient with candidaemia, do you feel confident enough to decide when treatment with fluconazole is indicated or when it is not? 5.4 2.25 8.0 1.29 48.0 −29.77 <0.001 Q27. How confident do you feel choosing empirical antimicrobial treatment for a patient with a serious infection? 6.2 1.98 8.0 1.13 30.7 −25.86 <0.001 Q28. And targeted antimicrobial treatment? 6.4 2.04 8.2 1.17 29.1 −24.03 <0.001 Q29. How confident do you feel to decide when to switch the antimicrobial treatment from the intravenous to the oral route in general? 6.3 1.99 8.2 1.09 29.0 −25.57 <0.001 Q30. How confident do you feel to decide when to stop the antimicrobial treatment? 6.3 1.79 8.0 1.09 26.6 −24.05 <0.001 Question Initial answer Final answer Variation (%) Student’s t-test P mean SD mean SD Overall score for the questionnaire 6.2 1.38 7.9 0.88 29.1 −36.51 <0.001 Q1. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials worldwide? 9.1 1.22 9.4 0.94 3.2 −6.04 <0.001 Q2. What is your opinion regarding the importance of the problem of bacterial resistance to antimicrobials at the national level? 9.0 1.28 9.3 0.96 2.9 −4.56 <0.001 Q3. How do you rate the response given to the problem of bacterial resistance to antimicrobials worldwide? 6.1 1.77 7.0 1.61 14.4 −12.05 <0.001 Q4. How do you rate the response given to the problem of bacterial resistance to antimicrobials at the national level? 5.9 1.80 6.9 1.62 16.9 −13.81 <0.001 Q5. How do you rate the response given to the problem of bacterial resistance to antimicrobials in Andalusia? 6.2 1.95 7.3 1.56 17.8 −14.61 <0.001 Q6. How confident do you feel when you prescribe an antimicrobial, evaluating potential side effects and drug–drug interactions? 6.3 1.63 7.5 1.28 18.1 −16.99 <0.001 Q7. In patients who require hospitalization for community-acquired pneumonia, do you know how to recognize in which situations the combined treatment of a β-lactam with macrolides or quinolones is necessary? 6.1 2.25 8.2 1.23 32.9 −23.83 <0.001 Q8. How confident do you feel when you prescribe amoxicillin to a healthy, non-smoking patient with typical community-acquired pneumonia (acute onset, cold sores and lobar condensation without associated effusion)? 6.2 2.29 8.1 1.46 30.4 −19.07 <0.001 Q9. If a patient hospitalized for community-acquired pneumonia progresses favourably with the prescribed treatment, could you identify the criteria necessary to switch the antibiotic to the oral route? 6.4 2.08 8.4 1.15 30.6 −24.90 <0.001 Q10. In patients with an infection of the skin and soft tissues, do you know the indications for empirical treatment for MRSA? 6.1 2.25 8.1 1.19 31.8 −22.87 <0.001 Q11. In a patient with a serious infection of the skin and soft tissues, do you feel prepared to recognize the diagnostic criteria of necrotizing fasciitis? 5.9 2.25 8.0 1.37 34.5 −25.29 <0.001 Q12. Do you feel well trained to evaluate the result of a culture taken from a pressure ulcer? 5.9 2.15 7.8 1.40 32.4 −23.99 <0.001 Q13. How confident are you when you evaluate an antimicrobial susceptibility test? 6.8 1.78 7.9 1.34 16.8 −17.53 <0.001 Q14. With an antimicrobial susceptibility test of an Escherichia coli isolate, do you know whether or not it is a potential strain producing ESBLs? 6.2 2.35 8.0 1.41 29.0 −21.28 <0.001 Q15. In patients with nosocomial fever, is your diagnostic and therapeutic assessment systematized? 5.9 2.15 8.0 1.33 35.5 −25.49 <0.001 Q16. How prepared do you feel to start the diagnostic workup and therapeutic care of a patient with septic shock? 6.4 2.24 8.2 1.42 28.4 −24.74 <0.001 Q17. Are you trained to establish the diagnostic value of a positive urine culture in a catheterized patient with no focal nosocomial fever? 6.2 1.99 8.1 1.25 29.0 −24.52 <0.001 Q18. Do you know the criteria for monitoring plasma levels of vancomycin? 5.1 2.59 7.8 1.59 52.1 −28.44 <0.001 Q19. How confident do you feel when recommending the duration of antibiotic treatment for a patient with complicated intra-abdominal infection? 5.5 2.13 7.7 1.34 39.7 −27.49 <0.001 Q20. How do you rate your level of training to assist a patient with febrile neutropenia after chemotherapy for lung cancer? 5.0 2.38 7.5 1.53 48.3 −27.77 <0.001 Q21. Do you feel confident to recognize the criteria of empirical antifungal treatment in patients with febrile neutropenia after chemotherapy? 4.8 2.20 7.6 1.41 56.4 −31.76 <0.001 Q22. For a patient with suspected ventilator-associated pneumonia, how confident do you feel to evaluate the diagnostic criteria? 5.4 2.36 7.7 1.49 43.5 −27.10 <0.001 Q23. For the same patient, how confident do you feel to establish the appropriate empirical treatment? 5.5 2.37 7.8 1.39 41.1 −26.43 <0.001 Q24. How confident do you feel for a patient with S. aureus bacteraemia? 6.3 2.07 8.1 1.18 28.2 −23.94 <0.001 Q25. Regarding treatment of ESBL-producing Enterobacteriaceae infections, do you feel trained enough to decide when the treatment of choice is a carbapenem and when it is not? 5.6 2.32 8.0 1.27 41.9 −27.88 <0.001 Q26. In a patient with candidaemia, do you feel confident enough to decide when treatment with fluconazole is indicated or when it is not? 5.4 2.25 8.0 1.29 48.0 −29.77 <0.001 Q27. How confident do you feel choosing empirical antimicrobial treatment for a patient with a serious infection? 6.2 1.98 8.0 1.13 30.7 −25.86 <0.001 Q28. And targeted antimicrobial treatment? 6.4 2.04 8.2 1.17 29.1 −24.03 <0.001 Q29. How confident do you feel to decide when to switch the antimicrobial treatment from the intravenous to the oral route in general? 6.3 1.99 8.2 1.09 29.0 −25.57 <0.001 Q30. How confident do you feel to decide when to stop the antimicrobial treatment? 6.3 1.79 8.0 1.09 26.6 −24.05 <0.001 Some areas of study had a greater improvement (>40%), such as knowledge of criteria for monitoring plasma levels of vancomycin (52.1%), which should be considered a strategic point, because the use of suboptimal dosing regimens of antibiotics can substantially contribute to the development of bacterial resistance.12 Other areas were antifungal treatment of post-chemotherapy febrile neutropenia, treatment of febrile neutropenia in lung cancer patients, treatment of candidaemia and ESBL-producing Enterobacteriaceae infections, and training in criteria for the diagnosis and empirical treatment of ventilator-associated pneumonia (56.4%, 48.3%, 48.0%, 41.9%, 43.5% and 41.1%, respectively). These patients have an increased risk of mortality and could therefore benefit more from adequate management with antimicrobial treatment.13–16 The items with the best final score (>8 points) were: evaluation of the importance of bacterial resistance at global and national levels; attitude towards sequential therapy; combined therapy for inpatients and treatment with amoxicillin in community-acquired pneumonia for outpatients; comprehensive treatment of septic shock; sense of confidence for switching from intravenous to oral treatment; management of Staphylococcus aureus bacteraemia and of MRSA skin and soft tissue infections; and interpretation of a positive urine culture in catheterized patients. A qualitative assessment after the course was provided by 218 participants, with 225 comments (Table S1, available as Supplementary data at JAC Online). The most common ones were very favourable and highlight the positive aspects of the course (teaching capacity and methodology used). This reflects the importance given by health professionals to e-learning courses for their professional development, particularly in the management and control of infectious diseases.17,18 Despite this, some comments showed aspects that could be changed, such as a more structured theoretical content and a summary with key ideas or technical problems with the platform. These largely coincide with published studies that compare e-learning and traditional methods.19 Furthermore, other comments suggest expansion of the areas of knowledge to other ones, such as primary care, because the course was aimed at addressing serious infections in hospital settings. However, most participants were specialists in family and community medicine, and this aspect may well have confused the picture, but it shows the interest of these professionals in further training in infectious diseases. General practitioners were invited to participate in the course because it was of the open access type, and in Andalusia many general practitioners work in the emergency departments of hospitals and the course covered issues of interest to them, although it could be a limitation of the study. As limitations of the study, we should mention that only about half of the participants completed the pre- and post-questionnaires, so they may have been completed only by better trained participants. Additionally, the inherent limitations of pre-/post-intervention studies, such as history, maturation, test effects and the regression to the mean effect, must be considered,20 although the short period of time that elapsed between the pre- and post-tests may have minimized these effects. Finally, the fact that scores were based on self-assessment may have led to greater before–after differences. For future activities, this subjectivity should be avoided by requesting participants to complete a baseline knowledge test. Nevertheless, the self-assessments performed provided valuable information on the perception of health professionals of their own knowledge, clinical decision-making capacity and self-confidence. Conclusions Our course with an e-learning (MOOC) design has shown considerable teaching capacity in the infectious diseases area for all the clinical situations analysed, with a greater scope for improvement detected in pharmacokinetic monitoring of antibiotics and management of post-chemotherapy febrile neutropenia, candidaemia and ventilator-associated pneumonia. The degree of learning after the course was high, most notably in knowledge regarding community-acquired pneumonia, septic shock, S. aureus infections and switching to oral antibiotics. For future editions of this training activity, the need to include other infectious diseases, especially infections in primary care, was highlighted. Acknowledgements We thank the teaching team of the course: Manuela Aguilar Guisado, Rocío Álvarez Marín, Juan José Castón Osorio, Elisa Cordero Matía, Juan Enrique Corzo Delgado, Alfonso del Arco Jiménez, Ángel Estella García, José Garnacho Montero, María Victoria Gil Navarro, Belén Gutiérrez Gutiérrez, Carmen Hidalgo Tenorio, Patricia Jiménez Aguilar, José Antonio Lepe Jiménez, Luis Eduardo López Cortés, Andrés Martín Aspas, José Molina Gil-Bermejo, Clara Natera Kindelan, Enrique Nuño Álvarez, Carmen María Pinto Nieto, José María Reguera Iglesias, Pilar Retamar Gentil, María Dolores Rojo Martín, Alberto Romero Palacios, Rafael Sierra Camerino, Lucía Valiente de Santis and Salvador Vergara López. Funding The e-learning course was supported by Merck Sharp & Dohme Corp. through an unrestricted grant. Transparency declarations None to declare. Supplementary data Table S1 is available as Supplementary data at JAC Online. References 1 WHO . Antimicrobial Resistance. Fact Sheet. http://www.who.int/mediacentre/factsheets/fs194/en/. 2 Zilberberg MD , Nathanson BH , Sulham K et al. Carbapenem resistance, inappropriate empiric treatment and outcomes among patients hospitalized with Enterobacteriaceae urinary tract infection, pneumonia and sepsis . BMC Infect Dis 2017 ; 17 : 279 . Google Scholar CrossRef Search ADS PubMed 3 Gutiérrez F , Masiá M. Teaching infectious diseases in the medical degree within the European higher education area . Enferm Infecc Microbiol Clin 2016 ; 34 : 372 – 83 . Google Scholar CrossRef Search ADS PubMed 4 Sinclair PM , Kable A , Levett-Jones T et al. The effectiveness of Internet-based e-learning on clinician behaviour and patient outcomes: a systematic review . Int J Nurs Stud 2016 ; 57 : 70 – 81 . Google Scholar CrossRef Search ADS PubMed 5 Rocha-Pereira N , Lafferty N , Nathwani D. Educating healthcare professionals in antimicrobial stewardship: can online-learning solutions help? J Antimicrob Chemother 2015 ; 70 : 3175 – 7 . Google Scholar CrossRef Search ADS PubMed 6 Liyanagunawardena TR , Williams SA. Massive open online courses on health and medicine: review . J Med Internet Res 2014 ; 16 : e191. Google Scholar CrossRef Search ADS PubMed 7 Moro J , Tejedor JM , Zancajo JL. La calidad de la formación especializada a través de la encuesta de opinión de residentes . Rev Calidad Asistencial 2006 ; 21 : 82 – 6 . Google Scholar CrossRef Search ADS 8 Nicol DJ , Macfarlane-Dick D. Formative assessment and self-regulated learning: a model and seven principles of good feedback practice . Stud High Educ 2006 ; 31 : 199 – 218 . Google Scholar CrossRef Search ADS 9 Luetsch K , Burrows J. Certainty rating in pre-and post-tests of study modules in an online clinical pharmacy course—a pilot study to evaluate teaching and learning . BMC Med Educ 2016 ; 16 : 267. Google Scholar CrossRef Search ADS PubMed 10 Cook DA , Ellaway RH. Evaluating technology-enhanced learning: a comprehensive framework . Med Teach 2015 ; 37 : 961 – 70 . Google Scholar CrossRef Search ADS PubMed 11 van Buul LW , Sikkens JJ , van Agtmael MA et al. Participatory action research in antimicrobial stewardship: a novel approach to improving antimicrobial prescribing in hospitals and long-term care facilities . J Antimicrob Chemother 2014 ; 69 : 1734 – 41 . Google Scholar CrossRef Search ADS PubMed 12 Monogue ML , Kuti JL , Nicolau DP. Optimizing antibiotic dosing strategies for the treatment of Gram-negative infections in the era of resistance . Expert Rev Clin Pharmacol 2016 ; 9 : 459 – 76 . Google Scholar CrossRef Search ADS PubMed 13 Pagano L , Busca A , Candoni A et al. ; SEIFEM (Sorveglianza Epidemiologica Infezioni Fungine nelle Emopatie Maligne) Group . Risk stratification for invasive fungal infections in patients with hematological malignancies: SEIFEM recommendations . Blood Rev 2017 ; 31 : 17 – 29 . Google Scholar CrossRef Search ADS PubMed 14 Freifeld AG , Bow EJ , Sepkowitz KA et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America . Clin Infect Dis 2011 ; 52 : e56 – 93 . Google Scholar CrossRef Search ADS PubMed 15 Leavitt A , Chmelnitsky I , Colodner R et al. Ertapenem resistance among extended-spectrum-β-lactamase-producing Klebsiella pneumoniae isolates . J Clin Microbiol 2009 ; 47 : 969 – 74 . Google Scholar CrossRef Search ADS PubMed 16 Fujitani S , Sun H-Y , Yu VL et al. Pneumonia due to Pseudomonas aeruginosa: part I: epidemiology, clinical diagnosis, and source . Chest 2011 ; 139 : 909 – 19 . Google Scholar CrossRef Search ADS PubMed 17 Carter RR , Sun J , Jump RL. A survey and analysis of the American public’s perceptions and knowledge about antibiotic resistance . Open Forum Infect Dis 2016 ; 3 : ofw112. Google Scholar CrossRef Search ADS PubMed 18 Atack L , Luke R. Improving infection control competency through an online learning course . Nurs Times 2009 ; 105 : 30 – 2 . Google Scholar PubMed 19 Cook DA , Steinert Y. Online learning for faculty development: a review of the literature . Med Teach 2013 ; 35 : 930 – 7 . Google Scholar CrossRef Search ADS PubMed 20 Marsden E , Torgerson CJ. Single group, pre- and post-test research designs: some methodological concerns . Oxford Rev Educ 2012 ; 38 : 583 – 616 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Antimicrobial ChemotherapyOxford University Press

Published: Apr 25, 2018

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