#86: A Quality Improvement Study Using Blended Learning as Part of Antimicrobial Stewardship Program (ASP) to Improve Ampicillin Sulbactam Prescription in Pediatric Hospital in Bogotá, Colombia
Authors: Riaño-Galvis O E , Cerinza-Villanueva D P , Gutierrez-Tobar I F , Londoño-Ruiz J P , Marin-Castro A S , Bermudez-Bohorquez N 
Published: March 2021

Abstract

Background
Antimicrobial agents are the second most common prescribed drugs in hospital settings. Antibiotic resistance is a major public health problem. Some studies have found that 20–50% of antibiotics prescriptions are inadequate or not necessary. Ampicillin-sulbactam is the second most common prescribed antibiotic in inpatients children in our hospital. We designed a quality improvement study to improve ampicillin–sulbactam prescription in a third-level children hospital in Bogotá, Colombia.

Methods
A before and after study was designed. We obtained days of treatment (DOT) for ampicillin–sulbactam in last 3 years (2017, 2018, and 2019). In October of 2019, we included ampicillin–sulbactam as a targeted antibiotic in our ASP. We focus the efforts in 2 principals’ strategies: Educative strategy and audit and feedback strategy. Educative strategy included a blended learning intervention and audit and feedback strategy included surveillance of prescriptions in real time to evaluate local guidelines adherence with feedback to prescribers. We designed a form to collect and analyze data with Epi Info®.

Results
In 2 months of surveillance, we reviewed and analyzed 67 prescriptions. Median age of patients was 2 years (0.75–7.5 years). The main diagnosis was pulmonary infection in 70.1% (multilobar pneumonia 13 patients, lobar pneumonia 8 patients and bacterial co-infected bronchiolitis in 5 patients). Three prescriptions were based in etiologic isolation while 64 was an empiric formulation. Only 24 prescriptions (35%) were considered adequate according to local guidelines. The principal’s reasons of inadequate prescription were the possibility to use a narrow-spectrum antibiotic (58.1%) and error about inadequate infectious disease diagnosis (39.5%). In 43 of inadequate prescriptions, ASP changed the antibiotic in 24 patients, stopped all antimicrobial therapy in 14, and changed to oral rout in other 4. In the patient’s follow-up, all have an adequate clinical course, and only 3 required to restart antimicrobial therapy. There were no deaths related to infectious diseases. In the educational strategy we trained 34 staff members (32.9%) with lectures and 72 staff members (69.2%) using virtual strategy. We use a pre- and post-test evaluations, with a score improvement in 33% after the educational strategy. Finally, we compared DOT of ampicillin-sulbactam for the last 3 years and we found a reduction of 65% in prescription between October 2017 and October 2019 (Figure 1).

Conclusion
This is the first quality improvement study with an ASP targeting a narrow-spectrum antibiotic in children. Many ASP focused their efforts only in broad-spectrum antibiotics, but few studies have been published in narrow-spectrum antibiotics. The implementation of an ASP to improve prescription of ampicillin–sulbactam had a dramatic impact in reduction of prescriptions in our settings. The educational strategy using blended learning strategy is especially valuable in hospital education because virtual learning has a great flexibility and if facilitated by the high availability of mobile devices.