Training is an important key to improve the rationale use of antibiotics and help control antibiotic resistance. This study shows, in medical students, the high perception about the problem of antibiotic resistance and the rationale uses of antibiotics. We also demonstrated the impact of training in infectious diseases in the knowledge of antibiotic resistance and the need for continuous medical education to avoid the loss of the formative impact.
A global participation of 76.4% indicates a high participation rate and a great interest in antimicrobial resistance. The perception and assessment of the problem is high since the first grades, but after training in infectious diseases, 99.3% of medical students consider that antibiotic resistance currently represents a Public Health problem and 98.4% think the problem of antibiotic resistance should be considered before starting an antibiotic prescription.
Training and education of future prescribers is one of the main interventions to improve the rationale use of antibiotics. Training should begin in medical schools and continue throughout the professional life. Studies have shown that doctors with limited knowledge about antibiotics tend to unnecessarily prescribe more potent antibiotics and with a wider spectrum of action [9, 10].
In the study by Hecker et al, they observed that the most frequent reasons to inappropriate antibiotic therapy are the duration of therapy longer than necessary, treatment of noninfectious or nonbacterial syndromes, treatment of colonization or contamination and redundant antimicrobial coverage [9].
In the first situation, even 90.5% of students in group 3 consider that there is no need to carry out long-term antibiotic, but in the training questions section we found that only 14.3% of the students of this group hit the appropriate duration of antibiotic therapy. Comparison of the findings with those of other studies confirms a lack of confidence of medical students identifying the correct duration of treatment or oral treatment alternatives [7]. The second most frequent cause of inappropriate antibiotic use was the treatment of patients with noninfectious or a non-bacterial syndromes [11].
Regarding the duration of treatment, most of the students with complete training considered prolonged therapy unnecessary compared to 76.5% of the students without training (p<0.001). This finding is relevant because it shows that future prescribers are more likely to modify their treatment approaches during their formative years. Modifying these attitudes in infectious diseases physicians is often harder, despite clinical trials showing that the result does not differ. Recognizing the undergraduate training as the imprinting phase to instill the concept of shorter-is-better, could avoid future adverse effects, resistance to antibiotics, and reduce cost.
In our study, we observed a significant improvement in the ability of medical students to make an accurate diagnosis of infection after infectious diseases training. Misdiagnosis has been found to be a leading cause of unnecessary treatments [12]. In the questions to evaluate the value of microbiological data, the impact of training is also relevant, although it has already begun after training in clinical microbiology (group 2). Finally, related the impact of redundant antimicrobial coverage in inappropriate antibiotic use, we do not observe a significant improvement after training in infectious diseases. As in other points such as the choice of an empirical antibiotic treatment, it is related to the high perception of students of these problems from the first years.
After training in infectious diseases, knowledge of the stewardship antibiotic program increases from 9.3% in medical students in group 1 to 52.2% in group 3. This situation contributes to a better perception of the problem of antibiotic resistance and a better and rationale use of them. However, these results represent another important point of improvement in medical student to accept the benefit of these programs. It is likely that improving the training at these points from medical schools can improve future prescribing [13].
In the second block, we also observed an improvement in results after training in infectious diseases. The average of correct answers was 1.6 in group 1, 1.93 in group 2 and 3.14 in group 3, with statistically significant differences (p<0.001). The average percentage of correct answers in students after training in infectious diseases was 52.7%. As in the work of Hecker et al, in the hospital setting up to 50% of the prescriptions are inappropriate [9]. The impact of training in infectious diseases in our study was higher than that described by other authors [6, 7].
A final point is the partial loss of the formative impact over time. In our study we observed a median 9.7% decrease in correct answers (difference between subgroup 3A and subgroup 3B).
Training in infectious diseases in a medical school is an effective strategy to improve the use of antibiotics. However, as in other published studies, we observed a remarkable margin for improvement in training in infectious diseases and a rapid loss of knowledge one year after training [14]. Enhancing the training in the rationale use of antibiotics in medical schools, should represent an important stimulus for teachers to improve results and probably will have to go through a change in the teaching methodology [15].
We must adopt pedagogical measures to stabilize the knowledge learned in infectious diseases in medical schools and, through continuous medical education, establishing the training of future prescribers. According to pedagogical studies, learning consists in reconstructing knowledge [16]. That is, the new knowledge is built on the existing one. Therefore, to add knowledge, you must have a solid foundation that allows the student to deepen certain aspects [15]. In this way, Spanish students consider that the discussion of clinical cases and rotations in infectious diseases are the most useful among their medical degree [17].
Several studies have investigated how to prevent the decline in the knowledge of students and professionals and others forms of learning such as role-playing, teaching in workshops or e-learning can also be implemented and have shown that they can improve students' knowledge [15, 16].
The opinions-responses expressed by doctors and medical students should help us to propose changes in teaching planning in undergraduate and postgraduate training.
Other measure that could be assumed to improve the safety and rationale use of antibiotics is the “P-drugs method”. This method recommended by the WHO [18] and successfully applied in several countries has shown good acceptance among students and favors an adequate use of antibiotics [19, 20].
Some limitations of this study, despite the high participation, it has been carried out in a single center, participation in the survey depends on class attendance and an unvalidated questionnaire has been used whose degree of discrimination of certain questions is difficult to assess.
In conclusion, in this study training of medical students improved the recognition of antimicrobial resistance as an important problem. But this knowledge decreased after a year of education.