Impact of a virtual learning environment on the conscious prescription of antibiotics among Colombian dentists.

Appropriate antibiotic prescription contributes to reducing bacterial resistance; therefore, it is critical to provide training regarding this challenge. The objective of this study was to develop a virtual learning environment for antibiotic prescription and to determine its impact on dentists' awareness, attitudes, and intention to practice. First, the learning content on multimedia resources was developed and distributed into three challenges that participants had to overcome. Then, a quasi-experimental study was performed in which the virtual learning environment was implemented on dentists from seven Colombian cities. The median of correct answers and the levels of awareness, attitudes, and intention to practice were compared before, immediately after, and 6-months post-intervention. Wilcoxon signed-rank and McNemar's tests were used to determine the differences. A total of 206 participants who finished the virtual learning environment activities exhibited a favorable and statistically significant impact on the median of correct answers of awareness (p < 0.001), attitudes (p < 0.001), and intention to practice (p = 0.042). A significant increase occurred in the number of participants with a high level of awareness (p < 0.001) and a non-significant increase in participants with high levels of attitudes (p = 0.230) and intention to practice (p = 0.286). At 6 months, the positive effect on the median of correct answers on awareness and intention to practice persisted (p < 0.001); however, this was not evident for attitudes (p = 0.105). Moreover, there was a significant decrease in the number of participants who showed low levels of awareness (p = 0.019) and a slight increase in those with high levels of the same component (p = 0.161). The use of a virtual learning environment designed for dentists contributed to a rapid improvement in awareness and intention to practice antibiotic prescription; however, their attitudes and information retention need reinforcement.

Introduction

In 2018, 700,000 deaths associated with antibiotic resistance were reported globally including common diseases such as respiratory tract, sexually transmitted, and urinary infections [1]. This number is expected to increase to 10 million deaths annually by 2050, as anticipated by the British government [2]. In 2015, the World Health Organization (WHO) published a global action plan on antimicrobial resistance aimed at inviting all healthcare sectors to contribute to the fight against this multifaceted problem that affects the entire population [3]. Subsequently, the FDI World Dental Federation, through its policy statement on antibiotic stewardship in dentistry, highlighted the critical role of dentists in combating this crisis and encouraged them to prescribe these medicaments rationally [4].

Public health measures to reduce antimicrobial resistance include optimizing antibiotic usage in all healthcare fields [5]. In dentistry, most diseases caused by oral bacteria (dental caries, gingivitis, pulpitis, and periapical, peri-implant, and chronic periodontal infections) only require local intervention; therefore, antibiotic therapy is not needed [6]. However, in some clinical conditions, an antibiotic prescription is essential as a therapeutic or prophylactic measure. In a therapeutic context, antibiotics are prescribed to patients with certain medical conditions that may affect local treatment or as adjuvant therapy after a local intervention in aggressive odontogenic infections that can be life-threatening (such as orofacial abscesses, necrotic periodontal diseases, and pericoronitis) [7]. The American Heart Association (AHA) recommends the use of antibiotics primarily in patients at increased risk of developing infective endocarditis (IE), such as those with certain heart diseases [8]. Prophylactic therapy is not recommended for patients with joint replacement, although the American Dental Association (ADA) indicates that in some cases, the orthopedic surgeon may define the antibiotic regimen [9]. Additionally, the American Association of Endodontics (AAE) suggests that in other health conditions (immunodeficiencies, diabetes, and joint infections), the dentist, physician, and patient should consider the potential risks if a dental procedure is carried out without antibiotic prophylaxis as well as those that can be derived from antibiotic therapy [10].

Studies that have assessed antimicrobial prescription patterns in dentists, through the analysis of awareness, attitudes, and intention to practice or practices, reported unnecessary prescriptions associated with the lack of clarity in antibiotic prescribing guidelines, lack of professional updates, and fear of complications after treatment [11, 12]. Awareness is defined as the conscious and personally relevant knowledge on a particular topic [13]; attitudes refer to the evaluation of objects of thought that can be observed as stable entities stored in the memory or temporary judgments constructed from information [14], and intention to practice is considered as the mental preparation of an individual before defining an action to perform [15, 16]. Together, these three components permit researchers to collect information to design and implement strategies that improve antibiotic prescription practices.

Within the global action plan on antimicrobial resistance developed by the WHO, the first strategic objective is to “improve awareness and understanding of antimicrobial resistance through effective communication, education, and training” [3]. In this regard, some studies have implemented educational interventions aimed at improving antibiotic prescription in dentistry [17], with only a few of them performing in a virtual scenario [18, 19], although it has been shown that virtual learning environments (VLEs) favor the transfer of knowledge and abilities to a limited number of participants [20]. Some environments use technology with didactic and administrative support needed for the learning process [21]. Moreover, these environments follow an academic curriculum and contain didactic resources as well as systems to track student activities, online support, and other components that seek to simulate a real academic scenario [22].

Didactic virtual resources include multimedia education that uses different tools such as videos, texts, sounds, graphs, and animation [23], presenting dynamic and interactive information that stimulates cognitive processes and facilitates learning. The above is associated with Mayer’s cognitive theory of multimedia learning, which states that course design should be aligned to the human cognitive architecture or how human beings process information [24] and comply with certain characteristics such as motivation, stimulation, and information delivery in a simple way with a linear sequence [25]. Considering that knowledge improvement of antimicrobial resistance through robust educational and awareness activities is a priority, the objective of this study was to develop a VLE for appropriate antibiotic prescription in dentistry and to determine its impact on dentists’ awareness, attitudes, and intention to practice. Our null hypothesis was that the development and implementation of a VLE on conscious antibiotic prescription in dentistry does not have a favorable impact on participants’ awareness, attitudes, and intention to practice.

Materials and methods

Study design and study population

This study was approved by the ethics subcommittee of Universidad Cooperativa de Colombia on the 18th of May 2018 (No. 015–2018). Participants provided written consent through the VLE. A quasi-experimental multicenter study with a before-and-after design and without a control group was conducted from March to May 2020 in seven Colombian cities: Barranquilla, Bogota, Cali, Cartagena, Medellin, Monteria, and Villavicencio. Dentists who had been part of our preliminary study on awareness, attitudes, and intention to practice antibiotic prescriptions [26] were invited to participate by researchers in each city. The sample size was calculated for each city, including dentists with a dentistry degree until 2016, according to the last update from the Observatorio Laboral para la Educación through a paired sample t-test (repeated measures). By accepting an alpha risk of 0.05 (5%) and a beta risk of 0.1 (10% potential) in a bilateral contrast, a total of 140 dentists were required. A 15% loss to follow-up was also estimated. At least 20 dentists per city registered at the local Health Secretary or the Sistema Integrado de Información de la Protección Social of the Ministry of Health were required.

Educational strategy

The VLE was designed in accordance with the results from our prior study [26] and was named “Conscious antibiotic prescription in dentistry.” This VLE contained dynamic and interactive multimedia learning resources and a storytelling technique with an animated character represented by a bacterium acting as a moderator, which intended to dominate the world and challenged the participant through different learning moments (Fig 1).

Fig 1

Multimedia learning resources.

Different types of learning resources were used in the virtual learning environment for conscious antibiotic prescription in dentistry. Reprinted from [VLE “Prescripción consciente de Antibióticos en odontología”] under a CC BY license, with permission from [Universidad Cooperativa de Colombia], original copyright [2020].

The Brightspace platform (Desire2Learn, Kitchener, ON, Canada) was used to implement the course; three groups were created, each supported by a collaborator that served as guidance for technical issues and an expert professor with whom the participants interacted during the two learning forums. The course comprised five sections, including three interactive learning challenges. Virtual spaces contained subjects and activities for competence accomplishment, as well as academic assessments (Table 1). The course duration was 8 weeks, with an hourly intensity of 6 h/week. Additionally, a Question & Answer webinar was presented during Challenge 2 by an expert in pharmacology.

Table 1

Subjects included in the course sections.

Sections	Lerning moment	Subjects
Introduction	Introduction	• Questionnaire regarding awareness, attitudes, and intention to practice antibiotic prescription in dentistry.• Antibiotic resistance problem.• Real situations of patients with resistant bacterial infections.
Challenge 1	To associate the antibiotic effect on pathogen bacteria and resistance mechanisms they develop.	• Nature and classification of pathogen microorganisms.• Characteristics of bacteria to generate infections.• Principles and practices on infection control.• Mechanisms of action of main antibiotics used in dentistry.• Resistance mechanisms to antimicrobials.• Knowledge of the activity spectrum of common-prescribed antibiotics in dentistry.• Pharmacokinetics and pharmacodynamics of antibiotics.• In challenge 1, the participant had to associate a type of antibiotic with a bacterial infection.
Challenge 2	To comprehend the clinical picture of patients attending a dental outpatient appointment that results in the appropriate administration of antibiotics according to clinical protocols.	• Key elements for antibiotic prescription in dentistry.• Appropriate use of antibiotics for prophylaxis therapy.• Type of infections (pathologies) that require an antibiotic prescription.• Clinical cases that may or may not require an antibiotic prescription.• Complementary tests for decision making on antibiotic prescription.• Responsibility and legal aspects for an antibiotic prescription.• Leaflet “Do You Need Antibiotics from Your Dentist?” from Centers for Disease Control and Prevention [39].• Challenge 2 contained clinical cases where the dentist had to select whether antibiotic treatment should or should not be used (feedback included).
Challenge 3	To apply microbiological and clinical foundations for appropriate antibiotic prescription according to a comprehensive health assessment.	• Guidelines and protocols for antibiotic stewardship in dentistry (American Heart Association [AHA] [13], American Association of Endodontists [AAE] [14], American Academy of Pediatric Dentistry [AAPD] [40], American Academy of Orthopedic Surgeons [AAOS]-American Dental Association [ADA]) [41].• Prevention of unnecessary administration of broad-spectrum antibiotics.• Dosage calculation of antibiotics in children.• Clinical cases for antibiotic prescription in dentistry.• Challenge 3 consisted of clinical cases where the participant had to select the best treatment (feedback included).
Course completion	Final	• Questionnaire regarding awareness, attitudes, and intention to practice antibiotic prescription in dentistry.• Satisfaction and applicability questionnaire.

Impact of the VLE on dentists

To determine the effect of the VLE on dentists, participants answered a questionnaire intended to measure their levels of awareness, attitudes, and intention to practice antibiotic prescription before, immediately after, and 6 months post-intervention. The immediate impact (“immediately after” intervention) was compared to the first measurement (“before” intervention) of the total sample of dentists who completed the course. To analyze information retention, results from dentists who answered the questionnaire at 6 months (“6 months” post-intervention) were compared to the data obtained from the same population that answered the initial questionnaire (“before” intervention). The questionnaire was previously validated through a focus group, an expert panel, a pilot test, and a survey of dentists (n = 98) to determine confidence, psychometric index, and one-dimensionality questions (biserial correlation > 0.0, discrimination index > 0, no response index = 0 − 0.15, one-dimensionality index p = 0.930, and internal consistency = 0.810) [27].

The questionnaire consisted of five sections: the first part contained general information questions such as sex, type of practice, years of practice, and specialization; the second segment comprised six questions on “awareness,” including antibiotic effectiveness, antibiotic resistance, and the association between prescription and resistance; the third section had eight questions on “attitudes,” including decision making on prescription and non-clinical factors influencing prescriptions; the fourth segment comprised 22 questions on “intention to practice” according to the AHA and ADA guidelines, and recent studies [6−8], including clinical cases in which antibiotics are prescribed, as well as the duration and frequency of prescription in the dental practice; and the fifth contained four questions on complementary information. Each question from the sections covering awareness, attitudes, and intention to practice were scored and classified according to the number of correct answers as follows: low level (awareness 0 − 3, attitudes 0 − 4, and intention to practice 0 − 9), medium level (awareness 4 − 5, attitudes 5 − 7, and intention to practice 10 − 13), and high level (awareness 6, attitudes 8, and intention to practice 14 − 22).

Course satisfaction and applicability

After the course completion, a satisfaction and applicability questionnaire was implemented within the same platform, consisting of pre-coded closed-ended questions and a five-point Likert scale ranging from strongly agree (5 points) to strongly disagree (1 point). Additionally, questions regarding whether the participant had previously attended virtual courses and the time of dedication to the current course activities were included. Finally, scores from the three academic assessments (one per challenge) were extracted from the platform.

Statistical analysis

Data analysis was performed using IBM SPSS version 25.0 (IBM, Armonk, NY, USA), in which sociodemographic data were analyzed and frequencies of awareness, attitudes, and intention to practice (individual questions and level classification) were obtained. With the number of correct answers, a descriptive analysis was performed to determine the central tendency (median) and measures of position (quartiles). To assess the effect of the VLE before and immediately after the intervention, the results from participants who completed learning activities, academic assessments, and answered the questionnaire were compared. To evaluate the 6-month impact results from participants who answered the questionnaire at the beginning and after 6 months were compared. Comparative analysis of the number of correct answers (quantitative variable) was performed using the non-parametric Wilcoxon signed-rank test, as the data did not follow a normal distribution. McNemar’s test was used to compare the levels of awareness, attitudes, and intention to practice (qualitative variables). A significance level of 5% was used for all statistical tests.

Results

Sociodemographic characteristics

A total of 279 dentists initiated the VLE, of which 73.8% completed the course. Of the participants, 69.9% were women, 60.2% had a private clinical practice, 45.6% had more than 10 years of clinical experience, and 27.2% were based in Villavicencio; dentists with or without a postgraduate degree were equal (Table 2). Furthermore, 57.3% and 80.1% of dentists showed a medium level of awareness and attitudes, respectively, and 91.3% had a high level of intention to practice (Table 3).

Table 2

Sociodemographic characteristics of the participants (n = 206).

Characteristic	Absolute Number	Percentage (%)
Sex
Women	144	69.9
Men	62	30.1
City
Barranquilla	25	12.1
Bogota	34	16.5
Cali	10	4.9
Cartagena	34	16.5
Medellin	16	7.8
Monteria	31	15
Villavicencio	56	27.2
Type of practice
Private	124	60.2
Public	33	16
Mixed	49	23.8
Years of practice
<5	81	39.3
6–10	31	15
>10	94	45.6
Dental Specialization	103	50
Specialized dentists
Endodontics	16	15.5
Health Administration/Management	16	15.5
Periodontics	15	14.6
Pediatric Dentistry/Pediatric Stomatology	11	10.7
Oral/Maxillofacial Surgery	10	9.7
Oral Rehabilitation/Implantology	7	6.8
Health Services Audit	5	4.9
Orthodontics	4	3.9
Basic Sciences	4	3.9
Orthopedics	3	2.9
Health Promotion	2	1.9
Education	2	1.9
Esthetics	1	1.0
Prosthodontics	1	1.0
Other	6	5.9

Table 3

Baseline levels of awareness, attitudes, and intention to practice of the participants (n = 206).

Characteristics	Absolute Number	Percentage (%)
Levels of awareness
Low	28	13.6
Medium	118	57.3
High	60	29.1
Levels of attitudes
Low	30	14.6
Medium	165	80.1
High	11	5.3
Levels of intention to practice
Low	3	1.5
Medium	15	7.3
High	188	91.3

Impact of the VLE on awareness

The immediate impact of the VLE among 206 participants showed a statistically significant increase in awareness, specifically in the median of correct answers (before: 5.0 interquartile range [IQR] [4.0 − 6.0], after: 6.0 IQR [5.0 − 6.0], p < 0.001) as well as in the number of participants with a high level of awareness (p < 0.001) (Figs 2A and 3A). Likewise, a significant reduction in the number of participants with low (p < 0.001) and medium levels of awareness (p = 0.001) was observed (Fig 3A). Furthermore, regarding questionnaire, a significant increase in the number of participants who correctly answered most of the questions was detected, including those related to antibiotic efficacy, antibiotic resistance, and the association between antibiotic prescription and the generation of resistance (S1 Appendix).

Fig 2

Impact of the virtual learning environment on the number of correct answers.

The number of correct answers on awareness (a), attitudes (b), and intention to practice (c) before the application of the questionnaire, immediately after, and 6 months post-intervention. The median and interquartile ranges are shown. Differences are determined using Wilcoxon signed-rank test. *p < 0.05, **p < 0.01, ***p < 0.001.

Fig 3

Impact of the virtual learning environment on levels.

Percentage of participants showing low, medium, or high levels of awareness (a), attitudes (b), and intention to practice (c) before the application of the questionnaire, immediately after, and 6 months post-intervention. The median is shown. Differences are determined using McNemar’s test. *p < 0.05, **p < 0.01, ***p < 0.001.

The 6-month impact among 155 dentists who answered the questionnaire once again showed a significant increase in the median of correct answers (before: 5.0 IQR [4.0 − 5.25], after: 5.0 IQR [4.0 − 6.0], p < 0.001) (Fig 2A) and in the number of participants who correctly answered the questions from this section, except in the definition of antibiotic resistance (S1 Appendix). Similarly, an increase in the number of participants who showed a high level of awareness was observed; however, this result did not show a statistically significant difference (p = 0.161). Finally, the number of participants with a medium level was similar (p = 1.000), whereas a statistically significant reduction in those with a low level of awareness was obtained (p = 0.019) (Fig 3A).

Impact of the VLE on attitudes

A significant increase in the median of correct answers immediately after the course completion was observed (before: 6.0 IQR [5.0 − 7.0], after: 6.0 IQR [6.0 − 7.0], p < 0.001) (Fig 2B), and in the number of participants who correctly answered two questions, which were related to prescription based on patients’ symptoms and prescription following international guidelines (S1 Appendix). Moreover, a significant reduction in the number of participants with a low level (p = 0.001) and a non-significant increase in the medium (p = 0.152) and high levels of attitudes (p = 0.230) was observed (Fig 3B).

Regarding the 6-month impact, the median of correct answers was slightly lower and did not reach statistical significance (before: 6.0 IQR [5.0 − 7.0], after: 6.0 IQR [5.0 − 6.0], p = 0.105) (Fig 2B). Similarly, a non-significant increase in the medium level of attitudes (p = 0.392) and a non-significant reduction in the high level (p = 0.092) was detected (Fig 3B). Finally, the correct answer to one question from this section (prescription following international guidelines) remained significantly high (p = 0.014) (S1 Appendix).

Impact of the VLE on intention to practice

In general, a statistically significant increase in the median of correct answers was observed (before: 17.0 IQR [15.0 − 18.0], after: 17.0 IQR [16.0 − 18.0], p = 0.042) (Fig 2C). Regarding levels of intention to practice, a reduction in the number of participants with low (p = 0.500) and medium levels (p = 0.523) and an increase at the high level (p = 0.286) was evident; all differences were not statistically significant (Fig 3C). A favorable effect of the VLE was detected, as most of the participants considered it uncommon to prescribe antibiotics in their dental practice (p < 0.001) and would not prescribe antibiotics for acute gingivitis and stomatitis (p = 0.036), after simple tooth extraction (p < 0.001), endodontic procedures (p < 0.001), and implant placement (p < 0.001) (S1 Appendix). In the question regarding antibiotic prophylaxis to prevent IE, a positive effect was observed with the correct answer on antibiotic prescription in patients with a pacemaker (p < 0.001). Conversely, a significant reduction in the number of participants who correctly answered the question concerning patients with autoimmune diseases (p = 0.005), under immunosuppressive therapy (p = 0.037), and diagnosed with AIDS (p = 0.017) was observed (S1 Appendix). The above findings reflect confusion among dentists regarding antibiotic prophylaxis.

The 6-month impact showed a significant increase in the median of correct answers (before: 17.0 IQR [15.0 − 18.0], after: 18.0 IQR [16.0 − 19.0], p < 0.001) (Fig 2C), and in the number of participants who correctly answered most of the questions from this section, which demonstrates that intention to practice antibiotic prescription is maintained over time (p < 0.01, p < 0.05) (S1 Appendix). Unlike immediate impact, an increase in the number of participants who correctly answered the question regarding antibiotic prophylaxis to prevent IE in patients with autoimmune diseases, those undergoing immunosuppressive therapy, and those diagnosed with AIDS was obtained; however, this was not statistically significant (S1 Appendix). Regarding levels of intention to practice, none of the participants were at a low level, there was a slight increase at the medium level (p = 0.804), and a high level was maintained over time (p = 1.000) (Fig 3C).

Immediate and 6-month impact of the VLE on other questions

The week before the application of the first questionnaire, patients receiving antibiotics were reduced as a high number of participants did not prescribe antibiotics to any of their patients (p < 0.001) or prescribed to 1–5 patients (p < 0.001), 6–10 patients (p = 0.388), and > 10 patients (p < 0.039) (Fig 4A). Moreover, these results were obtained during the coronavirus disease (COVID-19) lockdown and should be interpreted with caution.

Fig 4

Impact of the virtual learning environment on antibiotic prescription.

(a) Percentage of participants that prescribed antibiotics the week before the application of the questionnaire, immediately after, and 6 months post-intervention. (b) First choice antibiotic among participants. Differences are determined using McNemar’s test. *p < 0.05, **p < 0.01, ***p < 0.001.

At 6 months, the number of dentists not prescribing antibiotics to any patient increased; however, this was not statistically significant (p = 0.392). Conversely, a slight reduction in the number of participants who prescribed antibiotics to 1–5 patients was observed (p = 0.085); however, the number of dentists who prescribed to 6–10 patients (p = 1.000) and > 10 patients remained the same (p = 1.000) (Fig 4A). Among the first-choice antibiotics, amoxicillin was preferred by dentists, followed by amoxicillin/clavulanic acid. After implementing the VLE, a slight inclination for azithromycin, metronidazole, clindamycin, and cephalexin was detected (Fig 4B).

Academic assessments, level of satisfaction, and course applicability

The median score of academic assessments from participants that completed the course was 4.4 IQR [3.6 − 4.8], and the median in each learning moment was 5.0 IQR [2.5 − 5.0] for Challenge 1, 5.0 IQR [4.2 − 5.0] for Challenge 2 and 4.5 IQR [3.9 − 5.0] for Challenge 3 (Fig 5A). Of the participants, 60.5% had previously completed a virtual course, 82.2% did not have any issue understanding the sections of the VLE, and 56.8% reported a dedication of time between 3 and 5 hours per week (Fig 5B).

Fig 5

Academic assessments, level of satisfaction, and applicability of the virtual learning environment.

(a) Score of academic assessments from Challenges 1, 2, and 3. Median and interquartile ranges are shown. The maximum score is 5.0. (b) Level of difficulty and time of dedication to the course. (c) Perception of participants on applicability, involvement, and quality of the course.

Generally, participants strongly agreed with most of the questions related to the quality of the course (77.9% − 88.5%). Regarding applicability, the question associated with the acquisition of consciousness on antibiotic prescription was the most strongly agreed by professionals (92.1%), followed by application of knowledge (91%) and the intention to modify prescription (84.2%) (Fig 5C).

Discussion

The findings from this study allowed us to reject the null hypothesis, as significant differences in awareness and intention to the practice of participants on antibiotic prescription were observed. Furthermore, the VLE developed and implemented in the present study confirmed the strengths of virtual education, such as flexibility, affordability, accessibility, and overcoming of geographic and time limitations [17, 20], favoring the formation process of the conscious prescription of antibiotics on dentists from seven Colombian cities. The results showed that implementation of the VLE had an immediate positive effect on the median of correct answers and an increase in the number of dentists that correctly answered some of the questions from the questionnaire. Additionally, an increase in the number of dentists with improved levels of consciousness was observed, particularly their levels of awareness. The effectiveness of virtual learning spaces on the acquisition of knowledge and abilities for antibiotic prescription has also been demonstrated in different medical disciplines [28, 29] and dentistry [19, 30], which confirms the relevance of virtual scenarios in the transfer of knowledge on healthcare careers.

Regarding the 6-month impact, a significant increase in the median of correct answers on awareness and intention to practice as well as the number of dentists that correctly answered some of the questions from the questionnaire was maintained; however, information retention was not compared to a control group. Unlike this study, other authors implemented a VLE on antibiotic prescription in medical students and found significantly higher results when compared to a control group (non-virtual education) [28].

Additionally, at 6 months, the present study identified a reduction in the median number of correct answers and the number of dentists that reached a high level of awareness compared to the immediate impact. In another study that implemented virtual tools, despite participants obtaining high scores immediately after the intervention, a non-significant reduction in theoretical test scores after 2 months was observed [29]. For this reason, the combination of multifaceted strategies that include audit trails and feedback processes to achieve a significant impact on antibiotic prescriptions is recommended [17].

Regarding attitudes toward antibiotic prescription 6 months after the course, the results showed that dentists could not modify them. This may be because attitudes are stable entities stored in the memory, implying that new information competes with previously-stored judgments [14]. Therefore, the above suggests that a more robust strategy for individual attitudes must be considered before implementing virtual environments.

Antibiotic prophylaxis is one of the primary actions that should be improved in dental practice, as antibiotics are commonly prescribed before dental procedures to reduce bacteremia [31]. However, some participants could not distinguish antibiotic prophylaxis to prevent IE and complications in patients with certain systemic conditions, which may be due to insufficient time spent on course activities and might have negatively impacted the understanding of antibiotic prophylaxis. Additionally, confusion between prophylactic and therapeutic prescriptions among dentists has been highlighted in the literature [32, 33] and requires a robust educational strategy to overcome the current situation in our field.

Due to the COVID-19 pandemic, the immediate impact of the VLE on the frequency of antibiotic prescriptions could not be explained. Interestingly, after 6 months, dentists resumed their clinical practice and prescribed fewer antibiotics to their patients, although whether the COVID-19 pandemic affected dental outpatient appointments remains undetermined. Accordingly, a study showed that implementing a multimodal strategy comprising an educative section and an online tool on antibiotic prescription in dentistry demonstrated a reduction in antibiotic prescription and inappropriate indications in the long term [19].

Amoxicillin remains the first-choice antibiotic among prescribed antibiotics; however, other antibiotics are being considered among dentists. This may be explained by the fact that amoxicillin was included in several clinical cases during this course, as this antibiotic has demonstrated safety and efficacy in dentistry [34]; therefore, it is the first choice by most dentists, as described elsewhere [35]. Nevertheless, it would be interesting to evaluate the use of other types of antibiotics in a broader context that can be used safely in dental practice. For example, the Australian Therapeutic Guidelines recommend phenoxymethylpenicillin prescription against oral bacteria (primarily gram-positive) due to its high efficacy (85%) and reduced spectrum compared with amoxicillin [19, 32].

Regarding scores obtained during the academic activities, good performance of most participants on academic assessments was observed, with the assessments from Challenge 1 (association of a type of antibiotic with a bacterial infection) and Challenge 2 (clinical cases to select whether antibiotics should or should not be prescribed) producing better scores than those obtained from Challenge 3 (clinical cases to select the best treatment). In a similar study, an online course given to 310 medical students showed that the majority had an average score of 90% on activities related to basic knowledge (principles of antibiotic stewardship). Moreover, 153 of these participants completed all five interactive online clinical cases, with approximately half scoring over 90% in the first attempt [36]. Therefore, the transfer of theoretical knowledge through virtual tools is more effective than its integration, which represents an important challenge for the development of these types of environments and encourages the exploration of alternative technologies such as virtual reality [37, 38].

Finally, the level of satisfaction and course applicability among participants was high, indicating good acceptance of the virtual tool. It has been reported that virtual education is well accepted compared to traditional education as it promotes an attractive, interactive, and cognitive formation process through multimedia resources that facilitate learning [24, 38]. Thus, the acceptance of our virtual tool is superior to that of other virtual strategies [36, 39]. Although the impact of the VLE on attitudes was not significant, this course may contribute to increasing awareness of the appropriate use of antibiotics in Colombia and other Hispanic countries. In addition, it might have an impact on bacterial resistance and in the reduction of adverse effects such as diarrhea, allergic reactions, anaphylaxis, and infection by Clostridium difficile [40]. Therefore, this course was provided on an open-access platform to reach more dentists.

A limitation of the present study is related to the absence of a control group receiving a traditional strategy or non-virtual education to compare the impact of the VLE, which was due to the distance between the seven Colombian cities and the interest in implementing the VLE to a higher number of dentists. Similarly, score categorization was a limitation, as according to the percentile classification during the questionnaire validation, a high level of awareness and attitudes was achieved with 100% of correct answers, whereas for intention to practice, a high level was reached with 63 − 100% of correct answers [27]. Finally, other limitations include a selection bias as dentists had participated in our previous study where the questionnaire to determine awareness, attitudes, and intention to practice antibiotic prescription was implemented [26], and the COVID-19 pandemic and the lockdown in Colombia from March to August 2020, which did not allow us to measure the frequency of antibiotic prescription among participants and, consequently, the impact of the VLE on practices.

Despite this, new knowledge, reinforcement of the concepts regarding antibiotic prescription, acquisition of consciousness, and intention to modify prescription resulted from the VLE implemented here. These are the starting points that may contribute to preventing the generation of antibiotic-resistant bacteria [41]. However, further interactive and reflexive activities that improve attitudes, a deep understanding of the indications for antibiotic prophylaxis, and knowledge retention should be reinforced.

Conclusions

This study successfully developed and implemented a VLE on conscious antibiotic prescription in dentistry, with dynamic and interactive learning that contributed to improving Colombian dentists’ awareness and intention to practice. However, it is important to highlight that low information retention on attitudes after 6 months demonstrates the need to develop a more robust approach that modifies this factor and effectively contributes to promoting the appropriate use of antibiotics.

Immediate and 6-month impact of the virtual learning environment (VLE) implementation.

Impact on the number of participants who correctly answered questions from the questionnaire.

(DOCX)

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14 May 2021

PONE-D-21-04062

Impact of a Virtual Learning Environment on the conscious prescription of antibiotics in Colombian dentists

PLOS ONE

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Prof. Dr. med. dent. Dr. h. c. Andrej M Kielbassa

Academic Editor

PLOS ONE

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The article was well written, and the study was well designed. However, some doubts remained:

1. How were the participants included in each city? Was the sample probabilistic or non-probabilistic? It is necessary to describe more details;

2. The authors must discuss the absence of a control group;

3. The objectives and the conclusions must be aligned; the authors did not cite the development of a Virtual Learning Environment in the objectives;

4. Why did dentists were unable to modify their attitudes on antibiotic prescription six months after the course, besides modifying their awareness? Due complexity of this theme, maybe is necessary a more profound discussion based on educational psychology. Courses cannot be the best strategy.

Reviewer #2: General remark

- Please revise for minor typos, and double check grammar. See, for example, "however this was not" and "however, the number of". Revise for missing commas.

Abstract

- Please see Guidelines for Authors, and consult some recently published Plos One papers. No subheadings mandatory here. Please delete "Background:", "Methods :", "Results:", and "Conclusion :". Revise carefully for proper spacebar use.

- Please provide complete results, and add exact P values on a 3-digit basis (example: p=0.109). Revise carefully.

- Remember that this section allows for 300 words, see Guidelines. Currently, your word count would be 216, and it seems unclear why you obviously have failed to provide a complete section presenting the most important outcome convincingly.

- With your conclusions, please do not simply repeat your results. Instead, stick to your aims, and provide a sound and reasonable extension of your outcome. This extension must be based on your results, but a simple repetition would not seem convincing.

- This section has been poorly elaborated only. There are 12 (!) (co-)authors of this draft, all of them having read and approved this manuscript, right? This should result in a flawless paper, without any typos, and with sound conclusions. I hope you will agree.

Intro

- Would seem basically sound.

- Please provide your objectives. Remember that there is a clear difference between "aims" and "objectives".

- A sound null hypothesis is missing. Note that H0 must be deducible from the forgoing thoughts.

Meths

- Do not use legal terms like "®", and so on. This is unusual with scientific writing, please delete.

- - With ALL materials and methodologies (including statistical software), please use general names with your text, followed by (brand name; manufacturer, city, STATE (abbreviated, if US), country) in parentheses. Stick to semicolon. Revise thoroughly.

Results

- Would seem sound.

Disc

- Stick to H0 when staring this section.

- Do not use authors' names with your text. The latter will be acknowledged with your Reference list. Delete "Sikkens et al.", and focus on your main thoughts.

- Same with "Soltanimehr et al", and with "Teoh et al.,".

- Please add some educated thoughts on the generalizability of your outcome, to Columbia, and to other countries.

Concl

- Your aims were "(...) this study aimed to determine the impact of a VLE designed to improve awareness, attitudes and intention to practice on antibiotic prescription". With your conclusions, please stick exclusively to your aims, and provide a reasonable extension of your outcome.

- "High scores on course characteristics and applicability such as design, content, quality, organization, timing as well as in the acquisition of knowledge, acquisition of consciousness and intention to modify prescription were received." This might be right, but it does not stick to your aims. Revise carefully.

Refs

- Please see recent Plos One papers, and add pmid numbers.

All in all, the authors have submitted a nice draft, considered interesting and easily intelligible. This paper should be worth following after major revisions.

Reviewer #3: Thank you for the opportunity to review your paper. There is clearly much work which has been undertaken and your findings are an important addition to the literature. However, the very comprehensive nature of your paper makes it rather difficult to read.

General - explaining some of the technical terminology would be helpful - I do not understand 'intention to practice' - does this mean intention to prescribe antibiotics within the US guidelines which you have highlighted as the basis for Colombian dentistry?

Introduction - Too many references - 37 in just 5 paragraphs. Please think really carefully about the best one or two to chose to make each point rather than including up to 5 citations per sentence. For example, your first sentence should include the FDI World Dental Federation's policy statement or white paper on tackling overprescribing of antibiotics in dentistry ahead of many of the other references. And in the opening sentence of your third paragraph, could I suggest a single systematic review which looked at why dentists prescribe antibiotics unnecessarily: https://academic.oup.com/jac/article/74/8/2139/5475276

Introduction - para 2 - guidelines for appropriate dental antibiotic prescribing differ around the world so you need to be clear in this paper that you are referring to that which is deemed appropriate in Colombia. And I think you have a typo as periodontal abscesses are less likely to be life-threatening than periapical abscesses. Later in the same paragraph, you state that orthopaedic surgeons 'must' define the antibiotic regimen - this does not make sense given the first part of this sentence.

Introduction - para 3 - other than the first sentence of this paragraph, much of it would sit more comfortably in the discussion section.

Methods - Be clear about when you undertook this study - this is particularly important as you refer to it in the discussion section.

Thinning out the detail to that which is essential will make this section much clearer. Don't repeat information which is already in the tables. And be careful of jargon: alpha risk and beta risk mean nothing to the general reader. Simply say that your sample size was calculated as 140 dentists based on a cut off for significance of p=0.05 and .... Also, could you mention the date when the ethics committee approved it?

Table 1 - this needs to be streamlined to get rid of superfluous detail (eg 'welcome message' and 'course detail')

Results - Again don't repeat information from the tables in the text. For example in the second sentence just say 'Details of the sociodemographic characteristics of participating dentists are included in Table 2.' In spite of its title, you have included more than just sociodemographic characteristics in Table 2. Baseline levels of awareness, attitudes and 'intention to practice' should be in a separate table. And Table 3 has WAY too much detail for the paper. You need to find a way to summarise this into a format digestible by the reader - or put it into an on-line appendix.

Discussion - the key messages from the paper need to come through this section much more clearly. Given the extensive use of the US guidelines in the rest of the paper, I was rather surprised that you didn't reference any of the US work on dental antibiotic stewardship from Suda, Durkin or Goff.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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29 Aug 2021

Dear Editor:

Prof. Dr. Andrej M Kielbassa

Academic Editor

PLOS ONE

Please, in the attached file, you will find the revised manuscript PONE-D-21-04062: " Impact of a Virtual Learning Environment on the conscious prescription of antibiotics in Colombian dentists" by Angarita Diaz et al., that we are submitting for publication in "PLOS ONE". We have added responses to the suggestions and comments of the reviewers and would like to thank them for all their time and consideration of our work.

Best regards,

The authors

RESPONSE JOURNAL REQUIREMENTS:

-Comments to the Author

-Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: We confirm that our manuscript meets PLOS ONE’s style requirements. Also, the file naming meets the requested style.

-We note that Figure 1 in your submission contain copyrighted images. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution.

Response: The images used in this manuscript contain the Creative Commons Attribution License (CC BY 4.0). The course is a product of this research and is Open Access.

We uploaded the completed Content Permission Form in our submission, and we added in the figure caption the following: Reprinted from [VLE “Prescripción consciente de Antibióticos en odontología”] under a CC BY license, with permission from [Universidad Cooperativa de Colombia], original copyright [2020]”. Line 157 (manuscript with track changes).

-We note that Figure 1 includes an image of a participant in the study.

Response: We inform you that Figure 1 does not include an image of a participant in the study. The person who appears is a teacher of the webinar. However, we reduced the size of this photography with the idea of avoiding the image of the person.

-Thank you for including your ethics statement on the online submission form:

"The present study was approved by the ethics subcommittee from Universidad Cooperativa de Colombia (No. 015-2018). A Written consent was obtained through the VLE.".

To help ensure that the wording of your manuscript is suitable for publication, would you please also add this statement at the beginning of the Methods section of your manuscript file (to include type of consent provided by participants).

Response: We added the request. Line 137 (track changes).

- Thank you for your response to our copyright queries. Could you please confirm whether the person in figure 1 is shown as part of the “Prescripción consciente de Antibióticos en odontología” under the CC BY 4.0 license? If this identifying image is being republished it will be acceptable to include their image, but otherwise it will need to be removed.

Response: We confirm that the person in figure 1 is part of the “Prescripción consciente de Antibióticos en odontología” under the CC BY 4.0 license.

RESPONSE TO REVIEWERS

REVIEWER 1

Dear reviewer, thanks for your comments that support us to improve the manuscript. We specify the changes and corrections made as follows:

-Comments to the Author

How were the participants included in each city? Was the sample probabilistic or non-probabilistic? It is necessary to describe more details.

Response: We included specifications about the sample and how we incorporated the participants in each city. Line 143 (manuscript with track changes).

- The authors must discuss the absence of a control group

Response: In the discussion we explained the absence of a control group. Line 384 (track changes).

- The objectives and the conclusions must be aligned; the authors did not cite the development of a Virtual Learning Environment in the objectives.

Response: We modified the objectives and conclusions, including the development of the Virtual Learning Environment in the objectives. Line 131 and line 472 (track changes).

- Why did dentists were unable to modify their attitudes on antibiotic prescription six months after the course, besides modifying their awareness? Due complexity of this theme, maybe is necessary a more profound discussion based on educational psychology. Courses cannot be the best strategy.

Response: In the discussion we explained why dentists may not be able to modify their attitudes on antibiotic prescription 6 months after the intervention. Line 401 (track changes).

RESPONSE TO REVIEWERS

REVIEWER 2

Dear reviewer, thanks for your comments that support us to improve the manuscript. We specify the changes and corrections made as follows:

Abstract

- Please see Guidelines for Authors,and consult some recently published Plos One papers. No subheadings mandatory here. Please delete "Background:", "Methods:", "Results:", and "Conclusion :". Revise carefully for proper spacebar use.

Response: We modified the abstract, deleting "Background", "Methods", "Results", and "Conclusion" and we revised spacebar use. Line 30 (manuscript with track changes).

- Please provide complete results and add exact P values on a 3-digit basis (example: p=0.109). Revise carefully.

Response: We added the p-value on a 3-digit basis throughout the manuscript. Line 45 (track changes).

- Remember that this section allows for 300 words, see Guidelines. Currently, your word count would be 216, and it seems unclear why you obviously have failed to provide a complete section presenting the most important outcome convincingly.

Response: We completed the abstract presenting the most important outcomes. Line 30 (track changes).

- With your conclusions, please do not simply repeat your results. Instead, stick to your aims, and provide a sound and reasonable extension of your outcome. This extension must be based on your results, but a simple repetition would not seem convincing.

Response: We modified the abstract without repeating the results. We sticked the conclusion to our aims. Line 53 (track changes).

- This section has been poorly elaborated only. There are 12 (!) (co-)authors of this draft, all of them having read and approved this manuscript, right? This should result in a flawless paper, without any typos, and with sound conclusions. I hope you will agree.

Response: Dear reviewer, thanks for your comments. We agree that the abstract needed a more thorough elaboration. We modified this section. Line 30(track changes).

Intro

- Would seem basically sound.

- Please provide your objectives. Remember that there is a clear difference between "aims" and "objectives".

Response:

We added the objectives. Line 131 (track changes).

- A sound null hypothesis is missing. Note that H0 must be deducible from the forgoing thoughts.

Response: We modified the last section of the introduction with the idea to make the hypothesis deductible. Line 129 (track changes).

Meths

- Do not use legal terms like "®", and so on. This is unusual with scientific writing, please delete.

Response: We deleted the legal terms. Line 164 (track changes).

- With ALL materials and methodologies (including statistical software), please use general names with your text, followed by (brand name; manufacturer, city, STATE (abbreviated, if US), country) in parentheses. Stick to semicolon. Revise thoroughly.

Response: We included brand name information, manufacturer, city, state, and country. Line 164 and line 214 (track changes).

Results

- Would seem sound.

Disc

- Stick to H0 when staring this section.

Response: We modified this section to improve the discussion of the hypothesis. Line 367 and line 371 (track changes).

- Do not use authors' names with your text. The latter will be acknowledged with your Reference list. Delete "Sikkens et al.", and focus on your main thoughts.

Response: We deleted authors' names. Line 387 (track changes).

- Same with "Soltanimehr et al", and with "Teoh et al.,"

Response: We deleted authors' names. Line 394 and line 419 (track changes).

- Please add some educated thoughts on the generalizability of your outcome, to Columbia, and to other countries.

Response: We included information about the generalization of our outcomes to Colombia and other Hispanic countries. Line 453 (track changes).

Conclusion

- Your aims were "(...) this study aimed to determine the impact of a VLE designed to improve awareness, attitudes and intention to practice on antibiotic prescription". With your conclusions, please stick exclusively to your aims, and provide a reasonable extension of your outcome.

Response: We wrote the conclusion having in mind the objective of the study. Line 472 (track changes).

- "High scores on course characteristics and applicability such as design, content, quality, organization, timing as well as in the acquisition of knowledge, acquisition of consciousness and intention to modify prescription were received." This might be right, but it does not stick to your aims. Revise carefully.

Response: In the conclusion, we deleted information about scores on course characteristics and applicability. Line 472 (track changes).

Refs

- Please see recent Plos One papers, and add pmid numbers.

Response: We added PMID numbers. Line 484 (track changes).

All in all, the authors have submitted a nice draft, considered interesting and easily intelligible. This paper should be worth following after major revisions.

RESPONSE TO REVIEWERS

REVIEWER 3

Dear reviewer, thanks for your comments that support us to improve the manuscript. We specify the changes and corrections made as follows:

-General - explaining some of the technical terminology would be helpful - I do not understand 'intention to practice' - does this mean intention to prescribe antibiotics within the US guidelines which you have highlighted as the basis for Colombian dentistry?

Response: In the introduction, we added information about the meaning of Awareness, Attitudes, and intention to practice. Line 102. In addition, we specified in the Methods section, subheading “Impact of the VLE on dentist”, “intention to practice” the following: according to the AHA and ADA guidelines, and recent studies Line 194 (manuscript with track changes).

-Introduction - Too many references - 37 in just 5 paragraphs. Please think really carefully about the best one or two to chose to make each point rather than including up to 5 citations per sentence. For example, your first sentence should include the FDI World Dental Federation's policy statement or white paper on tackling overprescribing of antibiotics in dentistry ahead of many of the other references. And in the opening sentence of your third paragraph, could I suggest a single systematic review which looked at why dentists prescribe antibiotics unnecessarily: https://academic.oup.com/jac/article/74/8/2139/5475276

Response: We reduced the references, including only the relevant studies. Moreover, we incorporated the FDI World Dental Federation's policy statement and the recommended systematic review. Line 73, line 86, line 102, line 115, line 117, line 121 and line 526 (track changes).

-Introduction - para 2 - guidelines for appropriate dental antibiotic prescribing differ around the world so you need to be clear in this paper that you are referring to that which is deemed appropriate in Colombia. And I think you have a typo as periodontal abscesses are less likely to be life-threatening than periapical abscesses. Later in the same paragraph, you state that orthopaedic surgeons 'must' define the antibiotic regimen - this does not make sense given the first part of this sentence.

Response: We modified this paragraph according to the recommendations. Line 79 and line 87 (track changes).

-Introduction - para 3 - other than the first sentence of this paragraph, much of it would sit more comfortably in the discussion section.

Response: We decided not to include this information because, in the methods section, we specified that the course was developed according to the results from our prior study and included the reference. Line 151 (track changes).

-Methods - Be clear about when you undertook this study - this is particularly important as you refer to it in the discussion section.

Response: In methods, we added the time frame of the study. Line 141 (track changes).

-Thinning out the detail to that which is essential will make this section much clearer. Don't repeat information which is already in the tables.

Response: We deleted information that is contained in the tables. Line 167 (track changes).

-And be careful of jargon: alpha risk and beta risk mean nothing to the general reader. Simply say that your sample size was calculated as 140 dentists based on a cut off for significance of p=0.05.

Response: We changed to “The sample size was calculated as 140 dentists based on a cut-off for significance of p=0.05”. Line 143 (track changes).

-Also, could you mention the date when the ethics committee approved it?

Response: We included the date when the ethics committee approved the study. Line 137 (track changes).

-Table 1 - this needs to be streamlined to get rid of superfluous detail (eg 'welcome message' and 'course detail')

Response: In table 1, we deleted non-relevant information. Line 175 (track changes).

-Results - Again don't repeat information from the tables in the text. For example in the second sentence just say 'Details of the sociodemographic characteristics of participating dentists are included in Table 2.' In spite of its title, you have included more than just sociodemographic characteristics in Table 2. Baseline levels of awareness, attitudes and 'intention to practice' should be in a separate table. And Table 3 has WAY too much detail for the paper. You need to find a way to summarise this into a format digestible by the reader - or put it into an on-line appendix.

Response: We deleted repeated information from the tables and separated the table containing baseline levels of awareness, attitudes, and intention to practice. In addition, we moved Table 3 as a supplemental appendix (S1 Appendix). Line 229, line 235 and line 237 (track changes).

-Discussion - the key messages from the paper need to come through this section much more clearly. Given the extensive use of the US guidelines in the rest of the paper, I was rather surprised that you didn't reference any of the US work on dental antibiotic stewardship from Suda, Durkin or Goff.

Response: We organized the ideas to present them more clearly. Also, we included references about US work on dental antibiotic stewardship from Suda, Durkin, and Goff. Line 599, line 615 and line 439 (track changes).

Submitted filename: Responses reviewers F.docx

Click here for additional data file.

28 Sep 2021

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Prof. Dr. Dr. h. c. Andrej M Kielbassa

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Abstract

- Please note that "(p=0.000)" is not very probable. Please double check, and revise for "(p < 0.0001)". Please revise thoroughly throughout your text.

- Revise for Journal style. "(p=0.042)" must read "(p = 0.042)".

- Double check for typos, see "(p=0,000)", and revise carefully. Please note that one flawless drafts will be considered ready to proceed, and please note that all 12 co-authors have approved this version, so such typos would not seem understandable.

Intro

- Still, English remains a concern, see "This number is expected to continue increasing (...)." Again, revise carefully.

- Still, a sound null hypothesis is missing at the end of this section. Remember that H0 must be deducible from the foregoing thoughts.

Meths

- Heading must read "Materials and methods". Even if boring, all co-authors are strongly encouraged to stick to https://journals.plos.org/plosone/s/submission-guidelines.

- "The sample size was calculated as 140 dentists based on a cut-off for significance of p=0.05." This would seem hard to follow. Please provide your primary end-point for this cut-off value.

- Again, do not use legal terms with your text, delete "Corp".

Results

- "(...) and baseline levels of awareness, attitudes, and intention to practice are shown in Table 3." Do not leave the reader alone with your Tables. Instead, you must guide the reader with your full text. Without doubling each and every result, please provide the most important outcomes.

- Please double check and revise for correct parentheses, see "(before: 5.0 IQR [4.0-6.0], after 6.0, IQR [5.0-6.0], (p=0.000)", and compare to "(before: 5.0 IQR [4.0-5.25], after 5.0, IQR [4.0-6.0] p=0.000)". Revise carefully for uniform formatting.

- Regarding the p values, see comments given above, and revise carefully.

Disc

- Refer to H0 when starting this section.

Refs

- Again, please revise for uniform formatting. Again, it would seem astonishing why the 12 co-authors simply have ignored the previous recommendations (which would seem easy to follow).

- For example "Sofhauser C. Intention in nursing practice. nursing science quarterly. 2016;29(1):31-34. https://doi.org/10.1177/0894318415614629 PMID: 26660773." must read "Sofhauser C. Intention in nursing practice. Nurs Sci Q. 2016; 29(1): 31–34. https://doi.org/10.1177/0894318415614629 PMID: 26660773" Double check for spacebar use, correct Journal abbreviation, correct hyphen ("–", not "-"), and so on. Remember to re-submit a flawless manuscript, to avoid possible errors with the proofs. This is considered the Co-Authors' task, not the Reviewers' (or the Type-setter's) one.

In total, this revised and re-submitted draft has been considerably improved, but is not ready to proceed.

Reviewer #4: This paper is about the prescription of antimicrobials in dentistry, and describes the implementation of a VLE course and it´s impacts on awareness, attitudes and intention to practice regarding antibiotic prescription in dentistry. In the face of the challenge of increasing microbial resistance, this is an important topic, and successful experiences must be reported. Thus, I think this article is worthy of publication. However, I have a few comments that might help to improve the quality of the article before publication. I will refer to the page and line numbers in the PDF version of the Revised Manuscript with Track Changes.

ABSTRACT:

- Line 45: the authors correctly followed the recommendation of reviewer 2 and modified the P values ​​on a 3-digit basis. However, the notation when the value of p is less than 0.001 must be p<0.001, and not p=0.000. I suggest this modification throughout the article.

INTRODUCTION:

- Line 129: although authors revised the text in response to reviewer 2's indication that a sound null hypothesis is missing, this H0 was not really clear. Perhaps a proposal is: "considering that the VLE is a teaching-learning method that may not improve awareness, attitudes, etc., we develop a VLE and measure the impact". I believe that the way of writing can make the null hypothesis clearer.

METHODS:

- Line 199: the score categorization used follows a certain logic for awareness and attitudes (high level being considered only if there is total correctness) and another for intention to practice (high level for those who get around 63 to 100% of the questions right). For awareness and attitudes, getting 63% of the questions right would mean low or medium level. I would like to understand the authors' option for this categorization, and, if they deem it pertinent, I suggest putting this as a limitation of the study in the discussion.

RESULTS:

- Lines 250 and 257: figures 2 and 3 always compare 4 sets of data, referring to "before", "immediate", another "before" and "6 months". In my opinion, the occurrence of 2 "before" is only clear when analyzing the supporting information. Thus, it may be worth clarifying in Methods that the comparisons were made with the total sample that completed the VLE course (first "before" and "immediate" sample) and with those who answered the questionnaire after 6 months (second "before" and "6 months" sample).

DISCUSSION:

- Line 438: revise English in the sentence "A study in the medical field, in which an online course was given to students and showed that >90% of the participants had a good score on activities related to basic knowledge (principles of antibiotic stewardship);".

- Line 460: the limitations paragraph is quite modest, associating the limitations mainly with COVID-19. In addition, the authors sticked a final paragraph of discussion on limitations. I suggest a distinct paragraph, inserting the following topics: 1. study design, without a control group; 2. score categorization (already indicated above in Methods, Line 199); and 3. indicate as selection bias the fact that dentists from a previous study were invited to participate in this study.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #4: Yes: Michel Laks

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8 Nov 2021

Dear Editor:

Prof. Dr. Andrej M Kielbassa

Academic Editor

PLOS ONE

Please, in the attached file, you will find the revised manuscript PONE-D-21-04062: " Impact of a Virtual Learning Environment on the conscious prescription of antibiotics in Colombian dentists" by Angarita Diaz et al., that we are submitting for publication in "PLOS ONE". We have added responses to the suggestions and comments of the reviewers and would like to thank them for all their time and consideration of our work.

Best regards,

The authors

RESPONSE JOURNAL REQUIREMENTS:

Reviewer #2:

Dear reviewer, thanks for your comments that support us to improve the manuscript. We specify the changes and corrections made as follows:

Abstract

- Please note that "(p=0.000)" is not very probable. Please double check, and revise for "(p < 0.0001)". Please revise thoroughly throughout your text.

Response: We modified according to your suggestion, and to the guide: “P-values. Report exact p-values for all values greater than or equal to 0.001. P-values less than 0.001 may be expressed as p < 0.001”.

- Revise for Journal style. "(p=0.042)" must read "(p = 0.042)".

Response: We put the corresponding spaces.

- Double check for typos, see "(p=0,000)", and revise carefully. Please note that one flawless drafts will be considered ready to proceed, and please note that all 12 co-authors have approved this version, so such typos would not seem understandable.

Response: We corrected the typo mistakes.

Intro

- Still, English remains a concern, see "This number is expected to continue increasing (...)." Again, revise carefully.

Response: We modified “This number is expected to increase up to 10 million deaths per year by 2050, as anticipated by the British government”. Line 57 (manuscript with track changes). We recheck and improve the English of the entire document.

- Still, a sound null hypothesis is missing at the end of this section. Remember that H0 must be deducible from the foregoing thoughts.

Response: We added the null hypothesis: The null hypothesis of the study is that the development and implementation of a VLE on conscious antibiotic prescription in dentistry does not have a favorable impact on participants’ awareness, attitudes, and intention to practice. Line 121 (manuscript with track changes)

Meths

- Heading must read "Materials and methods". Even if boring, all co-authors are strongly encouraged to stick to https://journals.plos.org/plosone/s/submission-guidelines.

Response: We modified the mistake with the heading. Line 126 (manuscript with track changes)

- "The sample size was calculated as 140 dentists based on a cut-off for significance of p=0.05." This would seem hard to follow. Please provide your primary end-point for this cut-off value.

Response: We added information about the sample size: “The sample size was calculated for each city including dentists with a Dentistry degree until 2016 according to the last update from the Observatorio Laboral para la Educación through a paired sample t-test (repeated measures). By accepting an alpha risk of 0.05 (5%) and a beta risk of 0.1 (10% potential) in a bilateral contrast, a total of 140 dentists were required. A 15% loss to follow-up was estimated.” Line 136 (manuscript with track changes)

However, in this document, we specify that reviewer # 3 on may, wrote: Just say that your sample size was calculated as 140 dentists based on a significance cutoff of p = 0.05. For that reason, we had deleted the information on the before copy.

- Again, do not use legal terms with your text, delete "Corp".

Response: We deleted “Corp”. Line 213 126 (manuscript with track changes).

Results

- "(...) and baseline levels of awareness, attitudes, and intention to practice are shown in Table 3." Do not leave the reader alone with your Tables. Instead, you must guide the reader with your full text. Without doubling each and every result, please provide the most important outcomes.

Response: We included: “Most of the participants were female (69.9%), performed a private clinical practice (60.2%), and had more than 10 years of clinical experience (45.6%); dentists with or without a postgraduate formation were equal (50%) (Table 2). Furthermore, most dentists showed a medium level of awareness (57.3%) and attitudes (80.1%) and a high level of intention to practice (91.3%) (Table 3)” Line 230 (manuscript with track changes).

In this document, we specify that reviewer # 3 in the correction above, wrote: Again don't repeat information from the tables in the text. For example in the second sentence just say 'Details of the sociodemographic characteristics of participating dentists are included in Table 2.' For that reason, we had deleted the information on the before copy.

- Please double check and revise for correct parentheses, see "(before: 5.0 IQR [4.0-6.0], after 6.0, IQR [5.0-6.0], (p=0.000)", and compare to "(before: 5.0 IQR [4.0-5.25], after 5.0, IQR [4.0-6.0] p=0.000)". Revise carefully for uniform formatting.

Response: We compared and standardized the information.

- Regarding the p values, see comments given above, and revise carefully.

Response: We modified according to the guide and the reviewer.

Disc

- Refer to H0 when starting this section.

Response: We started the Discussion section with H0: “The findings from this study allowed us to reject the null hypothesis as significant differences in awareness and intention to practice of participants on antibiotic prescription were found”. Line 372 (manuscript with track changes).

Refs

- Again, please revise for uniform formatting. Again, it would seem astonishing why the 12 co-authors simply have ignored the previous recommendations (which would seem easy to follow).

Response: We modified according to the guide (which request doi) and recent Dentistry-Plos One papers (which request pmid).

- For example "Sofhauser C. Intention in nursing practice. nursing science quarterly. 2016;29(1):31-34. https://doi.org/10.1177/0894318415614629 PMID: 26660773." must read "Sofhauser C. Intention in nursing practice. Nurs Sci Q. 2016; 29(1): 31–34. https://doi.org/10.1177/0894318415614629 PMID: 26660773" Double check for spacebar use, correct Journal abbreviation, correct hyphen ("–", not "-"), and so on. Remember to re-submit a flawless manuscript, to avoid possible errors with the proofs. This is considered the Co-Authors' task, not the Reviewers' (or the Type-setter's) one.

In total, this revised and re-submitted draft has been considerably improved, but is not ready to proceed.

Response: We did check for spacebar use, corrected the journal abbreviation, and fixed the hyphen. Also, modified according to the guide, which request doi: “A DOI number for the full-text article is acceptable as an alternative to or in addition to traditional volume and page numbers. When providing a DOI, adhere to the format in the example above with both the label and full DOI included at the end of the reference (doi: 10.1016/j.molimm.2014.11.005). Do not provide a shortened DOI or the URL.”

Reviewer #4:

Dear reviewer, thanks for your comments that support us to improve the manuscript. We specify the changes and corrections made as follows:

This paper is about the prescription of antimicrobials in dentistry, and describes the implementation of a VLE course and it´s impacts on awareness, attitudes and intention to practice regarding antibiotic prescription in dentistry. In the face of the challenge of increasing microbial resistance, this is an important topic, and successful experiences must be reported. Thus, I think this article is worthy of publication. However, I have a few comments that might help to improve the quality of the article before publication. I will refer to the page and line numbers in the PDF version of the Revised Manuscript with Track Changes.

ABSTRACT:

- Line 45: the authors correctly followed the recommendation of reviewer 2 and modified the P values on a 3-digit basis. However, the notation when the value of p is less than 0.001 must be p<0.001, and not p=0.000. I suggest this modification throughout the article.

Response: We modified according to your suggestion and, to the guide: “P-values. Report exact p-values for all values greater than or equal to 0.001. P-values less than 0.001 may be expressed as p < 0.001”. Line 42 (manuscript with track changes).

INTRODUCTION:

- Line 129: although authors revised the text in response to reviewer 2's indication that a sound null hypothesis is missing, this H0 was not really clear. Perhaps a proposal is: "considering that the VLE is a teaching-learning method that may not improve awareness, attitudes, etc., we develop a VLE and measure the impact". I believe that the way of writing can make the null hypothesis clearer.

Response: We added the null hypothesis: “The null hypothesis of the study is that the development and implementation of a VLE on conscious antibiotic prescription in dentistry does not have a favorable impact on participants’ awareness, attitudes, and intention to practice.” Line 121 (manuscript with track changes).

METHODS:

- Line 199: the score categorization used follows a certain logic for awareness and attitudes (high level being considered only if there is total correctness) and another for intention to practice (high level for those who get around 63 to 100% of the questions right). For awareness and attitudes, getting 63% of the questions right would mean low or medium level. I would like to understand the authors' option for this categorization, and, if they deem it pertinent, I suggest putting this as a limitation of the study in the discussion.

Response: We added and explained the limitation: “….score categorization was a limitation as according to the percentile classification during the questionnaire validation, a high level of awareness and attitudes was achieved with 100% of correct answers whereas, for intention to practice, a high level was reached with 63% - 100% of correct answers [27]. Line 466 (manuscript with track changes).

RESULTS:

- Lines 250 and 257: figures 2 and 3 always compare 4 sets of data, referring to "before", "immediate", another "before" and "6 months". In my opinion, the occurrence of 2 "before" is only clear when analyzing the supporting information. Thus, it may be worth clarifying in Methods that the comparisons were made with the total sample that completed the VLE course (first "before" and "immediate" sample) and with those who answered the questionnaire after 6 months (second "before" and "6 months" sample).

Response: In Materials and Methods, we clarified about your suggestion: The immediate impact (“immediately after” intervention) was compared to the first measurement (“before” intervention) of the total sample of dentists that completed the course. To analyze information retention, results from dentists that answered the questionnaire at 6 months (“6 months” post-intervention) were compared to the data obtained from the same population that answered the initial questionnaire (“before” intervention). Line 175 (manuscript with track changes).

DISCUSSION:

- Line 438: revise English in the sentence "A study in the medical field, in which an online course was given to students and showed that >90% of the participants had a good score on activities related to basic knowledge (principles of antibiotic stewardship);".

Response: We modified the sentence “In a similar study, an online course given to 310 medical students showed that the majority had an average score of 90% on activities related to basic knowledge (principles of antibiotic stewardship). Moreover, 153 of these participants completed all five interactive online clinical cases, with about half of them scoring over 90% in the first attempt [36]”. Line 441 (manuscript with track changes).

- Line 460: the limitations paragraph is quite modest, associating the limitations mainly with COVID-19. In addition, the authors sticked a final paragraph of discussion on limitations. I suggest a distinct paragraph, inserting the following topics: 1. study design, without a control group; 2. score categorization (already indicated above in Methods, Line 199); and 3. indicate as selection bias the fact that dentists from a previous study were invited to participate in this study.

Response: We organized the limitation according to your suggestion. Line 462 (manuscript with track changes).

Submitted filename: Responses to reviewers.docx

Click here for additional data file.

23 Nov 2021

23 Dec 2021

Dear Editor:

Prof. Dr. Andrej M Kielbassa

Academic Editor

PLOS ONE

Please, in the attached file, you will find the revised manuscript PONE-D-21-04062: " Impact of a Virtual Learning Environment on the conscious prescription of antibiotics in Colombian dentists" by Angarita Diaz et al., that we are submitting for publication in "PLOS ONE". We have added responses to the suggestions and comments of the reviewers and would like to thank them for all their time and consideration of our work.

Moreover, according to the comment, “I am convinced that your revised paper will be worth following, even if your revised version still would benefit from thorough re-edits and language polishing.”, we performed the editing process on this occasion and added the certification. During the edition, one word of the manuscript's title changed: Impact of a Virtual Learning Environment on the conscious prescription of antibiotics among Colombian dentists"

In relation to the comment, “Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice”. We thoroughly reviewed the reference list.

Best regards,

The authors

RESPONSE JOURNAL REQUIREMENTS:

Reviewer #1:

Dear reviewer, thanks for your comments that support us to improve the manuscript. We specify the changes and corrections made as follows:

Some concerns remained and requested minor revision.

Material and Methods

I suggest adjusting the text:

l. 128 “The present study is minimal risk research and was approved….”

for this phrase, “This study was approved….”

Response: We modified this phrase according to your suggestion. Line 126. (manuscript with track changes)

The calculus of sample size remains unclear. A total of 140 dentists were required, but how many dentists per city were needed, considering the total number of dentists per city?

Response: We specified the total number of required dentists per city: “At least 20 dentists per city registered at the local Health Secretary or the Sistema Integrado de Información de la Protección Social of the Ministry of Health were required.” Line 138. (manuscript with track changes)

Results

l. 230 “A total of 206 dentists completed the course.”

How many participants initiate the course? Please, write about the loss of the participants. It is essential to know how many participants initiated the course and how many completed the course.

Response: We added the number of participants that initiated the course and how many completed the course: “A total of 279 dentists initiated the VLE, of which 73.8% completed the course.” Line 227. (manuscript with track changes). We would like to specify that we did not ask about the reasons for course dropout in the study.

I suggest complementing the legend’s information of the Tables:

l. 237 Table 2. Sociodemographic characteristics of the participants (n = 206)

Response: We modified this legend according to your suggestion. Line 235. (manuscript with track changes)

l. 239 Table 3. Baseline levels of awareness, attitudes, and intention to practice of the participants (n = 206)

Response: We modified this legend according to your suggestion. Line 237. (manuscript with track changes)

The first column of Table 2 and Table 3 indicates the Absolute Number and not Frequency. The Frequency means prevalence(percentage).

Response: We modified this column according to your suggestion.

l. 232 “Furthermore, most dentists showed a medium level of awareness (57.3%) and attitudes (80.1%) and a high level of intention to practice (91.3%) (Table 3).” Does 80.1% represent a medium level?

Response: We modified the redaction as follows: “Furthermore, 57.3% and 80.1% of dentists showed a medium level of awareness and attitudes, respectively, and 91.3% had a high level of intention to practice practice (Table 3).” Line 231. (manuscript with track changes).

Why was the Wilcoxon signed-rank test used instead of the Friedman test? The comparison was made among three groups (basal, immediately after, and 6 -months post-intervention) and not only two groups.

Response: The comparisons were between two groups. Line 169 specified this information regarding the comparisons: “To determine the effect of the VLE on dentists, participants answered a questionnaire intended to measure their levels of awareness, attitudes, and intention to practice antibiotic prescription before, immediately after, and 6 months post-intervention. The immediate impact (“immediately after” intervention) was compared to the first measurement (“before” intervention) of the total sample of dentists who completed the course. To analyze information retention, results from dentists who answered the questionnaire at 6 months (“6 months” post-intervention) were compared to the data obtained from the same population that answered the initial questionnaire (“before” intervention).”

According to the instructions, the authors must reorder:

• Acknowledgments

• References

• Supporting information captions

Response: We re-ordered the sections.

Submitted filename: Responses to reviewers.docx

Click here for additional data file.

5 Jan 2022

Impact of a Virtual Learning Environment on the conscious prescription of antibiotics among Colombian dentists

PONE-D-21-04062R3

Dear Dr. Angarita Díaz,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Congratulations!

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards, and stay healthy, please

Andrej M Kielbassa, Prof. Dr. med. dent. Dr. h. c.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: This revised and re-submitted manuscript has been consididerably improved, and would seem ready to proceed.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

19 Jan 2022

PONE-D-21-04062R3

Impact of a Virtual Learning Environment on the conscious prescription of antibiotics among Colombian dentists

Dear Dr. Angarita-Díaz:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Dr. med. dent. Dr. h. c. Andrej M Kielbassa

Academic Editor

PLOS ONE