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Background: Antimicrobial resistance (AMR) is spreading rapidly and is considered to be one of the greatest public threats worldwide. The inappropriate use of broadspectrum antimicrobials has contributed to the emergence of AMR. The WHO has developed Access, Watch, Reserve (AWaRe) classification to support hospitals and countries in promoting the appropriate utilisation of antimicrobials. Studying broadspectrum antimicrobial utilisation and the determinants of broad-spectrum antimicrobial prescribing can assist in developing strategies and policies to improve the local prescribing practice for these agents. Aim: To evaluate the practices of broad-spectrum antimicrobial prescribing to provide potentially effective and feasible recommendations and interventions that will result in improvements in broad-spectrum antimicrobial prescribing practices in a hospital setting in the Kingdom of Saudi Arabia (KSA). Methods: An explanatory sequential mixed methods approach was adopted. First, a quantitative, observational, retrospective, cross-sectional, drug utilisation study, which included adult patient data on carbapenems (imipenem/cilastatin or meropenem) and piperacillin/tazobactam use retrieved from a hospital database for the period from 1 January 2016 to 31 December 2017, was conducted followed by a qualitative study of physicians' views and perceptions of broad-spectrum antimicrobial prescribing. The qualitative study employed semi-structured interviews with 16 physicians to identify and explore the determinants of broad-spectrum antimicrobial prescribing practices, recommendations to improve practice and possible barriers. This study was carried out in a single tertiary care institution in the KSA. Results: A total of 2,871 patients received 5,250 courses of antimicrobial treatment with at least one of the studied broad-spectrum antimicrobials across 3,671 patient admissions over a two-year period. It was shown that 4,106 (82%) of broadspectrum antimicrobials were prescribed for empiric indications. Of the assessed prescriptions, only 2,787 (56.5%) were prescribed appropriately, with 2,142 (43.5%) deemed inappropriate. The three most common reasons for inappropriate empiric perceptions were: spectrum of activity was too broad 1029 (40%), antimicrobial used without a culture request 929 (36.2%), and failure of suitable antimicrobial deescalation 570 (22.2%). Interview findings identified key determinants of broadspectrum antimicrobial prescribing practices, including patient co-morbidities and clinical presentations, the unavailability of local guidelines, physicians' perceptions and attitudes toward broad-spectrum antimicrobials prescribing and several institutional constraints. Suggestions prioritised by physicians for improvements to the practice of prescribing broad-spectrum antimicrobials included education and training, monitoring and feedback, improved logistics of care and antimicrobial stewardship. Conclusion: This research adds to our knowledge on broad-spectrum antimicrobial prescribing practices and recommended intervention and strategies for improving the appropriateness of broad-spectrum antimicrobials prescribing in a hospital setting in the KSA. Implementing a multifaceted intervention can possibly improve antimicrobials prescribing practices. Educating physicians about the importance of antimicrobial stewardship practices could be considered. Moreover, introducing antimicrobial prescribing guidelines should be significant part of the intervention to improve the appropriate prescribing of broad-spectrum antimicrobials. Both education and guidelines should consider the factors that influence physicians prescribing and involve physicians to impact effectively and positively on their inappropriate prescribing practices and reduce the risk of AMR.

The aim of this study is to investigate whether the use of social networking (SN) website-based learning activities can promote students’ critical thinking (CT) skills and their participation in course activities. For this, an educational intervention was designed and implemented through several stages, drawing from the ADDIE (Analysis, Design, Development, Implementation and Evaluation) learning design model. The intervention is a type of learning activity design based on the WebQuest model, and included open-ended questions and different SN website sources. In order to answer a given question, students were required to browse, criticise and evaluate the source content and present their thoughts in an argumentative essay. I adopted the design-based research (DBR) approach within a mixed methods research design framework to evaluate the effectiveness of the research intervention. Research tools included a CT rubric and student questionnaires as the quantitative tools; and observations, student focus groups and student reflections as the qualitative tools. The main study was conducted in one semester course (16 weeks) with 24 undergraduate female students at King Saud University (KSU), in the first semester of 2014-2015. The quantitative and qualitative data were analysed at the same stage, at the end of the semester. The quantitative data was analysed using one-way repeated measures analysis of variance (ANOVA), Pairwise Comparisons (post-hoc test) and some descriptive statistics. In addition, the qualitative data was analysed thematically using the research questions as a basis for the analysis themes. The intervention revealed positive findings in terms of students’ CT and argumentative writing skills as well as their attitudes. The findings also provide a deeper understanding of students’ perceptions of SN website usage and investigate the factors that affect students’ participation in these course activities. This study found that SN websites alone cannot promote student participation in course activities. SN website usage should be combined with other aspects/factors such as choosing activity topics, the teacher’s role in introducing and implementing activities and consideration of students’ time and other course’s requirements. This study contributes to knowledge by exploring how social constructivism propositions can apply to SN website-based learning activities to help Saudi students learn and apply CT skills.