59. Nobbling the Nonfermentors: Pseudomonas Part 1

It was a long time coming, but it’s here. Jame and Callum set off on our mini-series, Nobbling the Nonfermentors, starting with an introduction to glucose-nonfermenting organisms before moving on to the biggie: Pseudomonas aeruginosa! 

Part 2 next week covers treatment of Pseudomonas, including a deep dive into Pseudomonas resistance mechanisms. Stay tuned!

Transcript

Jame: 0:00

Hi everyone, welcome to the Idiot's podcast that's Infectious Disease Insight of two specialists. I'm James, that's Callum, and we're going to tell you everything you need to know about Infectious Disease.

Song: 0:09

Soon may the editing come to discontinue the taser sun. One day when the seer piece done will take our leave and go. Callum, how you doing.

Callum: 0:21

I'm good. I was thinking that I was reflecting on podcasting and I was thinking that recently we've done quite a few episodes which are more of a kind of rant style. Yes, you might say that they were something of a. We're having a bit of a moan in those episodes, Uh huh, and this time I thought we were not going to do a specific moan episode, but we're maybe going to do, but moan adjacent, would you say. It's sort of maybe like a pseudo moan episode. Also, we're drinking soft drinks which are not fermented.

Song: 1:15

Oh, we're getting to this episode.

Callum: 1:20

Well.

Jame: 1:22

I hope you're happy. I'm very happy. Yes, that's right. Yes, we're doing a pseudo moan episode today. This has been a long time coming.

Song: 1:30

The bugs are back in town.

Callum: 1:31

Yeah, the bugs are back in town.

Jame: 1:35

But first I think we should talk about the definition of known fermenters, because sometimes that gets confused, particularly with early years trainees, with lactose non-fermenting as a means of identification. I certainly got them mixed up. When people started talking about non-fermenters, they didn't explain. They meant glucose non-fermenters.

Callum: 1:56

Yeah, yeah, and termites just used to be non-fermenters. There's like well, you're not non-fermenting, there's lots of things in non-fermenting.

Jame: 2:01

There's lots of things you don't ferment. Yeah, so, Callum, what are non-fermenters?

Callum: 2:08

So when people say non-fermenters, so let's well, we'll kind of zoom out a little bit on what we're talking about, because we're still in the world of the gram-negative organisms and we've sort of gone through some of those already, and this is us coming at long last back triumphantly to our bug episodes style. And within the gram-negatives, we've already talked a lot about the entorobacter rallies, which contain the entorobacteria and other sort of the classic gram-negatives, I guess. And those organisms all ferment glucose, so they take glucose and they break it down and other carbohydrates and they get energy from them that way. And what the non-fermenters is defined by is the fact that, unlike things like E coli, they do not ferment glucose.

Callum: 2:58

And, as with a lot of microbiological categorization, that is being done based on historical way that we identified them using biochemical tests. And this was an important biochemical test that you could say does this organism ferment glucose or does it not? And I think it remains relevant, not because we really don't really use that test now to differentiate them, but because when you put these organisms together into a category, there are things that are very similar between them and so it's still a useful way of thinking about it. And so, like a lot of microbiology. We are still categorizing and grouping organisms based on things that we don't necessarily do, but it is useful because when you put them together, they have similarities. Yeah, yeah.

Jame: 3:50

Yeah, so it's a fairly heterogeneous group, but certainly the big four all have similarities that they're fantastic for, yeah, that make them difficult to treat, and so it's worthwhile considering them as a group. So the big four that I think of are Pseudomonas, berkholderia, stenotrophomonas and Acenetobacter, and so if you've got any familiarity with those genuses, you will immediately realize that they are colonizers of damaged lung tissue, a cause of hospital acquired infection, in particular VAPs and HAPs and things of that nature. They're not the only non-fermenters, though. Well, I just run through these quickly and then we'll move on to Pseudomonas.

Callum: 4:34

Yeah, we've come up with a song that you can sing along to, like the alphabet song.

Jame: 4:37

Wait, I haven't done that, have you so we're going to discuss elsewhere a few, which are things that the listener may not have considered non-fermentative, but they are. So that's Legionella, moraxella, the respiratory pathogens and Bordetella. But then there, if you go and look at the SMI identification of Pseudomonas and other non-fermentative organisms, you will see a big sort of hodgepodge of other genuses which occasionally get confused for Pseudomonas.

Callum: 5:11

But they Well. I think it's worth saying here that there's a lot of recategorization that happens in microbiology, and I think specifically in the last 10, 20 years, as we've had the ability to easily sequence these organisms and then use genetic you know that's information from the genetics of the bacteria to say actually this is related and this isn't. And so a lot of these genesis now were once part of Pseudomonas but it's sort of moved out and I think the overall family is called Pseudomonade ECA, which is mouthful, but I can just think about these as Pseudomonades. It's a lot of the time.

Jame: 6:01

Yeah, and that's how they would be initially identified anyway. But for what it's worth, lawyer listener, the other non-fermenters.

Callum: 6:09

Do you alternate? Let's do one each, all right, okay, yeah.

Jame: 6:12

Acid Dvorax. Echromobacter Alchrylogines.

Callum: 6:17

Brevundumonas Clumamonas Delftia Elizabeth Kingia. Methylobacterium Ocrobactrum Oligela Pandoraea Cycrobacter.

Jame: 6:30

Ralfstonia Rosiumonus Siwinella.

Callum: 6:34

Sfingobacterium. And there they are and we will be doing a tape where we just list bacteria and hopefully we'll release that as an aid for you to fall to sleep.

Jame: 6:47

Well, I'm sure this is a very enthralling podcast content for the loyal listeners. But, luke, that's the group that we're sort of talking about. In general, we are not really going to have episodes on anything other than the Big Four and we'll the Legionnel, moraxella and Bordesella will be covered elsewhere, but today's episode is going to focus on the main agent of this group that causes most of the infections Pseudomonas.

Callum: 7:16

The president of the Pseudomonas itself.

Jame: 7:19

Yes, so there are a bunch of different species of Pseudomonas, but really the three that cause almost all the infections are the species Ergonosa, poutida and Fluorescens, and Ergonosa is easily causing more than 95% of Pseudomonas infections. Is that what you said? Is this our big disagreement on pronunciation?

Callum: 7:47

Yeah, I think I would say Pseudomonas originosa.

Jame: 7:49

I don't think the Juh was in the original Latin. You're about to come back at me and say that we're not speaking Latin. We're not speaking Latin. I could sort of see on your lips.

Callum: 8:01

I know how I say things and I know that other people say different things and I'm fairly certain that the way I say bacteria is probably wrong and that there's probably a right answer. But I guess it's fun, isn't it, to disagree sometimes Fine.

Jame: 8:17

Well, go on then, calmy, you take us through. Where do you find Pseudomonas originosa?

Callum: 8:23

Yeah, I think the most of the time. So Pseudomonas is a very successful bacteria. It's very adaptable and it's also quite hard to kill and we find it a lot in the environment. So it can break down a lot of different chemicals to get energy. It's quite resilient to conform biofilms quite easily, and so if you look for Pseudomonas and Pseudomonas in the environment, you'll find them in places that are wet. So you know what are those.

Callum: 8:56

Well, the main thing that we think about, particularly in hospitals, are the sort of plumbing systems so drains, water supply units, hot water tanks, waterways, built environment.

Callum: 9:10

But they're pretty widely spread generally in the environment and that's a real problem. And I think most of the time that I'm talking about Pseudomonas at work is either infections in patients who have some degree of even compromise, or vascular, intravascular device, that sort of things when it's causing infection. But the other big thing that we think about it from is from an infection prevention control perspective, and whenever you see someone who has a pseudomonas, I think one of the things that has to go through your head is you know, do I need to be worrying about the water? Because you know hospital environments are not safe places and despite a lot of work and designing, building and maintaining these buildings and sort of checking stuff like water safety. There's a lot of dangers and I think this is one of the big ones, and the more I learn about water systems, infection control and plumbing sinks, the more I'm like oh God, this is really scary. If you get pseudomonas outbreak in your ICU from the water, that can be really, really dangerous.

Jame: 10:21

So it's very important.

Jame: 10:23

So when you a little bit of promotional material for the Health Care Infection Society now is that they've got a bunch of trainee infection prevention days which are really worth going to if you're a UK trainee and one of them is on the built environment and infection control from that, and when they're talking about water systems, if I'm remembering right Cam, the idea is that if you've got a hot water system, you want it to be above 50 degrees because Legionella can't grow above 45.

Jame: 10:57

And you want your cold water systems to be below 20, because that also impairs pseudomonas growth and colonization. But of course that's really difficult to maintain in a purpose-built building, let alone. Most NHS. Hospitals were built in stages over decades of the time, sometimes by people who didn't really care about infection control and safety, and that is true today the same as it was 50 years ago. So you then get this issue with overgrowth of pseudomonas or Legionella, and that can be right next to the tap, in which case you can just replace the front end and decolonize it, or it can be deep within the system and that's much more difficult to deal with.

Callum: 11:44

It's a really pernicious problem water safety and it is a big headache and a big source of anxiety, I think, for a lot of infection control teams is how do you once you have pseudomonas in your systems? Because there's a definite balance between recognizing that people need water to do good patient care and also saying that water is dangerous and trying to control. That is a real challenge. So things like filter of taps. Ideally and I think I may be coming around to this more and more is things like waterless ICUs, so you just don't have sinks and you don't have water.

Jame: 12:22

And maybe that's for a good thing. What are the ICUs? What do they clean with? Just like alcohol, jen.

Callum: 12:25

Yeah, you get cleaning wipes and other things, so you just don't have water. I think we could talk about water for a long time.

Song: 12:33

And this isn't an infection control podcast.

Callum: 12:35

What I was thinking there was that I was glad that James someone who doesn't really have infection control in his job plan as a consultant coming up, got something from these infection control days. So, yeah, I found them incredibly helpful.

Jame: 12:48

So, if you get the opportunities to hand, I was going for the foundation certificate in IPC, which I think most trainees should at least try for, but I never got it in the end. I wasn't a CCT before I got the chance, but he's still the phone and the going to the days useful, particularly when they moved online during the pandemic and then it became much easier because before you had to take a trip down to London and that's difficult for some.

Callum: 13:15

Yeah, I think we're not an infection control podcast. We're not trying to be. I think it's worth really focusing and emphasizing the importance of water and its links to pseudomonas, and the importance of that is because, at the end of the day, infection prevention controls everyone's responsibility, no matter where you work in healthcare, and being vigilant. If you're like an ID doc on the ward or you're a scientist or something and saying like okay, oh, there's pseudomonas here, I need to think about where does that come from, because prevention is better than cure.

Callum: 13:51

If you're looking for infection control podcasts, the two that I've listened to anyway have been infection prevention conversation, which is the his infection control podcast. I'm just looking at the list of organisms here. Organisms they have an episode called something in the water where they talk about the problems in the built healthcare facility and the sort of difficulties of water. So check that out. And then the other podcast that I've listened to you about infection control is infection control matters, which has 108 episodes at the time of recording, and there's loads of stuff in there, including some stuff on water safety and pseudomonas. So check them out. We are going to stick with our regular content and not pretend to be infection control experts or any experts, because we are just idiots, but those two podcasts and a recommendation if you're in the UK for the foundation program and infection control.

Callum: 14:53

Yeah, we'll put the link to that in the episode.

Jame: 14:56

So what are the risk factors for acquiring pseudomonal infection? Callum?

Callum: 14:59

Yeah. So I think that most of the people that you see with this are people that are in contact with healthcare, so you know that's anybody in hospital, but particularly intensive care admission, those who've got sort of disrupted immune barriers. So the two main things I think are abnormal lung so this is like patients with cystic fibrosis or related diseases bronchiectasis and we sort of talk about pseudomon COPD. I think COPD is this, you know, chronic obstructive pulmonary disease is this huge group of patients which range from people with a more bronchitis to people with sort of severe airway disease and I think somewhere along that journey potentially towards bronchiectasis, people start getting problems with pseudomonas.

Jame: 15:46

Yeah, the lung becomes sufficiently abnormal for pseudomonas to colonize it, because pseudomonas doesn't really like being in the lung. It likes being in, you know, mucous laden biofilm, damaged airway which has fewer immune cells than normal. But it doesn't like being in normal lung tissue but COPD lung tissue isn't normal.

Callum: 16:09

And then in other risk factors are things where you have, like you know, we've got some sort of prosthetic material, so particularly like urinary catheters and travascular catheters or any sort of prosthetic you know. So another thing is like your sort of neurosurgical infections, so you've got like a ventricular access device or a drain, a shunt.

Jame: 16:27

Yeah, so any plastic where an environmental organism because this is what it is really is able to colonize and form biofilm.

Callum: 16:35

Loads of stuff A catheter associated UTI. Yeah, catheter associated UTI. Someone's talked about an episode of UTI.

Jame: 16:42

I mean recurrent UTIs is a risk factor in and of itself for pseudomonal infection, and whether or not that's a combination of the infection damaging the urinary tract and then making it amenable to colonization and the repeated antibiotic exposure, I'm not sure. But certainly having catheter helps. So like the proportion of couties caused by pseudomonas as opposed to UTIs caused by pseudomonas is greater, because the plastic is there, yeah, and I think you know the other thing to think about is skin.

Callum: 17:14

So you know, if you've got chronic ulcers, wounds, particularly those that are like dressed and like in sort of like a wet dressing, I guess, or like sacral sores, you often find pseudomonas lurking there and they just got this sort of. I'm gonna talk about this a bit in the sort of micro mode section. But you often find pseudomonas colonizing these sort of wounds and sometimes it becomes invasive and causes infection, although usually it doesn't, and so maybe that's a risk factor. You know, if you're pseudomonas colonized, to get a pseudomonas infection and differentiating those is quite tricky. And I guess you know sometimes people you find pseudomonas colonizing the gut, it's not usually a gum commensal.

Jame: 17:54

Does it do a lot, though, or is it transient colonization?

Callum: 17:56

I think it's probably a degree transient. You know, it's not an organism that you tend to find in the gut, because it's so aerobically it grows aerobically generally but you do find that sometimes in stool samples and stuff, particularly people that have been in a hospital environment. Yeah, yeah, and I think that's probably a risk factor in itself.

Jame: 18:16

Yeah, in terms of how it causes damage or causes pathology. There's sort of list in the Oxford handbook of infectious disease and microbiology. I don't think that these are worth memorizing particularly, but there's a variety of exotoxins and anendotoxins.

Callum: 18:37

In general for pseudomonas it makes people very unwell and when you've got a pseudomonas battery you know they're generally very sick. But it doesn't have the same degree of pathogenicity, doesn't have the same sort of virulence factors as your sort of classical staphocloxorias and beta-hemolytic strep. So it's not making people that unwell but it does have a couple of key toxins that sort of mediate its pathogenicity, which we won't go into detail. But it's got some exotoxins, exotoxins A and S, endotoxins, various cytotoxins, all these sort of things. I don't think you know, I don't either of us know those. And does it really matter from a clinical management point of view? Not really Probably not.

Jame: 19:19

It's interesting to know how the pathogen lives, but I think the main thing to know if you're going to learn something about how it lives are the resistance mechanisms, which are numerous and which we'll come on to in a little bit. Yeah, james is a pharmacologist, so what? Clinical syndromes does it cause?

Callum: 19:39

All right, fine, I'll take this one. Will you take one?

Jame: 19:41

I'll take the next, fine, so I suppose the main time that you'll see it are in hospital acquired or ventilator acquired associated pneumonias. So haps and baps and then UTI. But like you said, it can cause loads of other stuff. It just does it less commonly than those two things. So they're the two main places that you'll see it. So wet environments where they can be, you know, colonized directly from the environment, and usually sometimes there's plastic there too. But then it can cause surgical site infections in the post-op period. Battery, yeah, obviously they can be a cause of otitis externa and particularly necrotic otitis externa. So the pseudomonas can colonize wet skin and you know, I suppose surgical wound is wet skin. A chronic, non-healing ulcer, that's wet skin and will. The external bit of your ear is fairly moist as well. It is cause of hot tub vasiculitis. Hot tub vasiculitis, there you go, and then eye infections as well.

Callum: 20:51

So if you're interested in hot tub vasiculitis, dr Gluckumfacken, the famous ophthalmology comedian, has an excellent video on the dangers of hot tubs.

Song: 21:00

Oh, does he?

Callum: 21:01

Which is very funny, as is always infection content.

Jame: 21:04

I mean, all that stuff is gold actually.

Callum: 21:05

Actually, maybe he's the Premier Infection podcast. He's actually quite.

Jame: 21:10

Maybe he is actually he's just started a podcast. I'm sure it's ludicrously more successful than ours. And then rarely they can be cause of bone and joint infection, particularly if you've got multiple operations and prolonged exposure to the hospital environment. Endocarditis I've never seen a case.

Callum: 21:26

but I mean, all endocarditis guidelines have said that very rarely it can do it.

Jame: 21:32

So, it must be true, and then spondylodyscitis as well.

Callum: 21:36

Ceptic arthritis in general, especially the prosthetic joint.

Song: 21:40

It's a bit of a disaster.

Callum: 21:41

Pseudomonas is not something you want. It's propensity to form biophones strong yeah.

Jame: 21:47

And once it's in, what should oral option? It's quinolones, right, yeah, and yeah, yeah Barrier resistance is easier. Quinolones are generally considered to have a reasonably high barrier to resistance, but that does not apply to pseudomonas.

Callum: 22:02

At all yeah, and I don't know if you mentioned that. So I guess any sort of so eye infections is another thing. So if someone you know you've got a implant put into an eye, it's really tricky place to treat as well. Pseudomonas can be an issue there and I think neurosurgical infections are somewhere that we think about it and see it quite a lot as well. You've got this sort of bit of plastic going into our brain so we always cover that in pericleaner in our regimens where we're covering sort of post-op.

Jame: 22:30

What do you use by the?

Callum: 22:31

way for. I think our protocol is vancomycin and keftazidine Same.

Jame: 22:37

Yeah, yeah, same. So both branches of Nidosh Royal Enfermie are using keftaz for the yeah. Micro mode engaged. Micro mode engaged Alright, go on then, cal, and take us through it. What is tell me of the bug? Well, pseudomonas is a bacteria.

Callum: 22:59

It's got a cram negative broad. It's classically. I read an other thing somewhere and it said it's strictly aerobic. Okay, so it only only respires aerobics. It may respire anaerobically in the presence of nitrate. Like, is that strictly aerobic?

Jame: 23:17

Maybe there's a set definition for that. The thing is with pseudomonas. I mean we've you know. We said it's in the environment, it's everywhere, like they've detected it in raindrops at high atmosphere.

Callum: 23:29

No, not raindrops. They were the one place we were said.

Jame: 23:36

They're an issue sometimes with storage of jet fuel, because they can consume it, so they can adapt to lots and lots of different environments. But if they had their druthers, they would like to be some place that's wet and some place where there's loads of oxygen.

Callum: 23:49

Druthers from Brighay and more Scots.

Jame: 23:52

No, I don't think druthers is that.

Callum: 23:53

Is it not Scottish?

Jame: 23:54

No. So yeah, it's usually almost always aerobic. What else?

Callum: 24:00

So it's non sporing, which is good. Don't like sporing things. It's motile, so it usually has a polar flagella, at least one. So generally most pseudomonas are motile. Some of the other sort of non fermenters aren't. It doesn't tend to have a capsule and it's generally straight or slightly curved rod. What kind of agarce do they grow on? It grows pretty easily on bloods, chocolate, mcconchiae gr. So it's not hard to grow and it grows pretty well in the laboratory.

Callum: 24:32

And in terms of the colonial appearances, I think pseudomonas is one of the organisms that when you're first starting out looking at plates, you quite quickly pick up what pseudomonas looks like. Now caveat that with all organisms, and particularly pseudomonas, can have what sort of appearances on agar plates. It doesn't always look like your typical pseudomonas, but when we say our typical pseudomonas, generally speaking they are regular colonies. They're quite like wet looking. They've got this pigmented look. So the pseudomonas aeruginosa generally has a sort of blue-green pigment. So they've got two chemicals that they make, I think pylverd and pylsin and or something which are. They get the blue and the green color together and they almost look metallic and they meant to have this sort of fruity smell which is almost like grapes.

Callum: 25:22

Yeah, I can't say, because I mean don't smell the plants, you smell on patients wounds sometimes, yeah, there's a pseudomonas smell which you can't really help but pick up, yeah, but I've never smelled that and thought, ooh, there are some grapes in the next room. No, you just like it is a very distinctive it's almost metallic.

Jame: 25:39

Well, apparently the chemical that they're secreting that's causing it is something called amino acetophenone and that is also present in grapes. So some people also describe it as cut grass, which, again, I've never smelled a pseudomonas infected leg and said ooh, I freshly cut to law in his next door either Fresh cut grass, oh man, that's a overlap to much. My nerdier podcast I listened to, so anyway, that's the regular colonial appearance and smell, I suppose. What about in respiratory samples, or is there a difference there?

Callum: 26:11

Yeah, I guess pseudomonas it's very adaptable and so it can have different, might not have that typical sort of pigmented appearance. I think the classic thing in my head is you know, you've got this blue green colony. It's sort of that smell and the oxidase is, like quickly positive. When you're looking at it in respiratory samples it can be a bit different, so it can be more mucoid, which is the sort of like wet and sort of gloopy appearance. I guess it looks like snot and the oxidase test might be slow positive which is the classical.

Callum: 26:43

Some of them can. Some pseudomonas can sort of fluoresce as well.

Song: 26:46

Yeah.

Callum: 26:46

I don't think we tend to use that in laboratory to identify them, not anymore I don't think so.

Jame: 26:51

The, the SMI for pseudomonas, has a really good flow chart for for how to identify them. And but just to sort of jump to the end, a pseudomonad would be the term used for any known fermentative GNB that is oxidase positive. So at that point there will be a presumptive diagnosis of pseudomonas and then, if you confirm that, you might confirm it in, you know, say, a Moldotov or there are some PCR applications which are used commercially, particularly in CF patient sputum, because you can identify pseudomonas earlier than traditional culture methods. Usually Moldy is the main way of identifying it and they are pretty good at identifying most of the non-fermenters. There are a couple of exceptions. So there's not a lot of reference data for two genesis, ralfstonia and sphingobacterium, so sometimes they can be a non-ident or a misident.

Jame: 27:51

But for the purposes of the part two mostly, it may be of interest to know which of the non-fermenters are oxidase positive and which are not. So pseudomonas is oxidase positive, obviously, and most of the pseudomonas species are, with the exceptions of pseudomonas Luteola and orizohabitans, which are Ox-Neg. The Broccardelia group, bercal data, copatia complex, is Oxidase variable. Malii and Gladioli, which is a small print species, are Oxidase negative, but Bercal data pseudomalii is Oxidase positive, which causes me the odors.

Jame: 28:30

Yeah, we'll be talking about that in our future episode. Stenotrophinum small tophola is Oxneg, and then Acetine, tabacter, pandoria and Rosium onus are Oxneg and every other nonfermenter in that big list that we gave at the start are Oxidase positive. And so the SMI flowchart has advice on how to plate out and culture the pseudomonas and then ask you to have a look at the colonial morphology, duogramstein, and then do an Oxidase test and if it's Ox, pause, it's got a list of the potential species it could be, top of which is pseudomonas, and then if it's Oxneg, it's got a much smaller list of. You know the pseudomonas, luteal and orizohabitans, sum Bercal data, steno, acetine, tabacter, rosium onus, pandoria, and then says to further ident and in commercial labs, or, sorry, in hospital labs, the main way that you identify is with Malditov or if you're on, say, the urodens bench, it will be a presumptive ident based on colonial morphology and color.

Callum: 29:35

Another thing that the SMI points out, while we're still on micro mode, is that pseudomonas aeruginosa grows at quite a wide range of temperatures, so all away from five degrees Celsius up to 42 degrees Celsius. I'm not translating it to Fahrenheit. Switch to Celsius America.

Jame: 29:51

Yeah, sorry American listeners, you're gonna have to do some sums, yeah so and that's unusual.

Callum: 29:56

So most of the other pseudomonas won't grow at 42 degrees. So that's worth thinking about and I think it's also maybe explains what we're talking about earlier on about the water systems. So yeah, I think that you know it's quite adaptable and that range of temperature is really problematic. One thing that we saw historically, but maybe so less so now, is that hot water tanks was quite a common way, so you'd have like a tank in your attic or some part of your house which stored or water and you kept it warm and ready to use. And pseudomonas love that, loves a tank, and so does the Janela. So you know really the great ways to grow bugs if you have a big tank of hot water.

Jame: 30:35

Yeah, so I mean, luckily there is heat on demand, a thing of the past in most UK homes. Yeah, right time to kill these bugs, cal.

Callum: 31:03

Just like the Oxiday's test splits pseudomonas into two groups, we decided to split this into two episodes. Comments, suggestions to idiots podcasting at gmailcom. Got a five star review in your pocket. We'd love to hear it put it in the podcast player of your choice. Tweet us, or rather jam at idiots underscore pod. Want to buy us a coffee? You can now do so. See the link in the episode description. So until next time, I'm James. That's Cal. Goodbye.