83. BSAC Spring Conference 2024

Jame was there but Callum wasn't! The British Society for Antimicrobial Chemotherapy have several conferences throughout the year, including a Spring meeting with their AGM. But what topics were discussed, I hear you wonder? WELL WONDER NO MORE: Jame'll take you through it!

Notes for this episode here

Transcript

Jame: 0:18

Callum, do you know what will happen if you violate the Idiot's Podcast, Inappropriate Workplace Contact regulations?

Callum: 0:25

Yes, I do. You will bee sacked.

Jame: 0:28

And what a coincidence that is Callum, because what are we talking about today?

Callum: 0:32

We're talking about bee sack.

Jame: 0:34

Hehehehe, indeed we

Callum: 0:35

is a thing that you hold your bees in. Many people think it's a hive, but it's actually a bee sack.

Jame: 0:40

Oh, I strongly suggest you delete that. Yes, the British Society of Antimicrobial Chemotherapy had their spring conference, and I went to it, and you didn't.

Callum: 0:50

Yeah, way to rub it in.

Jame: 0:52

Ha ha ha ha ha ha it was London, which was a hop, skip and a jump for me, but quite a big flight for you.

Callum: 0:58

Yeah, the mysterious location of Nidosh South.

Jame: 1:01

Exactly, exactly, and the equally mysterious location of Nendosh North. Will I tell you what I learned?

Callum: 1:08

You learned something, that's good.

Jame: 1:09

Yeah,

Callum: 1:09

stuff.

Jame: 1:10

Eventually, eventually some stuff will seep into the seep into the noggin. Yeah so it was it was really good. BSAC again, I, I feel I should point out, we have no financial affiliation with either the conference or the British Society of Antimicrobial Cape Therapy at all. Unlike the BIA, who we do have an affiliation with. So BSAC, if you're listening, you're getting this one for free, but this is just a taster of what could be yours. But BIA, be assured that we have nothing but the strongest loyalty to you as well, if you're listening, which I'm sure you're not. Okay I mean, there's loads of stuff that happened on the day, I'm not going to talk about all of it, Cal but there was just a few things that sort of tickled my fancy. it was this one was aimed quite a lot around antimicrobial stewardship, this is a big sort of driver for BSAC. And many UK listeners will know the latest five year plan for keeping antimicrobials working was just released the week prior, the new UK AMR National Action Plan from 2024 to 2029 just dropped, and so that sort of overshadowed a lot of the conference, and a bit of it got presented at the conference. One of the goals is that you probably know Cal, that we're now dividing our antibiotics into the WHO access watch and reserve categories and the access, the ones that we're meant to use up front, watch or second line and reserve are in reserve for, antibiotics last resort. And that's things like, Linase, lidocarbapenems, the stuff that you would expect. And the the From 2024 to 2029, our goals are that we're going to be using 70 percent access antibiotics as a proportion of our total use per trust and to reduce overall usage of antibiotics by 5%. Now that first one I think would be reasonably easy for some trusts to do, assuming that they can, generate sufficient faith in gentamicin and cotrimoxazole for their gram negative infections. But the second one is a bit more tricky, Cal. Unless you come to the realization that seven days of antibiotic therapy for every indication is maybe not What we should be doing, and if you, as a reminder, if you move from 7 days treatment for a pneumonia, say, to 5 days, what you've actually done is reduced your antimicrobial usage by 30 percent or thereabouts. So I think that this target is achievable as long as people start moving, their, their recommendations and microguide and antimicrobial companion apps from, seven days to five. I think you'll be able to achieve that fairly quickly.

Callum: 4:00

Because I guess we measure antimicrobial use on a wider scale by the volume, the total, it's not possible to look at courses and so on. So it's that amount ordered, isn't it?

Jame: 4:10

It's usually done by DDDs, defined daily dosages. So like whatever, the dosage of amoxicillin is, say it'll be 500 TIDs. So they will look at. All the amoxicillin used per truss and they will, divide that by 1. 5 grams and see what they get. And that's your DDDs.

Callum: 4:27

one interesting point there, I guess, is that as UCAST come out with their susceptible and increased dose criteria, and we're using higher doses of some antimicrobials, your defined daily dose, If you're using a higher dose than what is defined as a daily dose, then that can skew things a little bit as well, so it might contribute towards a sort of artificially increased, use.

Jame: 4:49

yes, that's, that's true. Actually. Yeah, yeah. And then I, I suppose the next thing that that tickled my fancy was a talk on HAP that was given by Dan Wooten. He's researcher out of Liverpool. He's actually not an ID guy by trade. I think he's a respiratory guy. I was lucky enough to get to chat to him afterwards. And he was very generous with his time. But the talk that he gave on HAP was really, interesting. There's about 75, 000 haps in the UK every year. About 15, 000 die. And each episode is associated with about 9 extra bed days. And, that would be bad enough if that was in a regular hospital bed. But a bunch of these will be happening in high dependency and intensive care settings as well. Then It's a financial nightmare those nine extra bed days, most of your most of the money spent is just on keeping the patient in a hospital bed each day. And the diagnostics of this was, a mess. So some will, some places will define any pneumonia 48 hours after admission. To hospital as a HAP or if the patient's in a nursing facility, any pneumonia that they get is a HAP and that's he pointed out the issues with that because that's not entirely identifying the population that we want to look at. And there's a trial that you mentioned called the HapFast trial, where they're trying to have a look at the mechanics of haps in the UK. And one of the criteria is that they're trying to get some sort of sputum to try and get the microbiology locked down, but, the acquisition is really poor, so they're only getting about 14 percent of cases have a sputum culture associated with them. And then he went on to the bit that I was really interested in, which was what treatments you can use. And then we went on to the the bit that I like, which is discussing different treatment options. And there he mentioned that the NICE guidance, such as it is based on nine RCTs, only one of which was done in the UK, and the UK one had ten patients. So the, our entire guidance is based on ten UK patients, then a bunch of trials done in in other countries where different, microbiology might predominate. But anyway, like for, for low risk they're recommending Comox, but also things like, Cotrim, Doxy, Keflex, and stuff that we might be, comfortable using. But for high risk, it's a complete mess, Cal, because there's watch antibiotics, like Keftraxone, and then there's watch antibiotics with pseudomonocover, like Keftazidime. levofloxacin and PIPTAS, and then there's reserve antibiotics such as meropenem and also keftazidime avobactam. So which of these are you meant to choose when you're trying to stick this in your microguide? Do you want pseudomonocover? Do you want, cover for ESBLs and AMPSIs built in, in which case you're, you basically have to use meropenem or, levofloxacin like It's, if Kefiroxime and Keftraxone are appropriate, why not just use them? Why are you also recommending carbapenem? And there's no guidance on which one to choose, you just have to guess.

Callum: 8:07

Yeah, I guess the issue there is that it's quite a heterogeneous group. There's, I almost feel like there's hap and then there's hap. There's,

Jame: 8:14

Yeah, yeah.

Callum: 8:16

low level patient, a little bit unwell, with a slight fever, all the way up to, your patient is severely unwell with a significant, the whole lungs are white out. And, also a huge range of organisms that are there, people with gram negative pseudomonas. So it, it does feel a little bit like maybe the guidance should be a bit more along the lines of here's a empirical treatment or stratify patients by there's a Pseudomonas risk, then, use this are the risk factors for Pseudomonas. Or really hammer down on the diagnostics, which I think they probably do already, but I guess it's a slight problem with antimicrobial, guidance is that, if an infection specialist comes along and says here's someone with HAP and then someone asks you which antibiotic to give I'm sure there's quite a lot of complex thinking that goes on there. The absolute best antibiotic treatment. Now, I'm not saying that every single person of a HAP should get an ID consult or a microbiology call or infection input. But I guess the guidelines should really be just as good as that review. And so maybe guidelines are easy to use, but that have that sort of complexity of decision making baked into them would be better.

Jame: 9:30

Maybe, maybe. Yeah, it was, it was an interesting discussion of it, and I, I mean, you're right, because I mean, somebody who's, developed signs of a pneumonia 49 hours after they were admitted, but they're on a general medical ward, and, some guy on intensive care who's just been extubated and now has deteriorating respiratory function. They're two very different people, but they're both covered in HAP. So yeah, it was interesting talk to to be at certainly. And I, I think that, it's a evolving field as well. There's even more information going to be coming out about this.

Callum: 10:06

Yeah, we just don't have much data, do we? So I guess this HapFast trial that you've mentioned, and I've, I put a link to that in the Notion show notes, We'll hopefully give us a bit more information and maybe we should do a proper pod episode on Hap at some point.

Jame: 10:21

We should actually, because we've Done a pneumonia episode, but we haven't done a a HAP episode. HAP's a HAP and VAP specific one. Yeah.

Callum: 10:29

Cool. Okay. That sounds interesting. I'm going to keep an eye out for this HapFast.

Jame: 10:33

Yeah, I hadn't heard of it before actually, but yeah. And then, I suppose the next thing that was, it was interesting think so. There's been a big stushy, we'd call it in Scotland. Bruhaha, we would say in England about pharmacists prescribing antimicrobials. And this was a follow on from a pilot trial that happened in Scotland a few years ago, before the pandemic actually there was pharmacy led prescribing for a very limited range of conditions. One of which was sore throat and one of which was, I think skin infection. I think it's coming up in a moment, but one of which was an UTI and there was the, in Wales, they implemented a, a sort of sore throat test and treat protocol where you would go to your pharmacist and you would be assessed for your sore throat as a way of offloading pressure on GP practices, which are quite strained at the moment in the UK.

Callum: 11:25

I think very strained.

Jame: 11:26

Yeah, very strange. And the pharmacist would do an assessment on a sort of proforma, and then they would do your centaur score and your fever pain score, one or the other. Most of the time they used 90 percent of the time they would use fever pain. And then if your fever pain score was 2 So deliberately kind of in the in the low range They would do a group A strep rapid antigen test which they could do in the pharmacy department And then they would either at that point decide to give you either antibiotics or supportive treatment only and supportive treatment was like It says paracetamol. Here's a lozenge. Here's an anesthetic throat spray. Go home And they say of everybody that came, about a quarter didn't qualify for the rapid antigen test. And then of those tested, the remainder, the remaining three quarters were tested. And of those 29 percent were positive. And then Most of them went on to get an antibiotic, typically penicillin, and that was prescribed by the by the pharmacist. And they put up the number of GP appointments that this probably saved. And it was in the thousands, but I'm afraid I didn't manage to get the number in time. It was an interesting success, because I know there was a lot of sort of trepidation when it was rolled out across NHS England, pharmacists prescribing. I don't really know why of all the allied health professions that are being given, that would prescribe antibiotics, the most stewardy ones of them would I think be pharmacists. And so this sort of test and treat implementation in Wales was a validation that it can be done safely. That was quite cool.

Callum: 13:02

That was in Wales, you said.

Jame: 13:03

Yeah.

Callum: 13:05

Yeah, that's, it's really interesting. And I guess, just reflecting on that and comparing it to HAP, where, where this sort of protocolized medicine works really well is where we have good data, we've got clear protocol, penicillin allergy is another way, where allied health professionals such as pharmacists can have a big impact and that's been shown in, in some trials in Australia.

Jame: 13:26

Yeah. And, and the space study actually, which just published a few months ago NADOSH South was involved in that as well. And it was pharmacist led, de prescribing.

Callum: 13:35

People might have reluctance about this sort of thing, but ultimately there's not enough doctors and healthcare is overwhelmed. So we need to have other ways of working. And I think this is really good. Take that simple stuff away and say, okay, this is straightforward. It's a protocol. You just follow the protocol. It's safe. We can, we can prove that. And then we'll leave the complex stuff to those sort of people. Medics, which, which is, I guess sometimes in my practice, I'm like, Ooh, a straightforward case. This is great. I can just do this without really having to challenge myself too much. But it's probably not the best use of, of, your, your specialist doctors or your GPs or specialists and in community medicine, I

Jame: 14:18

the difference, as ID doctors, when we're, dealing with the bacteremias and the complex cases and when the decision is not straightforward, certainly. In fact, maybe now I'll chat a bit about Pharmacy first because there was a presentation by Andrew Seton who is the head of the Scottish Antimicrobial Prescribing Group, a physician in Glasgow, and as of a few days ago the head of BSAC. He's the new chair. So congratulations Dr. Seton. And he presented on Pharmacy First Scotland. And so this is the. Where you, you go to a pharmacist in Scotland for your mild to moderate complaint. And what are these complaints, Callum? They are shingles, UTI in females only, hay fever, which is not really an infection impetigo, and skin conditions, which are, anything from boils to, to mild cellulitis. Apparently, over the last few years, 31 percent of the population has accessed pharmacy first. Mostly kids. So that's 1. 62 million. Scotland's got about 5 million people in it. That's a lot. 85 percent of them end up receiving treatment. And as an example for sort of female UTI, about 215, 000 people have been seen so far, of whom about 83 percent were given an antibiotic and 6 percent were referred on to the GP and the remainder were told you don't need it, you don't meet the criteria. And they, they were wondering like, is this going to have a massive impact on the amount of 90 frantone or trimethoprim used in the community? Because that's the two options that the pharmacists have. And they had a look and there was no impact, it was exactly the same, but there was less quinolone use. Because the pharmacists can't prescribe quinolones, but the GPs can. And so Pharmacy First is a a sort of seems to have this interesting phenomenon of being like a stewardship measure in Scotland. And that's where it's been going on for the most. and obviously it's been introduced in England. And they're doing the same thing. They did present some preliminary data, but I didn't capture all of it, but their indications are slightly different. Sore throat and UTI, percent of the attendances are for one or the other of those, and then 17 percent sinusitis, 12 percent otitis media, and then the remainder are impetigo, shingles, and infected insect bites, and they all make up about 15 percent in total. And yeah. So it's just getting started in in England and it's set up slightly differently. But it'll be interesting to see how it goes over the next few years.

Callum: 16:54

think, I think, it's very positive. I guess it aligns quite well with something I think about a lot recently is realistic medicine, there's a white paper, from the chief medical officer in Scotland about that. And it's a sort of priority, and there's various principles that underlie the aspect, doing the right thing for the right patient at the right time, et cetera. One of them is unwanted variation in practice.

Jame: 17:15

Yeah. Yeah.

Callum: 17:17

I think. That this human nature that we are not machines, we will have our own biases. And I mean, that's a big part of clinical reasoning is, is thinking about, what influences our decision making ultimately. But there's sometimes where that's useful. But there's sometimes where actually you should just do what it says in the protocol because we know that's the right thing to do.

Jame: 17:36

True enough. Speaking of which, Callum the, the next bit was what? There was little sort of gram negatives mini section that I found really, really interesting. And I'm a, I'm a sucker for difficult to treat gram negatives. I find them quite fun and

Callum: 17:50

we should do an episode on that

Jame: 17:51

maybe we should,

Callum: 17:52

or something.

Jame: 17:53

yeah, well it's on, it's on the back burner column. But yeah, I think it was Myrie McLeod who was presenting on, the Scottish experience with kephidercal she's a microbiologist from Glasgow, and It was interesting because they were, they were talking specifically, they didn't have a huge amount of use of Kefiderico the Trojan horse, but they were, they were pointing at the instances where they had encountered resistance, because I think there's been a lot of signals about failures with Kefiderico. It had been sold by Shinogi as a bulletproof, resistance proof drug. That was certainly how I experienced it as the end user but anyway like the, the iron transport mechanism, like everybody thought that this was like, just going to be the be all and end all. And it was impossible to overcome, but it turns out that's not the case. And so they were talking about the times where they had encountered resistance to Kephidergal. And quite a lot of them were associated with an NDM 5 carbapenemase. And the They were all in E. coli actually. And there were some other instances of resistance where they, a couple of times people just tested negative. The other time they would get a really random carbapenemase like oxa 23 and 48 and they weren't, I, my impression was they weren't sure whether or not that was contributing towards the resistance, if but maybe I got that wrong. And then they talked about the times when they had try to use Kefidercol in Scotland. So the couple of cotrim resistant stenos that they treated with Kefidercol and minocycline and, a DTR pseudomonas where the only other options were aminoglycosides and colistin. So when your back's to a wall like that and you've got a beta lactam available, even I say use it, and I'm team aminoglycoside through and through. So that was quite interesting. And then following on from that was like a description of the UK subscription model from Professor Philip Howard. He's a sort of big wig working for NHS England and NHS Improvement. And he was talking about the sort of de linked scheme and how it works. So a lot of countries will be aware that the subscription model has been trialed in the UK for kephiderical and keftazidime avobactam, and they were chosen, obviously, with some care. Keftadercol, because it's got a very wide spectrum against all the carbapenemases, and Keftazavi, because it basically covers everything except metallobacillactomases. And so that's things like NDM, Viminimp. But then, for that you either need to use Kefidericol or you need to use Astraenam in combination with Habvovactam, which is now available in Europe. And so he went through the system set up. Basically, there's four tiers, and depending on how useful your drug is There's only two so far, but the way it's going to be run in the future is depending on how useful the drug is, there's four tiers and you will either get 5 million, 10 million, 15 million or 20 million a year and that varies with the importance of the drug, whether or not there's any sort of suitable alternatives and they do This sort of mapping out of sort of qualities qualities per year and what you would use it for in the app. The expected numbers of patients that are going to be given the drug per month and they work all that and they then work out the UK's fair share of the global market for each antibiotic. So for, I think for Kevdarco that was worked out as about 10 million a year and then they offered that to the drug company. Thank you. And the drug company just gets that and we're allowed to use as much of it as we want up to a ceiling, and I don't know what the ceiling is. And, how has it gone? Most of the time they've been used to treat either Pseudomonas aeruginosa or Klebsiella pneumoniae. Those are the top two organisms. And then, what, what other antibiotics of last resort have we been, has, has the usage increased or decreased? They're coolest in use. has decreased and we think that, that could be due to the new agents we're using, but it also could be because of a lot of CFTR modulating therapies becoming widespread in the CF population because DTR pseudomonas disproportionately affects the CFs and those CFTR modulators are really bordering on magic in terms of their effectiveness. And then, amikacin is another difficult to treat gram negative treatment. Its usage has stabilized, and they think part of that, they were expecting a decrease, but they think part of that is that the, they're being used less for difficult to treat gram negatives, but increase in gentamicin resistance in some areas has meant that trusts have moved over to amikacin as their default aminoglycoside. So that was interesting. And yeah, some other countries are trying pool models that, that are slightly different from that. So they talk about push models and pull models. And so France are doing a minimum pricing guarantee for for reserve antibiotics that meet a non inferiority threshold in RCTs. And Germany are exempting reserve antibiotics from internal price referencing, whatever that is, Callum. So there's not, there's not only one way to to encourage drug companies to produce new antimicrobials for us. But certainly the subscription model seems pretty pretty good at what it's doing. And I'm hearing no complaints from Shinogi, let's put it that way, or whoever makes Keftazidime Avobactam.

Callum: 23:41

One question I had just there, which is probably a silly question, but say if you were just

Jame: 23:47

Perish the thought, Callum.

Callum: 23:49

interesting, you wanted to save money as a, as a hospital and you were presented with an option, and you said, and it was either, say, meroperine vaborbactin, which is now Recommended by the IDSA guidance for KPCs. So you're thinking, I want to use that, but, to pay for that, KEFTAS AVI is free.

Jame: 24:14

free. Yeah functionally free for the trust. I mean, obviously NHS England are playing, but it's all about what comes out of your purse, isn't it? You're right, Calum, there is a, an issue there. I guess I would say that,

Callum: 24:32

Ultimately when you're making a decision for a patient, you're making what you should be deciding what you think the best treatment for that patient is there and

Jame: 24:40

yeah.

Callum: 24:40

But, you do have to consider cost. that environment, you can't just ignore it, otherwise, we just give everyone d'Alba Vanson and job done.

Jame: 24:49

Yeah. Yeah. Wouldn't you? Yeah. True enough. True enough. I suppose I was going to say that you just have to rely on your friendly neighborhood microbiologist or ID physician or whoever's involved in the case to make the right choice for the patient. And I think you could argue it both ways. If you argued that they've got a key PC and that's the thing that IDSA are recommending, I think you'd be right. And I think if you turned around and said I'm not in America, so I'd have to follow those guidelines and it's not mentioned in ESMED. You would also be right,

Callum: 25:17

fairness, I think locally in Nadosh North, it's quite hard to access Meropim Veybaptim. By the time I got it, it was probably too late anyway.

Jame: 25:24

that's the thing. The availability trumps all, I feel.

Callum: 25:28

We're going far too much into the difficult to treat gram negatives now. And the listeners aren't here for that. They're here for the BSAC Spring Conference Summary from our BSAC correspondent.

Jame: 25:40

correspondent, Dr. McRae. Okay, fair enough. I mean, why don't we take a little sideswipe, Callum, into invasive candida infections?

Callum: 25:49

isn't Unless we don't do Canada, this isn't This isn't a Canada

Jame: 25:52

This is not a a fungal podcast yet, but I'm afraid we have to because we had a presentation on interviews of candida in general and the new Wonder Drug Res Afgan by friend of the show Twitter legend and occasional D physician and Neil Stone. So he presented on the second day and it was a really interesting overview of Candida in the first instance And so the he gave a sort of interesting overview of the sort of challenges of treating candida, in particular the rising issues with using fluconazole as your first line therapy. So there's more fluconazole resistance going about than there used to be. I don't know if this has hit Scotland yet, Cal, so I don't know if you're still using fluconazole as your default. But a lot of other places are moving to the echinocandins, and of course there's, in many ways they're well tolerated, and they're once a day IV infusions, but they are IV. And, what are the alternatives? People have probably heard of ibrexifungir, which, Functions in much the same way is an Akanacandon but Azoral, and one of the other options is Razorfungan, and he presented the last third of his talk on Razorfungan, so this is a long acting Akanacandon, and he put up the molecular structure of that in, I think, Caspifungin. And there's just, it's just some tiny little organic chain off the side of the molecule. But that makes all the difference and has prolonged the half life quite a lot. And the good thing about this is the half life is about 5 or 6 days, so you can give it once a week. And I think for, OPAT practice in, in particular in treatment of candidal infections, that will be very interesting to use in the future. So you give it as a 400 milligram load and then you would follow up with 200 milligram weekly infusions. There's no adjustment for renal or hepatic impairment or old people or obese people. And the, the only kind of side effect of note is derangement of the LFTs. And. The, he went over the sort of evidence base for this. The third, the, sorry, the phase three trial was called Restore, and that was invasive candle infection. The comparator was ca with Fung and the outcome was day day 30 mortality due to invasive fungal infection. And there was non-inferior endpoint cure rate was 60% in both groups. 60% you might think is quite poor, but actually for invasive fungal infection, that's pretty good.

Callum: 28:18

Got it.

Jame: 28:19

And then, the last thing that I took notes on, certainly there's loads of other presentations that I'm not mentioning by the way, but these are the ones that tickle my fancy was a a presentation from Glasgow from Rachel Roger, and that's a microbial pharmacist. And they were presenting data on IV to oral switch of metronidazole on on the surgical wards. And they were identifying the barriers to using that.'cause Metron is highly buy available. Why wouldn't you if you had the oral route available and then it was this, the stuff that you would be expecting. Calum, a chaotic environment at work and sort of hierarchy issues, not wanting to go against the consultant's desire for IV. And so what they did was they, Did it did a bunch of stuff to try and change the culture, including implementing the UK national IV or switch criteria, which we should put a link to in the in the show notes as well, and then standardizing the sort of guidance highlighting that the oral would be just as good and putting oral as first and IV a second. In their recommendations for metronidazole. And the, their old guidance, they'd said at the end, Oh, you could use this oil if you want to. Sort of way, way down at the bottom. But only about 13 percent were switching based on that. And they did some other stuff that was quite good. They, they had quite a nice poster about how plastic heavy using IVs was. And so I think a convincing argument that a lot of people are using is that it's way, way less plastic, which doesn't get recycled, it all gets incinerated. And so if you care about, the planet Callum you can switch them to Oro and that would be much more green and eco friendly. And so they did that and the last thing they did was that on their electronic prescribing, they put an alert saying hey, if you consider switching this to oral, I'm not sure how annoying that was, but their outcome was really impressive. So they did this over three years and they reduced the DDDs of IV metronidazole by two thirds and they reduced their overall metronidazole spend because IV is more expensive than oral by 40 percent. So it's cheaper and it's just as effective and it's way less nursing time about 1, 900 fewer IV administrations per month and that's 659 fewer nursing hours per month and 35 tons of co2 annual saving they Worked out with some jiggery pokery that I didn't completely understand so, you know kind of food for thought actually because we're you know in the midst of going over our sort of sepsis guidance and whenever I see it in microguide we're trying to move over to the Scottish empirical sepsis treatment in Nadosh Royal Infirmary South. So amox, gent, plus or minus metronidazole if you suspect surgical sepsis and the metronidazole is listed as oro and then in brackets you can also give IV, they give the dose. I'm trying to get the same done for amoxicillin. As well. So after dose one, you can just consider switching right away.

Callum: 31:38

Forms of medications and switching them. Fluconazole was one, There was someone on IV Clary. I was like, why? I guess, Ivosing metronidazole is great. And this is huge data. Even better is just saying, do we actually need metronidazole? I think that's an upcoming episode. We're going to do an episode on aspiration pneumonia and anaerobic cover in general because that's something that I've been reading about a lot recently. Yeah, today I was like, you don't actually need metronidazole for a mild aspiration pneumonia, it's something that's such in the consciousness.

Jame: 32:10

Really difficult to shift, but I mean, the people just don't know enough about any ropes to know what covers and what doesn't. Do you know what I mean?

Callum: 32:18

until recently I didn't really understand anaerobes.

Jame: 32:20

Oh I'm sure you

Callum: 32:21

I'm not saying I'm an expert on

Jame: 32:22

No, no, no, no, you've said it Callum, so you can just enlighten us in a few episodes time, alright? Fine, but that's all I had to say.

Callum: 32:30

that's it, only however long that was,

Jame: 32:33

Yeah, I know.

Callum: 32:34

lot to say. So all I had to say is so much.

Jame: 32:37

Good luck editing all that down, pal.

Callum: 32:40

Yeah, I've, the notion page has got notes, all this, and we've tried to get some links together. I've been, I've been reading a little bit there about the, on the keep antimicrobials working page by Resources on there.

Jame: 32:53

Yeah, I was going to look at that later. So that's resources for teaching in medical school. Antimicrobial stewardship and one of my feathers in my cap is that I, I teach at a medical school and so I'd be interested to know how much of this is actually being, taught where I work. But yeah, BSAC has lots of educational initiatives and that's one of them. So that's worth checking out. Keep Antimicrobials working. If you Google that, you'll get to the site.

Callum: 33:18

maybe we could get some from BSAC to come and tell us a bit more about that.

Jame: 33:21

Ah, maybe.

Callum: 33:24

to talk about. Too little time.

Jame: 33:26

True enough. And now our time has run out Callum.

Callum: 33:29

Our time tonight has come to an end.