52. Escalation Emancipation

Loyal Listeners! Free yourselves from this outdated language! Emancipate your hospitals from 'Escalation antibiotics'!

In today's episode, Callum and Jame rant for 35 minutes about how we talk about changing therapy, and how talk of escalating antibiotics leads to desire for 'big gun' antibiotics.

Apologies for Callum's audio quality on this episode. We'd apologise for Callum in general, but you chose to listen, really you've only yourself to blame.

Links:
Tunnocks Tea Cakes
Ledaig whisky
ID:IOTS guide to Aminoglycosides

Chapters

• 0:00 Challenging the Language of Antibiotic Escalation
• 10:03 Rethinking Antibiotics
• 21:18 Antibiotic Knowledge in Clinical Practice
• 33:41 Antibiotic Management and Escalation

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.

Speaker 2: 0:10

Soon may the ID team come, to discontinue the Tazoci n. One day, when the CRPs done, we'll take our leave and go.

Callum: 0:21

Callum you're here. Yeah, you're very zoomed in this time.

Jame: 0:31

It is, isn't it God? it's streamed and I thought it would be.

Callum: 0:34

I know it's got used to EJM and now it's live in-flesh.

Jame: 0:39

Here in flesh.

Callum: 0:41

Yeah, our mini infection conference On today, the day that the Be an Idiot collaboration was The Be an.

Jame: 0:51

Idiot collaboration was announced. Yes, we can talk about that later. For now, would you like a drink? Oh, thank you. Yes, to celebrate your little visit to Nadore South, we have here some Lecheg. That's L-E-D-A-I-G, a ten-year pita-twisky from the Taubermore distillery in Mull.

Callum: 1:16

There we go, lovely, and what better to pair it with than the highest quality in Scottish.

Speaker 2: 1:22

The greatest sweet in the history of all sweets.

Callum: 1:26

Your words are not mine. The marvellously lush and fancy Tunnex tea cake.

Jame: 1:36

King of all tea cakes. And if the American listeners are wondering what a tea cake is, we can't describe it any more than we already have. So just google it Tunnex tea cake. Or we can put a link in the show notes. I just taste like home. I don't even like them.

Callum: 1:55

So obviously I've travelled down to Nadore South to record an episode of the podcast and there's no other reason.

Jame: 2:11

Do you remember that time that we were on the flight and there was an emergency And this guy had emergency senses and needed antibiotics, but the antibiotics in the airport were at the other end and we had to run up several moving walkways with the antibiotics to deliver them to the patient?

Callum: 2:32

Yes, you do, i do apparently. Yes, i do yes.

Jame: 2:37

I remember it well. We had to escalate those antibiotics. Yes, and that Callum is the only time that that phrase should be used.

Callum: 2:48

Yes, that's the rant done. So, yeah, i guess I was reflecting that we were doing a wardrobe and getting plans for patients and we were thinking ahead to what happens if the patient gets more unwell, which is always a difficult situation, because when you say, well, if someone gets more unwell, are they more unwell because of the infection you're treating them for or, if they don't have an infection, which infection is causing them to be unwell? And we know that the type and source of your sepsis has a big impact on which antibiotics you want to use, because that's which organisms are going to be there. And I think our lexicon for antibiotics often includes the term escalate, and I was really reflecting on is that the right term? And I'm going to try and convince you. I don't think it is.

Jame: 3:39

You don't need to, because I already think it's not the right term. I'm not talking to you. Oh right, sorry, sorry, sorry, it's you. Oh, the loyal listeners.

Jame: 3:46

Yes, i think this has been coming up more and more down here as well, has it? Yeah, because we, you know, particularly, you know, to my mind, treatment failures can be classified thus you have the wrong drug for the bug, and that can be because of resistance or just because you've got, you know, one that's low by availability and it's not getting in sufficient concentration to the target site. Two is that you've got the wrong diagnosis, you know so, like that could be not an infection or it could be a different infection. And three is just that, no matter what you do, you're not going to get on top of it. So there are some infections that we just can't fix and we get there too late and you can escalate to meropenem or, you know, insert any other antibiotic that's sometimes described as a big gun there, you know to your heart's content, and the patient will still die. And you know, i kind of feel that quite a lot of the time, that the escalation is happening to placate the clinical team and not to benefit the patient. We talked about that.

Callum: 5:03

There's a bit of a philivia in one of the episodes about antibiotics that end the life and that is a stewardship target and it is really difficult when you're faced with that individual person. And I think the flip side of that is you know there's plenty of situations where we escalate antibiotics, quote unquote, and people you know don't do well despite that because of usually host factors or you know infection factors like severe skin. So tissue infections is an example where you know antibiotics, no matter what you do, is not going to get the perfect management. Things might not go well for that person. And the flip side of that is also there's times where we will quote unquote, escalate antibiotics and the patient gets better and is attributed to that Like well, last time I had this I had to give the Meropenem film to get better, whereas in fact it's a natural history and I think a really good example for that is skin cell tissue infections like cellulitis, where we see that the clinical court of Pylone Fitis is another good one. It does take a few days for that sort of inflammatory response to settle down And once you start, say your flucoxophilum and our capilliform erythema on that limb may extend, the fevers may continue, the CRP continues to go up. Because of the CRP lag, these things change. And because they get worse, we're like, well, oh well, we're not on the right antibiotic, so we should? people think about thinking about that classification of failure. They think we've not got the right drug for the bug, so we're going to change. And I've seen that once with cellulitis.

Callum: 6:29

Where we went from, you know, i think they were on flucoxosilin and Ben Penn was added in and Clinton and Eism was added in, and then we were on Tileson and we were on Meropenem And I was sitting there and like this isn't, you know, it's very junior. At the time I was like this isn't seem right, this isn't what I've seen. When I was working in my ID And I wasn't right And it was a complete like it was just the natural history of this person's disease. If we just kept them on the flucoxophilum, i'm sure that things would have gone the exact same way. In fact, maybe they would have gone better, quicker. You know, is Meropenem better than flucoxosilin for cellulitis?

Callum: 7:00

Well, I mean the holistic approach of the side effects and risks of antibiotics and the effect of microflora on your flora?

Jame: 7:09

No, but I also think that you know when it comes to you know killing strap, which is what you need to do in cellulitis, you would have a hard time persuading me that anything is basically better than either Benpen or Flukelocks. I've seen no literature to suggest that Meropenham kills Streptococcus any better than Benzopenicillin does, and you know that for Flukelocks the MIC breakpoints are actually a bit lower for some of the Bedi-Hemolytic Streps than with Benpen. So if somebody was on IV Flukelocks and I would now roll Kefsoin into this, i'd argue that they are on optimal therapy. Yeah exactly.

Callum: 7:51

And this comes to, i guess, my analogy, which is that I think when we talk about antibiotics and infection doctors and I find myself doing this, I'm trying to stop myself doing it.

Jame: 8:01

It's really difficult to reverse your language.

Callum: 8:03

It's so embedded in the culture of antibiotics, culture right. The idea is in everyone's head. I think there is a little ladder, or a re-ladder. If we're going to get the talking Scottishers on A re-ladder of antibiotics right And at the bottom of the ladder is Pidolnylilipopenicillin. This, you know, the weak antibiotic and it's not doing any better. Yeah.

Jame: 8:26

Pidtas keeps on stealing its lunch from the other thing.

Speaker 2: 8:28

What's a?

Callum: 8:29

moxicillin, we go up to Coa Moxiclava. Tazazin is better than Coa Moxiclava, isn't it? And then a mox, metronidazone, gentemisin, somewhere around there. I think people generally put that below Tazazin. If you've got your own ladder, why don't you tweet at us at idiots? underscore podd ads, is that it? There's the answer At idiots.

Jame: 8:50

We've had this Twitter handle for a year. Yes, it's idiots.

Callum: 8:54

Underscore podd, i tweet us there with your antibiotic ladder. Maybe draw it, get your kids to draw it. Everyone get involved.

Jame: 8:59

But you know, at the top of that is your carbapenin. Oh, you still have one there.

Callum: 9:02

So we're going up from Tazazin. You know, i don't know exactly some of the weird lactams going into that episode.

Jame: 9:09

Or you're in the UK in particular we've got this bias against any Kefal spawn that isn't Kefrax on the Kefal tax into Kefapen. You know that's a fourth gen, It's very broad spectrum, It's got absolute model things. I sort of put that up there And then above that would be the carbapenin You know, like Kefal, pure, Kefal, exan.

Callum: 9:27

You know everyone's ladder is different. I'll be placing these, which kind of feeds, into what my next point is. So you know some people's idea of antibiotics and it's quite hard, when there maybe isn't data for a lot of these situations, to say X is better or non inferior or inferior to Y, Yeah, And when we have those studies, it's absolutely amazing to be able to say no, vancomycin is worse than flukoxicillin for snaforius And Jamie, you talked about this before. You said that vancomycin was the Rolls Royce of antibiotics.

Jame: 9:59

No, I didn't. I said the opposite of that. I said that I'd said it when I was an F2. I know.

Callum: 10:03

I mean you'd thought that, and our ladder changes in our head has been no more about antibiotics and effects, and I guess what we equate the increasing quote, unquote strength or, you know, escalating antibiotics is broadening spectrum. But in a lot of situations that is not only no better or sometimes worse, like vancomycin and flukoxicillin for snaforius, but it also has the often deleterious effects on things like your microbiome and other other sort of worse side effects. You know, increased risk of Candidemia with, say, maripena, yeah, and so I guess my thought was and I'm sure not the first person to think this, but anyway is that instead of thinking about antibiotics as a ladder, we need to think about it as a, as a Venn diagram, and instead of saying we're going to escalate antibiotics in our anticipatory planning, we can say what's our broadening plan? Yeah, one term that you could use I'm not sure that's a perfect term.

Jame: 11:07

Well, no, i I use this, try and use the same terminology. I talk about broadening antibiotics And you know classic James usually my method of broadening out cover is usually worried about gram negative cover And usually I add gentamicin into it as as well. Come as a shot to precisely nobody in the audience Maybe it's guides, and me like a size to hear as one of our best performing episodes, partly because I was just so passionate Taking this the word escalation out of the equation, because that also implies betterness.

Jame: 11:46

You know, maripena is better than well, not for group A strip, it's not. You know, for grandpa's to cover, it pops out at. You know, flu clocks are selling basically beyond that. If you're using something else is because of resistance And usually, you know, particularly with with staff of caucus, it's PbP mutations And if you know the PbP is to a instead of two, basically no be, the latter will work except gift Tarley. So carbapenems are out, piptaz is out, comalox gloves out. You can use anything you like, won't work. You're stuck with the second line stuff. You know your vancomycins, your deptomycin is Linnaeus lid which is rapidly becoming the dominant alternative.

Callum: 12:33

Yeah, i think when we, when we talk about it. but it's, why is this matter? I guess when we're doing educational thing you start with you know why is it important? I think it's important because the way we talk about antibiotics can have a big effect effect on stewardship. I admit there was a lot of sessions about, like the behavioral science aspects or things and I didn't get to go to all of them, but I certainly spoke to a lot of people that have been And I think we may be underplay that in medicine, the culture around our practice and the things that influence people's trust in decision making. You know that discussion where you say to someone why don't we use KefalX in here And the response says I don't like antibiotic X. I find that really problematic.

Jame: 13:14

Yeah, i hate that. That could be a separate rant on the self. But, like when people say I don't like this drug you know a lot of people don't like amyloxides, for example, i think to myself you just don't know how to use them right.

Callum: 13:27

So just to walk us back to the point, which is that the way that we talk about antibiotics can have an influence on the way in which they're used, and that is a big stewardship issue, i think, and I think we maybe under recognize how often this quote unquote escalation can be really harmful. And my experience of giving escalation plans, which we do for our intensive care patients or people that we expect might come on well, is essentially you're tired, it's overnight, you don't know the patient, you don't know the team. Potentially you're presented with someone who has a new fever, or, quote unquote, a new fever. They've been spiking for three days And you know as much. As I say to them here's an escalation plan, but only use it if you know parameter X or Y. They go into shock, you know, maybe comes to be early, unwell, and I know what I mean by that.

Callum: 14:20

What's written in the notes might not reflect that discussion, and then what happens overnight might just be I'm busy, i'm tired, i'm gonna escalate, because that is, you know, quote unquote, the same things to do, and they don't want to be criticised for not escalating. And so you get into this pattern of behaviour where a response to patients not settling quickly with infections, even when we might expect them to have ongoing signs of infection despite antibiotics being started, is to change the broad-respection therapy And it kind of goes against what we're doing in stewardship now, which I think is really good, which is start, broaden and narrow down.

Jame: 15:01

Well, i think you know, particularly when it comes to intensive care, you don't want people like that. that's one of the areas where you don't want to restrict the use of kind of broad-spectrum antibiotics, because people need to be able to to broaden out those antibiotics at fairly short notice because you know they're the sickest people in the hospital. So you don't want to like ban carbapenems unless microbiologists approve, because A they'll phone for approval and they might get through to somebody who doesn't know the patient is sleep deprived, doesn't know what they're doing. Your escalation plan, given ours earlier, is probably the safest way to make sure that antimacrobial vice, you know, is followed. So, like giving a given an escalation or broadening plan, then the clues, moving to a carbapenem isn't necessarily a fail, do you know what I mean? Because the alternative is somebody who doesn't have a clue about the patient We're going to reserve antibiotics for certain cases who are really reserving for, not these really sick, unwell patients.

Callum: 16:04

But I think and it's really hard to move away from it I think labelling that as escalation is harmful because in situations where we don't need broader cover, we end up with people believing that these broader agents are better for their patients, and I don't think they are. I think they're causing harm And I think we need to say you know, like narrowing spectrum or de-escalating doesn't sound good, but I think like focused therapy. Well, let's focus the antibiotics. They've grown this bug. Let's do focused therapy. Focus sounds great. I like the term focus.

Jame: 16:38

Yeah, so it's like you're intensifying like a magnifying glass under that you know to burn it.

Callum: 16:47

And maybe we need qualitative studies on the sort of aspect, or maybe those exist. If they do, then please send them to me and educate me. But I, yeah, I think that there's a real problem with the way we talk about antibiotics in infection specialties and elsewhere, which leads to this ladder existing people's heads And there isn't. There isn't a set ladder, And maybe there is a ladder for specific bugs.

Jame: 17:16

Well, no, I just couldn't, because when it comes to antimicrobial resistance, that ladder does exist. Okay, do you know what I mean? There's your stuff that treats ESBL, but it doesn't treat anything else There's a lot of blah blah, blah.

Callum: 17:29

I mean I said because it's not like a ladder because there's some things you go higher up the ladder and they're missing runs below on the ladder. You know you might have the broad. As you broaden spectrum you might lose aspects of cover. And ladder is not a good analogy because you know as you go up you might lose lower down runs. Is there several ladders at once?

Jame: 17:51

Well, it gets fuzzy at the time, but when I'm thinking about beta-latomases in gram negatives, i am thinking about it in a stepwise fashion.

Callum: 17:58

You know like actually now, when does? that fit in the ladder Because it's going to cover some things that are not going to treat. I think we need to throw the ladder out the window And I think about antibiotics and you know, spectrum of activity and broadening and narrow as, I guess, like a 3D Venn diagram. Does that make sense? Do you know those topographic maps you get, Which is like the height maps of hills and stuff?

Callum: 18:26

And like some people might make like a 3D model of them. So it's like you cut out one of my friends and it's really amazing And it makes like maps of the minerals in Scotland and puts them up to different levels And I think there's a Venn diagram where you say you know all the organisms laid out in a chart. However, you want to do it gram positive, colchi, gram negative and spread out to the monocover part of that And the sort of area covered by the antibiotic is all the areas it covers And then how high it goes up in terms of elevation is you know kind of how effective I think it is. So you know vancomycin might have a broad coverage over gram positives. There's maybe not as high. Penicillin has got a narrower area of coverage.

Jame: 19:12

But the peak is higher. Okay. Okay, I sort of I didn't know who you were going with it, But yeah, I think I'm starting to come around to it.

Callum: 19:20

So I don't know, i'm not sure I have the solution to that issue And obviously there's lots of issues in infection medicine And maybe this isn't the biggest one, but what I think there's some issues on both sides though, calum.

Jame: 19:36

So there's on the, on the home team's side, there's this patient's getting worse. Oh, really, have their, their pulse gone up, as their respiratory requirements, you know, gone up, as you know what's happened exactly? Well, they're, they're still feverish, and that's the only thing that's gotten worse. So, like the trigger for escalation is quite low in the, in the known infection teams, i would say And your, your pilot of rights, is a classic example of that How many times Calum, you've been called in Nadosch And they've said this person, we need to escalate the antibiotics. It's been three days and they're still feverish. Oh, how are they? Well, they want to go home, back to the job, because they're feeling much better Still the CRP has gone up.

Callum: 20:22

Well, you know, and yeah, it's that holistic assessment, yes, i think is the key is, you know, how is a patient feeling, what are their observation, what are their prioritizing that because a dying patient doesn't feel better.

Jame: 20:37

But then the other bit is us, the microbiologist and the infection specialist, that are giving the advice because we say escalate all the time.

Jame: 20:46

You and me have said it accidentally tens of times in the middle of this podcast, we were specifically writing about that. Do you know what I mean? Like we're as guilty as anyone. This language is kind of you know, it's not for the birds, everybody's still using it, but it is one aspect of stewardship that we could probably enact fairly easily with like a low barrier, Just sort of say escalation is gone From now on. We're talking about broadening out focus.

Callum: 21:18

I did sort of hold my tongue a lot when I was thinking about this.

Callum: 21:23

And then one woman on a wardrobe and I thought I'm going to tell people And I sort of gave my little spiel talk that I think I need to practice to some more junior doctors and intensive care unit, and I think they got it. Why? But I just got the sense they didn't care And I guess that's the thing is how can you do a big thing to change And how would you convince people that they're going to be able to do that? How would you convince people that it is, you know, important? I'm not sure, and I think a lot of people's.

Callum: 21:55

I guess the solution would be right is that everybody had the same knowledge of antibiotics And I don't have a complete knowledge of antibiotics And I think you have a much better antibiotic, certainly the pharmacology of them. But you know, if we were able to go on, everybody clinically working was educated about antibiotics and knew about spectraactivity and knew that Vank was worse than the box of this and that broader didn't necessarily mean better. That would be the ideal. But like that is a pipe dream And that goes back to university and you know the curricula is so crowded with stuff It is quite hard to make sure that we're getting people with this knowledge. And actually recently I gave a lecture and one of the students said to me why do we need to know anything about antibiotics and what they cover? Because we're just going to look at the guidelines. And I was like, well, you know.

Jame: 22:44

Well, that kid has a point, Because you just can look at the guidelines.

Callum: 22:47

Yeah but then? but then at least the point where you're outside of the. I don't think I need to convince you, but when you're outside of the guidelines are things don't quite fit. Or maybe they've been on a moxiesilin, gentamicin, metroninosilin, someone's stopped the gent and they're getting worse. You need to think maybe the gram-negative cover needs to be added back in. But because infection specialists are so available, just phone them And then it leads to this situation where people see us talking about escalation, talking about antibiotics in a certain way, and it leads to a lot more interaction with infection specialists.

Callum: 23:21

That maybe isn't needed. Yeah, so you know, we do need plans for if people get worse. I think it's whether you say you know your plan might be a broadening or say you've already got an organism in diagnosis. It might be an increased focusing or an increased intensify therapy. Maybe that's a better way of talking about it. Yeah, so if we're talking about, you know, a group, a strep, the intensification of therapy might be adding clandamycinulin or giving an IDIG dose. You know, is that a better term? Maybe we need to do a Twitter poll. That's how you decide everything.

Jame: 24:00

I guess I suppose the only thing with that is that I could well imagine somebody would think intensifying therapy meant escalating, to Do you know what I mean? I?

Callum: 24:11

don't know. I don't know if this is a battle I'm going to win Instantly. How did you answer that kid? It was real. It was quite challenging lecture because the fire alarm had gone off about five minutes into it And it was someone else's slides and I wasn't very familiar with them And I was having a lot of technology issues. The lecture feature wasn't working well on the sound recording, It was just things weren't going as well as I had planned.

Callum: 24:36

And I think what I said to him was that there's an argument that everything in medicine can be put in a guideline And we could say to you you don't need to learn this because it's in the guideline. But we're not training people to be like postgraduate year one doctors And if you come out of somewhere of a medical degree you should have an understanding of most areas. And I'm not expecting them to be like experts in antibiotics, But that basic level of knowledge sort of equips people to say when things aren't right, You know to recognize when things haven't gone well or you've got an allergy. And also the other thing I said to him and I think this hit home was fine, You may work in Nade or Schnorf and I might be available.

Callum: 25:24

You know, give you my personal number and be available on call 24 seven to the stock? No, no, I'm not. But you might have easy access to infection advice, But you may go and work in the low middle income country and you may not have access to that advice, And what are you going to do then? Or maybe there isn't guidelines where you work well. So I think it's important. I guess it's convincing everybody else.

Jame: 25:51

What's on your mind?

Jame: 25:56

Did you have the same same medical I'm teaching pharmacology to a medical school in England And as part of that I was asked to give like a lecture on antibiotics in general, like a revision session. It was big and it was long and I basically went through every drug class. I thought they needed to know something about like so that it could be used as like a reference for revision. And, but I pointed at the beginning, almost every trust in England has a micro guide or an antimicrobial companion app. We will expect you, as F ones, to just follow everything that's in there. The issue is that the app or the guideline doesn't know anything about the patient, so it doesn't know if the patient is allergic or not or if it gets a side effect with this antibiotic or that antibiotic.

Jame: 26:46

So you are still going to have to choose and in order to choose you need to know what you're doing. Maybe not the spectrum so much because they'll have been pre selected And you'll pick that up passively. But certainly the side effect profile, frequency of administration, whether or not can be IV or oral, all that sort of stuff is worth being passively familiar with and You know, at the end of the day it's like you say, we're not training them to be the Crappist daughters in the hospital on the first Wednesday in August. We're training them to be good doctors at. Good doctors know a little bit about antibiotics. They're not infection specialists, but they know what they're doing with the antiposses that they use.

Callum: 27:26

It's not uncommon. I do feel like it should Play a stronger part of the curriculum when it takes up so much of what we see is like 30% of inpatients have an infection. So yeah, what?

Jame: 27:38

30% of inpatients are on antibiotics all six and 30% of people are coming to same-day emergency care leave on antimicrobials. So I'm with you that. I think it should be taught to be percent of the curriculum.

Callum: 27:50

What That'd be amazing. Well, taught better and not a lot more work to do Stewarded harder.

Jame: 27:56

But part of that stewardship is avoiding this idea that the You know the cure is almost to escalate the antibiotics. Sometimes it's just holding on.

Callum: 28:07

So there's two things that go through my head when you're saying that, james, when you were talking about the student, and One is that there is so much diagnostic uncertainty I don't think we're good at talking about that a lot of time.

Callum: 28:20

When we talk about clinical reasoning, the notes will note CAP community acquired pneumonia and It'll give a plan for antibiotics and we don't write differential and we don't acknowledge the uncertainty in the diagnosis. You know, maybe we write sepsis, unknown origin, and that's that's difficult as well. And I guess having more antibiotic knowledge allows you to recognize like, okay, we're gonna give this patient a moxilmetionizant entomysin for inter abdominal sepsis or a tazacin for inter abdominal sepsis or something like that Piper, still in taste of that time. But we also think they might have a community acquired pneumonia and it could be atypical, because there's bilateral changes and The guidelines won't tell you what to do when you're trying to cover these two different things. But having a little bit of antibiotic knowledge might make you think oh well, maybe I should add in something of atypical cover and Or, or maybe you've got some of pneumonia but they've also got you know, two things going at once, which organisms are covered, which things are, and I Think people are proud of that.

Callum: 29:22

Yeah, so like acknowledging diagnostic uncertainty and what to do when things Overlap is one thing, and the second thing the eyes cannot see Well ahead does not know. I love that saying in clinical reasoning, because when we talk about how you make decisions in All basically have this thing called like disease scripts. So that's like your knowledge of so, say I talk about like Lemme or syndrome, as like a quite unusual, you know infection caused by a fusobacterium. Yeah, and you know, jake, when I say that, when I say lemme or syndrome, what pops into your head?

Jame: 29:59

Juggler phlebitis caused by local invasion of an anaerobic organism, usually fuse a bacterium, but occasionally stupidly stripped caucus.

Callum: 30:06

Yeah, and you can add things and onto that and as you get more infectionology, get that.

Callum: 30:11

And I think that we kind of have disease scripts for antibiotics in a way.

Callum: 30:15

You know, when I say like super foxes in and Allergies, then the whole load of things gonna pop into your head And so if we don't train people in like the knowledge of antibiotics and spectrum, then it maybe doesn't pop into their head like they're on these antibiotics and not getting better. What does that mean about source or Those sort of things? so I think I think that's one of the things I might use to convince people is that you know, you can't look everything up all the time, you can't always have time to look at guidelines and if you don't know that super foxes and causes a Super-spinatus tendonitis in not an insignificant of patients, if you're patient on sip and riff for their Super fox and riff ambison for their hip prosthetic joint infection as shoulder pain, you might not think To do. You know. You know you realize that that's to do with a super fox. That's sort of aside from this, the escalation many around, isn't it? we straight into why is important to teach people What I think it's all part of it.

Jame: 31:13

I think that one Failure of the way that current micro guides are set up or set up, is that they are They're sort of diagnosis dependent, whereas I think that body system dependent might be a better way to go. Do you know, like the?

Callum: 31:29

diagnosis is Sometimes, you know, like aspiration and warning versus cap.

Jame: 31:34

It's like Yeah, versus like COPD exacerbation and all that, but like at the end of the day They're all sort of getting the same thing. Yeah, in the NATO's north guidance We for intraabdominal sepsis. We had a bunch of different you know pages with a bunch of different indications and one of our bosses simplified all to intraabdominal sepsis and and You know, gave a regiment and said to continue the regiment till four days after source control.

Jame: 32:02

That was it. I And then if you want to continue promoting that, give us a call because we would like to discuss those cases And I think that that is an interesting way of approaching it. There's some you know, other abdominal things that have indications that have separate antimicrobial guidance, But for most other stuff you would get that advice And it was all the same antimicrobial regimen and all the different pages There's a real challenge when writing good guidelines And James is a good person to ask about us because he writes very good guidelines, I think.

Callum: 32:42

The challenge I think is that you want the good guideline to be simple and easy to follow, But often there is a lot of nuance and complexity in decision making that you need people to follow And I wonder if and this is coming is decision support software is a way to go, because then you can get really quite complicated flow charts or decisions or questions into a format which just asks people yes or no questions, or like ask them to put a number in, And then doesn't really allow people to skip, because when you get a flow chart, I don't know about you, but I always read on different parts of the flow chart just to you know. It's like choose your own.

Jame: 33:20

Eventually You flip to different pages and try to get the best one, oh yeah, and you dog-ear one of the pages and then you flip back if you die. Yeah, yeah, i've done that.

Callum: 33:27

So you know there is a section about like how much do we simplify our guidelines and take away the nuance and how much do we need to make sure that the right decisions are being made? I went to a talk ages ago and a medical student was presenting on this paper about doxycycline for a hospital heart pneumonia.

Callum: 33:47

And basically saying it was as good as broad spectrum intravenous therapy. And the comments were pretty harsh and it was basically saying that we can't just have one size fits all antimicrobial management for patients. I'm like that you can just give them a doxy and you should like alternate and change antibiotics and like resistance and build up on all this stuff. And it was I was. I didn't really agree with it, but I thought it was really interesting in an era where we've basically de-skilled everybody in antibiotics management. Maybe they weren't skilled before and they were just doing their own little ladder that they were climbing up, but their ladder was different from everybody else's ladder.

Jame: 34:30

Yeah, I mean, I think that's much more likely. Everybody was just using keftraxl and then jumping up to something else.

Callum: 34:35

They just did what they usually did without any legal thought or consideration and thought they knew that they were doing because they did it a lot And you know, maybe it worked, but you know there's definitely problems with that. What we'll summing up is that antibiotic escalation should be binned because antibiotics aren't a ladder. Everyone's got different ladder in their head and it's much more complicated than that And I would propose that is as a 3D you know, height, map, Venn diagram of antibiotics and their spectrum And we should, instead of saying escalate, we should say broaden or focus therapy.

Jame: 35:10

I'll drink to that Cheers.

Speaker 2: 35:14

Now that the episode's done. We hope you learned and had lots of fun. So go forth and treat people with some of what you now know.