84. BIA Spring Meeting 2024

The Spring Meeting of the British Infection Assocation is a must for UK infection trainees; In this week's episode Callum summarises for Jame (who was there, but didn't take any notes) the main learning points from the meeting.

Show notes for this episode here

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Transcript

Jame: 0:18

Callum, you have a spray in your step. Have you recovered from that yellow and black stripey insect that flew into your mouth as you were cycling home the other day?

Callum: 0:27

Oh, that bee I ate.

Jame: 0:30

Yes, that one, exactly, yes.

Callum: 0:33

Yes, I have actually, and that's why I have a spring in my step.

Jame: 0:37

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

Callum: 0:41

we'll be talking about that B. I. A. Spring Conference.

Jame: 0:48

Yes, the British Infection Association had their Spring Trainees Day and 26th Annual Clinical and Scientific Meeting on the 7th and 8th of May 2024 in Bristol and for reasons best known to them, they invited Jamin Callum of the Idiots Podcast to join them. How did you enjoy it, Cal? No,

Callum: 1:09

I had a great time, Bristol was lovely, I felt very welcome, the hotel was good, and the B. I. A. did great

Jame: 1:16

Yeah, I had lots of fun too. I thought it was great. I was really glad that we did all our talking on day one, so we didn't have to do anything on day two. But yes, it was, a lovely, conference and the Bristol trainees in particular, shout out to any of them that are listening made All the other trainees feel nice and welcome, and it was lovely talking to them after the after the conference was over in the evening. Okay, so why don't we go through what we did? What was presented there?

Callum: 1:41

And so we'll just run through some of the highlights for us of the program and some learning points that we took away. So the first session on the trainee day was the clinical grand round, which was a series of complex cases presented by trainees in the UK to an expert panel and the I always find these really useful. We talked about this at ECMID and the phys episodes using clinical case vignettes to take home learning points. So the first case was titled of mice and men, and that was by Dr. Dr. Irogabu. Basically the story was someone who presented with myalgia, diarrhea and vomiting and a week long prodrome with pyrexia. And there was a discussion about this generally and then it came out in the history that the person was a rat owner or a rat fancier. As they're called, and so really discussion was around rat related pathogens. When a case is presented at a clinical grand round at an infection conference. You kind of already know it's going to be an unusual infection diagnosis. So I think often in clinical practice, when someone's got a pet or there's some unusual exposure, as interested as I am, when I take the history in the back of my head, I'm usually thinking it's probably is just a bit of red herring. But in this case, the rat history was really relevant and the panel talked through some of the sort of rat related pathogens like leptospirosis. And I think we also talked about rat bite fever, so caused by streptobacillus or spurial minus. So I think we also talked about rat bite fever, so caused by streptobacillus or spurial minus. But in the end the diagnosis ended up being Hantavirus. Specifically the Seol variant. Or at least that's what they thought from the serology. And there was a discussion from the presenter around hantavirus and its presence, you know, very generally, it's usually in the urine of rodents and it's very prevalent within rats population and probably the pet rats were colonized and it causes something called hemorrhagic fever and renal syndrome. And there's another sort of subtype as well. So that was a really interesting case. I think hantavirus is something that I, that we often talk about in patients where there's no clear diagnosis and there's exposure history. Never diagnosed someone with it

Jame: 4:00

yeah, people put it in the differential when they don't know what they're looking at and the person has been someplace vaguely foreign or has, been within spitting distance of a rodent. What was the next case then, Cal?

Callum: 4:13

The next case was presented by Dr Greenbury, and it was titled a Cavitatory Lung Region Following Travel to the USA. And this is someone who'd come along with three weeks of dry cough, fever, wheeze, and fatigue, and they were relatively immunocompromised of asthma they were on some immunosuppression for Crohn's. And there was a discussion about the causes for cavitatory pneumonia. The panel went through the different differentials for bacterial, fungal, and mycobacterial disease, and lung cancer came up as well. And the interesting part of this story was that the, on initial presentation, there hadn't been a full travel history taken. And when a travel history was taken, it turned out the person had traveled to Arizona recently. And they'd actually been doing some very fun things out in the countryside. Quad biking, lots of dust, and hand wearing a mask. And I guess lots of people will be guessing where this is going, but the eventual diagnosis was curcuriomycosis which is a dimorphic fungus disease that is very present in that part of the world in dust and inhalational disease. Which I would say we don't really see much of in the UK, and we do talk about it. I did see a case recently in Nadosh North, which was really interesting to deal with. And most of the disease is pulmonary, but you need to worry about meningitis which is a potential very serious complication which needs lifelong therapy.

Jame: 5:41

And so what was the exposure in your case?

Callum: 5:44

Oh, in my case! Also travel to Arizona. Sure. It's to do the epidemiology related to weather. So when you get particular wet seasons and then there's a dry spell that's when you're most at risk.

Jame: 5:58

Yeah, you get clonal expansion in the wet weather, and then the dry weather causes the spores to form,

Callum: 6:03

So I think the learning point is never leave your house and don't travel.

Jame: 6:06

Well, certainly don't travel to Arizona and go quad biking.

Callum: 6:10

Well, I think you can still travel to Arizona. Come on.

Jame: 6:12

no, no, no. The whole state is off limits for

Callum: 6:15

Our, the Arizona musselers are going to be emailing in Jim.

Jame: 6:18

Sorry to anybody who lives in Arizona. I'm sure it's a lovely place.

Callum: 6:23

I think the real take home message was always take an accurate travel history because it

Jame: 6:27

Aye, totally. Yeah.

Callum: 6:30

And then the fifth case was called from the Nile to the NHS. And this was a person who'd been abroad in Egypt and they presented to healthcare with fevers, shivers, and headache. And there was a history of a tooth extraction. And then they had a streptomyitis on a blood culture. And there was some discussion from the panel about the possibility of infective endocarditis. But later on They end up having an MRI of their back because of ongoing fevers, and they had anterior superior end plate erosion, which is called the Pedro Paz. Sign. And apparently this is very indicative of Brucella, and later on the serology was positive for Brucella, and a history emerged of unpasteurized milk drinking in Egypt, which nobody else in her group had been doing. And I guess the the take home message here from that case for me was that they made a point about Brucella had come up and it was only really when they thought about the diagnosis that they asked the question about unpasteurized milk. And usually you think about, you ask in the history and you get the exposure and then that makes you think of the diagnosis. But actually here they had the imaging which sort of led it. backwards. So yeah, I think it's a useful question to, to ask about. So yeah, five cases, which I, think I took something from and it was really useful session. Next, we came on to the NITCAR the NITCAR session, which NITCAR, we've talked about before in our FIZ. Roundup, that's the National Infection Teams Collaborative for Audit and Research.

Jame: 8:02

Yeah. So this is for. Like registrars and TU or consultants that are training in the UK to get together and collaborate on trials. Yes.

Callum: 8:13

Two things. One was the DI Blood UK study, which, or audit, which is looking at what sort of rapid diagnostics people are doing on blood cultures throughout the UK. And then the other thing was on the salvage trial, which is looking at management of Lyme infection so really worthwhile projects that we got a little bit of a update

Jame: 8:33

And, and if anybody who's listening, who's a UK trainee is interested in collaborating or finding out more about those studies, they are available on the nicar website. So if you just search for nicar you'll get that and you can get involved and they're looking for people to get involved.

Callum: 8:50

Yeah, I think that cars are really good example of, you know, we do a lot of audits and we have to do audits in our training and a lot of them don't really have much impact, but Nick Carr is trying to leverage, leverage, leverage that requirement for people to get involved and do something meaningful and worthwhile. So yeah, next session after that was on sexually transmitted infections by Professor Richardson. And really there, there was talk about, the normal route for enteric pathogens being through like fluids fields, flies, and fingers. So really going from stool of one person through one of those vectors into food or water, and then that leads to transmission, but sexual practices can lead to that sort of bypassing that route. So we obviously, we all think about our usual STIs, but thinking about, things like bacteria, like Shigella, Campylobacter E. coli, sugar toxin producing in particular drug resistant. Shigellosoniae. It's a big risk.

Jame: 9:49

Yeah, that was the main thing that I took from this presentation was the drug resistant Sony eye that we've been dealing with for the last couple of years so.

Callum: 10:01

Yeah, and then as well as bacteria and viral, parasitic things like Entamoeba and Giardia. And the talk really went through all the different causes, how common they were seen and what's different in this population. And, I'm talking about sexual transmission, that's really high risk sexual activity, particularly seen in men who have sex with men. Now really, I guess the take home The message was around the different sort of lists of organisms that we might have seen. And there's new BASH, so the B A S H H, so the British Association of Sexual Health. And hIV guidance for the management of sexually transmitted enteric infections. So I hadn't been aware of that before. So that was a good thing to have highlighted. Following that we had a session on syphilis by Dr. Shiva, and that was really a masterclass of syphilis Because it's a difficult topic a couple of take home messages I took from that. One was if you have someone with deranged LFTs, do a syphilis test,

Jame: 11:02

Oh yeah,

Callum: 11:03

sometimes it's missed off that liver screen.

Jame: 11:05

Yeah, I wouldn't normally do a syphilis test as part of a liver screen. So that was an interesting recommendation from him.

Callum: 11:12

There was a little bit of talk about spirochetes in general which we're going to cover in future podcast episodes. And something I hadn't really heard of before which came up, I can't remember which talk it was in, was about intestinal spirochetosis, caused by brachyspira, and that's a sort of fairly benign condition in some people.

Jame: 11:33

I'm not sure I would call myself looking forward to when we do the Idiot's Guide to Syphilis, but obviously we'll have to divide it into testing and treatment. And I think it would be interesting to compare the ESMID, the BASH and the, if IDSA have them their guidance is to see what they variably recommend. There's been some movement on syphilis treatment recently, like in particular the Japanese study having a look at just amoxicillin monotherapy. So in, in the BASH guidance, you can use amoxicillin with probenicid to, to boost it's time over MIC. But there was a A study using Amoxicillin 500 TID compared to standard of care. I think it was an observational study. I'm not sure if it was an RCT or not, but the, appeared to be non inferior. And so that would be a very convenient therapeutic regimen. Particularly given the shortages of Procaine penicillin and benzathine penicillin that we've we sometimes experience every now and again. I think for syphilis, we need other options. The issue that we have is that we can't really test it in vitro because we can't grow it in vitro. We always have to go with, Clinical endpoints and I've tested in real humans and see what we get and there's no animal reservoir either as far as I'm aware

Callum: 12:58

Yeah. Yeah, it's pretty difficult. There was a brief mention about Ezalid as a future potential agent, with some promise,

Jame: 13:06

I think using a reserve antibiotic should be a last resort. And Linzolid is the only sort of oral reserve antibiotic that we've got. So it sort of applies to just it and to Dizzolid. But when I look at the syphilis treatments, I feel that we have quite a lot of options. I'm not sure that we need one more. But I suppose having it in the tank is, is a reasonable thing to to have.

Callum: 13:32

but I'd want it for those penicillin resistant patients. I wanted it for those patients that are anaphylactic to penicillins and you're in a bit of a bind sometimes about what to do. Particularly the CNS involvement as well.

Jame: 13:46

yeah, although I would argue that you could use Keftra accent for that, but maybe not for CNS involvement, too. So yeah. Yep, fair enough. true enough. And then, and then there was an afternoon session, my favourite infection paper, where people were presenting for five minutes on the best papers that have changed infection practice in the previous 20 years. Starring Callum. Starring Callum and some other people.

Callum: 14:13

Well, it was starring some of the big wigs of the BIA including the, the president and the vice president and other sort of invited speakers. And then there was two idiots,

Jame: 14:25

Yeah, you and me.

Callum: 14:26

Yes. Yeah.

Jame: 14:27

Did you present on?

Callum: 14:29

Well, I have presented on my favourite graph, which is a really great paper out of Denmark, which is a study where they basically took all the people in the country, over a long period of time, that had a streptococcal bloodstream infection, And then link that to people that had infective endocarditis and they then did some logistic regression and adjusted it. And they basically came up with this graph, which plots both the number of bloodstream infections against a risk of infective endocarditis. And I really like it because one, it helps you with that situation where you've got a patient with a strep bacteremia and you're trying to decide how worried you are about infective endocarditis. And two, it managed to convey a lot of information very clearly, very quickly. And I think that is just really a good skill to have. So I think that was my favorite paper. What did you present on, Jim?

Jame: 15:24

I did the poet trial. I thought that was pretty practice changing. And so I did a poem on

Callum: 15:31

Well, I'm sure listeners would like to hear that as much as everybody at the conference. Well, they didn't get a choice whether they heard it or not,

Jame: 15:39

No, they didn't get a choice, did they?

Callum: 15:41

They didn't really leave, but

Jame: 15:42

Well, if the listeners are good, then they may be in for a treat then.

Callum: 15:46

yeah, it was pretty good. Even if people couldn't understand your Scottish accent. The next session was called Latent TB MDT, and essentially we're going through some case based discussions, looking at increasing numbers and complexity of this difficult treatment done by Dr. Martin and Professor Parikh. And I took some things away from that. So we're talking about, increasing rates of TB, and the majority of these being non pulmonary in the UK, certainly. how do we most effectively screen who should we screen and where should we screen? And essentially talking about people that were less than five years having moved into the UK doing a single step IGRA rather than any skin testing in the community. And how to do it was essentially screen with the IGRA immunoglobulin gamma release assay and and then taking history. But often people that have active TB, you have symptoms negative, and then you would do a screening chest x ray to see if there's any sort of signs of active TB, because really what you're looking for is does this person have latent TB or active TB? And there was some discussion around considering cross sectional imaging, like a CT, if you have access to it so if patients have negative chest x ray, but you're suspicious that they may have active TB, and if none of that comes up, then you can do treatment for latent TB. And then the other thing that was discussed around latent TB, which is certainly an issue locally as people that are going on to immune suppressants and really trying to better categorize which type of immune suppression is high or low risk for latent TB reactivation, who should we be screening and who should be getting prophylaxis and how does that work and the timing. And it's really useful sort of revision summary for that. What was the next session, Jame?

Jame: 17:34

The last session of day one. It was us, Callum. Our day in the sun. We went over the difficult to speak gram negatives An Idiot's Guide.

Callum: 17:48

Hopefully we can bring that to your ears soon.

Jame: 18:10

So I think one highlight for me was the TB action plan presented by Dr. Robertson, the head of the TB unit who works for the, Mycobacteria Reference Lab in UKHSA, the health security agency, which somewhat confusingly doesn't cover the entire UK. It only covers England and Wales. It doesn't cover Scotland. We've got a separate health security agency, which is not called a health security agency anyway. But she presented the results of the TB action plan so far and it made for depressing listening, Callum.

Callum: 18:45

yeah. I feel like a lot of stuff in the healthcare at the moment is depressing listening. We have this really ambitious target to do something really great with TB, and we're nowhere near meeting it.

Jame: 18:55

Yeah, we're missing the mark by quite a lot, but in, in the UK HSA's defence, it seems like everybody is missing the mark by quite a lot. TB is proving tricky to treat and the vaccine is, you know, widely regarded as not being up to snuff. But yeah, the, the lack of progress made in England, certainly made for sobering listening I should say. But they have plenty of plans, and we will have to see, and the, and it's been rolled into the, the next five year action plan, so we'll just have to see what What comes of that, I suppose

Callum: 19:28

Next highlight, would be around the, RSV in older adults and the potential impact of vaccine by Dr. Diaz Domingo.

Jame: 19:35

yet now this has been published, the Spanish experience of rolling out the RSV vaccine and showing a decline in RSV related pneumonias of something like, was it 80% Callum, but a total decline of all pneumonia of something like a 60%. In, relevant age groups. And so that was very impressive, I thought.

Callum: 20:00

Yeah, I I don't really think about RSV that much because it's not something that I end up dealing with because I don't really do that much pediatrics. But, Yeah, I guess that the older adult, it's around a bit, see it and don't really, I don't really think too much about it, probably doesn't come to the infection ward.

Jame: 20:14

I, I think the issues that I don't know if it, I can't remember if it's on the respiratory panel that NADOS North uses. But in NADOS South, We're using a biophire that does flu, COVID and RSV in one. So we do see a bit of RSV. We had a bit of an uptick a little while ago. So we do sometimes see it in, older adults, yes, and kids. But sometimes adults less old than you might think. It will be interesting to see the effects of vaccination of RSV on, our respiratory virus burden, because certainly, during the winter months, it seems that everybody's got a cold or a flu or a respiratory infection of some description. And, I feel that quite a lot of my time when I'm working on ambulatory care is stopping people all but certain to have viral infections from receiving antibiotics. I think that's one of the main ways that I'm sort of effective in an ambulatory care setting is in a sort of a stewardship, step away from the amoxicillin and we'll talk kind of. Situation.

Callum: 21:20

Yeah, and then the next session was some free papers. So, just, Picking up some highlights. So there was a presentation from Dr. Diaz about delayed blood culture transport time and there is some some quite complex statistical analysis of a lot of data to essentially see if a delay in the blood cultures reaching the lab led to longer time to positivity or less positive results. And their studies, I think their hypothesis was that it wouldn't and they didn't. Found actually this. So I can't remember the exact numbers, but for every hour, there was a sort of decline in the positivity rate and also a longer time to, getting the results, which is quite interesting. And I think Potentially important to consider. I think we kind of think about that and maybe discuss that in our back to back Dreamy episode. But,

Jame: 22:12

Yeah, it sort of makes the argument for on site incubators and then, the positive ones you then send to the lab for further workup. But certainly, we've thought about this, haven't we? When we were training in ADOS Royal Infirmary North, it was one of our consultants that, you know, that, because somewhat paradoxically, the infectious disease unit is not located on the same site as the microbiology lab. And so we, we have patients who were really worried about them. From bacterial infection perspective, and we take blood cultures and they then the blood cultures have to take a lovely little trip over, over the city to get to the lab, to get to the incubator. And we wondered what effect that would have, so to speak.

Callum: 22:59

yeah. So yeah, I thought that was quite useful. Then there was someone who did a little bit of an audit looking at IV to oral switches, and people have grabbed negative bacteremia and exploring why people who met the sort of national UK criteria for IV to oral switch weren't getting switched. Okay. And a lot of it really came down to sort of, physician anxiety, I guess, about the switch to oral antibiotics,

Jame: 23:22

Yeah, this was an infuriating talk to to listen to so this Dr. Benjamin did her level best with the toolkits that she had available to try and improve IV to oral switching. She, I, I think the best bit that she presented was the reasons for the reluctance and my memory is that by far and away it was the fact that they were at the weekend. And the people didn't want to make the switch until the regular team was back and so they were left on IVs and all the itinerant risks of that and all the increased workload that the nursing team at the weekend, no less, would have to we'd have to deal with in order to maintain this person on IV antibiotics until Monday, because of reluctance to switch. And that sort of gave me some ideas for how to implement switching in my own practice, which I think was the the best sort of take on the intervention that you tried was I think it was a EPR entry. Saying this patient is suitable for switching or they are switching, suitable for switching if they meet these criteria. And it didn't work. And I remember thinking at the time, I'm not surprised because given the number of, Messages and things that are rolled into the average EPR, I think that would be the easiest thing in the world to ignore. So I, I wasn't surprised that intervention didn't work, but I thought that the information that they gathered in the audit cycle was really interesting. So, well done to Dr. Benjamin for for doing that.

Callum: 24:59

yeah, I guess it's there was a talk at ECMOD last year, didn't get to go this year, unfortunately, but about behavior change and antimicrobial stewardship. Looking at how do we actually get people to change the behavior because it's really about, instilling that confidence in people and what you saw in that audit come across was that, ultimately the, false assumption from the clinicians was that IV is better than oral.

Jame: 25:22

Yes, my thoughts have been made clear on that

Callum: 25:25

Yeah,

Jame: 25:25

particular issue. We should have another deep teardown of that. But if anybody wants some information on that, then Brad Spellberg has made it his life's mission to try and tear down this dogma. And if you just Google his name, then you'll get to his website where there's more than enough information on the evidence base for IV being a dogma. You know, non inferior non superior, I should say to oral. But yeah.

Callum: 25:52

then the final session was really thinking about, essentially an infection medicine in the UK. there's a bit of a workforce crisis. I think 17 percent of consultant posts that unfilled and really the last session was about diversifying the workforce a non traditional roles within the microbiology infectious disease. Team and antimicrobial stewardship team members as well. So we heard about the role of clinical scientists advanced care practitioners advanced nurse practitioners stewardship pharmacists physician associates a consultant clinical scientist. So yeah, I think it's really using making use of the MDT and what different sites, how they are utilizing different parts of the team to relieve the pressure that is being placed with on infection services with, ongoing demand and potentially reducing resource or staff to deliver it. I don't think that's a UK specific problem. Reading about listening on febral, but match and the issues facing ID in North America and lots of other places as well, I'm sure.

Jame: 26:58

Yeah, true, true.

Callum: 27:01

So, yeah, that was a really brief wrap up of our two days BIA run lots of really interesting events, and I think their next meeting is in the autumn where is that going to be? Sheffield.

Jame: 27:13

is in Sheffield. So yeah, I'll be looking forward to going to that in the autumn as well. These meetings, they're not particularly expensive and they're very high yield, I think. I'm always happy when I've got the time and availability to go to them.

Callum: 27:29

Yeah, I feel like I missed out. I've not really been to many as a trainee, but I'm certainly going to try and prioritize going to them in the future.

Jame: 27:34

Yeah, yeah, yeah, same, same. I think that's the other thing. This is specifically for UK trainees now because I don't know about the study budgets in other countries, but in the UK it's particularly paltry. Five or six hundred pounds a year. And if that is, the case with you, then. It is worth thinking about going to the BIA conferences because they are very cheap. For BIA members, it's 100 for the conference. That's the full two days. In person or virtual. And membership of the BIA is free for trainees. So, that's something to think about if you're not already a member. Then certainly for UK trainees, it's a no brainer.

Callum: 28:21

Well, we'll be bringing to you some more content from the BIA soon, but thanks for listening. And we'll be returning to our usual bug episodes shortly, but we've got some exciting stuff coming up on the horizon.

Jame: 28:35

So we do. But anyway, see you later, Cal.

Callum: 28:37

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