93. World AMR Awareness Week special: The Scottish Antimicrobial Prescribing Group (SAPG)

WAAW! This week, to celebrate World AMR Awareness Week, Callum is Joined by Andrew, Fran, Jo and Simon from the Scottish Antimicrobial Prescribing Group.

Listen in to hear all about SAPG and their important work, plus we discuss WAAW and what you can do to help tackle AMR.

Show notes for this episode here, including links to the resources mentioned.

Sign up to be an #antibioticguardian here.

Transcript

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Callum 0:18

Hello, it is Callum here no Jame this week, which you may be music to your ears or you might just turn off now, but I'm privileged to be joined this week. by the Scottish Antimicrobial Prescribing Group, which, if you're an avid or regular, or a loyal listener, you will have heard us wax lyrical about in previous episodes, including our penicillin allergy episodes, and also some heard from some members of SABG at some of our conference wrap ups. So, Very excited to be joined by the team to hear a bit more about, about this initiative in Scotland. So I'll go around and ask our guests to introduce themselves and their roles within SABG

Andrew 1:04

callum, well I guess on behalf of us all, thank you very much for introducing us and to bring us on to your fantastic podcast. I'm Andrew Seaton, I'm an infectious disease physician in Glasgow and I am the current chair of SAPG or S A P G, the Scottish Antimicrobial Prescribing Group.

Fran 1:24

I am Fran Kerr and I am the project lead for the Scottish Antimicrobial Prescribing Group. I'm also an antimicrobial pharmacist by background.

Jo 1:34

I'm Jo McEwen, I'm the lead antimicrobial stewardship nurse in NHS Tayside, but I'm also the chair of the Scottish Antimicrobial Nursing Group, and the first ever antimicrobial nurse in not only Scotland, but the UK, and I'm led to believe the world as well, so.

Callum 1:52

Wow. That's a badge. That's an accolade

Jo 1:54

yes.

Callum 1:55

a little medal. I don't know how these things work in nursing, but that's, yeah, no pressure. And finally, Simon.

Simon 2:06

Hi Calum, thanks for inviting us onto your podcast. I'm also an avid listener to your podcast as well as appearing in it before that. So hopefully, when you said avid listener, hopefully I qualify slightly for that. I've listened to a fair few episodes, so they're all very good. Yeah, so I'm Simon, I'm a microbiology consultant. I work with you in ODE and I'm the clinical lead for our antimicrobial management team.

Callum 2:28

truly a multidisciplinary team we're joined by all professions here. So I came up with some questions before we started. So. I guess the outline of today is just briefly we're going to go through the why, the who, the what, the how, and the what next of Sabji. So I thought it'd be interesting to first hear a little bit about the why of this group. What the goal and purpose of the group is and where this has come from. So for listeners out there, how did this come to be and why do you do, what do you do?

Andrew 3:05

So I'll take that one, Callum. So I guess myself and Joe have been members of S A P G or S A P G since 2008 when it was born in fact out of a piece of work called Scott Morath, which was a sort of action plan that was produced to address antimicrobial resistance in Scotland and also followed on from a previous bit of work called the antimicrobial prescribing policy and practice document in about 2005. So, SAPG formed following the introduction of antimicrobial management teams. This is the sort of the fundamental piece or the foundation of our national stewardship program, which is what SAPG became. But yeah, we formed antimicrobial management teams first in Scotland, which were multidisciplinary teams of pharmacy, infectious diseases, and microbiology primarily, and then pulling in nursing. And as Jo has already said, she's the first antimicrobial nurse probably in the world and possibly the best as well. Sorry, Joe, but yeah, SAPG was really the brainchild of Dilip Nathwani consultant physician in infectious diseases in Tayside, and a good friend and colleague of mine, and Joe's who works in Tayside also, and Yeah, it came out of ScotMorap and actually coincided with the Vale of Leven and the Vale of Leven was a moment in history in Scotland where it's a large kind of Clostridium difficile outbreak and it led to some local antimicrobial stewardship initiatives. And my board and greater Glasgow and Clyde, and then subsequently this spread via the work of SAPG to go across Scotland. And it was landmark episode that led to that's national stewardship group supporting AMTs around Scotland. bringing all the AMTs together to tackle C diff and at the same time as tackling C diff, it was also tackling AMR. So effectively, SAPG is a, I kind of think of it as a sort of consortium. of antimicrobial management teams from around Scotland. So it's a big, it's a kind of big AMT for all the AMTs management teams around Scotland. The Scottish Antimicrobial Prescribing Group is an integral part of Healthcare Improvement Scotland as part of the Evidence Directorate. And it pulls in other key stakeholder groups from Scottish Government, from the Scottish Microbiology, Virology Network, from the IPC Network and a few other groups, but basically all the kind of key people are around the table to ensure that we're doing all the right things with antimicrobial prescribing, and I've almost forgotten the most important stakeholder, which is our high Scotland or the antimicrobial resistance and healthcare associated infection team based in NHS services. And that's and the key person maybe who's not on the call today is Billy Malcolm, who's been with SAPG at the beginning and what that group does is that brings intelligence about prescribing, intelligence about antimicrobial resistance, and other antimicrobial effects like C. diff, so. That's a crucial part. So we need intelligence, we need education, and we need quality improvement initiatives. So those are the 3 pillars of SAPG, which sit within this consortium of antimicrobial management team members. And I could go on and on, but I'll pause there because I've probably said a little bit too much too quickly.

Callum 6:43

It's spoilers. Thank you, Andrew. That's a rapid rundown of SAPG and where it's come from. What would you say the why is in summary, is that written down somewhere

Andrew 6:53

yeah, it's taking care of antimicrobials now and for the future, that's what we're about. So safe use of antimicrobials now, optimizing their use and preserving their future use. That's the real why if I didn't come across very clearly in my opening remarks. and also variation in practice. So that really is a key thing because a lot of the work of SAPG is aligned with realistic medicine in Scotland, which is the brainchild of former chief medical officer and also current chief medical officer in Scotland. And that's about individualizing therapy, reducing harm, reducing waste, and all these sort of things, all these kind of or elements of good clinical practice come into what we try to do in SAPG. So, don't use too many IV antibiotics, switch to oral, use short course therapy utilize our resources as best we can, don't be wasteful, reduce harm. And you've talked about penicillin algae delabeling, for instance, that's, it's one example of our initiatives. you know, not overusing, using antimicrobials at the end of life.

Callum 8:03

Mentioned a couple of things there that James and I have covered, and some that we haven't, that are really useful things produced by SAPG. So that's the why, I guess the who. So, Andrew, you're the. The chair. What's everybody's roles and how does it all fit together?

Andrew 8:17

So there's no one person who owns all the ideas or the initiatives. Personally, I would regard everything as a collaborative. I think when I started, I was anxious because I was filling big shoes. Dilip Nathwani is a well known person on the global stage. I thought, stewardship is done and dusted. What, can possibly be done? But then the more you think about it, the job of stewardship is never done. And essentially, SAPG functions by getting all the good ideas. From across our boards, and then trying to amplify them and, making that best in class pulling everybody up to be the best, to achieve what that best of classes So there are initiatives that come out of the discussions in SAPG, and in a sense, we workshop some of these ideas and then form little subgroups that take them on a bit further and then, bring them back to the group. And all the time we're using, data to look at where the variation is, who's doing well, how we can, how can we can learn from each other. Effectively, in short, I would chair the meeting, which is every two months. Have some ideas, generate some ideas, share ideas and I'll let Fran speak more about her role, but I guess I'd also share some of our subgroups as well and help with the kind of direction of travel of the group and continually trying to think about how we can future proof things and particularly promote good ideas and promote good people with good ideas is also another key thing.

Callum 9:44

Thanks, Andrea. Really interesting to hear your perspective, Fran, as the as project lead. Yeah.

Fran 9:49

Yeah. So as Andrew said, we we have a really wide range of members. So we have a lot of clinical representation across infectious disease. We have, antimicrobial pharmacists, antimicrobial nurses, we have infectious disease clinicians, microbiologists, everyone you would need to have in the room to make these kind of decisions about infectious diseases. I guess one of the core things that Andrew hasn't mentioned already that I think is really important and why we're so successful, I guess, is because We take a once for Scotland approach. So while if you were in an antimicrobial management team in a health board, you would be thinking about how to improve prescribing locally. A lot of the health boards are all trying to do the same thing. So we look at, well, how can we use the collective brain for want of a better word to do that once and then to save time and effort for everyone having to do that but as project lead I work as part of the evidence that it to that within health care improvement and that is where in Saatchi sets in currently. This ensures then that we really think about the evidence based approach to the guidance that we develop. And. Then on top of that, when the evidence isn't available, we then turn to expert opinion. So as you can see, we do have the right people in the room to start those conversations. And then when we don't, we put out the call for that if we're moving in, because antimicrobials stewardship goes across every specialty. So sometimes, we do We do go to the specialties to get more detailed information behind what we're doing. But as I said at the beginning, as an antimicrobial pharmacist myself, then we work closely with lots of different groups and Andrew's mentioned a few of them, but I was just gonna mention the Association of Scottish Antimicrobial Pharmacists because they are expert knowledge and antimicrobials is really a valuable part of the multidisciplinary team and it really helps us to get that detail that we need when we're developing the the clinical guidelines that we do. And obviously Joe's with us today, so we also work really closely with antimicrobial nurses and Joe's. I might want to say a wee bit more about the role of the of where the nurses fit into the SAPG membership, because they are a really vital part of the team as well.

Callum 12:14

Yeah, that'd be great to hear from you, Joe, and maybe just a little bit of history about how you came to be the first antimicrobial nurse and how things have maybe changed since you trailblazed that, that path.

Jo 12:26

Well, so again, it all boils down to Dilip Nathwani who was again the brainchild behind this position, who for many years had really campaigned to have more nurse inclusion in antimicrobial stewardship and was successful in obtaining funding for this post. And that's where it started. So when it started there were two papers in the literature about antimicrobial stewardship. So really not a lot to go on, but you don't really need the evidence. Logic prevails. We have to date 73, 000 registered nurses in Scotland. So when we look at the role of nurses, that's 73, 000 opportunities for stewardship, because nurses have. an ingrained role in antimicrobial stewardship. They do it already, although perhaps not under what they would view as the umbrella of antimicrobial stewardship. Their role in medicines management is significant. They are responsible for safely and effectively administering medicines to people every day across many different care settings. They also have a responsibility for observing and monitoring. detect and deterioration in people that they care for. And again, across many different settings and where patients are prescribed an antibiotic, it tends to be nurses that review response to that therapy. And that's just from a general nursing perspective, but if we move Towards the horizon scanning perspective, just recently, our undergraduate program has changed as well. And just as many other health professionals have extended roles within their professional responsibilities, so do nurses. So nurses now graduate becoming IV antibiotic administration ready. They are prescriber ready, although they don't have the physical qualification to enable them to prescribe. They have the pharmacology education in undergraduate prescribing nursing as well. So the landscape is moving. So we need to think not only what can nurses do, contribute towards antimicrobial stewardship now, but also where does that future take us? So that horizon scanning, and when Fran and Andrew have highlighted that we work collaboratively, I certainly could not have done this role without the support of my infectious disease colleagues and most certainly not without my antimicrobial pharmacists who I've never been so grateful to share an office with. Three of them in my life, they have certainly bolstered and supported me in this role since the beginning and certainly championed, and let's see, SAPG were the first to embrace the role of the nurse as an antimicrobial stewardship nurse and that support has never wavered. So from that perspective, I am certainly eternally grateful. I just wish that we had a little magic wand and were able to knit some more for other health boards so they could see the value of the nurse and antimicrobial stewardship as well.

Fran 15:44

Listening to Joe has just made me really think about, well, we are looking at what we've been doing and we've talked a lot about the history of where we've came, where we've come from and how we've managed to go. I think The future is really interesting because not only are nurses now IV administration ready, but a lot of, in a couple of years time, all pharmacists are going to come out prescriber ready as well. So ready for a whole change in system prescribing and a whole new way of thinking about who will be prescribing antimicrobials in future. And I guess when you're thinking about, medical training, I think. A lot of people move around really quickly and some of the core people that stay in roles maybe a wee bit longer could be, the pharmacists and the nurses are really stable part of the multidisciplinary team. So I guess really has a big role for pharmacy and nursing as well as obviously the infectious disease specialty as well.

Andrew 16:43

I was just going to say, Joe's a real sort of inspiration for us. I can't tell you how hard we've been working, particularly with colleagues in Scottish government, to try and get traction on this question promoting antimicrobial stewardship in nursing. And it's tough, we're working in a very resource limited setting now. Seems to be no money for anything anymore. but if we could have more, Joe McEwans around Scotland, we would, we'd be going some way and, In addressing the challenges of antimicrobial overuse. I think Joe didn't mention it but nurse prescribing and primary care is now significantly more than dental prescribing. So, nurse prescribing and primary care is now approaching the level of prescribing that we're seeing in hospitals. more than 80 percent of prescribing happens in primary care. So less than 20 percent of prescribing happens in hospital and a growing proportion of that primary care prescribing is nurses. You can see that. It won't be long before nurse prescribing and. Decision making with antimicrobials in general is going to overtake in volume what we're seeing in hospital. So it's quite a, it's quite a thought. So we have to think about resources that we develop and initiatives that we come up with need to not just address. Doctors or even pharmacists, but we've really gotta engage with nursing and in fact, not even, not nursing. So podiatrists are now coming out of podiatry podiatry school prescribe already as well. So prescribing is certain antimicrobials is no longer just the remit of the doctor and it's very much part of a really expanded and growing health. Health healthcare force,

Callum 18:23

I'll go to Simon. And just ask, about your role as a local anticoagulant management team within a health board and how that sort of links up with SAPG.

Simon 18:34

Yeah, so the local antimicrobial management team represents all those different health care professionals. So I'm a infection clinician, a microbiologist we also have infectious disease clinicians. The team as well. We've got. Pharmacists, we've got a specialist nurse, data analyst, team administrator. So really work as a whole team to look at prescribing across the piece. So we've got reach for both primary care, where most of the prescribing is being done, and for secondary care. And again, it's the same remit of SAPG, just to ensure that antibiotics are used well, preserved well, and for the future. there's lots of things that we do. And how we link into. SAPG, so I represent our team, and so hopefully we contribute in a positive, productive way. Also, it's a collaboration, so often I'm listening in to see what other people are doing, what's worked well in other boards that we can replicate in Lothian, and we're feeding into kind of the Scottish national approach in Edinburgh. So that's the role that I currently play

Andrew 19:37

and it does play a really useful role. Just add, so Simon's a really important core member of SAPG and maybe Callum, we didn't quite, I think you introduced us as SAPG, we've probably got about, I don't know, 40 members. It's quite a big committee. So all the antimicrobial management team leads are represented on the group plus all the other stakeholders that I mentioned.

Callum 20:00

Yeah. So that's a big beast of antimicrobial management to manage which maybe comes on to my next question, which is, and we've touched on this a little bit about some of the things like penicillin allergy and antimicrobials at the end of life. But in terms of like the activity that SAPG does. Do you like what? How do you achieve your aims? So I guess it's what do you do and how do you do it? And one sort of question there. Maybe we could find like one recent project. That's went well. And just talk through like how that went from beginning to end. Like how did it start as an idea and then how did you manage it? And the other question I guess, and this is a lot of questions in one, so we'll come back to them, but how do you measure your impact and the success of this initiative? Because I imagine that might be quite difficult.

Andrew 20:50

Yeah, very good. Really excellent questions. So, an initiative. Trying to think, you know, what I mentioned earlier that we look at variation in practice. So, so one thing is some boards use more comoxiclav. than other boards. We generally prefer not to use Comoxaclav because it's either unnecessarily a broad spectrum agent for common conditions in primary care or doesn't have enough coverage for empirical management in gram negative infections, for instance. so some time ago we did a, We had a look using the data to look at variation in use of coamoxiclab versus doxycycline versus cotrimoxazole for instance, and we saw quite a wide variation in practice, so we produced a document talking about the evidence for using one agent versus another, say, amoxicillin versus coamoxiclab In lower respiratory tract infections, or doxycycline versus comoxaclav, and then what the opportunities were for using cotrimoxazole rather than, for instance, quinolones. So, we presented the argument in a paper in an SBAR format with presenting also the data showing the variation, and then our kind of job is then to just put it out to the antimicrobial management teams who effectively are asking us for this data because having this kind of national perspective showing the variation between boards is then use useful for our teams to leverage influence locally. So we've done that. And I think that has led to some evening out of. Of the prescribing of these different agents we did a project and it's not really a project, but we did a sort of survey probably about 6 years ago now. And that was actually, to look at variation in our prescribing guidance. In secondary care, and when we actually did this, because we were looking towards a national guideline for Scotland, and all the AMTs said, no, we don't want to have a national guidelines because, and the reason for that was because they wanted to be able to discuss it and take their own prescribers on board and have that go through that process, which is totally understandable. But when we actually surveyed all our antimicrobial prescribing guidance around Scotland, we found that everybody's guidance was pretty much. the same. And then Joe's just prompted me to mention OPAT and yeah OPAT has been an area of main focus for us. That's outpatient parenteral antimicrobial therapy. So we formed a subgroup I guess during lockdown because Pressure on the boards to keep people out of hospital do things differently. And some boards we're not so well developed with their services. So we engaged essentially with the Scottish government. We engaged with our teams across Scotland, we managed to secure a bit of short term funding, which for many boards has become. More substantial funding, and we've been developing kind of good practice recommendations around specific antimicrobial agents in OPAT, which is helping everybody to sort of level the playing field, the way we're doing things, bringing some OPAT services in tune with the with, more regular practice in some of the big in the bigger centers and overall, we've seen a massive increase in uptake.

Callum 24:04

the resources that SAPG have produced to support OPAT have been really meaningful. And you mentioned earlier on there that you were able to use data to guide the variation in practice in COMO and then you could see that data becoming more aligned. And in terms of something like OPAT where it's about use and so on. So in terms of, Fran and Joe, what were your sort of roles in that, that, that project? how did everybody work together to encourage people and, support the local teams about OPAT uptake? Maybe I can go to you, Joe, first in terms of, because certainly locally, our OPAT is heavily nurse led. So there'll be, nurse prescribers, nurse specialists doing a lot of that sort of initial assessment. So it's a really nursing focused service.

Jo 24:50

So, I wasn't personally involved in the OPAT subgroups. We defaulted that to our lead nurse for OPAT because there's no point in me going on a group to talk for a nursing group that I have no involvement with other than a supportive role. So, really empowering our lead nurse. and some of our specialist nurses from the OPAT team to take on those national pieces of work so that they can own those pieces of work as they have relevance and meaning to what they're trying to deliver within their service. And certainly from a SAPG perspective, all of the protocols and the treatment pathways all came through. So my role as part of, as a SAPG member, would be to look at those from a context of nursing and clinical care delivery from a nursing perspective and offer comments and feedback and alternatives in that feedback mechanism.

Fran 25:46

you asked how SAPG supported the development of OPAT. So I think what we did was we brought everyone who had an interest in OPAT together in the first instance to start those conversations. And then we looked for, well, who's doing what and where are the areas of practice that we could potentially be sharing. So if someone's doing a cellulitis pathway, for example, can we. Bring all that together and agree that this could be something that could be done, not just in one region, but potentially to support, OPAT services across the whole of Scotland. So we've developed several different pathways now doing exactly that. One for cellulitis, one for patients with UTI and no oral problems. Agent options left due to resistance, so we've got a pathway for people who would just need to get, for example, windows of gentamicin that keeps them out of hospital. And, as Andrew had mentioned before, stopping people coming into hospital and getting them out quickly is really helping a really overstretched system because OPAT, saving a substantial amount of bed days now, by actually freeing up people who only need antibiotics to be getting those antibiotics via a different service. So as part of the pathway development, then we were asking people, what would you want pathways on? So then we worked again across the multidisciplinary team and going out to other specialists as and when we needed to, in order to develop these pathways. And then it became clear that sometimes the antibiotics that were used For these pathways where I'm being used in a way that you would normally see them used in a hospital setting. So then we tapped into how are we using them in this case and how can we help others to understand how they're being used in this setting. So then we've developed a whole set of guidelines around, the actual individual antibiotics and how they're used differently in an OPAT service. So, I guess we just. Provide that forum for people to be able to say, Oh, you've developed Europat service this way. I wonder what opportunity there is for us to do the same thing or to bring that conversation back to our health board. So it's really a combination of that collaborative working, plus the clinical focus, plus, looking for what are the gaps and where can we support the service to develop. But Andrew's, Again, back to data, I've been collecting an awful lot of data from all the health boards who all provide us data weekly and have for years now to show the impact of all the work that's been done on OPAT and just what a difference it is making to patients because, although we've talked a lot about the clinician side of things and who's involved and who does what, actually the whole purpose of everything that we're doing is obviously for improving patient care and if a patient doesn't need to be in hospital, well that has a big impact on a patient family and the patient themselves if they don't need having IV and we can, give them another option to do that. That really matters to people when it comes down to it. So I guess we, we bring all of these things together. I'm in a bit of a conduit to make sure that all of the information is there and shared so that people can then, develop their own services and take back the good ideas as Andrew had said at the beginning to try and develop it. And over the last few years with the emphasis of Staying out of hospital that COVID produced in the first place has really gained a lot of traction over the last few years and we've been able to be there in the middle of it, supporting the service delivery.

Callum 29:20

I've certainly seen that in training as OPAT has become more and more of the sort of standard approach for a lot of our infections. And I think Andrew, you're going to come in and then I'll go to Simon because you've, you were going to talk about guidelines and the AMTs to support OPAT.

Andrew 29:36

Yeah. Thanks. I just wanted to, make the point that 1 of the things we've been trying to do is. It's because it's not about giving IV antibiotics in the community. So the whole development of OPAT that we've been stressing, I think, in Scotland and between our teams is proper vetting and triage of referrals. Many of the patients that referred on to OPAT don't go on to OPAT, they get clinical advice and that's something that's being replicated around Scotland. And that means they can still get out of hospital, but they don't need to. IV antibiotics, and then probably about a third or a half, so in our practice in Greater Glasgow and Clyde is they will go on to complex oral therapy that we supervise for a period until they're safe to then go on to a clinic. So it's no longer just, we've gone from OPAT to COPAT or complex outpatient antimicrobial therapy. And that's very much what's going on in, in Scotland and what we're trying to promote amongst our network. So that's a great opportunity for us to have that network to make sure that the, core stewardship elements are embedded within OPA. And for me personally, that's a really important part of it, as well as improving flow reducing pressures in hospital, getting people out earlier. And that's the kind of stuff that has real resonance with the hospital managers. And that's helps us get resource to do all the good things.

Callum 30:59

I guess we made OPAT very easy to refer to and access, which is great, but sometimes it felt like that became like a Oh, I can, you know, if I'm busy, I can just quickly send them off to OPAT and they'll sort it out and give them some Keftrax the end of it. And now with the provision to include COPAT into that, hopefully we can avoid that sort of perpetuation of IV as the superior treatment modality which I guess segues into Simon, so your role has been supporting OPAT including in guidance. So how did that work in the sort of, your role within SAPG and the local AMT.

Simon 31:38

so as our EMT, our role is tend to support. or CoPath or that the best patient care pathway when it comes to antimicrobials? So what we've been doing is we've been trying to integrate kinda opac CoPath pathways in our guidelines. So when our users think about antibiotic decision making, when they've got the diagnostics of to, to help support it and even in the laboratory, how we think about what antibiotics we test against certain agents, or pathable antibiotics, we want to ensure that they're. Tested and they are reported directly to physicians and to the users there and also things like therapeutic drug monitoring. How is the laboratory we can support that? So there's lots of different things that OPAT involves that we help support as a team,

Callum 32:22

so that's, a good example amongst many other different things that you've been working hard on and we've been benefiting from. Yeah, I said earlier on How you know what you're doing is helping what's working. You have any sort of data that would demonstrate the impact of Notepad?

Andrew 32:38

Yeah, so data is a little bit difficult because the way our health system works in Scotland, we're not recording data in the same way. So we've set up this, our own surveillance. system where we each of our OPAT teams will generate data on a weekly basis. So, on average per week in Scotland currently our OPAT teams and I think there are nine or ten of them around Scotland between them are leading to the avoidance of more than 2, 000 bed days per week. So that's, more than a district general, general hospital worth of activity for Scotland. And then overall, since we started collecting data in the beginning of 2022 we've avoided. More than 300, 000 bed days as a result of increased activity. And I'd say overall, if you look nationally at the way it's been going, we've been measuring activity in exactly the same way for, more than 2 and a half years. Now the activity has more than doubled. Over that period, I think on average, Every week in Scotland, there are about 200, I think it's 200, 300, I can pause there.

Callum 33:54

Well, that's that's hugely impressive figures. And I, you know, obviously SAPG have had a leading role in, in supporting the teams and delivering that. Maybe we'll need to come back and do a full Opat episode at some point in the future and take a deep dive into how that works and how it can support stewardship. So, um, wow! Our World Antimicrobial Resistance Awareness Week. So I thought maybe I could ask you all some thoughts as we are releasing this episode. As part of World Antimicrobial Resistance Awareness Week we're talking about antibiotic, antimicrobial stewardship here So what's the purpose of this week and what can people do to help, and what are SAPG doing?

Fran 34:40

Yeah, so, I'm sure everyone, most people have probably heard of this before, but World AMR Awareness Week occurs in the 18th to 24th of November every single year, so it's a movable feast, it's not the same day, but it's usually run over a week at the same dates. And this is a chance really just to amplify the message, so everyone talks about antimicrobial resistance, everyone talks about keeping our antibiotics working, we all do that at the same time across social groups. media platforms and use radio stations wherever we have the opportunity to talk about it. And that amplifies the message to hopefully get it out a bit further than it would that would normally be. And this year the World Health Organization theme is for 2024 is educate, advocate and act now. And I think, the acting now and doing something about it rather than just being aware of it. Previously, we were raising awareness. Now we're looking for action. So I guess for us, World AMR Awareness Week is an opportunity to amplify that message that we need to keep antibiotics. We need to work together to keep antibiotics working. Everyone here can imagine it's a really difficult place to think about. The world without antibiotics, but if we don't do something to protect them, this is the reality of what we may actually be facing. And it's really important that we get the message out to people that we only use antibiotics when we really need them. And when we do use them, we use them correctly with the right antibiotic for the right dose, the right route, the right duration, as we've been talking about all the way through here. So, SAPG, as you've heard from some of the work that we're talking about, works to ensure that there's that consistent message about how to use antimicrobials and antibiotics correctly in all settings. You know, primary care, secondary care in patient education, just as because actually everyone has a responsibility to ensure antibiotics are used correctly and only when needed. And that's not just the role of SAPG to do that. It's actually the role of anyone involved in health care, all of the public, it's really, it's, it sounds like something that's really easy to do, but it's actually really difficult to challenge your family and friends when they see, Oh, I just, I've got a really bad cough. I'm going to go to the doctor and get an antibiotic or I've got a really sore throat. I need an antibiotic. A lot of the time. taking that step and advocating that actually you probably don't is a really hard part to make in any general conversation that you're in, despite knowing all of the reasons why that's probably not the case. Just that next step of engaging in that conversations. It's always quite tricky to do, so we're just advocating that everyone has a responsibility in this and SAPG then is obviously sharing resources, there's UK wide resources, there's World Health Organization resources, Scottish Government's developed some new resources for this year that we can use as well, and we've put all of that on our SAPG website. We're happy to share the link with anyone who'd be interested. See that and we'd really like to encourage any of the listeners here to see and think about how you can help and get involved as well, try and, think about what you could actually do to raise awareness of this issue, because it's been termed sure many people have heard this before. The kind of silent pandemic so and I always quite a big strong advocate for the job and the role that I have and I always say what's going to happen in 10 years time when people turn around if we don't manage to contain this and do what we're actually suggesting that we should do here people are going to turn around to me and say But you knew 10 years ago, why, what have you done? Why have you not done something about it? And I think everyone has that role if they understand what the threat of AMR is to actually get up and do something about it. But anyway, I think a really useful suggestion, I would like to encourage our listeners to maybe pledge a using the antibiotic guardian campaign, which is a. a national campaign, which has roles for everyone. So even they could advocate, for pet owners or people who have a healthcare role or whoever it is, there's always, there's a role in all of it and everyone should pledge to do something, I would say and SAPG will do their best to amplify this message and get that message across as much as they can

Callum 38:56

what a tour de force, like I'd never heard it explained that well before Fran, so thank you. I was about to feel guilty, but I have actually. Pledged to be Antipodic Guardian, thankfully, because otherwise I would have felt really bad and I'll get the links off you and I can share the link to all those resources mentioned there and you can find the show notes on the podcast player of your choice at the bottom and we'll link into there. So yeah, there's a lot going on this week from lots of organizations sharing and amplifying this message of educate, advocate and act now.

Jo 39:27

Think that translates into the health boards as well. So every antimicrobial management team across Scotland and beyond will this week be having activity within their organizations, showcasing and promoting The messages from SAPGE, from World Health Organization and beyond. And I think that's where the translation is important. Because we've got the high level messages, but what does it actually mean to the people working? on the ground. And that's the role of the local health board antimicrobial management team. So making it relevant to the people where it's going to make a difference. So one of the things that we are running this week is sector of the week. So showcasing all the fantastic work around antimicrobial stewardship that happens across various different sectors, because it's quite easy for us to focus on the hospital setting. I think we are all hospital based. in the main on this podcast. So that tends to be where your comfort area is drawn to, but antimicrobials are prescribed, consumed, administered across every single healthcare sector. in health systems. So it's really driving that message to the deepest, darkest corners of our health systems to make sure that it's there as well and involving the different health care professionals that work in these areas. It doesn't matter if you're a doctor, you're a nurse, if you're a physiotherapist, A carer, a health care assistant, every single person has a role to play in antimicrobial stewardship. And the way they can influence that is critical and may or may not influence that prescribing decision.

Andrew 41:12

Yeah, and just to, to stress also that this is a One health, one system problem. It's not just humans. We know that there are more antimicrobials actually prescribed to animals than humans on a kind of global, on a global level. So previous messaging with World Antimicrobial Resistance Awareness Week has also encompassed small animal practice. What they're doing in the vets talked about antibiotic amnesty, taking your antibiotics into your local pharmacy, rather than keeping them in the cupboard for a rainy day and using them when they may not be at all appropriate, or they may be out of date, not flushing them down the toilet because we've got to think about the environment. So a lot of activity, a lot of activity happening, a lot of opportunities for everybody to think, and as Fran said making a pledge and trying to do things a little bit differently.

Callum 42:05

Thank you all. I you explained that very clearly and I'm sure listeners will be left with a sense of reinvigorated enthusiasm to get out there and act this week and pick up on some of these resources that we've shared. That's this week. I guess, next week and going forward. Or maybe the next 10 years as Fran so aptly people are asking, you knew 10 years ago, what have you done? Where are things going next, both for SAPG and stewardship?

Andrew 42:33

I guess we have a national action plan. So we've got the UK National Antimicrobial Resistance Action Plan, which was produced in May 2024. It's a 5 year action plan and this has come out with a series of ambitious targets to reduce our prescribing to reduce drug resistant infections, to reduce cram negative resistant infections. And there's a whole tranche of initiatives that are going to come out of this action plan. So we're, right at the moment. We're in the process of working out how we can implement and how we can deliver on this plan. But this is going to be the sort of major focus, UK wide and each country around the world will have their own national action plan. And that's. Again, that's informed by the United Nations who only last month, produced their high level declaration to reduce antimicrobial resistance. so that should drive national action plans throughout the world, but essentially the world is signed up. On paper, at least, and in the United Nations to reduce antimicrobial resistance, and that feeds international action plans like the UK National Action Plan. So it's our job, I think, in SAPG to tackle the human health side of this and to do everything we can to keep thinking about how we can improve prescribing. I guess one of the major challenges I see ahead for us is tackling the changing landscape in the UK and Scotland, and that's about there's more remote prescribing going on. There's a study recently published that shows there's a 25 percent increase in prescribing in through a remote consultation compared to a face to face consultation, and we need to rethink the way that we tackle antimicrobial stewardship in these remote settings because remote consultations are here to stay. We hear this very clearly from our colleagues in primary care. And since so much prescribing goes on in primary care and a significant proportion of that is, is happening remotely, we really need to start tackling that and we need to properly engage, I worry that we talk. And kind of silos and we talk in echo chambers and we're all on this podcast agreeing with each other, but we need to reach out and speak to people who are prescribing, making sure that we explore those avenues. And make sure we tackle the concerns and the barriers and think of what the enablers are to making prescribing better wherever you are, so, when, as I started the job as Dr. Chair of S-A-P-G-I was worried that most of the work is done. It didn't take long to realize that the work, there's still tons of work to be done, and as I'm probably coming towards the end of my tenure as chair of SAPG I'm increasingly anxious that there is still so much more to be done.

Callum 45:23

There's always work to be done in infection and stewardship in particular, isn't there? And as you mentioned there, It's a, working out where we can collaborate and maybe I can throw to Simon now to talk what other sort of actions are SAPG and what else is happening on a sort of more international basis, Simon?

Simon 45:40

An example, in Edinburgh, we are, a part of the Fleming Fund Initiative, and that's a large UK government aid program, and it's about working with partners throughout the world around antimicrobial stewardship, so we're supporting fellows, fellows are healthcare professionals similar to us. Pharmacists, nurses, laboratory, scientists, clinicians, so particularly we have been supporting fellows from Uganda, Malawi, Zambia, and Kenya, and we've been both out there and in our communities. Coming to Scotland around this time. again, it's around the one health. It's fellows from both human health, but also from veterinary health and environmental health. So it's just an illustration of, the W and wow or whatever you like to call it now. It's world. So, yeah, having partnership globally with people and also thinking about repeats one health, but it's not just us as human health people. And I suppose. More specific things, how SAPGs have been involved in projects in Ghana as well.

Fran 46:45

Yeah, so I totally agree. I mean, I think we can work really hard To improve prescribing in Scotland, but it's just a small country in the whole of the world. So there's a lot that other countries can do. And we recognize that some countries might need a bit of support to do that. So, over the last, this is a sort of five year project that we've been working on. So we started off with a couple of hospitals in Ghana, and now we've spread out to a six hospital collaborative working to support antimicrobial stewardship in these hospitals in Ghana it's called the CW PAMS and that stands for the Commonwealth Partnership for Antimicrobial Stewardship Scheme. And that is again, as as Simon was talking about, supported by The Fleming fund we are just supporting them to develop their own network and to look at antimicrobial stewardship I guess from the can hear from what Andrew said right at SAPG has been running for a long time. So it's not that we have all of the answers. It's just that we've fallen down a lot of the pits that everybody else's is coming across. And that's why we feel we can. We can support other people do this because we've already learned those painful lessons, I guess, that's part of the reason why we're in a position that we can support others now, but I think what we found from the work there is that all the challenges that are faced. That are faced by people, whatever they are trying to improve antimicrobial stewardship, there, way more similarities than differences about what it is that people are trying to do, which is why a big part of what we do is about quality improvement, because you have to find solutions to issues. We also have a big focus on behavior change because quite often you find that the challenges are. are related to relationships and relationship building and changing people's minds and advocating, different ways of doing things. So it's never as straightforward as just saying, this is the right one and that's the wrong one. Cause that never, ever works. I mean, I don't know about yourself, but someone turns into me and says, you're wrong. It's the first thing to stop me in my tracks and go, hang on a minute, I'm not wrong. So I think when you're trying to do this, you need to think about how you. How you tackle it and how you start those conversations and conversations happening, everywhere across the world as antimicrobial stewardship is becoming bigger into focus is exactly where we need to be going for the next phase of what's happening. Because as I said, if we're trying to do this on our own, it would really make any. difference to the world impact of what EMR can actually do. And just as a reminder, World Health Organization does have antimicrobial resistance as one of the top 10 threats to the whole of human health. So I guess, we just have to remember it's not just about us in every corner, but everyone needs to do something about this.

Callum 49:39

I couldn't agree more. And I think we've heard. A lot of really important stuff that SAPG are doing both in local health boards to support the national bodies and even supporting other parts of the world. So to wrap up, could ask you each if you have any final takeaway thoughts for our listeners

Jo 50:04

Could I make a plea to listeners to involve their nurses in antibiotic conversations? And that might be a starter for 10 to get nurses thinking about antimicrobial stewardship. On a broader scale and to be receptive to any questions that they might have because that's the one fear when chatting with nurses about antimicrobial stewardship is that they're going to get shot down in flames because they are not the prescriber, the end of the day, they are just having a clinical conversation with a fellow colleague.

Fran 50:36

From my point of view is if you've enjoyed listening to the podcast and it's made you really think about, Antimicrobial prescribing in a slightly different way, I would really encourage you to follow the guidance of the World AMR Awareness Week that's on this week and take action. So I guess, what would you be thinking about doing as a result of having listened to this? You could be, just making sure you're aware of your local. Call antibiotic policies. You could link in with your antimicrobial management teams. You could have a look at the SG website and see what kind of guidance that we have available. Or, an alternative would be, sign up and everyone should do this as well, obviously, but you could sign up to be an antibiotic guardian and do your bit to protect antibiotics.

Simon 51:18

I suppose, this is maybe targeting for a lot of kind of infection trainees. It's just like use opportunities in your training to be engaged in stewardship and, yeah, keep listening to the podcast. It's great.

Callum 51:31

Oh, that's very kind, Simon. Thank you.

Andrew 51:33

Well, for me, the most important thing is as rounding off statement, is antimicrobial stewardship is everyone's business. And it's from the nurse that takes the swab or takes the urine sample, who sees that the patient has got a fever and reports it to the doctor to the person prescribing the antibiotic to the. The microbiologist who's reporting the result from the lab. So there's a huge continuum and every element in that chain is crucially important. The diagnostics steward from the practical sides of prescribing and making those decisions. So I think for. For trainees, particularly listening, to be aware of that, that huge chain of consequences, basically, and being engaged in it and getting engaged with your stewardship team and I would like the last word actually to be about antimicrobial stewardship and nursing and the crucial role that they play. And I say this all the time, but I really hope that we can, get much better traction, not just in Scotland, but around the UK and around the world, because nurses are, potentially a really important solution to the AMR problem and the human health side.

Callum 52:46

Brilliant. Well, thanks to all of you for coming forward and agreeing to come on the pod and giving us your time and thoughts there because I've certainly learned a lot and I'm sure our listeners will too. I'll share all those resources that we've spoken about. And if you do sign up to be an antibiotic guardian and then you can tweet us. On X or Twitter or send us an email, let us know that you've signed up and you're going to start doing your part and I'm going to certainly go back to the boards and speak to my nursing colleagues shout out to some of them who I know listen to, see what we can do to support them locally, great, thanks very much Andrew, Fran, Joe and Simon for joining us wow, what a team that we had for this episode. So thanks. Thanks everybody.