142. AWaRe

Access 

Watch

Reserve (IE the cool stuff)

What are they? Where are they? WHO ARE THEY? 

Listen on and find out! (Looking at the prep notes strongly advised for this one). 

Transcript

Jame 0:00

Callum, are you doing? Oh, is that what you're gonna wear to the episode? Oh, I don't like the look of that at all. I think you need to dress a little bit more snappier. I think you need to be more focused on what you're going to aware,

Callum 0:13

Who are you?

Jame 0:15

and what a coincidence that is. 'cause What are we talking about today, Callum?

Callum 0:19

Well, we are going to access some learning. Unfortunately you can't watch this 'cause it's an audio medium. But maybe you can

Jame 0:28

it later, I suppose, and be

Callum 0:30

Yeah,

Jame 0:30

The content.

Callum 0:32

Well, we're talking about the AWARE classification. That's A for access, W for watch, A for watch, R for reserve. Be a reserve Aware.

Jame 0:48

Excellent.

Callum 0:49

the A, the w and r are capitalized.

Jame 0:52

And where did this come from, Carl?

Callum 0:54

This came from the WHO, the World Health Organization, and there has been a UK version a ized version by the uk, HSA.

Jame 1:04

fine. And any idea why they decided to do this?

Callum 1:08

I, my understanding is that it is meant to improve stewardship efforts worldwide. So I guess with antibiotics we can say, oh, that's a broad spectrum antibiotic. Oh, that's a narrow spectrum antibiotic. Or you should use that one. Don't use meropenem use amoxicillin. But I guess from a data point of view, it could be quite hard to say. This antibiotic good, that antibiotic bad using this here. Good using this here bad. And so, the aware classification, I think is meant to provide some framework or measurable metric by which you can benchmark your country health board area, hospitals antimicrobial prescribing against some sort of standard.

Jame 1:53

Yeah, and I think the WHO decided to do something about it when they got interested in antimicrobial resistance. And again, to give particularly low middle income countries, framework to work from. I think what happens a lot of the time is that the countries will adapt it to their local prescribing practices and the drugs that are available in their country, you know, including what the UK has done as well.

Callum 2:20

And I think it was first developed in 2017 by the WHO expert committee on the selection and use of essential medicines. And the intent to update it every two years. So it's something that's gonna continue to be useful, Which is great.

Jame 2:34

Yeah. Yeah. And I don't know that the that every medicine that we are about to talk about is in the Poo Essentials medicines list, but most of them are if not all of them. So let's talk about what we mean by access Watson Reserve. So we've got these

Callum 2:46

Okay.

Jame 2:47

Usually people apply a traffic light coding. Let's talk about what they are. Cal, do you want to take access?

Callum 2:56

Access is a green and they've got a little picture of a door because you can access the door. The antibiotics with narrow spectrum of activity are in here. Those with fewer side effects, lower potential to drive. Antimicrobial resistance and first or second choice, antibiotics which are recommended for empiric treatment of the most common infections.

Jame 3:20

Yeah, and you could argue about that fewer side effects given that the UK has got Gentamycin in the access category. But,, the overall thing is that these are meant to be your workhorses, the things that you reach for in the first instance. And what about watch?

Callum 3:35

What are our broader spectrum antibiotics? They generally have a higher resistance potential, and they are usually first or second choice. Antibiotics indicated for a limited number of infective syndromes and their use should be carefully monitored.

Jame 3:52

And then I'll take reserve. The reserve ones

Callum 3:55

You reserve the best for yourself.

Jame 3:57

for the best for last. Exactly. Thank you, Callum. So these are the last resort antibiotics. I mean, this category might as well be called cool shit for infectious disease doctors and not for the likes of you, but reserve will do in a pinch. But these are the things that you. Want to hold back and not use in a broad manner, unless you absolutely have to. And particularly stuff that's really useful for MDR bacteria, be that hospital superbug, MRSA, or be it your MDR gram negatives or your difficult to treat pseudomonas, that kind of stuff. So access, watch and reserve. Think of like, as like a traffic light system. let's talk a little bit now about the who aware classification. So we've got a picture here. This really is an episode where I would advise going to the prep notes if you were sort of interested in this. 'cause what I've done is I've divided all of the agents that are in the WHO system into Access, watch, reserve in three columns. And then the. In the rose, I've got all the cell wall agents grouped together. The protein synthesis agents grouped together all the anti folate and anti DNA agents, and then other is down at the bottom there.

Callum 5:12

And those are the ones that don't fit into those categorizations of the broad types of mechanism of action.

Jame 5:21

Yeah. I gotta say there's some in this this table that I'm, really never heard of before. And actually as well as that cal, there's tons of antibiotics, ones that I've never heard of and ones that I have and had basically forgotten existed. Didn't you find

Callum 5:35

Yeah. And that it would be reassuring until you realize that most of 'em are just me too drugs that are very similar to something that we use regularly, but just never really won that, won the popularity contest or things that, don't really have much clinical use. 'cause there's something better and easier correlated.

Jame 5:51

well, I guess that's the sort of argument forin isn't it? So like Tsar with cla acid is that Piptaz that same ecological niche. And maybe has slightly better pseudomonas cover, if I remember rightly so. There was no situation in which you would want to use to mention that you couldn't just use peptides if you needed

Callum 6:12

Yeah.

Jame 6:12

kind of thing.

Callum 6:13

Yeah.

Jame 6:13

Yeah. Is there anything in this table that we want to, highlight?

Callum 6:20

There's a typo. You've written Piperacillin slash Tazo Act

Jame 6:26

Son of a bitch. I'm gonna have to redo that. thanks for nothing, Callum. You did wanna point that out before we started recording. Awful. Awful. You're such a bad egg. Callum much. You're

Callum 6:39

I think it would be useful to point out that it's quite a useful way to look at antibiotics and think about antibiotics in part of our continuing thinking about antibiotic series. 'Cause some, someone, as I said before, an ward asked me recently, how would you learn antibiotics? So I still puzzle on that question quite a lot actually. And.

Jame 7:00

the website, learn antibiotics.com and the associated book could be a first starting place for the,

Callum 7:05

is quite a good use useful thing. But we have to answer that question. Learn antibiotics com. They can.

Jame 7:10

why am I advertising on behalf of other educators?

Callum 7:13

So maybe now, dear listeners, Wafa, just delving into some examples of access watch and reserve and why certain things are certain columns or thoughts on them. So maybe we could just start with access.

Jame 7:28

Yeah. Okay. So for access, starting with the cell wall agents, we've got most of the narrow spectrum, penicillin. So amoxicillin, ampicillin, all the benzo, penicillin variants, you know, including zaine and protein penicillin. and then you've also got flu clocks. Omo CL is in here, which is interesting because it's watch in the UK system as we'll. Come onto, there's a bunch of interesting differences really. and then we've

Callum 7:55

So there's, just to clarify, this is the who system of the fucking money?

Jame 7:58

we're talking

Callum 7:58

Yeah.

Jame 7:59

and then we've got a load of penicillins here. And Callum, I think we, if we're going have any one, Callum and Jane read the alternate names out. It'll have to be the penicillins here. So what do you

Callum 8:09

Oh God.

Jame 8:09

What do you say?

Callum 8:11

I almost prefer the cephalosporins because it's the controversial thing, but okay. We'll do the penicillins for once.

Jame 8:17

Azi Doin.

Callum 8:18

Ba Bain

Jame 8:19

Clo Soin

Callum 8:20

Oxacillin.

Jame 8:21

Diox Sill. Hein

Callum 8:24

Max. Oh, that makes more sense. Mac,

Jame 8:29

Methicillin.

Callum 8:29

Methicillin

Jame 8:31

Nain.

Callum 8:32

IC

Jame 8:33

Penicillin.

Callum 8:34

p Vanillin.

Jame 8:35

Proin. Ampicillin, Alam.

Callum 8:39

Salt of missin,

Jame 8:41

cell bactam.

Callum 8:42

salt of sun.

Jame 8:43

see I wonder if there's a bunch of those that the listener has just like never heard of. I'd never heard of a bunch of them as well, and I wonder how many are actually in clinical practice. But the WHO have clearly kinda felt that it would be best overall if you include them all

Callum 8:59

I, I love this.

Jame 8:59

them all. Yeah.

Callum 9:00

I think it's just like we are gonna, every antibiotic there is, we're gonna categorize it. So there's no doubt you're not gonna be like,

Jame 9:07

Oh, I wonder

Callum 9:08

you know, just

Jame 9:08

Yeah,

Callum 9:08

very comprehensive. I think it was quite a fun job to have come up with this.

Jame 9:12

I bet this took bloody ages.

Callum 9:14

I think this should be your career aim James is to get onto this committee.

Jame 9:17

only. And then just tell everybody to use Korum all the time. Yeah, I mean, it's a work in progress, isn't it, Kyle?

Callum 9:22

So, the other thing that's Anxi for cell wall is the first generation ke sporin. So we've got our Keflex in Keel and Zolin.

Jame 9:32

And Ketin. And Kerine, which I think are much less commonly used. I mean, I've never used anything. It's, except in Keflex and Zolin. And then you've got other more small fry calfs that are in the the table that we won't go on.

Callum 9:46

I think one alternate reading is just about as much as the listener can tolerate. Someone asked me recently, why did we do that? There's no reason.

Jame 9:53

what, why do we, why are we doing this at all? Why are we doing anything and not to vaguely entertain ourselves and vaguely educate the listeners. I mean,

Callum 10:00

i'm sure people learned a lot from that list of mispronounced antibiotics.

Jame 10:04

Well, exactly, yes. I mean,

Callum 10:06

Yeah,

Jame 10:06

be properly pronounced if you had bothered in the first place too. Actually, well, I wouldn't insult you anymore

Callum 10:11

go to antibiotic pronunciation school like I should have done you

Jame 10:14

Well, maybe that's the next website that I'll set up. And then you can be the only person who subscribes to the to the site.

Callum 10:20

voiceovers record. I was recording an increasingly fixed Scottish accent, so people are like.

Jame 10:27

I know sometimes people, they're like, oh you pronounce it wrong. You pronounce it wrong. We're the ones speaking the queen's English over here. Okay. Into protein synthesis. We've got doxycycline and tetracycline. And then what about the Amide Cow?

Callum 10:42

So we've got Gentamycin, spect, mycin, and Amikacin.

Jame 10:46

Yeah. Again, never used my life. And then in the other category, I guess you've got Chloramphenicol, Thiam, phenic. Which one? Presumes is a Amphenol. Like Chloramphenicol and Clindamycin. Yeah.

Callum 10:59

No.

Jame 11:00

So Clindamycin separated out from the rest of the macrolides there?

Callum 11:03

Interesting that Clindamycin gets into access.

Jame 11:05

I think maybe because it's used broadly elsewhere for skin and soft tissue. I can't think what

Callum 11:12

Yeah.

Jame 11:12

be used for really.

Callum 11:14

Has it maybe got less of a propensity to develop resistance?

Jame 11:19

I

Callum 11:19

know, IMY,

Jame 11:20

heard of,

Callum 11:20

there's some data about macrolides and, microbiome tosses a T, but

Jame 11:24

but

Callum 11:24

I don't know. I don't know.

Jame 11:26

pretty microbiome toxicity

Callum 11:28

that's true. It's true.

Jame 11:29

the resistance profiles even the same. It's the ml SB phenotype, isn't it? That point mutation that sort of knocks out micro micronized, linco of mine and strep garmins.

Callum 11:38

Yeah.

Jame 11:38

So, yeah, I don't know. But anyway, somebody thought it was worth putting in access, and so they did. And then Cal, we've got our DNA and folate inhibitors. Now all of the quinolones are in watch. So the access ones, the ones that you will have heard of are Trimethoprim and Cotrimoxazole. And the ones that you wouldn't have heard of are all these other sulfur sulfonamides. And Smide combinations, almost all of which are combined with trimethoprim. So like Sulfadiazine, trimethoprim, sulfa.

Callum 12:10

some of them are recognized, some from like HIV medicine, but not many of them.

Jame 12:14

Well, some of them are used for what's the one that is Sulfur Paridine. that's still sort of used. And sulfadiazine and stuff like that. I

Callum 12:23

so basically.

Jame 12:24

of the rest. But all these other sulfa drugs, like a bunch of them are with RI except for Sulfadiazine with Tero Prim, which I've also never heard of.

Callum 12:35

That's you listening to two idiots. You haven't heard of things.

Jame 12:37

I know our recurring theme in this.

Callum 12:39

and then the access other a, the other mechanism actions in the access group. So we've got our trust, old friend ol we've got OL

Jame 12:49

Yeah. It's

Callum 12:50

and Nitro and. Which I think are the three that you'll actually have heard of.

Jame 12:53

the

Callum 12:54

So if you capitalize the ones that people have heard of and you left in lower case, the ones that we probably don't know about.

Jame 12:59

Yes. And the ones that are in bold are the ones that aren't in the KHS.

Callum 13:05

Oh, right. Would, wouldn't you make more sense to bold the ones that are in the uk, HS say, and Non bold to the other ones?

Jame 13:12

Just full of little comments today, aren't you? Moving on.

Callum 13:16

That makes so much more sense.

Jame 13:17

You make so much more sense.

Callum 13:20

Thank you. So let's move on to watch, so we're starting with cell inhibitors, so we've

Jame 13:28

Pip and Timo, and then a bunch of other stuff that again, you've, you might not have heard of

Callum 13:33

Yeah

Jame 13:34

there,

Callum 13:35

that's our Pen.

Jame 13:35

you've got. Kelo and Kol Ketin and Kevar ine, which are all called second generation ke SSPORs. Even though Kein is a kef M and not a ke sporin technically. But anyway, I know what

Callum 13:50

That nobody cares though.

Jame 13:51

of other ones. Yeah, I know, but I kind of care, but I know I shouldn't. But anyway. then the third gens, Arex, CFET, taxine, Ceftin, ceftriaxone. then a bunch of other ones you've never heard of. And then your fourth gens are kepe and then three others that you never heard

Callum 14:07

Yeah, interesting here that Keine is in your watch rather than your reserve.

Jame 14:11

Well, if you think that's odd, then you're going to absolutely blow your head off at the next classification because all of the carbapenems, the oral agents like Bapen and Pippen and Teop, penem are in the watch category.

Callum 14:25

Yeah. Yeah. That's interesting.

Jame 14:27

That set the cat amongst the pigeons. Callum,

Callum 14:30

Yeah. I think, obviously we're fortunate to work in a country where we have, lower level problems with gram-negative resistance. Like we still get carbos producing intra like everybody else does, but it's still thankfully quite rare.

Jame 14:44

Whereas ESBLs are about 30% of the gram negative workload in places like a Italy and gre.

Callum 14:50

If you're working somewhere like South Africa, like Ben listening to her talk about it on micro bale, which is excellent, then, you just see that's so different. So I guess if you're gonna be like, oh, don't use these carpen, which are the only drugs that you have that will treat these infections, I think that might be a bit unfair.

Jame 15:05

and

Callum 15:05

From who?

Jame 15:06

as Julie and Aaron on a recent episode from the Break Points podcast, the break points breakout said, if you're not gonna use a carbapenem for ESBL, what are you holding them back for?

Callum 15:16

Yeah.

Jame 15:17

I mean? Like they're the first line

Callum 15:18

They are great. So I can kind, I can get on board of that. And I guess kp I guess in the same sense is probably like similar use cases, isn't it? So,

Jame 15:27

I think so. It's still active against, you know,

Callum 15:29

yeah.

Jame 15:30

and ESBLs as well, I think.

Callum 15:32

Yeah.

Jame 15:32

So, yeah.

Callum 15:33

Another cell will active thing. So we're get starting to get the glycopeptides coming in. So our vancomycin and Tyco plan in are watch antibiotics and then protein synthesis. Watch antibiotics.

Jame 15:45

Yeah, you've got your tetracycline, so Cylin, oxytetracycline, and. The first of quite an annoying theme here, oral, but not IV minocyline because oral minocycline is watch and IV is reserve. I'm not really sure how it's managed to straddle both sides of the categorization here. And then for the amano, glycosides, neomycin and Tobramycin are there but not Amikacin. Amikacin is access, as we've said

Callum 16:11

So we reserve tobramycin. Is that just 'cause we're wanting to, I mean, so that's, we're watching tobramycin use because higher side effect.

Jame 16:20

think it's because it's the prime anti pseudomonal aminoglycoside,

Callum 16:24

Right? So that.

Jame 16:25

areas would want to try and reserve that.

Callum 16:28

So there's a bit of a talk about like the Scottish Am OG Glycoside and if the recent changes to UCAS break points, you know, should we move away from Gentamicin as the backbone? Because people are concerned about the way that the break points are set now, and we're still relying on systemic infection, essentially

Jame 16:44

Yeah.

Callum 16:45

And we're getting around that by core, giving it amoxicillin. But the discussion is moving to tobramycin. Backbone, but that's not so appealing if you're then being judged on these standards saying that should be watched.

Jame 16:57

Yeah. I suppose, I mean, you would have to try and move it into access if you were wanting to, because

Callum 17:02

Yeah.

Jame 17:02

of a Mogen plus minus me is that it's an all access regimen. Whereas you would be losing that with that, I mean, whether you want that the aware to wag the antimicrobial stewardship dog is a topic for another time.

Callum 17:16

And then fed dexamycin protein synthesis inhibitor. So in, in watch where's oral van? Is that just in watch as well then?

Jame 17:25

Vancomycins Vancomycin.

Callum 17:26

Okay. So both for c diff drugs, so no difference. So use more CIN probably. And then

Jame 17:32

got the

Callum 17:33

PRIs. Mycin.

Jame 17:34

Cincin.

Callum 17:35

Yeah, which is

Jame 17:37

And

Callum 17:37

useful.

Jame 17:38

got clindamycin dad vancomycin in there. And then the macrolides. All of the macrolides are there. Azithro, Clari area through and a bunch of others. And then the

Callum 17:47

Yeah.

Jame 17:48

again, all the ones that you've heard of and a bunch of others that you haven't are in the watch category. And then down at the bottom you've got fused date. Oral Phosphomycin, but not iv and then rifampicin and cousins and something called ol, which I did look up what that was, but have since forgotten what it's

Callum 18:08

Yeah.

Jame 18:08

then the reserve category, let's just run through this quickly. You've got your weird kelo sporin beta activase inhibitor combinations. Your Keda calls your Keef as avie. The anti MRSA Kelo Sporin Keef Bypro are here, Keef in Tazo, and then your carbapenem combination with betalactamase inhibitors. This is where they are. So Ira l Mein and vaborbactam as Trina. Is here, whether or not it is included with avibactam. Yeah.

Callum 18:40

Oh

Jame 18:40

cousin Karu mon, which is not commercially available yet. And then farro, another carbapenem, agent. I dunno why this is here, but all the other oral agents are there as well. Maybe it ist oral actually. And then your long-acting glycopeptides DBA Van

Callum 18:58

yeah. Yeah

Jame 18:59

are there.

Callum 19:00

that makes sense to me.

Jame 19:01

And then Cal protein synthesis blockers.

Callum 19:03

Yeah, we've got a raic, anti Tline and IV minocycline, and then Minocyline. And we did that episode before on the weird tetracyclines, if you wanna go back and look into that. Yeah.

Jame 19:16

And then what else have we got?

Callum 19:18

Pla mycin, the tragedy of plasma mycin. It's stuck in reserve.

Jame 19:23

but that will be useful for the American to have access to it and I Absolutely, no one else nails anything else.

Callum 19:29

We've got our old favorite EZ and ez, oh God,

Jame 19:32

Teli, what is with you this evening?

Callum 19:35

EZ.

Jame 19:36

and mispronunciation.

Callum 19:37

That's me, my Jim son.

Jame 19:39

That will be on your

Callum 19:40

And then left. Left a mullen.

Jame 19:42

Lefamulin, the plural. Mutual. So reserve just so that absolutely nobody will ever use it. For pneumonia, which is license

Callum 19:50

Yeah, I also Quin Newry and DFO PRIs in combination, which is interesting that's in reserve. But Pristine and Mycin is watch, but we shouldn't say anything more about that 'cause they're both very small print.

Jame 20:00

know probably 'cause Cincin oral maybe. And then in the other category you've got Colistin and Polyon, B iv, phosphomycin Daptomycin, and ILO Prim, which is a Trimethoprim cousin

Callum 20:12

Daptomycin is in reserve.

Jame 20:14

I know.

Callum 20:15

'Cause I'm just thinking about our local practice and there's some bits here that I'd missed the fact that Dapto was in reserve. It is interesting and I also think that we use a lot of esli and I often think I feel like we should be holding this back more. Like it is quite, quite an appealing choice. It's highly bi available, it's very effective. Don't need to worry about resistance done esli. And I do sometimes think actually, are we being bad stewards in the department? I'm saying we I don't know if that's me, but there's a lot of getting prescribed and I sometimes think like, why didn't you know, you could have used a different antibiotic here.

Jame 20:50

Yes, that's true. But I also think that might be you know when you buy a brand of car and then you start seeing that everywhere on the roads, I think that you are seeing a lot of SLI use because the patients who need lint are concentrated. Into your clinical

Callum 21:05

Yeah, that might be true.

Jame 21:07

And I mean, you're right. When people are using SLI and they shouldn't be, very frustrating. But I

Callum 21:14

I think also people,

Jame 21:15

of the, if you look at a lot of those cases, a lot of those SLI may well be the best agent to use,

Callum 21:20

also it seems like people have, faith in Neli. So what I've seen is people have, well, a lower threshold at which to I ost. There's iVOS to Esli compared to something else like Coum, doxy,

Jame 21:34

Yeah.

Callum 21:34

So they'll all switch earlier, so then you're like, oh, well I'm not really sure we should be using Esli here, but I'm also happy that we've oral switched, so that's fine.

Jame 21:43

Yeah. It's kind of hard, but I think that just to talk about it for a sec. If you have a bunch of options that you're going to use for say a staph or is Breia, and I'm thinking particularly of your saboto, low risk sap, which is something of a unicorn. But actually we've had a couple recently and we've had the options, you know, clinda, Cori or Esli, and I've gone. Pretty much invariably for Cotrimoxazole. 'cause I think it's the best tolerated of the three. In older people, certainly in, in younger people, you might argue that Clindamycin is the is the better agent, but I'm worried about the c diff risk. Right? And it happens to be the access. Antibiotic. And so I'm just using that and that's, you know, partially my extrapolating from Saboto and other trials, but it's also just my familiarity with the drug. You know me calm, I'm throwing it at everything with a pulse and some things without, and other peoples will feel that way about Lali.

Callum 22:38

Yeah, so we've spent a long time there talking through the who, So, you know, I guess this is a really comprehensive resource. It's got all the antibiotics much more extensive than the UK version. It excludes anti TB drugs. I think we discussed some of the interesting points as we went through there. So, as I say, look at the notes. It's color coded. It's quite easy to read, and the type will be fixed.

Jame 23:02

If I can remember it's in this table as well, because now I'm looking at the KHSA. So what, what happened was the KHSA looked at that big list as it came out in 2017 and said there's no way we're gonna be able to use all this stuff. Like, it's got like a bunch of macrolides and tetracyclines and. Quin loans that we just the UK just doesn't have a license for. The UK has only got a license for about 60 different drugs. So we're going to take that, we're gonna strip it down and we're going to shift some stuff about that. It makes more sense for UK practice, so they. Moved for example, the carbapenems into reserve. We are in a low ESBL prevalence country, and so it doesn't make sense to use them in a way that you would if they were watch antimicrobials and some other stuff. Controversially really got shifted up from access into what, so the first generation ke sporin got moved into watch the Sporin were purported to have a moderate to high c diff risk. Which is true of the higher generation Kelos borns, but not the first gens. They're more similar to like, amoxicillin or kind of flu CLOs. And so this was kind of pointed out to the UK HSA by numerous physicians. And so when they revised the list and published it in 2025, they did a few moves and one of the things that they did was they downshifted the first chain so that we can now use

Callum 24:29

Yeah.

Jame 24:30

And thank God they do

Callum 24:31

Alice Snap. Yeah.

Jame 24:32

imagine post snapp, if everybody moves to using Zolin for your staph oriented breia and it's watch, that's gonna really mess up your statistics. So the list that we've got here is much smaller. I don't know if we really want to go through it in

Callum 24:45

No, I don't think we need to go for, in detail. I think what's really important and really interesting is thinking about the differences between the who's one and K HSA one. If only someone would summarize the differences between the two.

Jame 24:58

Well, if you would hold your tongue for just a little second, I would be able to tell you to scroll down and see that I.

Callum 25:05

Yes, I know I was setting you up.

Jame 25:07

I know. But I wasn't gonna pass up an opportunity to insult you.

Callum 25:11

Oh, wow.

Jame 25:11

there's a couple of

Callum 25:12

Failed.

Jame 25:12

differences. One is that the TB meds are included, so your anti-TB medications, but they're all in the other category, which is much bigger. They're so a bunch of stock got moved into the other category. So they're not access watch reserve, that is things like. Things that I think they are trying to say, look, you don't really need to use any of this stuff. So like SPECT Mycin was moved over there, IV streptomycin was moved over there. Eclo Cyclin, which is the tetracycline that is used in S-I-A-D-H,

Callum 25:43

Yeah. Well, one thing that is a bit confusing from what you're saying, just to clarify, so we're talking about other mechanisms of action, but what James talking about here is the other category. So access, watch, reserve, and then other, which is what we're talking about, everyone. So maybe on the tables we can add in on the left hand column, other mechanisms

Jame 26:05

I had like to keep it confusing actually, but

Callum 26:07

or just change other di instead of saying other mechanisms. Right. Different categories or something. It's just confusing

Jame 26:13

Maybe I like the confusion.

Callum 26:15

more,

Jame 26:15

Alright, fine.

Callum 26:17

something like that.

Jame 26:18

But yeah, let's talk about the differences then. So if you look at the different, again, this is all on a table color coded, but if you look at the table, there's a theme, which is that for the cell wall agents, there's a bunch of stuff that the U-K-H-S-A have said is reserve. That the WHOC is what, or the carbapenems,

Callum 26:36

Yep.

Jame 26:37

the amoxil clave acid is watch in U-K-H-S-A, but access in

Callum 26:44

Yeah.

Jame 26:44

So it's

Callum 26:45

That's a big change.

Jame 26:46

Sh, you know, sh.

Callum 26:47

Yeah. And KLA is I think one of the workhorses of the NHS and I think, a lot of KLA is used and it's quite appealing. It covers strep generally. It mostly covers staph aureus and non-severe infections. Covers quite a lot of gram-negatives. It covers mouthy organisms. Bites and stuff like that. It covers chest, it covers urine mostly abdominal to a degree is, you know, it's easy, isn't it? It's easy medicine. You just come in and you prescribe everybody the same drug and then they all go away happy.

Jame 27:21

Yeah I guess if you were gonna have one drug as the everything drug, it would be that and the other advantage is, of course, that it's oral.

Callum 27:27

Yeah.

Jame 27:27

Too, I think that the, though that the HSE approach for us is. Is right

Callum 27:37

yeah, I.

Jame 27:38

One, the c diff risk is not in inconsiderable. But The thing that I really am mindful is that the U-K-H-S-A updated this aware classification and put it as an appendix in the S power report, English survey of prevalence of antibiotic utilization and resistance. And the first chapter of that is antibacterial resistance. And if you go and look at that, coli resistance in e coli is nudging up to 40% and in Klebsiella is over 30. And those are the big two gram negatives that we've got. And so if SCL was being given its license on the market today with that kind of prevalence of resistance in the gram-negatives, it wouldn't be given a license for UTI, it wouldn't be given a license to cover complicated intraabdominal infection. You would say, this is for pneumonias only. And if you're going to use it for intraabdominal stuff, you would have to combine it with a gram-negative active agent like Gentamicin, for example. Or not. Just not use it and use Ceftriaxone instead. And so I've got that reservation in my head that It's the everything drug

Callum 28:48

yeah,

Jame 28:49

and less the case.

Callum 28:50

yeah. It you, it allows you that false reassurance to say, I don't need to worry about what the source of infection is or what's happening, because I've given them comox.

Jame 28:58

Yes.

Callum 28:58

And actually it's about continually driving home, like. Make diagnoses, get samples, get microbiology to guide therapy in, in all male patients. And I think in the community, the question is what patient is, unwell enough that they really need cocal and you can't be more narrow

Jame 29:18

Yeah.

Callum 29:18

And if they are that unwell and should again, be getting samplings and making sure you've got the right diagnosis. Exceptions,

Jame 29:23

figure out what's going on and where.

Callum 29:25

yeah.

Jame 29:26

Yeah. And then what else have we got? There's, a bunch of protein synthesis things that are and WHO. But watch in KHSA. So Amikacin probably not something they want to promote. The use of particularly not that

Callum 29:45

Yeah. And I think that makes sense. 'cause Chloramphenicol is, in many countries a workhorse. It's a, cheap, very, broad. TRO antibiotic and used to be,

Jame 29:54

antibiotic. It

Callum 29:55

you know, in the UK it

Jame 29:55

it. It's kind of

Callum 29:56

used to be.

Jame 29:56

covers everything.

Callum 29:57

Yeah, it used to be a workhorse in the UK until, the, all the stuff about its irreversible side effects came out and you got carbapenems, careful sporin as well, like.

Jame 30:06

third gen, careful Sporin came in, that was the nail in

Callum 30:08

Yeah.

Jame 30:09

So to speak. and then a rare downgrading, so IV minocycline is reserve in WHO, but watch in U-K-H-S-A and that I think makes sense 'cause that just means a minocycline is

Callum 30:22

Yeah.

Jame 30:22

in the same area. So, yeah.

Callum 30:23

Just like Clindamycin is smoothed from access to watch. 'cause it, it felt a bit odd that it was an access drug in who? And it's gone to Watch and U-K-H-S-A, which I think makes more sense to me. Yeah,

Jame 30:35

me too. and then there's a bunch of stuff that the other stuff like the spectrum and omey and

Callum 30:42

yeah. Vision.

Jame 30:43

They.

Callum 30:43

It's gone into other. I think that makes sense. They're very specific indications. You don't want them like gumming up your antimicrobial stewardship data

Jame 30:51

And so too with your anti folate agents, sulfa, Perine, and Sulfadiazine, which are really just used by ID physicians, so their access in WHO, but other

Callum 31:00

Yeah.

Jame 31:01

KHSA, remind me, KA, is that mostly for toxo that we're using those?

Callum 31:05

Yeah, I think so. And then lastly, oral Phosphomycin is watch and WHO and it's access in U-K-H-S-A. So, we use a lot of phosphomycin. I think I've got mixed feelings about that. 'cause I feel like sometimes we're reaching for phosphomycin quite early and maybe we should be reserving this as a more of a, drug that we're using just in resistance. You see it being used more first line people like you just take a single sache, that's you three days done.

Jame 31:33

The thing. One and done, and it's oral as

Callum 31:34

Yeah. But the more we use it, the more likely we are to lose it.

Jame 31:38

Yeah. And resistance is actually very easy to acquire.

Callum 31:41

Yeah. Just see that.

Jame 31:42

in some bugs. In some bugs,

Callum 31:44

Yeah.

Jame 31:44

of them. Yeah. And actually IV phosphomycin, I feel I am not so confident in our treatment of difficult to treat gram-negative infection that I feel that we can just throw IV phosphomycin. Around increasing use of oral phosphomycin is just going to trigger resistance developing in the environment because, almost all of the phosphomycin that you, give to the patient is peed out, unchanged into the environment where all the gram negatives that live there can start developing resistance mechanisms, against it.

Callum 32:17

So I guess that's the main differences. Maybe we could end on just talking about why this is useful. Like why are we even talking about the aware classification?

Jame 32:29

I think the U-K-H-S-A classification,, a, it's useful for. ID trainees in the uk, which is normally our main audience, even though most of the audience is not in the uk it's useful for them to. Actually have a look at this classification and see, where drugs, certain drugs lie so that they can then tailor their prescribing recommendations, to that. it's also a, like, it's quite a nice example of how our country can take the WHO classification and mod it for their own. Purposes and end up with something that's usable and pretty to wrap your head around. This table that I've got here for the U-K-H-S-A could be printed on one side of a four and stuck up on a

Callum 33:15

Yeah,

Jame 33:15

you know what

Callum 33:16

I think you've done a great job summarizing, and I have to say two things. I think about it from. I guess learning point of view is one. Here are all the antibiotics that we use on a table color coded and categorized. So if you want to figure out, oh, there's so many antibiotics. What one should I learn? Learn these ones. There you go.

Jame 33:36

And you don't even need to learn all of them.

Callum 33:38

No, there's some,

Jame 33:39

don't need to

Callum 33:39

there's.

Jame 33:40

minocycline and oxytetracycline unless you're gonna be treating acne and, good luck trying to find some cylin to use in your day-to-day clinical practice.

Callum 33:50

In the, on the whole, I think it's useful as a sort of quick, if you want to know a little bit about all these antibiotics or sometimes if you're like, oh, just this just feels a bit overwhelming sometimes. Categorizing information and trying to get this sort of schema is what it's called in your head can be a useful way to help learn. And the other thing I think it's useful for on a day-to-day basis is say, going to treat someone's infection. I could use GEF Traxon or I could use say, cotrimoxazole. And then if this, if you're kind of at a bit of a point of pose, like either drug would be fine. I don't have a real reason to use one or the other. It's maybe not a good example. Maybe there's a better example ox Cloud versus Cotrimoxazole, and you're not sure which one to use. You can look at this and be like, well, ideally in my own prescribing and as a steward, as an antibiotic champion, I would want to use an access antibiotic over a watch antibiotic, over a reserve. So I personally find it quite helpful when I'm having these thoughts in my head about. Choice of antibiotics. I think if I can, and there's no reason that I have to use something of a higher level, I will default to using access antibiotics as much as I can. Which kind of ties into what I said earlier on about esli, which is a reserve antibiotic. So I challenge myself to be like, okay, yes, it would be very easy to use Neli here, and that would make me feel really reassured. But it is a reserve antibiotic, so we should be reserving it for when we really need it. So, could I use, Kein here or could I use. Clindamycin potentially. And that might not always be appropriate 'cause obviously, ultimately you have to make the best decision for that patient in front of you. But if there's no reason not to. I think it is useful in helping guide your antibiotic decisions.

Jame 35:40

Yeah I suppose the other context would be that if you are an antimicrobial steward and you are writing guidelines for other people to follow. This should be the framework that you should be working to. You should be trying to maximize your use of access antibiotics and minimize your use of watch and reserve.

Callum 35:59

Yeah.

Jame 35:59

that's why all the trusts in England and in Scotland as well have a target that started, I think at 55% antibiotic

Callum 36:09

Yeah,

Jame 36:09

the trust.

Callum 36:10

Now we're aiming for 70%.

Jame 36:11

We're at 70. Yeah. And so that's driving up over the years. So that, and we know that most antibiotic prescribing is done, by in agriculture and then even if you just combine it to humans, most of it is GP practices. like the bit that we can handle as hospital doctors is hospital antibiotics with

Callum 36:31

Yeah,

Jame 36:32

guidance.

Callum 36:33

and this will feed into the existing stewardship programs. You know, GP practices already get reports on their antimicrobial prescribing and things like Target. So example, being trying to focus on five day thousand seven day courses

Jame 36:44

Yeah. Yeah.

Callum 36:45

has been a big.

Jame 36:45

that other stuff. The, yeah.

Callum 36:47

It's tying into the wider work that's been going on before this, but I think is a useful thing just for communication and that, you know, adds to that.

Jame 36:54

Fine.

Callum 36:55

it's good.

Jame 36:56

Thank you, Callum. Well, hopefully you're a little bit more aware than you are at the beginning. Sometimes there's a pun at the end.

Callum 37:03

You reserve that one for right at the end. Watch it Jane.