143. Paediatric Antimicrobial Stewardship in the UK

Paediatric AMS? Surely there aren't any issues with antimicrobial use in paediatrics?!

Jame hears from Dr Charlotte Fuller and Dr Sanjay Patel that yes, yes there is a problem! And YOU can do something about it.

Listen in to hear the answers to these questions:

• What do we know about AMR and antimicrobial use in children? 
• What are the barriers to responsible antimicrobial use in children?
• How can DGH AMS teams and paediatrics support each other?  
• Are there any other paediatric-specific considerations for infection prevention, diagnosis and management?
• Where can microbiologists learn more about paediatric infection? HINT it is here: https://uk-pas.co.uk/ and here https://bsac.org.uk/paediatricpathways/

Transcript

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Jame 0:18

Hi, everyone. Welcome to the IDIOTS Podcast. That's Infectious Disease Insight of Three Specialists. I'm James, that's Charlotte, this is Sanjay, and we're going to tell you everything you need to know about infectious disease.

Speaker 0:28

Soon may the IT team come to discontinue the Tazo sun. One day when the CRP's done, we'll take our leave and go.

Jame 0:37

Charlotte, Sanjay, how are you doing?

Charlotte 0:39

Good. Very well, thank you. Thanks for having us

Jame 0:42

Do you want to introduce yourselves and then we'll tell the loyal listeners what the episode is about? Although they may have read the episode description before signing on

Charlotte 0:52

So hello, my name is Charlotte Charlotte Fuller. I am a pediatric infectious diseases and immunology clinical fellow at Leeds Children's Hospital, and I'm also a BSAC AMS scholar

Jame 1:03

And Sanjay?

Sanjay 1:04

Yeah, great to be here. Sanjay Patel. I'm a pediatric infectious diseases and immunology consultant based on the south coast of England in Southampton, and I'm also the national clinical advisor for pediatric KMS at NHS England

Jame 1:19

Okay. A pediatric infectious disease and immunology consultant. A big specialty in the UK?

Sanjay 1:26

Gee, that's a very good question actually. It's a small specialty. The big hitters are respiratory. We've got PICU, NICU, but pedes ID and immunology supports lots of those services. We're different to adults where you specialize in either ID/micro and very separately immunology. But in kids, because so many presentations of severe infections or autoimmunity relate to the immune system, we do both.

Jame 1:53

And how many consultants would there be in the UK, do you think?

Sanjay 1:57

Oh, there are about 30 consultants. Yeah

Jame 2:00

Okay. Real unicorn territory here

Sanjay 2:03

Very much

Jame 2:04

I am a member of infectious disease, a not very big specialty, and clinical pharmacology, an even smaller specialty. But even the clinical pharmacologists would win the tug of war between us and the pediatric infection immunology. Interesting that the specialties are united,

Charlotte 2:19

Mm-hmm.

Jame 2:20

there the two immunology and infectious disease. Fine, and others may have seen both of you at various BSAC and FISS conferences, at least the UK listenership. Sanjay, surely antimicrobial resistance isn't a problem in children

Sanjay 2:37

Oh, do you know what? That's so that, that's such an interesting choice of comment, isn't it? And I think a lot of people believe that. I think that a lot of people believe that AMR is a really big thing and an evolving issue in adults, and that children, that sort of Cinderella service to children, they don't really see many issues with resistance, and we just crack on and don't really have a problem. And I think that the data doesn't support that. The data actually shows that resistance rates are almost identical in children and adults. I think that the burden of resistance is still greater in adults, and I think that's because they're more likely to become bacteremic than children. And all of that energy that's gone into, catheters in the frail and elderly because those are the patients that they become septic with a bloodstream infection. I think that is f- that is fair. But pediatrics now is not the same as pediatrics 30 years ago, and I think acknowledging that the sorts of patients we look after are no longer just acute pedes, but it's essentially chronic comorbidities, either with respiratory comorbidities, heart comorbidities neuro comorbidities, has just changed that composition of patients. So I think AMR, we're seeing it in our tertiary centers and DGHs up and down the country. I think neonates is the big area that we've got to focus on because those kids, those babies do get bacteremic. They've got as high a rate of bloodstream infections as the frail and elderly. And so when they're colonized with resistant bugs, they become bacteremic, and then we struggle

Jame 4:11

because they're getting colonized almost instantly but from vaginal secretions from the mother or from kisses and cuddles from granny, all that sort of stuff. So any antimicrobial resistance in your adult microbiome is gonna get transferred to the child in short order. There's also the Lancet 2019 article, which I think the WHO have recently updated stating that about a fifth of all antimicrobial resistance-related deaths are in children, and that would be several hundred thousand a year comparable, but maybe not as much as the number of children that are dying of malaria every year. Think about the amount of effort that's going into preventing malaria with insecticide-treated nets and vaccine research and early access to therapies, et cetera. AMR is far less on the agenda I would say in pediatrics, which I guess is part of the reason that you set up what you did set up,

Sanjay 5:04

So, I think you're spot on when you talk about that global data on neonates. But actually even on our units, these babies are colonized at delivery from their mothers who are having e-ever increasing rates of resistant infections. They're also being colonized by the bioflora within those neonatal units, and I think e-exposure to broad-spectrum antibiotics on neonatal units is increasing that risk. Those babies have got lines in everywhere. They've got UACs, UVCs, they're tubed, they then get a long line, and that is why they're getting that incredibly high rates of invasive bloodstream infections. But the bit that we haven't spoken about is that additional risk of exposure to broad-spectrum antibiotics in very early life on the microbiome, and I think we're learning more and more about that, and there are long-term sequelae from disruption of the microbiota, and I think that is a big problem that we worry about as well. So I think neonates need a special focus, and they're managed in hospitals up and down the

Charlotte 6:08

long-term sequelae are public health problems, so that includes asthma, atopy, and obesity. And these are huge, focuses of funding, concern, resources to, to try and manage those conditions in the adult population. And so, that may even be starting in early life. So evidence is suggesting it might have knock-on effects for the rest of life really. So it's important we get it right at the start.

Jame 6:33

And w-we've done a couple of episodes on the microbiome. One, one an overview and the other talking about microbiome toxicity, so listeners can go and listen to those if they want a bit more detail from Tash Theodosiou, our microbiome correspondent for "The ADS Podcast." Charlotte, you gave a presentation at the OPAD conference, which I found very interesting, on pediatric antimicrobial stewardship in South Yorkshire, and I wonder if you could chat for a few minutes about why you did that. What is the issue, if any issue at all with antimicrobial resistance and antimicrobial use in children?

Charlotte 7:07

Yeah, my journey with this started when I took an out of program year as a leadership fellow and I was hosted by the Sheffield Children's Hospital, and my project was to improve AMS in pediatrics across South Yorkshire. To start with, I needed to understand, what's happening? What's the problem? I'd never worked in South Yorkshire before, and so I started by doing a service evaluation and some exploratory interviews. Essentially, I found that the the quality indicators that we use for AMS programs, you probably heard about the NG15, the standards that we have to design AMS programs. The quality indicators in adults within the DGHs were met in about 73%, but in peds it was only 53% and that was a huge inequality for me.

Jame 7:55

You give an example of a quality indicator? 'Cause it- we've got quite an international listenership, and probably not going to know what you're talking about

Charlotte 8:01

Yeah. So, they're in different phases, but say for example, in terms of the leadership and management area that that there is allocated funding specifically for AMS, that there is, a AMS in-minded person who sits on the drugs and therapeutics committee, and then further down you're thinking about is there education regularly for prescribers? Is there a monitoring of antibiotic use and feedback? Those sort of indicators. We weren't meeting that in the pediatrics of those district general hospitals. I went and had long chats the consistent messages that came back to me was, "We just don't have the staff to get over to pedes. We're barely managing by getting to intensive care." Nearly all hospitals had a gap in the microbiologist, and I'm sure this won't be a surprise to many microbiology listeners from the UK. And so I needed to design something that meant that I could take the workload off of individual centers in order to reach those pediatric services. And so, pulled together a microbiologist, a pharmacist, and a pediatrician from each of those district general hospitals, and we all came together to form a regional pediatric AMS network. So that included um, the AMS team from the Sheffield Children's Hospital.

Jame 9:18

The big teaching hospital

Charlotte 9:20

Yeah.

Jame 9:20

this area?

Charlotte 9:21

Yeah, and so After listening that, people are saying, "I don't have the time," I thought, "Okay, so I need to find a way where we can support each without duplicative efforts. So for example, it would be silly to ask a microbiologist to write an education session for prescribers and then a similar person Same with guidelines. I was hearing that it takes ages to write an antibiotic guideline. And so we needed a way to centralize it but support it. So we formed this ENT network, and we had meetings regularly, and together we designed quality improvement initiatives. So that was an education program for prescribers and nurses. So we delivered the same material but with little nuances in each district hospital. And then we also set up an antibiotic quality monitoring and feedback system where we essentially did a really quick PPS every other month, and we analyzed that centrally so that worked well. People were engaged and the main outcomes were that, we closed that gap between adults and pediatric services in that pedes were getting stronger AMS interventions and programs. And then we also reduced our unnecessary IV antibiotics from about fifteen percent down to seven point five percent in the context of, IV to oral switch.

Jame 10:44

So just to dial down on that? Were you switching earlier or were they never going on IVs in the first place?

Charlotte 10:51

They were switching earlier. And that was with support of many tools the UK HSA tool and education and getting people engaged. The biggest improvement was really the shift in culture. So having pediatricians and nurses and pharmacists really sharing that responsibility of good responsible antimicrobial use. And it became this culture. It was talked about more. And so as it became higher up on the agenda, we found that, the hospitals talked to each other more and there was a lot more discussion and referrals and it became this community of practice where we supported each other and we shared information. So sharing resource, sharing education, sharing data collection tools for quality improvement. We became one region rather than siloed hospitals. I think it was that cultural change that was the most impactful

Jame 11:45

Did you do any work with the actual antibiotic choice in the antibiotic guidance that the hospitals were meant to be following? Did you move people more towards oral agents or access antibiotics, that kind of thing?

Charlotte 12:00

So one of the challenges that the district hospitals were facing was that it, it took a long time to update their local antibiotic guidelines, and it would take, a lot of headspace and time from the microbiologists and the pediatricians who were updating it. So I introduced and we talked about the national UK PAS guidelines that are freely available and are designed and written and updated based on evidence, including NICE guidelines by national experts up and down the country. And so after discussion of that I think a couple of the district general hospitals have just taken that on and now defer directly to the UK PAS guidance. And of course, there was a quick check of the local resistance patterns in, in pediatrics.

Jame 12:48

I'm sure this will be music to Sanjay's ears as we'll come onto in a moment. Sanjay what are the barriers to responsible antimicrobial use in children that you have found?

Sanjay 13:00

I think there are a few things actually. Charlotte's alluded to some of the resources available, and I think when you look at the focus of efforts within all age hospitals, you just have to look at the makeup of those hospitals and about 10% of those beds are pediatric beds and 90% are adult beds. And I think that's resulted in a lot of the the energy that's gone into AMS and, people within those hospitals recognize that AMS makes a big difference to exposure to broad spectrum antibiotics but with the limited finite resources we have staffing-wise within hospitals that energy has gone towards adults and we found that in children's hospitals as well. We've done a deep dive into all of the children's hospitals across the UK and it's really variable, the staff that we have to support that. As we said at the start, I do pediatric infectious diseases and immunology, and our teams are very small and our focus is often, individual clinical cases. But we need to be able to take that step back and be more strategic when it comes to AMS. And so that's what we're trying to work on here. So I think that's one. I think knowledge is one, a barrier and I think an engagement of all of those key staff. So that's pediatricians, that's pharmacists, that's microbiologists. I think microbiology's got so complicated, hasn't it, over the past few years. In days gone by, there would be people who had done pediatrics as SHOs in my day and they would then decide to convert to microbiology and then they would become those pediatric microbiologists either in ter- in tertiary centers or even in DGHs. But we've kind of lost that through the current training routes. So you know, lots of barriers, but not insurmountable. Definitely not insurmountable.

Jame 14:41

No. But I suppose the, that's a good point 'cause we were just saying offline before we started, we haven't really covered pediatrics very much on this show because I'm not pediatrics trained. I have very little experience, and so I didn't particularly feel qualified to speak on the matter. And then in my day job, when I've been reviewing guidelines that are aimed at pediatrics in antimicrobial stewardship teams and various meetings, I've deferred to the pediatric qualified people on antimicrobial agent and choice and duration because I'm not as familiar with the evidence base. The other barriers that you mentioned, I suppose one of them has to be the size of the specialty, because y- if there's only 30 full-time consultants in the country, you're not going to be in every e-even every tertiary hospital, let alone every DGH. You're going to be scattered to the nine winds. And I guess, Charlotte, your project is a example of a potential solution to that a sort of a hub and spoke model. So yeah, let's talk about the role of the tertiary center and the DGH, so what do you think that in the future, the tertiary center's role and the DGH's role would be in antimicrobial stewardship in children?

Charlotte 15:56

So, for me, I think the first thing to say is that pediatricians use antibiotics all the time because, a huge proportion of children that come to hospital have a fever. And so really, infection management is the bread and butter of general pediatricians. And so I think whoever prescribes antibiotics, I think the prescriber needs to be thinking about the antibiotics that we use and the harms that, the potential harms that can have

Jame 16:21

yeah, but do you think that happens a lot? About a third of adult inpatients are on antimicrobials when they come in, and that, that's the medical population. The surgical population, that number would be higher. People use antibiotics a lot. I don't think that they think about antibiotics very much. They think of them as a wonder drug that will make this patient better

Charlotte 16:39

Yeah. And that is the challenge that comes with it. But think what's important is that the message of being careful with antibiotics and responsible with it is disseminated and becomes part of everyday practice for everybody. And that's, inc- that's nursing staff. I think it's important that it becomes the routine nature and the way that this DGH model has come about has meant that people who perhaps may not have previously been infection specialists are learning more. Taking on that little bit more responsibility of responsible antibiotic use, and it's penetrating into everyday practice a little bit more. But of course, you need a champion for responsible antibiotic use or a set of champions in each of those district general hospitals. And in our hub and spoke model, we have pediatric infection teams, which would consist of a pediatrician, a microbiologist, a pharmacist, and a nurse in each of those district general hospitals to then support their community of clinicians and nurses and pharmacists in their own setting to promote responsible antibiotic use and to implement the interventions that we often use for AMS. It's just important to make sure that it's a two-way conversation and everything is done in collaboration.

Sanjay 17:56

Yeah. Do you know what? I think you've raised a very good point about how pediatrics is different to adults in terms of small number of people with an expertise in that field. Lots of people who do this, treat infections. And I think we've just got to think of a new model because the model of education hasn't made a huge difference to antibiotic use. When you look at antibiotic use in children in hospitals it makes pretty sad reading. We use a lot of IV antibiotics even for general pediatric patients about, 40% of them are on antibiotics, majority of which are on IV antibiotics, the majority of which are on very broad spectrum third generation cephalosporins actually.

Jame 18:35

Yeah. That's very surprising to me, Sanjay, 'cause I remember I, I actually did do four months in pediatrics as part of my F2, and I remember being told, "Don't start people on IV antibiotics unless they absolutely... Don't put a cannula in a kid unless they absolutely need it." And so

Sanjay 18:53

was that? How many years ago? Which

Jame 18:55

I'm showing my age now, but it's 2007.

Sanjay 18:57

Yeah, so the big seed change since then is the sepsis narrative actually. And the sepsis narrative has been extraordinarily effective actually in the UK and the UK Sepsis Trust has got that think sepsis message everywhere, which has had, brilliant impact especially in adults where there were patients languishing in hospital with sepsis who were not recognized and great harm came to them. But in pediatrics, the situation is different we've seen a reduction in the rates of sepsis over the last 20, 25 years and a lot of that's related to the introduction of extraordinarily effective conjugate vaccines in children. But yet that narrative of think sepsis has got louder and so I think frontline clinicians are so concerned about missing a case of sepsis that they reach very quickly within an hour to an antibiotic that covers everything including cNS infections. It's often not the time for results to come back and I think that's the challenge we faced in pediatrics DGHs and tertiary hospitals. And so I think that's why your experience from 2007 is different to the experiences we're seeing on the shop floor now.

Jame 20:12

Let's turn now to UK PASS. Now, some people will have already heard of this 'cause, you've not ac-exactly been keeping it a secret, have you? But let's talk about what it is and how it can benefit clinicians in the UK and potentially further afield.

Sanjay 20:27

Yeah. So UK PAS was an initiative supported by BSAC, so the British Society for Antimicrobial Chemotherapy, and they recognized that there was a bit of a gap. A lot of energy had gone into adult AMS guidance and there was a paucity stuff for children. And maybe this is one of the times where having a small group of people is actually beneficial because those people can then come together and collaborate effectively, and many of us train

Jame 20:55

I- is that what you did? Every pediatric ID and immunology consultant in the country just got stuffed into one room in a

Sanjay 21:01

Yeah, almost. it is a bit like that. And then the Travelodge turned to to Teams and stuff after COVID because everyone started working virtually. But I think that is right. There were a core group of enthusiasts within those sort of 25, 30 people who had a real passion for antimicrobial stewardship

Jame 21:17

So what is UKPass, and what was the goal when you set it up?

Sanjay 21:22

Yes. So UK PAS stands for UK Pediatric Antimicrobial Stewardship, and it's a network of pediatric ID people, pediatricians, pharmacists with a goal of improving how we use antimicrobials in children, focusing predominantly on hospitalized children. I think primary care is different. so our focus was children being managed via a hospital in the UK. And what we did is we developed different bits of guidance. So one was this empirical antimicrobial guideline which Paddy McMaster up in in Manchester led on. And that's being used by lots of people around the country.

Jame 21:59

And was this originally on Microguide before Microguide got taken over by Yollis?

Sanjay 22:03

So it was in, on Microguide initially. What we're now in the process of doing is turning them all into webpages on the BSAC website so that people can actually embed that guidance directly into whatever platform they use in their own hospital.

Jame 22:19

And so is that work ongoing?

Sanjay 22:20

and hopefully to be finished in the next two or three months

Jame 22:23

And these pages, it would be like, chest infection, we recommend this, and this. Is there any other information on it? Does it just read like a normal Antimicrobial Guidance entry, or is there like a little splurge where you explain the evidence base or link to papers, that kind of thing?

Sanjay 22:38

Yeah, a bit of both. So it links to papers, it links to guidance. So we've developed common infection pathways for different clinical phenotypes, so it links to them. It links to a NICE guideline, other relevant guidance

Jame 22:49

And what clinical conditions does it cover? Does it cover everything? Like it,

Sanjay 22:54

It covers...

Jame 22:55

m- malaria and like all the weird and wonderfuls

Sanjay 22:58

does, and it's increasing its scope as well. So there's stuff on invasive fungal infections, parasitic infections like malaria, leishmaniasis. It's got all of the normal bread and butter stuff, and it's increasing into other areas. And each section is going to be led by a different infection center across the UK. So that's gonna ensure that things are kept up to date in a rolling three-year cycle

Jame 23:21

that's a brilliant way of doing it and keeping people involved so that they know that little section of UK Pass is their baby,

Sanjay 23:28

And I think keeping them involved is the key bit because if we want to then roll out initiatives like Charlotte's described of these hub and spoke networks, we need each of those hubs to be engaged in this initiative so that they can then engage their DGHs that surround them and empower colleagues within those DGHs because clearly we don't have Peds ID people in each of those DGHs. So we've got to empower those infection teams within them, and that's how we're gonna achieve it. And I think the work Charlotte's described in Sheffield is a brilliant pilot. We've extended that to four centers across England now. So there's one based out of Bristol, one out of the Evelina London, obviously Sheffield and Southampton are the four. So we've got geographical spread across England. And if that pilot works, we're hoping to implement it across the whole of, England and then the UK.

Jame 24:16

Do you have to go to individual trusts and say, "We think this is a good idea," or are you going at it at a higher level?

Sanjay 24:22

Yeah, we started off with an expression of interest that we reached out to all of our colleagues around the country to say, "Look we'd like to set up these pilots. We've got a small amount of resource from NHS England to support some time for a clinician, for a Peds ID person and a pharmacist to develop this network," and that's what we're working on. And everyone's got a bit of a carte blanche for how to do it, and we're gonna see how different people have tried it and what works and what doesn't.

Jame 24:47

Okay. All right. So you think that Charlotte's way isn't the best way. You're trying to get a slightly better way before you roll it out nationally?

Sanjay 24:53

Yeah, I think one size doesn't fit all, does it? Behavior change is so utterly complicated, and engagement is the way forward

Jame 24:59

Yeah

Charlotte 24:59

And it's important that, what works in South Yorkshire is not necessarily gonna work elsewhere and we're all-- hospitals and people are changing in it all the time, and there's different priorities, and e-each population has different needs and, even within South Yorkshire, what worked for Doncaster didn't quite work for Chesterfield, and so it's-- we, we made little adjustments. But, overall, from what we've seen so far is that people are engaged. There are some really engaged clinicians, pharmacists, nurses, microbiologists that do-- really passionate about this. And so i-it's not for want of wanting. It's for want of support and

Jame 25:39

it's

Charlotte 25:39

that's-- Yeah. And that's what this model is trying to address to share the load and to prevent duplicative work across regions and allow, really enthusiastic and caring physicians to to do the right thing for their patients and to give them that support.

Jame 25:58

Charlotte, if people wanted to learn more about antimicrobial stewardship initiatives in children, what resources should they try to access and that I can link to in the episode description?

Charlotte 26:10

So from the clinician on the ground with the patient in front of them, I guess we've already mentioned the UK PAS antimicrobial guidance, which is easy to access in the middle of the night if your EODAS isn't working, for example, when you're in the hospital. The second thing is the BSAC common infection pathways. So we have pediatric pathways, which i- are very helpful again for the pediatrician, the junior to refer to in terms of management of infection presenting to secondary care. In terms of IV to oral switch, the UK HSA have developed a really great tool for children in terms of IV to oral switch

Jame 26:51

So is it child specific? 'Cause I've we've previously talked about the adult one on episode 90, where I was let's say unenthusiastic about some of criteria for oral switching. But there's a pediatric version as well, is there?

Charlotte 27:04

There's a pediatric version, yes. And, nothing is ever perfect, and of course, not every child will fit into all the boxes. But i-i-it's something which people can lean upon to, to support and to improve confidence in terms of stepping down

Sanjay 27:20

And just what was your lack of enthusiasm for the IV to oral switch guidance in adults?

Jame 27:25

Oh now the cat's out of the bag that you're not a loyal listener, Sanjiv. So basically It's assuming that the IV therapy is superior to the oral. So all of the oral switch criteria are like, is it safe? Have you done this? Have you done that? Have they de-fevered, et cetera, et cetera. It's all set up to assume that the IV treatment is better than the oral, which has never been proven in any clinical trial except by way of, dosage. A couple of the exclusion criteria were, like, endocarditis, and I was like the people that were given orals and endocarditis are now living longer than the ones that were given IVs, so, like, that shouldn't be in there in the first place.

Sanjay 28:03

Yeah, I think this is the biggest paradigm shift in infection management is our use of oral antibiotics, and it's happened in adults. You had some great studies especially starting off with the Aviva study, et cetera, that made people reflect on their use of IV antibiotics and challenge that belief that IV is better than oral. And I think in children we've probably been more aggressive about oral switches than in adults because practically IV access is more challenging in children often. But there's been some extraordinary studies conducted in the past few years in some of those areas that historically have resulted in long courses of IV antibiotics. And the two I just wanna reflect on is osteoarticular infections and a great Danish study published a couple of years ago where they randomized about 100 children to each group to exclusive oral. So these were children who weren't overwhelmingly septic, who didn't need immediate, b-bone debridement and didn't have prosthetic material in situ and stuff. So, most children aren't like that. Most children are relatively non-complex bone and joint infections, and they showed identical outcomes with exclusive oral regimens using carboxiclab. The other area is neonates. So a Danish and separately a Dutch group looked at IV to oral switches in neonates with likely bacterial infection and in the Danish group with confirmed bacterial infection in some of their children and showed identical outcomes. So I think the big move in pediatrics, and we've seen that in our service. We run a, an OPAT service and we've seen a huge drop in the number of children managed in our service because we're switching them so much earlier. the long run, we would like many of these children to not have antibiotics at all. But I think that stewardship has to be done in steps, and I think this move towards weaning people off IV antibiotics is the first step towards eventually getting them not to start in the first place. But we're getting there, and I think in pedes this has been a massive movement, and that's what we're trying to spread. That one message is probably the most important message to get out to our microbiology colleagues, our pharmacy colleagues, and our pediatric colleagues across the UK.

Jame 30:15

This is how you do it. First you, you reduce the duration day by day, and then you oral switch earlier, and then eventually nobody's on any antibiotics for anything. I think that's the ultimate goal, isn't it?

Sanjay 30:24

Vaccines, exactly. The group B strep vaccine trial might help with some of that for neonates

Jame 30:29

Here's hoping. All right Sanjay, Charlotte, thanks very much for coming on the show

Sanjay 30:34

you

30:35

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