Volledige transcriptie van 143. Paediatric Antimicrobial Stewardship in the UK

maybe not as much as the number of children that are dying of malaria every year. 00:04:46.276 --> 00:04:55.076 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. 00:04:55.516 --> 00:05:04.627 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, 00:05:04.718 --> 00:05:10.146 So, I think you're spot on when you talk about that global data on neonates. 00:05:10.247 --> 00:05:20.506 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. 00:05:20.906 --> 00:05:30.326 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. 00:05:30.946 --> 00:05:33.146 Those babies have got lines in everywhere. 00:05:33.266 --> 00:05:44.187 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. 00:05:44.247 --> 00:06:03.667 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. 00:06:03.708 --> 00:06:07.287 So I think neonates need a special focus, and they're managed in hospitals up and down the 00:06:08.454 --> 00:06:13.975 long-term sequelae are public health problems, so that includes asthma, atopy, and obesity. 00:06:14.384 --> 00:06:23.290 And these are huge, focuses of funding, concern, resources to, to try and manage those conditions in the adult population. 00:06:23.312 --> 00:06:26.691 And so, that may even be starting in early life. 00:06:26.732 --> 00:06:31.012 So evidence is suggesting it might have knock-on effects for the rest of life really. 00:06:31.052 --> 00:06:33.102 So it's important we get it right at the start. 00:06:33.173 --> 00:06:35.673 And w-we've done a couple of episodes on the microbiome. 00:06:35.814 --> 00:06:58.762 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. 00:06:58.923 --> 00:07:06.564 What is the issue, if any issue at all with antimicrobial resistance and antimicrobial use in children? 00:07:07.264 --> 00:07:22.744 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. 00:07:22.793 --> 00:07:25.293 To start with, I needed to understand, what's happening? 00:07:25.343 --> 00:07:25.903 What's the problem? 00:07:25.984 --> 00:07:32.245 I'd never worked in South Yorkshire before, and so I started by doing a service evaluation and some exploratory interviews. 00:07:33.045 --> 00:07:45.954 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. 00:07:46.013 --> 00:07:55.203 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. 00:07:55.323 --> 00:07:57.263 You give an example of a quality indicator? 00:07:57.324 --> 00:08:01.064 'Cause it- we've got quite an international listenership, and probably not going to know what you're talking about 00:08:01.254 --> 00:08:01.615 Yeah. 00:08:01.694 --> 00:08:23.105 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? 00:08:23.126 --> 00:08:25.836 Is there a monitoring of antibiotic use and feedback? 00:08:26.475 --> 00:08:27.656 Those sort of indicators. 00:08:27.937 --> 00:08:32.057 We weren't meeting that in the pediatrics of those district general hospitals. 00:08:32.146 --> 00:08:39.611 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. 00:08:39.662 --> 00:08:53.061 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. 00:08:53.150 --> 00:09:02.672 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. 00:09:02.672 --> 00:09:13.360 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. 00:09:13.399 --> 00:09:18.750 So that included um, the AMS team from the Sheffield Children's Hospital. 00:09:18.750 --> 00:09:20.209 The big teaching hospital 00:09:20.413 --> 00:09:20.954 Yeah. 00:09:20.954 --> 00:09:21.494 this area? 00:09:21.696 --> 00:09:32.086 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. 00:09:32.125 --> 00:09:41.536 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. 00:09:41.906 --> 00:09:45.385 I was hearing that it takes ages to write an antibiotic guideline. 00:09:45.436 --> 00:09:48.436 And so we needed a way to centralize it but support it. 00:09:48.495 --> 00:09:55.696 So we formed this ENT network, and we had meetings regularly, and together we designed quality improvement initiatives. 00:09:55.735 --> 00:10:00.005 So that was an education program for prescribers and nurses. 00:10:01.105 --> 00:10:05.566 So we delivered the same material but with little nuances in each district hospital. 00:10:06.105 --> 00:10:21.456 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. 00:10:21.596 --> 00:10:34.297 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. 00:10:34.697 --> 00:10:43.902 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. 00:10:44.225 --> 00:10:46.053 So just to dial down on that? 00:10:46.173 --> 00:10:51.573 Were you switching earlier or were they never going on IVs in the first place? 00:10:51.798 --> 00:10:52.658 They were switching earlier. 00:10:53.018 --> 00:11:00.461 And that was with support of many tools the UK HSA tool and education and getting people engaged. 00:11:00.551 --> 00:11:03.791 The biggest improvement was really the shift in culture. 00:11:04.291 --> 00:11:12.442 So having pediatricians and nurses and pharmacists really sharing that responsibility of good responsible antimicrobial use. 00:11:12.543 --> 00:11:13.903 And it became this culture. 00:11:14.003 --> 00:11:15.443 It was talked about more. 00:11:15.483 --> 00:11:30.740 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. 00:11:30.801 --> 00:11:36.301 So sharing resource, sharing education, sharing data collection tools for quality improvement. 00:11:36.620 --> 00:11:41.000 We became one region rather than siloed hospitals. 00:11:41.601 --> 00:11:45.361 I think it was that cultural change that was the most impactful 00:11:45.926 --> 00:11:53.414 Did you do any work with the actual antibiotic choice in the antibiotic guidance that the hospitals were meant to be following? 00:11:53.495 --> 00:12:00.014 Did you move people more towards oral agents or access antibiotics, that kind of thing? 00:12:00.178 --> 00:12:14.551 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. 00:12:14.610 --> 00:12:29.789 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. 00:12:30.330 --> 00:12:42.080 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. 00:12:42.209 --> 00:12:47.678 And of course, there was a quick check of the local resistance patterns in, in pediatrics. 00:12:48.623 --> 00:12:52.192 I'm sure this will be music to Sanjay's ears as we'll come onto in a moment. 00:12:52.633 --> 00:12:58.433 Sanjay what are the barriers to responsible antimicrobial use in children that you have found? 00:13:00.224 --> 00:13:01.724 I think there are a few things actually. 00:13:01.823 --> 00:13:18.954 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. 00:13:19.004 --> 00:13:40.673 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. 00:13:40.764 --> 00:13:48.913 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. 00:13:48.964 --> 00:13:57.704 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. 00:13:58.264 --> 00:14:02.283 But we need to be able to take that step back and be more strategic when it comes to AMS. 00:14:02.764 --> 00:14:04.403 And so that's what we're trying to work on here. 00:14:04.464 --> 00:14:05.283 So I think that's one. 00:14:05.624 --> 00:14:10.464 I think knowledge is one, a barrier and I think an engagement of all of those key staff. 00:14:10.504 --> 00:14:15.553 So that's pediatricians, that's pharmacists, that's microbiologists. 00:14:15.553 --> 00:14:18.894 I think microbiology's got so complicated, hasn't it, over the past few years. 00:14:18.943 --> 00:14:33.834 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. 00:14:34.234 --> 00:14:36.813 But we've kind of lost that through the current training routes. 00:14:36.894 --> 00:14:40.264 So you know, lots of barriers, but

not insurmountable. 00:14:40.303 --> 00:14:41.432 Definitely not insurmountable. 00:14:41.831 --> 00:14:41.971 No. 00:14:42.451 --> 00:14:53.662 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. 00:14:53.743 --> 00:14:59.701 I have very little experience, and so I didn't particularly feel qualified to speak on the matter. 00:14:59.741 --> 00:15:19.964 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. 00:15:20.033 --> 00:15:34.474 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. 00:15:34.533 --> 00:15:37.442 You're going to be scattered to the nine winds. 00:15:37.484 --> 00:15:45.023 And I guess, Charlotte, your project is a example of a potential solution to that a sort of a hub and spoke model. 00:15:45.923 --> 00:15:56.143 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? 00:15:56.143 --> 00:16:05.032 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. 00:16:05.652 --> 00:16:10.522 And so really, infection management is the bread and butter of general pediatricians. 00:16:10.561 --> 00:16:21.753 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 00:16:21.844 --> 00:16:23.204 yeah, but do you think that happens a lot? 00:16:23.764 --> 00:16:29.104 About a third of adult inpatients are on antimicrobials when they come in, and that, that's the medical population. 00:16:29.183 --> 00:16:31.273 The surgical population, that number would be higher. 00:16:31.993 --> 00:16:33.692 People use antibiotics a lot. 00:16:33.753 --> 00:16:36.354 I don't think that they think about antibiotics very much. 00:16:36.433 --> 00:16:38.812 They think of them as a wonder drug that will make this patient better 00:16:39.120 --> 00:16:39.561 Yeah. 00:16:39.762 --> 00:16:41.601 And that is the challenge that comes with it. 00:16:41.661 --> 00:16:53.249 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. 00:16:53.389 --> 00:16:55.349 And that's, inc- that's nursing staff. 00:16:55.448 --> 00:17:12.813 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. 00:17:12.864 --> 00:17:19.223 Taking on that little bit more responsibility of responsible antibiotic use, and it's penetrating into everyday practice a little bit more. 00:17:19.953 --> 00:17:26.333 But of course, you need a champion for responsible antibiotic use or a set of champions in each of those district general hospitals. 00:17:26.634 --> 00:17:49.243 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. 00:17:49.284 --> 00:17:56.265 It's just important to make sure that it's a two-way conversation and everything is done in collaboration. 00:17:56.605 --> 00:17:56.704 Yeah. 00:17:56.724 --> 00:17:57.085 Do you know what? 00:17:57.125 --> 00:18:06.125 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. 00:18:06.164 --> 00:18:08.605 Lots of people who do this, treat infections. 00:18:08.944 --> 00:18:15.905 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. 00:18:15.924 --> 00:18:21.224 When you look at antibiotic use in children in hospitals it makes pretty sad reading. 00:18:21.664 --> 00:18:34.544 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. 00:18:35.079 --> 00:18:35.233 Yeah. 00:18:35.253 --> 00:18:48.614 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... 00:18:48.914 --> 00:18:53.693 Don't put a cannula in a kid unless they absolutely need it." And so 00:18:53.905 --> 00:18:54.286 was that? 00:18:54.346 --> 00:18:55.007 How many years ago? 00:18:55.246 --> 00:18:55.546 Which 00:18:55.645 --> 00:18:57.527 I'm showing my age now, but it's 2007. 00:18:57.637 --> 00:19:01.778 Yeah, so the big seed change since then is the sepsis narrative actually. 00:19:02.118 --> 00:19:26.419 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. 00:19:26.778 --> 00:19:40.439 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. 00:19:41.058 --> 00:19:56.628 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. 00:19:56.689 --> 00:20:03.329 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. 00:20:03.349 --> 00:20:11.250 And so I think that's why your experience from 2007 is different to the experiences we're seeing on the shop floor now. 00:20:12.594 --> 00:20:15.673 Let's turn now to UK PASS. 00:20:15.733 --> 00:20:20.445 Now, some people will have already heard of this'cause, you've not ac-exactly been keeping it a secret, have you? 00:20:21.144 --> 00:20:27.197 But let's talk about what it is and how it can benefit clinicians in the UK and potentially further afield. 00:20:27.723 --> 00:20:27.824 Yeah. 00:20:27.884 --> 00:20:36.554 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. 00:20:37.024 --> 00:20:45.242 A lot of energy had gone into adult AMS guidance and there was a paucity stuff for children. 00:20:45.333 --> 00:20:55.452 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 00:20:55.497 --> 00:20:56.136 I- is that what you did? 00:20:56.197 --> 00:21:01.047 Every pediatric ID and immunology consultant in the country just got stuffed into one room in a 00:21:01.371 --> 00:21:02.250 Yeah, almost. 00:21:02.371 --> 00:21:03.251 it is a bit like that. 00:21:03.310 --> 00:21:09.240 And then the Travelodge turned to to Teams and stuff after COVID because everyone started working virtually. 00:21:09.309 --> 00:21:10.409 But I think that is right. 00:21:10.449 --> 00:21:17.489 There were a core group of enthusiasts within those sort of 25, 30 people who had a real passion for antimicrobial stewardship 00:21:17.579 --> 00:21:22.019 So what is UKPass, and what was the goal when you set it up? 00:21:22.365 --> 00:21:22.486 Yes. 00:21:22.546 --> 00:21:39.136 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. 00:21:39.557 --> 00:21:41.278 I think primary care is different. 00:21:41.416 --> 00:21:46.916 so our focus was children being managed via a hospital in the UK. 00:21:47.416 --> 00:21:49.916 And what we did is we developed different bits of guidance. 00:21:50.038 --> 00:21:56.876 So one was this empirical antimicrobial guideline which Paddy McMaster up in in Manchester led on. 00:21:56.977 --> 00:21:59.156 And that's being used by lots of people around the country. 00:21:59.156 --> 00:22:03.717 And was this originally on Microguide before Microguide got taken over by Yollis? 00:22:03.926 --> 00:22:05.788 So it was in, on Microguide initially. 00:22:05.987 --> 00:22:18.945 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. 00:22:19.046 --> 00:22:20.526 And so is that work ongoing? 00:22:20.738 --> 00:22:23.018 and hopefully to be finished in the next two or three months 00:22:23.998 --> 00:22:28.268 And these pages, it would be like, chest infection, we recommend this, and this. 00:22:28.368 --> 00:22:29.827 Is there any other information on it? 00:22:29.988 --> 00:22:38.627 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? 00:22:38.779 --> 00:22:39.539 Yeah, a bit of both. 00:22:39.700 --> 00:22:41.759 So it links to papers, it links to guidance. 00:22:41.819 --> 00:22:45.880 So we've developed common infection pathways for different clinical phenotypes, so it links to them. 00:22:46.279 --> 00:22:49.380 It links to a NICE guideline, other relevant guidance 00:22:49.507 --> 00:22:52.186 And what clinical conditions does it cover? 00:22:52.248 --> 00:22:53.106 Does it cover everything? 00:22:53.528 --> 00:22:53.906 Like it, 00:22:54.471 --> 00:22:55.111 It covers... 00:22:55.567 --> 00:22:58.606 m- malaria and like all the weird and wonderfuls 00:22:58.631 --> 00:23:00.852 does, and it's increasing its scope as well. 00:23:01.011 --> 00:23:06.942 So there's stuff on invasive fungal infections, parasitic infections like malaria, leishmaniasis. 00:23:06.961 --> 00:23:11.721 It's got all of the normal bread and butter stuff, and it's increasing into other areas. 00:23:11.741 --> 00:23:16.192 And each section is going to be led by a different infection center across the UK. 00:23:16.771 --> 00:23:20.971 So that's gonna ensure that things are kept up to date in a rolling three-year cycle 00:23:21.406 --> 00:23:27.808 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, 00:23:28.096 --> 00:23:49.266 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.

00:23:49.626 --> 00:23:54.135 So we've got to empower those infection teams within them, and that's how we're gonna achieve it. 00:23:54.175 --> 00:23:57.375 And I think the work Charlotte's described in Sheffield is a brilliant pilot. 00:23:57.655 --> 00:24:01.516 We've extended that to four centers across England now. 00:24:01.556 --> 00:24:07.935 So there's one based out of Bristol, one out of the Evelina London, obviously Sheffield and Southampton are the four. 00:24:08.175 --> 00:24:10.955 So we've got geographical spread across England. 00:24:10.976 --> 00:24:15.536 And if that pilot works, we're hoping to implement it across the whole of, England and then the UK. 00:24:16.832 --> 00:24:22.711 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? 00:24:22.987 --> 00:24:30.037 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. 00:24:30.467 --> 00:24:40.166 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. 00:24:40.207 --> 00:24:46.507 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. 00:24:47.803 --> 00:24:47.962 Okay. 00:24:48.324 --> 00:24:48.663 All right. 00:24:48.722 --> 00:24:50.363 So you think that Charlotte's way isn't the best way. 00:24:50.423 --> 00:24:52.883 You're trying to get a slightly better way before you roll it out nationally? 00:24:53.007 --> 00:24:55.087 Yeah, I think one size doesn't fit all, does it? 00:24:55.176 --> 00:24:59.336 Behavior change is so utterly complicated, and engagement is the way forward 00:24:59.413 --> 00:24:59.554 Yeah 00:24:59.886 --> 00:25:22.377 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. 00:25:22.396 --> 00:25:26.536 But, overall, from what we've seen so far is that people are engaged. 00:25:26.556 --> 00:25:35.536 There are some really engaged clinicians, pharmacists, nurses, microbiologists that do-- really passionate about this. 00:25:35.556 --> 00:25:38.135 And so i-it's not for want of wanting. 00:25:38.267 --> 00:25:39.626 It's for want of support and 00:25:39.657 --> 00:25:39.877 it's 00:25:39.967 --> 00:25:41.445 that's-- Yeah. 00:25:41.586 --> 00:25:57.665 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. 00:25:58.165 --> 00:26:09.650 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? 00:26:10.397 --> 00:26:23.887 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. 00:26:24.768 --> 00:26:28.287 The second thing is the BSAC common infection pathways. 00:26:28.326 --> 00:26:40.738 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. 00:26:41.258 --> 00:26:50.096 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 00:26:51.247 --> 00:26:52.686 So is it child specific? 00:26:52.787 --> 00:27:01.995 '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. 00:27:02.473 --> 00:27:04.214 But there's a pediatric version as well, is there? 00:27:04.645 --> 00:27:06.405 There's a pediatric version, yes. 00:27:06.787 --> 00:27:12.394 And, nothing is ever perfect, and of course, not every child will fit into all the boxes. 00:27:12.496 --> 00:27:19.026 But i-i-it's something which people can lean upon to, to support and to improve confidence in terms of stepping down 00:27:20.313 --> 00:27:25.063 And just what was your lack of enthusiasm for the IV to oral switch guidance in adults? 00:27:25.830 --> 00:27:29.250 Oh now the cat's out of the bag that you're not a loyal listener, Sanjiv. 00:27:29.352 --> 00:27:36.192 So basically It's assuming that the IV therapy is superior to the oral. 00:27:36.431 --> 00:27:39.221 So all of the oral switch criteria are like, is it safe? 00:27:39.599 --> 00:27:40.160 Have you done this? 00:27:40.221 --> 00:27:40.779 Have you done that? 00:27:40.830 --> 00:27:42.651 Have they de-fevered, et cetera, et cetera. 00:27:43.030 --> 00:27:53.642 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. 00:27:53.791 --> 00:28:03.863 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. 00:28:03.971 --> 00:28:11.342 Yeah, I think this is the biggest paradigm shift in infection management is our use of oral antibiotics, and it's happened in adults. 00:28:11.442 --> 00:28:22.082 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. 00:28:22.701 --> 00:28:32.882 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. 00:28:34.281 --> 00:28:44.102 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. 00:28:44.142 --> 00:28:56.422 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. 00:28:56.461 --> 00:29:05.265 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. 00:29:05.365 --> 00:29:06.845 So, most children aren't like that. 00:29:06.884 --> 00:29:15.154 Most children are relatively non-complex bone and joint infections, and they showed identical outcomes with exclusive oral regimens using carboxiclab. 00:29:15.211 --> 00:29:16.592 The other area is neonates. 00:29:16.902 --> 00:29:30.491 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. 00:29:30.971 --> 00:29:34.612 So I think the big move in pediatrics, and we've seen that in our service. 00:29:34.672 --> 00:29:41.872 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. 00:29:43.592 --> 00:29:47.451 the long run, we would like many of these children to not have antibiotics at all. 00:29:47.471 --> 00:30:00.072 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. 00:30:00.112 --> 00:30:04.832 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. 00:30:04.882 --> 00:30:13.332 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. 00:30:15.688 --> 00:30:16.448 This is how you do it. 00:30:16.547 --> 00:30:23.247 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. 00:30:23.306 --> 00:30:24.726 I think that's the ultimate goal, isn't it? 00:30:24.976 --> 00:30:26.096 Vaccines, exactly. 00:30:26.136 --> 00:30:29.675 The group B strep vaccine trial might help with some of that for neonates 00:30:29.804 --> 00:30:30.285 Here's hoping. 00:30:30.923 --> 00:30:33.673 All right Sanjay, Charlotte, thanks very much for coming on the show 00:30:34.509 --> 00:30:34.669 you 00:30:35.065 --> 00:30:41.005 The Idiots Podcast is supported by the British Infection Association, the UK's premier infection association. 00:30:41.065 --> 00:30:44.245 Membership is free for trainees and reasonably priced for everyone else. 00:30:44.605 --> 00:30:46.464 To join, see the link in the episode description. 00:30:46.615 --> 00:30:50.335 Questions, comments, suggestions, send them into idiotspodcasting@gmail.com. 00:30:50.535 --> 00:30:51.995 Have a five-star review in your pocket? 00:30:51.995 --> 00:30:53.174 Cal and I would love to have it. 00:30:53.174 --> 00:30:55.474 Please drop it in your podcast player of choice. 00:30:55.535 --> 00:31:01.755 We are on BlueSky@idiots-pod, and if you want to donate to support the show, there is a link to do so in the description. 00:31:02.005 --> 00:31:06.615 Now that the episode's done, we hope you learned and had lots of fun. 00:31:06.625 --> 00:31:10.995 So go forth and treat people with some of what you now know.