Pełna transkrypcja odcinka 142. AWaRe

00:02:39.116 --> 00:02:46.296 And I think it was first developed in 2017 by the WHO expert committee on the selection and use of essential medicines. 00:02:46.846 --> 00:02:49.986 And the intent to update it every two years. 00:02:50.046 --> 00:02:52.695 So it's something that's gonna continue to be useful, Which is great. 00:02:52.751 --> 00:02:53.141 Yeah. 00:02:53.171 --> 00:02:53.561 Yeah. 00:02:53.801 --> 00:03:01.850 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. 00:03:02.031 --> 00:03:04.671 So let's talk about what we mean by access Watson Reserve. 00:03:04.671 --> 00:03:05.181 So we've got these 00:03:05.201 --> 00:03:05.491 Okay. 00:03:06.201 --> 00:03:09.146 Usually people apply a traffic light coding. 00:03:09.366 --> 00:03:12.096 Let's talk about what they are. 00:03:12.146 --> 00:03:13.491 Cal, do you want to take access? 00:03:14.591 --> 00:03:18.941 Access is a green and they've got a little picture of a door because you can access the door. 00:03:19.481 --> 00:03:24.881 The antibiotics with narrow spectrum of activity are in here. 00:03:25.091 --> 00:03:29.681 Those with fewer side effects, lower potential to drive. 00:03:30.070 --> 00:03:38.951 Antimicrobial resistance and first or second choice, antibiotics which are recommended for empiric treatment of the most common infections. 00:03:39.176 --> 00:03:45.756 Yeah, and you could argue about that fewer side effects given that the UK has got Gentamycin in the access category. 00:03:45.756 --> 00:03:51.616 But,, the overall thing is that these are meant to be your workhorses, the things that you reach for in the first instance. 00:03:52.346 --> 00:03:53.336 And what about watch? 00:03:54.260 --> 00:03:57.191 What are our broader spectrum antibiotics? 00:03:57.421 --> 00:04:04.346 They generally have a higher resistance potential, and they are usually first or second choice. 00:04:04.346 --> 00:04:10.406 Antibiotics indicated for a limited number of infective syndromes and their use should be carefully monitored. 00:04:11.141 --> 00:04:12.671 And then I'll take reserve. 00:04:13.001 --> 00:04:13.811 The reserve ones 00:04:14.111 --> 00:04:15.971 You reserve the best for yourself. 00:04:16.105 --> 00:04:16.855 for the best for last. 00:04:16.855 --> 00:04:17.245 Exactly. 00:04:17.245 --> 00:04:17.875 Thank you, Callum. 00:04:18.245 --> 00:04:20.315 So these are the last resort antibiotics. 00:04:20.315 --> 00:04:27.725 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. 00:04:28.156 --> 00:04:29.896 But these are the things that you. 00:04:30.331 --> 00:04:37.600 Want to hold back and not use in a broad manner, unless you absolutely have to. 00:04:37.901 --> 00:04:49.311 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. 00:04:49.790 --> 00:04:51.651 So access, watch and reserve. 00:04:52.290 --> 00:04:55.031 Think of like, as like a traffic light system. 00:04:56.261 --> 00:05:00.071 let's talk a little bit now about the who aware classification. 00:05:00.471 --> 00:05:01.730 So we've got a picture here. 00:05:01.730 --> 00:05:06.581 This really is an episode where I would advise going to the prep notes if you were sort of interested in this. 00:05:06.581 --> 00:05:16.600 '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. 00:05:16.990 --> 00:05:17.951 And then the. 00:05:18.761 --> 00:05:22.870 In the rose, I've got all the cell wall agents grouped together. 00:05:22.870 --> 00:05:30.651 The protein synthesis agents grouped together all the anti folate and anti DNA agents, and then other is down at the bottom there. 00:05:31.245 --> 00:05:39.286 And those are the ones that don't fit into those categorizations of the broad types of mechanism of action. 00:05:39.901 --> 00:05:40.261 Yeah. 00:05:40.501 --> 00:05:45.531 I gotta say there's some in this this table that I'm, really never heard of before. 00:05:45.561 --> 00:05:53.311 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. 00:05:53.670 --> 00:05:54.240 Didn't you find 00:05:54.446 --> 00:05:54.626 Yeah. 00:05:55.076 --> 00:06:07.735 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. 00:06:07.735 --> 00:06:09.686 'cause there's something better and easier correlated. 00:06:10.141 --> 00:06:13.485 well, I guess that's the sort of argument forin isn't it? 00:06:13.485 --> 00:06:19.995 So like Tsar with cla acid is that Piptaz that same ecological niche. 00:06:20.751 --> 00:06:24.411 And maybe has slightly better pseudomonas cover, if I remember rightly so. 00:06:24.411 --> 00:06:30.771 There was no situation in which you would want to use to mention that you couldn't just use peptides if you needed 00:06:30.886 --> 00:06:31.175 Yeah. 00:06:31.191 --> 00:06:31.581 kind of thing. 00:06:31.740 --> 00:06:31.920 Yeah. 00:06:31.971 --> 00:06:32.300 Yeah. 00:06:32.961 --> 00:06:37.230 Is there anything in this table that we want to, highlight? 00:06:39.050 --> 00:06:39.831 There's a typo. 00:06:39.860 --> 00:06:42.355 You've written Piperacillin slash Tazo Act 00:06:44.511 --> 00:06:46.191 Son of a bitch. 00:06:46.641 --> 00:06:48.110 I'm gonna have to redo that. 00:06:49.071 --> 00:06:50.031 thanks for nothing, Callum. 00:06:50.031 --> 00:06:52.221 You did wanna point that out before we started recording. 00:06:53.391 --> 00:06:53.990 Awful. 00:06:55.011

--> 00:06:55.490 Awful. 00:06:55.490 --> 00:06:56.540 You're such a bad egg. 00:06:56.540 --> 00:06:57.170 Callum much. 00:06:57.170 --> 00:06:57.261 You're 00:06:57.501 --> 00:07:09.341 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. 00:07:09.680 --> 00:07:14.631 'Cause some, someone, as I said before, an ward asked me recently, how would you learn antibiotics? 00:07:14.930 --> 00:07:18.901 So I still puzzle on that question quite a lot actually. 00:07:19.040 --> 00:07:19.370 And. 00:07:19.461 --> 00:07:24.170 the website, learn antibiotics.com and the associated book could be a first starting place for the, 00:07:24.221 --> 00:07:25.605 is quite a good use useful thing. 00:07:25.735 --> 00:07:27.386 But we have to answer that question. 00:07:27.626 --> 00:07:28.735 Learn antibiotics com. 00:07:28.735 --> 00:07:28.975 They can. 00:07:29.126 --> 00:07:31.735 why am I advertising on behalf of other educators? 00:07:32.216 --> 00:07:43.466 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. 00:07:44.865 --> 00:07:46.221 So maybe we could just start with access. 00:07:46.605 --> 00:07:47.026 Yeah. 00:07:47.055 --> 00:07:47.415 Okay. 00:07:47.475 --> 00:07:53.716 So for access, starting with the cell wall agents, we've got most of the narrow spectrum, penicillin. 00:07:53.716 --> 00:08:00.706 So amoxicillin, ampicillin, all the benzo, penicillin variants, you know, including zaine and protein penicillin. 00:08:02.266 --> 00:08:05.295 and then you've also got flu clocks. 00:08:05.506 --> 00:08:09.225 Omo CL is in here, which is interesting because it's watch in the UK system as we'll. 00:08:09.225 --> 00:08:11.596 Come onto, there's a bunch of interesting differences really. 00:08:12.675 --> 00:08:13.906 and then we've 00:08:13.980 --> 00:08:16.680 So there's, just to clarify, this is the who system of the fucking money? 00:08:16.816 --> 00:08:17.175 we're talking 00:08:17.311 --> 00:08:17.581 Yeah. 00:08:17.805 --> 00:08:20.206 and then we've got a load of penicillins here. 00:08:20.206 --> 00:08:25.786 And Callum, I think we, if we're going have any one, Callum and Jane read the alternate names out. 00:08:25.786 --> 00:08:27.286 It'll have to be the penicillins here. 00:08:27.286 --> 00:08:27.706 So what do you 00:08:27.781 --> 00:08:27.821 Oh God. 00:08:28.096 --> 00:08:28.725 What do you say? 00:08:29.836 --> 00:08:34.175 I almost prefer the cephalosporins because it's the controversial thing, but okay. 00:08:34.175 --> 00:08:35.405 We'll do the penicillins for once. 00:08:35.953 --> 00:08:36.553 Azi Doin. 00:08:36.603 --> 00:08:36.833 Ba Bain 00:08:37.994 --> 00:08:38.853 Clo Soin 00:08:39.055 --> 00:08:39.456 Oxacillin. 00:08:39.675 --> 00:08:40.365 Diox Sill. 00:08:42.390 --> 00:08:42.680 Hein 00:08:42.680 --> 00:08:43.640 Max. 00:08:45.230 --> 00:08:46.280 Oh, that makes more sense. 00:08:46.400 --> 00:08:46.520 Mac, 00:08:47.591 --> 00:08:48.280 Methicillin. 00:08:48.280 --> 00:08:48.850 Methicillin 00:08:49.650 --> 00:08:49.941 Nain. 00:08:50.755 --> 00:08:50.916 IC 00:08:52.201 --> 00:08:52.870 Penicillin. 00:08:52.870 --> 00:08:53.711 p Vanillin. 00:08:54.097 --> 00:08:54.447 Proin. 00:08:56.878 --> 00:08:58.108 Ampicillin, Alam. 00:08:58.450 --> 00:08:59.710 Salt of missin, 00:08:59.815 --> 00:09:00.595 cell bactam. 00:09:00.595 --> 00:09:01.600 salt of sun. 00:09:01.810 --> 00:09:06.169 see I wonder if there's a bunch of those that the listener has just like never heard of. 00:09:06.230 --> 00:09:11.009 I'd never heard of a bunch of them as well, and I wonder how many are actually in clinical practice. 00:09:11.009 --> 00:09:17.379 But the WHO have clearly kinda felt that it would be best overall if you include them all 00:09:17.690 --> 00:09:18.289 I, I love this. 00:09:18.389 --> 00:09:18.720 them all. 00:09:18.779 --> 00:09:19.049 Yeah. 00:09:19.305 --> 00:09:23.355 I think it's just like we are gonna, every antibiotic there is, we're gonna categorize it. 00:09:23.355 --> 00:09:25.144 So there's no doubt you're not gonna be like, 00:09:26.120 --> 00:09:26.570 Oh, I wonder 00:09:26.585 --> 00:09:27.034 you know, just 00:09:27.080 --> 00:09:27.259 Yeah, 00:09:27.424 --> 00:09:28.085 very comprehensive. 00:09:28.085 --> 00:09:30.875 I think it was quite a fun job to have come up with this. 00:09:30.875 --> 00:09:32.644 I bet this took bloody ages. 00:09:32.750 --> 00:09:35.930 I think this should be your career aim James is to get onto this committee. 00:09:36.034 --> 00:09:36.335 only. 00:09:36.335 --> 00:09:38.524 And then just tell everybody to use Korum all the time. 00:09:38.524 --> 00:09:40.534 Yeah, I mean, it's a work in progress, isn't it, Kyle? 00:09:40.880 --> 00:09:45.980 So, the other thing that's Anxi for cell wall is the first generation ke sporin. 00:09:46.341 --> 00:09:50.846 So we've got our Keflex in Keel and Zolin. 00:09:51.076 --> 00:09:52.245 And Ketin. 00:09:52.245 --> 00:09:54.916 And Kerine, which I think are much less commonly used. 00:09:54.916 --> 00:09:55.966 I mean, I've never used anything. 00:09:55.966 --> 00:09:57.946 It's, except in Keflex and Zolin. 00:09:58.826 --> 00:10:04.600 And then you've got other more small fry calfs that are in the the table that we won't go on. 00:10:04.650 --> 00:10:08.010 I think one alternate reading is just about as much as the listener can tolerate. 00:10:08.721 --> 00:10:10.461 Someone asked me recently, why did we do that? 00:10:10.821 --> 00:10:11.661 There's no reason. 00:10:11.841 --> 00:10:14.480 what, why do we, why are we doing this at all? 00:10:14.480 --> 00:10:18.681 Why are we doing anything and not to vaguely entertain ourselves and vaguely educate the listeners. 00:10:18.681 --> 00:10:19.041 I mean, 00:10:19.091 --> 00:10:23.275 i'm sure people learned a lot

from that list of mispronounced antibiotics. 00:10:23.316 --> 00:10:24.395 Well, exactly, yes. 00:10:24.395 --> 00:10:24.666 I mean, 00:10:24.740 --> 00:10:24.890 Yeah, 00:10:25.056 --> 00:10:27.755 be properly pronounced if you had bothered in the first place too. 00:10:27.806 --> 00:10:29.635 Actually, well, I wouldn't insult you anymore 00:10:29.801 --> 00:10:32.650 go to antibiotic pronunciation school like I should have done you 00:10:32.725 --> 00:10:34.796 Well, maybe that's the next website that I'll set up. 00:10:34.796 --> 00:10:37.816 And then you can be the only person who subscribes to the to the site. 00:10:38.490 --> 00:10:39.900 voiceovers record. 00:10:40.230 --> 00:10:44.306 I was recording an increasingly fixed Scottish accent, so people are like. 00:10:46.380 --> 00:10:49.036 I know sometimes people, they're like, oh you pronounce it wrong. 00:10:49.066 --> 00:10:50.056 You pronounce it wrong. 00:10:50.056 --> 00:10:52.566 We're the ones speaking the queen's English over here. 00:10:53.926 --> 00:10:54.225 Okay. 00:10:54.225 --> 00:10:55.336 Into protein synthesis. 00:10:55.336 --> 00:10:58.036 We've got doxycycline and tetracycline. 00:10:58.485 --> 00:11:00.105 And then what about the Amide Cow? 00:11:01.480 --> 00:11:04.885 So we've got Gentamycin, spect, mycin, and Amikacin. 00:11:05.096 --> 00:11:05.365 Yeah. 00:11:05.365 --> 00:11:07.375 Again, never used my life. 00:11:07.735 --> 00:11:12.196 And then in the other category, I guess you've got Chloramphenicol, Thiam, phenic. 00:11:12.196 --> 00:11:12.615 Which one? 00:11:12.615 --> 00:11:14.836 Presumes is a Amphenol. 00:11:14.836 --> 00:11:17.265 Like Chloramphenicol and Clindamycin. 00:11:17.745 --> 00:11:18.015 Yeah. 00:11:18.291 --> 00:11:18.510 No. 00:11:18.645 --> 00:11:21.406 So Clindamycin separated out from the rest of the macrolides there? 00:11:21.620 --> 00:11:23.620 Interesting that Clindamycin gets into access. 00:11:24.346 --> 00:11:30.406 I think maybe because it's used broadly elsewhere for skin and soft tissue. 00:11:30.436 --> 00:11:31.066 I can't think what 00:11:31.100 --> 00:11:31.390 Yeah. 00:11:31.426 --> 00:11:32.145 be used for really. 00:11:32.735 --> 00:11:36.725 Has it maybe got less of a propensity to develop resistance? 00:11:37.639 --> 00:11:37.730 I 00:11:37.774 --> 00:11:38.674 know, IMY, 00:11:38.750 --> 00:11:39.049 heard of, 00:11:39.185 --> 00:11:43.105 there's some data about macrolides and, microbiome tosses a T, but 00:11:43.180 --> 00:11:43.419 but 00:11:43.419 --> 00:11:43.779 I don't know. 00:11:43.960 --> 00:11:44.470 I don't know. 00:11:44.544 --> 00:11:46.615 pretty microbiome toxicity 00:11:46.750 --> 00:11:47.320 that's true. 00:11:47.325 --> 00:11:47.705 It's true. 00:11:47.815 --> 00:11:49.825 the resistance profiles even the same. 00:11:49.825 --> 00:11:51.504 It's the ml SB phenotype, isn't it? 00:11:51.504 --> 00:11:56.029 That point mutation that sort of knocks out micro micronized, linco of mine and strep garmins. 00:11:56.860 --> 00:11:57.190 Yeah. 00:11:57.310 --> 00:11:58.930 So, yeah, I don't know. 00:11:58.930 --> 00:12:01.740 But anyway, somebody thought it was worth putting in access, and so they did. 00:12:01.740 --> 00:12:05.680 And then Cal, we've got our DNA and folate inhibitors. 00:12:05.680 --> 00:12:09.399 Now all of the quinolones are in watch. 00:12:09.460 --> 00:12:14.279 So the access ones, the ones that you will have heard of are Trimethoprim and Cotrimoxazole. 00:12:14.470 --> 00:12:19.730 And the ones that you wouldn't have heard of are all these other sulfur sulfonamides. 00:12:21.110 --> 00:12:26.409 And Smide combinations, almost all of which are combined with trimethoprim. 00:12:26.409 --> 00:12:29.205 So like Sulfadiazine, trimethoprim, sulfa. 00:12:29.340 --> 00:12:32.649 some of them are recognized, some from like HIV medicine, but not many of them. 00:12:32.810 --> 00:12:36.840 Well, some of them are used for what's the one that is Sulfur Paridine. 00:12:37.710 --> 00:12:39.149 that's still sort of used. 00:12:39.810 --> 00:12:41.909 And sulfadiazine and stuff like that. 00:12:41.909 --> 00:12:42.029 I 00:12:42.120 --> 00:12:42.740 so basically. 00:12:42.870 --> 00:12:43.379 of the rest. 00:12:43.379 --> 00:12:53.639 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. 00:12:53.639 --> 00:12:55.200 That's you listening to two idiots. 00:12:55.200 --> 00:12:56.100 You haven't heard of things. 00:12:56.100 --> 00:12:57.565 I know our recurring theme in this. 00:12:57.685 --> 00:13:03.685 and then the access other a, the other mechanism actions in the access group. 00:13:04.174 --> 00:13:07.455 So we've got our trust, old friend ol we've got OL 00:13:08.174 --> 00:13:08.475 Yeah. 00:13:08.504 --> 00:13:08.745 It's 00:13:08.774 --> 00:13:10.034 and Nitro and. 00:13:10.365 --> 00:13:12.284 Which I think are the three that you'll actually have heard of. 00:13:12.330 --> 00:13:12.450 the 00:13:12.555 --> 00:13:18.134 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. 00:13:18.365 --> 00:13:18.815 Yes. 00:13:18.865 --> 00:13:22.585 And the ones that are in bold are the ones that aren't in the KHS. 00:13:23.725 --> 00:13:25.164 Oh, right. 00:13:25.164 --> 00:13:29.725 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? 00:13:30.605 --> 00:13:32.524 Just full of little comments today, aren't you? 00:13:33.457 --> 00:13:34.447 Moving on. 00:13:34.697 --> 00:13:36.052 That makes so much more sense. 00:13:36.398 --> 00:13:38.077 You make so much more sense. 00:13:38.722 --> 00:13:39.052 Thank you. 00:13:39.562 --> 00:13:43.793 So let's move on to watch, so we're starting with cell inhibitors, so we've 00:13:47.138 --> 00:13:52.118 Pip and Timo, and then a bunch of other stuff that again, you've, you might not have heard

of 00:13:52.432 --> 00:13:52.733 Yeah 00:13:52.733 --> 00:13:52.972 there, 00:13:53.557 --> 00:13:54.067 that's our Pen. 00:13:54.202 --> 00:13:54.508 you've got. 00:13:56.168 --> 00:14:03.143 Kelo and Kol Ketin and Kevar ine, which are all called second generation ke SSPORs. 00:14:03.143 --> 00:14:07.702 Even though Kein is a kef M and not a ke sporin technically. 00:14:07.702 --> 00:14:08.423 But anyway, I know what 00:14:08.543 --> 00:14:09.358 That nobody cares though. 00:14:09.592 --> 00:14:09.983 of other ones. 00:14:09.983 --> 00:14:13.013 Yeah, I know, but I kind of care, but I know I shouldn't. 00:14:13.133 --> 00:14:13.702 But anyway. 00:14:14.423 --> 00:14:18.258 then the third gens, Arex, CFET, taxine, Ceftin, ceftriaxone. 00:14:19.048 --> 00:14:20.488 then a bunch of other ones you've never heard of. 00:14:20.967 --> 00:14:25.618 And then your fourth gens are kepe and then three others that you never heard 00:14:25.643 --> 00:14:29.572 Yeah, interesting here that Keine is in your watch rather than your reserve. 00:14:29.638 --> 00:14:43.618 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. 00:14:43.618 --> 00:14:44.038 Yeah. 00:14:44.278 --> 00:14:44.457 Yeah. 00:14:44.457 --> 00:14:45.628 That's interesting. 00:14:45.837 --> 00:14:47.518 That set the cat amongst the pigeons. 00:14:47.543 --> 00:14:47.903 Callum, 00:14:48.898 --> 00:14:49.108 Yeah. 00:14:49.108 --> 00:14:56.077 I think, obviously we're fortunate to work in a country where we have, lower level problems with gram-negative resistance. 00:14:56.077 --> 00:15:02.847 Like we still get carbos producing intra like everybody else does, but it's still thankfully quite rare. 00:15:03.057 --> 00:15:08.608 Whereas ESBLs are about 30% of the gram negative workload in places like a Italy and gre. 00:15:08.923 --> 00:15:16.173 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. 00:15:16.173 --> 00:15:24.123 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. 00:15:24.177 --> 00:15:24.258 and 00:15:24.423 --> 00:15:24.842 From who? 00:15:24.858 --> 00:15:34.937 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? 00:15:35.238 --> 00:15:35.528 Yeah. 00:15:35.567 --> 00:15:35.778 I mean? 00:15:35.778 --> 00:15:36.947 Like they're the first line 00:15:37.398 --> 00:15:37.967 They are great. 00:15:37.967 --> 00:15:40.288 So I can kind, I can get on board of that. 00:15:40.467 --> 00:15:45.567 And I guess kp I guess in the same sense is probably like similar use cases, isn't it? 00:15:45.567 --> 00:15:45.868 So, 00:15:45.868 --> 00:15:46.408 I think so. 00:15:46.457 --> 00:15:48.108 It's still active against, you know, 00:15:48.108 --> 00:15:48.528 yeah. 00:15:48.827 --> 00:15:50.347 and ESBLs as well, I think. 00:15:50.587 --> 00:15:50.858 Yeah. 00:15:51.097 --> 00:15:51.488 So, yeah. 00:15:51.668 --> 00:15:53.378 Another cell will active thing. 00:15:53.378 --> 00:15:55.418 So we're get starting to get the glycopeptides coming in. 00:15:55.418 --> 00:16:02.528 So our vancomycin and Tyco plan in are watch antibiotics and then protein synthesis. 00:16:02.888 --> 00:16:04.028 Watch antibiotics. 00:16:04.478 --> 00:16:09.118 Yeah, you've got your tetracycline, so Cylin, oxytetracycline, and. 00:16:09.883 --> 00:16:17.233 The first of quite an annoying theme here, oral, but not IV minocyline because oral minocycline is watch and IV is reserve. 00:16:17.712 --> 00:16:21.462 I'm not really sure how it's managed to straddle both sides of the categorization here. 00:16:22.253 --> 00:16:28.513 And then for the amano, glycosides, neomycin and Tobramycin are there but not Amikacin. 00:16:28.513 --> 00:16:29.692 Amikacin is access, as we've said 00:16:29.812 --> 00:16:31.582 So we reserve tobramycin. 00:16:31.582 --> 00:16:39.293 Is that just'cause we're wanting to, I mean, so that's, we're watching tobramycin use because higher side effect. 00:16:39.383 --> 00:16:42.653 think it's because it's the prime anti pseudomonal aminoglycoside, 00:16:42.863 --> 00:16:43.253 Right? 00:16:43.253 --> 00:16:43.493 So that. 00:16:43.552 --> 00:16:46.733 areas would want to try and reserve that. 00:16:47.148 --> 00:16:56.288 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? 00:16:56.707 --> 00:17:02.768 Because people are concerned about the way that the break points are set now, and we're still relying on systemic infection, essentially 00:17:02.903 --> 00:17:03.233 Yeah. 00:17:03.817 --> 00:17:06.038 And we're getting around that by core, giving it amoxicillin. 00:17:06.038 --> 00:17:08.762 But the discussion is moving to tobramycin. 00:17:09.377 --> 00:17:15.798 Backbone, but that's not so appealing if you're then being judged on these standards saying that should be watched. 00:17:15.897 --> 00:17:16.437 Yeah. 00:17:16.567 --> 00:17:20.853 I suppose, I mean, you would have to try and move it into access if you were wanting to, because 00:17:20.923 --> 00:17:21.212 Yeah. 00:17:21.393 --> 00:17:24.512 of a Mogen plus minus me is that it's an all access regimen. 00:17:25.492 --> 00:17:34.242 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. 00:17:35.143 --> 00:17:37.813 And then fed dexamycin protein synthesis inhibitor. 00:17:37.893 --> 00:17:41.593 So in, in watch where's oral van? 00:17:41.742 -->

00:17:43.212 Is that just in watch as well then? 00:17:43.948 --> 00:17:44.577 Vancomycins Vancomycin. 00:17:44.833 --> 00:17:45.103 Okay. 00:17:45.553 --> 00:17:47.833 So both for c diff drugs, so no difference. 00:17:47.952 --> 00:17:50.053 So use more CIN probably. 00:17:50.593 --> 00:17:50.833 And then 00:17:50.877 --> 00:17:51.627 got the 00:17:51.748 --> 00:17:51.928 PRIs. 00:17:51.928 --> 00:17:52.317 Mycin. 00:17:52.573 --> 00:17:53.442 Cincin. 00:17:54.147 --> 00:17:54.988 Yeah, which is 00:17:55.798 --> 00:17:55.948 And 00:17:56.097 --> 00:17:56.548 useful. 00:17:56.698 --> 00:17:59.968 got clindamycin dad vancomycin in there. 00:17:59.968 --> 00:18:01.518 And then the macrolides. 00:18:01.518 --> 00:18:02.897 All of the macrolides are there. 00:18:03.043 --> 00:18:05.208 Azithro, Clari area through and a bunch of others. 00:18:05.657 --> 00:18:06.137 And then the 00:18:06.212 --> 00:18:06.373 Yeah. 00:18:06.857 --> 00:18:11.573 again, all the ones that you've heard of and a bunch of others that you haven't are in the watch category. 00:18:11.623 --> 00:18:14.442 And then down at the bottom you've got fused date. 00:18:15.218 --> 00:18:25.928 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 00:18:27.193 --> 00:18:27.346 Yeah. 00:18:27.376 --> 00:18:30.076 then the reserve category, let's just run through this quickly. 00:18:30.176 --> 00:18:34.646 You've got your weird kelo sporin beta activase inhibitor combinations. 00:18:34.646 --> 00:18:36.807 Your Keda calls your Keef as avie. 00:18:37.116 --> 00:18:48.926 The anti MRSA Kelo Sporin Keef Bypro are here, Keef in Tazo, and then your carbapenem combination with betalactamase inhibitors. 00:18:48.987 --> 00:18:50.307 This is where they are. 00:18:50.707 --> 00:18:54.102 So Ira l Mein and vaborbactam as Trina. 00:18:55.106 --> 00:18:57.926 Is here, whether or not it is included with avibactam. 00:18:57.926 --> 00:18:58.227 Yeah. 00:18:58.672 --> 00:18:58.892 Oh 00:18:59.067 --> 00:19:03.626 cousin Karu mon, which is not commercially available yet. 00:19:04.106 --> 00:19:08.787 And then farro, another carbapenem, agent. 00:19:08.817 --> 00:19:11.987 I dunno why this is here, but all the other oral agents are there as well. 00:19:11.987 --> 00:19:13.307 Maybe it ist oral actually. 00:19:13.977 --> 00:19:16.932 And then your long-acting glycopeptides DBA Van 00:19:17.027 --> 00:19:17.317 yeah. 00:19:17.322 --> 00:19:17.382 Yeah 00:19:18.442 --> 00:19:18.892 are there. 00:19:19.342 --> 00:19:19.836 that makes sense to me. 00:19:19.852 --> 00:19:22.102 And then Cal protein synthesis blockers. 00:19:22.251 --> 00:19:28.247 Yeah, we've got a raic, anti Tline and IV minocycline, and then Minocyline. 00:19:28.342 --> 00:19:33.642 And we did that episode before on the weird tetracyclines, if you wanna go back and look into that. 00:19:33.971 --> 00:19:34.122 Yeah. 00:19:34.616 --> 00:19:36.477 And then what else have we got? 00:19:37.146 --> 00:19:39.692 Pla mycin, the tragedy of plasma mycin. 00:19:39.751 --> 00:19:41.711 It's stuck in reserve. 00:19:41.922 --> 00:19:46.602 but that will be useful for the American to have access to it and I Absolutely, no one else nails anything else. 00:19:47.497 --> 00:19:51.435 We've got our old favorite EZ and ez, oh God, 00:19:51.435 --> 00:19:53.506 Teli, what is with you this evening? 00:19:53.962 --> 00:19:54.163 EZ. 00:19:54.712 --> 00:19:55.883 and mispronunciation. 00:19:55.883 --> 00:19:58.022 That's me, my Jim son. 00:19:58.133 --> 00:19:58.823 That will be on your 00:19:59.232 --> 00:19:59.893 And then left. 00:20:00.002 --> 00:20:00.893 Left a mullen. 00:20:01.133 --> 00:20:02.272 Lefamulin, the plural. 00:20:02.272 --> 00:20:02.633 Mutual. 00:20:02.793 --> 00:20:06.452 So reserve just so that absolutely nobody will ever use it. 00:20:06.502 --> 00:20:08.153 For pneumonia, which is license 00:20:08.587 --> 00:20:14.288 Yeah, I also Quin Newry and DFO PRIs in combination, which is interesting that's in reserve. 00:20:14.288 --> 00:20:18.472 But Pristine and Mycin is watch, but we shouldn't say anything more about that'cause they're both very small print. 00:20:18.583 --> 00:20:21.323 know probably'cause Cincin oral maybe. 00:20:21.323 --> 00:20:30.403 And then in the other category you've got Colistin and Polyon, B iv, phosphomycin Daptomycin, and ILO Prim, which is a Trimethoprim cousin 00:20:31.127 --> 00:20:32.478 Daptomycin is in reserve. 00:20:32.803 --> 00:20:33.133 I know. 00:20:34.347 --> 00:20:41.238 '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. 00:20:41.698 --> 00:20:49.188 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. 00:20:49.188 --> 00:20:51.468 Like it is quite, quite an appealing choice. 00:20:51.468 --> 00:20:53.418 It's highly bi available, it's very effective. 00:20:53.418 --> 00:20:56.238 Don't need to worry about resistance done esli. 00:20:56.268 --> 00:20:59.907 And I do sometimes think actually, are we being bad stewards in the department? 00:20:59.907 --> 00:21:08.367 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. 00:21:09.208 --> 00:21:10.738 Yes, that's true. 00:21:10.887 --> 00:21:21.992 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. 00:21:22.367 --> 00:21:23.837 Into your clinical 00:21:23.918 --> 00:21:24.968 Yeah, that might be true. 00:21:25.788 --> 00:21:26.807 And I mean, you're right. 00:21:26.807 --> 00:21:32.748 When people are using SLI and they shouldn't be, very

frustrating. 00:21:32.958 --> 00:21:33.198 But I 00:21:33.423 --> 00:21:34.262 I think also people, 00:21:34.458 --> 00:21:39.407 of the, if you look at a lot of those cases, a lot of those SLI may well be the best agent to use, 00:21:39.423 --> 00:21:42.803 also it seems like people have, faith in Neli. 00:21:42.962 --> 00:21:47.718 So what I've seen is people have, well, a lower threshold at which to I ost. 00:21:48.387 --> 00:21:52.607 There's iVOS to Esli compared to something else like Coum, doxy, 00:21:52.607 --> 00:21:52.998 Yeah. 00:21:53.147 --> 00:22:01.873 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. 00:22:02.057 --> 00:22:02.327 Yeah. 00:22:02.327 --> 00:22:06.668 It's kind of hard, but I think that just to talk about it for a sec. 00:22:06.911 --> 00:22:16.364 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. 00:22:16.364 --> 00:22:24.564 But actually we've had a couple recently and we've had the options, you know, clinda, Cori or Esli, and I've gone. 00:22:25.193 --> 00:22:27.594 Pretty much invariably for Cotrimoxazole. 00:22:27.683 --> 00:22:29.993 'cause I think it's the best tolerated of the three. 00:22:30.574 --> 00:22:37.604 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. 00:22:37.604 --> 00:22:37.903 Right? 00:22:38.173 --> 00:22:39.824 And it happens to be the access. 00:22:40.229 --> 00:22:41.038 Antibiotic. 00:22:41.038 --> 00:22:49.318 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. 00:22:49.838 --> 00:22:55.538 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. 00:22:56.913 --> 00:23:04.433 Yeah, so we've spent a long time there talking through the who, So, you know, I guess this is a really comprehensive resource. 00:23:04.463 --> 00:23:09.233 It's got all the antibiotics much more extensive than the UK version. 00:23:09.683 --> 00:23:11.364 It excludes anti TB drugs. 00:23:11.673 --> 00:23:14.193 I think we discussed some of the interesting points as we went through there. 00:23:14.344 --> 00:23:15.993 So, as I say, look at the notes. 00:23:16.054 --> 00:23:16.864 It's color coded. 00:23:16.894 --> 00:23:19.774 It's quite easy to read, and the type will be fixed. 00:23:20.868 --> 00:23:26.578 If I can remember it's in this table as well, because now I'm looking at the KHSA. 00:23:26.578 --> 00:23:35.469 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. 00:23:35.469 --> 00:23:40.888

Like, it's got like a bunch of macrolides and tetracyclines and. 00:23:41.983 --> 00:23:44.683 Quin loans that we just the UK just doesn't have a license for. 00:23:44.683 --> 00:23:47.294 The UK has only got a license for about 60 different drugs. 00:23:48.344 --> 00:23:54.074 So we're going to take that, we're gonna strip it down and we're going to shift some stuff about that. 00:23:54.124 --> 00:23:56.884 It makes more sense for UK practice, so they. 00:23:57.588 --> 00:24:01.169 Moved for example, the carbapenems into reserve. 00:24:01.219 --> 00:24:12.469 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. 00:24:12.499 --> 00:24:24.409 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. 00:24:24.824 --> 00:24:29.233 Which is true of the higher generation Kelos borns, but not the first gens. 00:24:29.233 --> 00:24:32.584 They're more similar to like, amoxicillin or kind of flu CLOs. 00:24:32.584 --> 00:24:37.233 And so this was kind of pointed out to the UK HSA by numerous physicians. 00:24:37.233 --> 00:24:48.124 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 00:24:48.124 --> 00:24:48.394 Yeah. 00:24:48.884 --> 00:24:49.753 And thank God they do 00:24:49.874 --> 00:24:50.503 Alice Snap. 00:24:50.564 --> 00:24:50.923 Yeah. 00:24:50.983 --> 00:24:59.534 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. 00:24:59.584 --> 00:25:01.939 So the list that we've got here is much smaller. 00:25:01.939 --> 00:25:04.159 I don't know if we really want to go through it in 00:25:04.209 --> 00:25:05.769 No, I don't think we need to go for, in detail. 00:25:05.888 --> 00:25:13.989 I think what's really important and really interesting is thinking about the differences between the who's one and K HSA one. 00:25:14.318 --> 00:25:16.794 If only someone would summarize the differences between the two. 00:25:17.259 --> 00:25:22.479 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. 00:25:23.919 --> 00:25:25.628 Yes, I know I was setting you up. 00:25:25.929 --> 00:25:26.259 I know. 00:25:26.259 --> 00:25:28.808 But I wasn't gonna pass up an opportunity to insult you. 00:25:29.499 --> 00:25:29.828 Oh, wow. 00:25:30.128 --> 00:25:30.699 there's a couple of 00:25:30.814 --> 00:25:31.233 Failed. 00:25:31.269 --> 00:25:31.749 differences. 00:25:31.749 --> 00:25:39.669 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. 00:25:39.999 --> 00:25:42.759 They're so a bunch of

stock got moved into the other category. 00:25:42.868 --> 00:25:46.259 So they're not access watch reserve, that is things like. 00:25:47.114 --> 00:25:52.003 Things that I think they are trying to say, look, you don't really need to use any of this stuff. 00:25:52.003 --> 00:25:56.294 So like SPECT Mycin was moved over there, IV streptomycin was moved over there. 00:25:56.638 --> 00:26:02.024 Eclo Cyclin, which is the tetracycline that is used in S-I-A-D-H, 00:26:02.354 --> 00:26:02.653 Yeah. 00:26:03.074 --> 00:26:13.524 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. 00:26:13.524 --> 00:26:16.794 So access, watch, reserve, and then other, which is what we're talking about, everyone. 00:26:16.794 --> 00:26:23.213 So maybe on the tables we can add in on the left hand column, other mechanisms 00:26:24.074 --> 00:26:25.778 I had like to keep it confusing actually, but 00:26:25.854 --> 00:26:28.763 or just change other di instead of saying other mechanisms. 00:26:28.763 --> 00:26:28.973 Right. 00:26:29.538 --> 00:26:30.888 Different categories or something. 00:26:30.979 --> 00:26:31.878 It's just confusing 00:26:31.878 --> 00:26:33.409 Maybe I like the confusion. 00:26:33.528 --> 00:26:34.189 more, 00:26:34.278 --> 00:26:34.939 Alright, fine. 00:26:35.838 --> 00:26:36.274 something like that. 00:26:37.259 --> 00:26:39.179 But yeah, let's talk about the differences then. 00:26:39.179 --> 00:26:50.969 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. 00:26:52.138 --> 00:26:54.568 That the WHOC is what, or the carbapenems, 00:26:55.094 --> 00:26:55.314 Yep. 00:26:55.979 --> 00:27:02.608 the amoxil clave acid is watch in U-K-H-S-A, but access in 00:27:02.608 --> 00:27:02.909 Yeah. 00:27:03.269 --> 00:27:03.719 So it's 00:27:03.824 --> 00:27:04.604 That's a big change. 00:27:04.739 --> 00:27:05.489 Sh, you know, sh. 00:27:05.653 --> 00:27:05.774 Yeah. 00:27:05.774 --> 00:27:14.784 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. 00:27:14.834 --> 00:27:16.784 It covers strep generally. 00:27:17.834 --> 00:27:21.284 It mostly covers staph aureus and non-severe infections. 00:27:21.584 --> 00:27:23.413 Covers quite a lot of gram-negatives. 00:27:23.473 --> 00:27:25.733 It covers mouthy organisms. 00:27:26.308 --> 00:27:27.598 Bites and stuff like that. 00:27:27.598 --> 00:27:35.499 It covers chest, it covers urine mostly abdominal to a degree is, you know, it's easy, isn't it? 00:27:35.499 --> 00:27:36.338 It's easy medicine. 00:27:36.399 --> 00:27:39.763 You just come in and you prescribe everybody the same drug and then they all go away happy. 00:27:39.903 --> 00:27:45.423 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. 00:27:45.784 --> 00:27:46.074 Yeah. 00:27:46.134 --> 00:27:52.703 Too, I think that the, though that the HSE approach for us is. 00:27:54.953 --> 00:27:55.884 Is right 00:27:55.933 --> 00:27:56.564 yeah, I. 00:27:56.834 --> 00:28:00.044 One, the c diff risk is not in inconsiderable. 00:28:00.503 --> 00:28:12.534 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. 00:28:12.923 --> 00:28:17.094 And the first chapter of that is antibacterial resistance. 00:28:17.513 --> 00:28:28.284 And if you go and look at that, coli resistance in e coli is nudging up to 40% and in Klebsiella is over 30. 00:28:29.229 --> 00:28:32.328 And those are the big two gram negatives that we've got. 00:28:32.749 --> 00:28:48.649 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. 00:28:48.919 --> 00:28:51.979 You would say, this is for pneumonias only. 00:28:52.159 --> 00:28:59.388 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. 00:28:59.439 --> 00:28:59.828 Or not. 00:28:59.828 --> 00:29:02.538 Just not use it and use Ceftriaxone instead. 00:29:03.288 --> 00:29:07.209 And so I've got that reservation in my head that It's the everything drug 00:29:07.399 --> 00:29:07.729 yeah, 00:29:08.098 --> 00:29:09.028 and less the case. 00:29:09.229 --> 00:29:09.348 yeah. 00:29:09.388 --> 00:29:16.259 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. 00:29:16.509 --> 00:29:16.838 Yes. 00:29:16.939 --> 00:29:20.179 And actually it's about continually driving home, like. 00:29:20.608 --> 00:29:26.878 Make diagnoses, get samples, get microbiology to guide therapy in, in all male patients. 00:29:27.149 --> 00:29:35.729 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 00:29:36.838 --> 00:29:37.108 Yeah. 00:29:37.159 --> 00:29:41.328 And if they are that unwell and should again, be getting samplings and making sure you've got the right diagnosis. 00:29:41.328 --> 00:29:41.929 Exceptions, 00:29:42.394 --> 00:29:43.894 figure out what's going on and where. 00:29:44.358 --> 00:29:44.568 yeah. 00:29:44.713 --> 00:29:44.983 Yeah. 00:29:45.314 --> 00:29:46.693 And then what else have we got? 00:29:46.774 --> 00:29:53.763 There's, a bunch of protein synthesis things that are and WHO. 00:29:54.979 --> 00:29:56.719 But watch in KHSA. 00:29:56.719 --> 00:30:01.759 So Amikacin probably not something they want to promote. 00:30:01.759 --> 00:30:03.259 The use of particularly not that 00:30:03.544 --> 00:30:03.784 Yeah. 00:30:03.784 --> 00:30:04.713 And I think that makes sense. 00:30:04.713 --> 00:30:06.993 'cause Chloramphenicol is, in many countries a workhorse. 00:30:06.993 --> 00:30:08.953 It's a, cheap, very, broad. 00:30:10.213 --> 00:30:12.554 TRO antibiotic and used to be, 00:30:12.659 --> 00:30:13.318 antibiotic. 00:30:13.318 --> 00:30:13.439 It 00:30:13.499 --> 00:30:13.838 you know, in the UK it 00:30:13.979 --> 00:30:14.159 it. 00:30:14.159 --> 00:30:14.608 It's kind of 00:30:14.683 --> 00:30:15.284 used to be. 00:30:15.328 --> 00:30:15.929 covers everything. 00:30:16.423 --> 00:30:24.834 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. 00:30:24.834 --> 00:30:26.993 third gen, careful Sporin came in, that was the nail in 00:30:27.024 --> 00:30:27.233 Yeah. 00:30:27.604 --> 00:30:28.324 So to speak. 00:30:29.253 --> 00:30:40.538 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 00:30:40.719 --> 00:30:40.929 Yeah. 00:30:41.138 --> 00:30:41.949 in the same area. 00:30:41.949 --> 00:30:42.189 So, yeah. 00:30:42.368 --> 00:30:45.759 Just like Clindamycin is smoothed from access to watch. 00:30:45.788 --> 00:30:49.443 'cause it, it felt a bit odd that it was an access drug in who? 00:30:49.443 --> 00:30:52.923 And it's gone to Watch and U-K-H-S-A, which I think makes more sense to me. 00:30:53.884 --> 00:30:53.973 Yeah, 00:30:54.138 --> 00:30:54.558 me too. 00:30:55.308 --> 00:31:00.538 and then there's a bunch of stuff that the other stuff like the spectrum and omey and 00:31:00.808 --> 00:31:00.899 yeah. 00:31:00.929 --> 00:31:01.229 Vision. 00:31:01.673 --> 00:31:01.683 They. 00:31:01.959 --> 00:31:02.888 It's gone into other. 00:31:03.608 --> 00:31:04.388 I think that makes sense. 00:31:04.659 --> 00:31:06.009 They're very specific indications. 00:31:06.009 --> 00:31:09.939 You don't want them like gumming up your antimicrobial stewardship data 00:31:10.038 --> 00:31:17.838 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 00:31:18.784 --> 00:31:19.084 Yeah. 00:31:20.479 --> 00:31:23.259 KHSA, remind me, KA, is that mostly for toxo that we're using those? 00:31:23.934 --> 00:31:24.835 Yeah, I think so. 00:31:25.704 --> 00:31:32.390 And then lastly, oral Phosphomycin is watch and WHO and it's access in U-K-H-S-A. 00:31:32.420 --> 00:31:34.079 So, we use a lot of phosphomycin. 00:31:34.529 --> 00:31:36.509 I think I've got mixed feelings about that. 00:31:36.539 --> 00:31:45.964 '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. 00:31:46.545 --> 00:31:51.464 You see it being used more first line people like you just take a single sache, that's you three days done. 00:31:51.515 --> 00:31:51.755 The thing. 00:31:51.755 --> 00:31:53.125 One and done, and it's oral as 00:31:53.224 --> 00:31:53.495 Yeah. 00:31:53.674 --> 00:31:56.644 But the more we use it, the more likely we are to lose it. 00:31:57.069 --> 00:31:57.339 Yeah. 00:31:57.339 --> 00:31:59.920 And resistance is actually very easy to acquire. 00:32:00.365 --> 00:32:00.605 Yeah. 00:32:00.724 --> 00:32:01.234 Just see that. 00:32:01.390 --> 00:32:02.200 in some bugs. 00:32:02.200 --> 00:32:02.829 In some bugs, 00:32:02.855 --> 00:32:03.035 Yeah. 00:32:03.099 --> 00:32:03.339 of them. 00:32:03.339 --> 00:32:03.609 Yeah. 00:32:04.029 --> 00:32:14.680 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. 00:32:14.856 --> 00:32:34.797 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. 00:32:36.221 --> 00:32:39.072 So I guess that's the main differences. 00:32:39.521 --> 00:32:42.912 Maybe we could end on just talking about why this is useful. 00:32:43.182 --> 00:32:46.332 Like why are we even talking about the aware classification? 00:32:48.072 --> 00:32:52.916 I think the U-K-H-S-A classification,, a, it's useful for. 00:32:53.626 --> 00:33:01.817 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. 00:33:02.686 --> 00:33:12.547 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. 00:33:13.267 --> 00:33:20.436 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. 00:33:20.852 --> 00:33:27.451 Purposes and end up with something that's usable and pretty to wrap your head around. 00:33:27.451 --> 00:33:33.882 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 00:33:34.092 --> 00:33:34.271 Yeah, 00:33:34.301 --> 00:33:34.572 you know what 00:33:34.662 --> 00:33:38.832 I think you've done a great job summarizing, and I have to say two things. 00:33:38.832 --> 00:33:39.672 I think about it from. 00:33:39.721 --> 00:33:41.402 I guess learning point of view is one. 00:33:42.122 --> 00:33:48.932 Here are all the antibiotics that we use on a table color coded and categorized. 00:33:49.021 --> 00:33:52.592 So if you want to

figure out, oh, there's so many antibiotics. 00:33:52.771 --> 00:33:53.642 What one should I learn? 00:33:53.731 --> 00:33:54.481 Learn these ones. 00:33:54.541 --> 00:33:54.961 There you go. 00:33:55.396 --> 00:33:56.807 And you don't even need to learn all of them. 00:33:57.311 --> 00:33:57.822 No, there's some, 00:33:57.866 --> 00:33:58.287 don't need to 00:33:58.301 --> 00:33:58.481 there's. 00:33:58.767 --> 00:34:08.951 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. 00:34:09.001 --> 00:34:17.922 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. 00:34:18.342 --> 00:34:26.301 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. 00:34:26.631 --> 00:34:32.341 And the other thing I think it's useful for on a day-to-day basis is say, going to treat someone's infection. 00:34:32.701 --> 00:34:38.192 I could use GEF Traxon or I could use say, cotrimoxazole. 00:34:39.067 --> 00:34:43.766 And then if this, if you're kind of at a bit of a point of pose, like either drug would be fine. 00:34:44.486 --> 00:34:46.826 I don't have a real reason to use one or the other. 00:34:46.886 --> 00:34:48.056 It's maybe not a good example. 00:34:48.056 --> 00:34:53.796 Maybe there's a better example ox Cloud versus Cotrimoxazole, and you're not sure which one to use. 00:34:54.546 --> 00:35:06.516 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. 00:35:06.666 --> 00:35:11.576 So I personally find it quite helpful when I'm having these thoughts in my head about. 00:35:12.251 --> 00:35:13.511 Choice of antibiotics. 00:35:13.511 --> 00:35:24.341 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. 00:35:24.581 --> 00:35:28.931 Which kind of ties into what I said earlier on about esli, which is a reserve antibiotic. 00:35:29.546 --> 00:35:36.536 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. 00:35:36.596 --> 00:35:41.756 But it is a reserve antibiotic, so we should be reserving it for when we really need it. 00:35:42.056 --> 00:35:46.376 So, could I use, Kein here or could I use. 00:35:47.236 --> 00:35:48.616 Clindamycin potentially. 00:35:49.136 --> 00:35:53.876 And that might not always be appropriate'cause obviously, ultimately you have to make the best decision for that patient in front of you. 00:35:53.876 --> 00:35:55.576 But if there's no reason not to. 00:35:55.726 --> 00:35:58.576 I think it is useful in helping guide your antibiotic decisions. 00:35:58.751 --> 00:36:07.461 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. 00:36:08.401 --> 00:36:10.531 This should be the framework that you should be working to. 00:36:10.681 --> 00:36:17.341 You should be trying to maximize your use of access antibiotics and minimize your use of watch and reserve. 00:36:17.731 --> 00:36:18.001 Yeah. 00:36:18.001 --> 00:36:27.781 that's why all the trusts in England and in Scotland as well have a target that started, I think at 55% antibiotic 00:36:27.976 --> 00:36:28.216 Yeah, 00:36:28.231 --> 00:36:28.621 the trust. 00:36:28.766 --> 00:36:29.981 Now we're aiming for 70%. 00:36:30.041 --> 00:36:30.701 We're at 70. 00:36:30.701 --> 00:36:31.001 Yeah. 00:36:31.181 --> 00:36:33.551 And so that's driving up over the years. 00:36:33.551 --> 00:36:44.131 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. 00:36:45.121 --> 00:36:50.131 like the bit that we can handle as hospital doctors is hospital antibiotics with 00:36:50.141 --> 00:36:50.381 Yeah, 00:36:51.181 --> 00:36:51.631 guidance. 00:36:51.916 --> 00:36:54.166 and this will feed into the existing stewardship programs. 00:36:54.166 --> 00:36:59.036 You know, GP practices already get reports on their antimicrobial prescribing and things like Target. 00:36:59.036 --> 00:37:02.981 So example, being trying to focus on five day thousand seven day courses 00:37:03.081 --> 00:37:03.321 Yeah. 00:37:03.326 --> 00:37:03.446 Yeah. 00:37:03.601 --> 00:37:04.101 has been a big. 00:37:04.166 --> 00:37:04.886 that other stuff. 00:37:04.891 --> 00:37:05.521 The, yeah. 00:37:05.586 --> 00:37:13.317 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. 00:37:13.426 --> 00:37:13.726 Fine. 00:37:13.861 --> 00:37:14.461 it's good. 00:37:14.686 --> 00:37:15.466 Thank you, Callum. 00:37:15.526 --> 00:37:19.576 Well, hopefully you're a little bit more aware than you are at the beginning. 00:37:19.817 --> 00:37:21.136 Sometimes there's a pun at the end. 00:37:22.051 --> 00:37:23.491 You reserve that one for right at the end. 00:37:24.883 --> 00:37:25.933 Watch it Jane.