good afternoon good evening to our friends and colleagues and Welcome to our CW pams 2 virtual shared learning webinar next slide please my name is Nikki Dary and I am the technical project manager for the integration and use of microbiology data workstream for CW pounds next slide thank you today is the second of our quarterly webinars which we are running as part of our Commonwealth Partnerships for antimicrobial stewardship program we are running a series of eight webinars focused on strength in the capacity of Health Partnerships through sharing good practices tools and resources that can support effective implementation of the CW pams 2 projects as our CW pams 2 program progresses and your Partnerships and projects develop we’ll be reaching out to you to get involved to share your learning from the health Partnerships we cannot host shared learning webinars without the input from the people who are bringing our CW pams program to life across our eight African countries and the UK today I am delighted to be hosting our second webinar introduction to basic clinical microbiology this is the first time that the CW Pam’s program has incorporated laboratory data and processes into its project plans and we’re really excited to expand the scope of our AMS activities to include this vital resource and the teams who generate the data we are aware however that resources and staff can be limited in some facilities which hinders the use of the microbiology lab in informing clinical practice the aim of our work stream is to try to understand this work in the context of all of your facilities and to get get to know how we can support you in integrating lab Personnel into your AMS committees and teams and how to integrate and use microbiology data in clinical practice unfortunately it’s currently beyond our remit to secure supplies or equipment through CW pams but we have heard this as an issue from a number of you and we’re taking this up with other Grant providers who may be able to offer support we generated a survey to send to the microbiology contacts at each of your facilities and we’ll send this out to you soon please bear in mind that there are no right or wrong answers here so please do encourage people to complete this openly and honestly we hope to arrange a follow-up meeting with some of you on video calls to discuss your survey responses further and we will be in touch for today we have some quick questions that we would like to ask you to respond to on the poll that will show on your screen um if you could just answer these this will help us to understand how you’d like to work with us um hopefully you have the poll popped up now and we’ll give you a few moments to complete that next slide please so here is the agenda for today’s webinar we’ve got quite a lot of content to get through but hope we will have some time at the end to answer any questions that you may have we’ll be monitoring the chat throughout so please do feel free to use this to ask us questions and we hope to respond in real time next slide some housekeeping so this session is being recorded and we will provide you with details of how to access the recording at the end of the webinar if you haven’t already done so um please could you also take a few minutes to complete the pre-session survey via the link in the chat that should pop up soon and the next slide please um so please also keep your microphones muted throughout the presentations and if we do open up to questions please raise your hand and then you’ll be invited to turn on your microphone and Camera you next slide so we have two excellent speakers joining us today uh firstly we have Dr Gina Driscoll a consultant microbiologist and AMS lead at buckinghamshire Healthcare NHS trust here in the UK Jean has been a consultant microbiologist since 1995 and was director of infection prevention and control for 10 years she has an undergraduate degree from University College cork a masters in clinical microbiology and is a member of the roal College of Pathologists and became a fellow of the college in 20 uh in 2002 next slide please also joining us today is Dr Lis Sweeney a consultant medical microbiologist at Manchester University NHS Foundation trust Lise has specialist knowledge of infection in hematology and Transplant patients antimicrobial susceptibility testing and the approach to clinical management of multi-drug resistant gram negative infections Louise is a council member of the British Society for antimicrobial chemotherapy so now I will hand over to Dr Gina dris to begin our webinar next slide please hi good morning and or good afternoon everybody Welcome to the session I’m just going to introduce a few basic principles and then hand over to Louise for more detail about um the use of the lab and antibiotic testing so next slide please so microbiology is a study of microbes and as you know our bodies contain numerous species of microbes which are part of the normal flora particularly the mouth the FX and the large intestine so bodies become colonized shortly after birth and within one day of life the large intestine and the mouth will be colonized with a variety of normal bacteria such as STA forus hemophilus and numus in the respiratory tract and eoli and Anor robes in the large intestine next slide so I think it’s really important to know the difference between colonization with bacteria and infection because if you um have colonized bacteria these do not need to be treated with antibiotics whereas if there’s an infection obviously antibiotics may be indicated so as I say the body live lives in symbiosis with lots of normal microorganisms um and these this is called colonization but if if an inflammatory response ensues then this is so-called infection or disease so colonization is just the presence of bacteria and diseases where there’s an inflammatory response due to those bacteria next slide please so I just thought I’d mention a few clinical syndromes which arise when infections uh result from infection with bacteria so for example in the upper respiratory tract you can have infection of the sinuses with organisms such as pneumococcus hemophilus and Morella um in the throat you can have bacterial infection due with group a strp or you can have viral infections or there can be infections due to other bacteria bacterial pathogens such as strep pneumonia or hemophilus next slide please and in the lower respiratory tract um we can have the syndromes of bronchitis bronchiolitis and pneumonia um pneumonia would be the most severe of these Clin clinical syndromes um which can be caused by viruses including covid and bacteria such as streptococus pneumonia and other bacteria such as hemophilus storus and some gram negative organisms next slide please so in the urinary tract we can have urinary tract infections which can affect the upper urinary tract or the lower urinary tract the upper urinary tract would involve infe ction of the kidney which is pylon fritis or the urur which is uretritis and these would be characterized by flank pain high fever dark or small F smelling urine and then the lower urinary tract which involves infections of the bladder and urethra which really causes cystitis and these symptoms would be more of disuria frequency of urine um and it’s more common in women next slide please and obviously you can get infections of the skin such as cellulitis which is shown here which is a rening of the skin um it’s good idea to Mark the edge of the rash so that you can monitor the progress of the infection and this can be a serious uh bacterial infection next slide please so the infections of wounds can arise from storus infections betah hemolytic streptococcal infections especially group a strep and some gr negative organisms and um Anor robes again sometimes bacteria can be colonizing the skin and in this case they do not need to be treated with antibiotics but if there is sign of clinical infection then antibiotics may be indicated next slide please and obviously diarrhea can have infectious causes which can be non-inflammatory or inflammatory the non-inflammatory include causes such as viruses like norovirus or rotavirus which are quite very common or protozoa such as Giardia or cryptosporidium or bacterial causes um including chalera and the inflammatory diarrhea cytomegalo virus is quite uncommon but amasis can be a cause of diarrhea and then there are various bacterial causes including the common ciloa shigella and salmonella causes next slide please so um it’s really important um when sending samps to the microbiology lab to follow some general good principles first of all only send samples if there’s a definite evidence of infection ensure the sample and any forms are correctly labeled with the patient details date of birth any Hospital numbers um then give relevant clinical information for example if there had been travel to another country if the patient is on an antibiotic if the patient has a p has an antibiotic allergy for example these can be helpful for the laboratory when they’re doing the testing avoid contaminating any samples especially blood cultures make sure there’s a sufficient volume of a specimen to ensure tests can be performed for example with urine samples and stool samples ensure the sample reaches the laboratory as soon as possible usually within half an hour of it being taken if there’s going to be a delay then the sample should be stored and the at the correct temperature either refrigerated or kept at room temperature depending on the sample if the sample is particularly urgent it’s a good idea to let the lab know that you’re sending it and to let them know how you can be contacted after the result is available and as I say it’s quite important to make sure that the samples are kept at correct temperatures before they reach the lab next slide please so this is all part of diagnostic stewardship which is really a a cycle from the clinic assessing the patient making the diagnosis sending the right samples in the right way making sure they arrive at the right time and that the lab does the right tests and um chooses the right antibiotic sensitivity testing to do and then reports in a timely man manner so that the correct decisions can be made by the clinician as regards choice of antibiotics next slide so um it’s important as I say to collect samples properly for urine samples if you’re suspecting a urine retract infection it’s important to use a Midstream urine sample rather than say the first sample um ped um in all of these cases hands should be washed before taking samples often gloves should be worn as well um as I say it should be the Midstream uh sample that’s collected so the the first sample should be discarded and then halfway through urination the container should be filled and then the the the lid should be put onto the container and this should all be done in a very clean way to avoid any contamination of the specimen next example next slide uh so for taking uh samples from patients with catheters in place urinary catheters it’s important to use a sampling Port not to take the sample from the drainage bag because um this will not provide a good indication of the organism causing the infection because there could be urine hanging around in the drainage bag for some time and there can be contamination of the bag and it’s really important to wash your hands as I say and use gloves uh before taking the sample to avoid contamination next slide please um as regards sending sputum samples it’s really important to send a good sample of sputum which is usually quite thick and maybe yellow or green rather than just a salivary sample which won’t contain any bacteria so uh if somebody has got a chest infection and they’re coughing up a yellow or green sputum then it’s important to send a sample of this but if they can’t cough anything up that’s significant then there isn’t really any point in sending a sample to the laboratory the next slide please for stool samples again it’s important to get a good volume of of stool sample about usually a third to a half of one of the containers of of uh stool samples um and it’s really important to wash your hands before and after taking the samples um soap and water should be used uh because organisms such as norovirus and kustum are resistant to um alcohol gel so good old oldfashioned soap and water is what you should use when dealing with any of these samples next slide please for wound swabs um it’s important to try and get rid of any surface um contamination so you should what you should clean the surface first with normal sine and then swap the base of the wound again as I mention at the bottom of the slide the wound sh swabs should only be taken when there’s good clinical evidence of infection so not just because there’s a wound with no surrounding cellulitis or no signs of infection there’s no point in sending a wound swap then because what we’ll get is colonizing Flora rather than any pathogenic bacteria next slide please for blood cultures this is a particularly important to avoid contamination of the samples so what we would recommend is first of all washing your hands then cleaning the the site of the venie puncture using maybe an alcohol wipe with chlorohexidine um and then it should be the surface of the uh the skin that you’re using should be um clean for about 30 seconds um and then the uh remove the plastic cap of each blood culture bottle and the actual rubber stopper should be decontaminated and allowed to dry then put on gloves after that um the and then use either a syringe or directly into a blood culture by a vacu caner caner container system um and if it’s drawn into a syringe the blood should be uh put into the vies without changing needles in the past there was this idea that you should change needles between bottles but that actually um introduces a risk of contamination and if you’re taking lots of of blood tests you should always do the blood culture test first before uh taking blood for say full blood count or Ura or electrolytes um and obviously this this the bottles should be labeled at the bedside and the samples should be kept at room temperature they shouldn’t they should never be refrigerated until they’re sent to the lab they should be sent as quickly as possible to the lab um within four hours of being taken they should have reached the lab and be put on the be analyzed by the lab and the procedure should be documented well the patient medical records uh next slide please um this is just um what we use in the UK we use two blood culture bottles per set an aerobic and an anerobic bottle and it’s important to put 10 mills of blood into each bottle um and in order to facilitate that it might be an idea to Mark the uh the volume of the bottle at the side of the bottle um just mark it with a line so that you can see that you’ve put enough blood into the blood culture bottle because if you don’t have enough then that really reduces the sensitivity of testing and you may get false negative results thanks very much um I think I’m handing over now to Louise hello thank you very much Jean um hello everybody um I am going to now talk about actually what we do in the laboratory and how that can make a real difference to management of patients before I do that can I just remind everybody um if you can if you haven’t already to fill out the poll um that was introduced at the beginning of the session we have re launched it so you should be able to fill it in if you haven’t had the opportunity yet so let’s start by talking about the microbology laboratory so there is great variability from Lab to lab in terms of what kind of resource what kind of tests are provided even within the United Kingdom from Lab to lab there can be quite vast variability in the available tests but some things are pretty standard and that’s what we like to call our bench microbiology so microbiology unlike some other pathology Specialties has continued despite the the development of newer exciting faster tests to still very much much rely on basic principles and it’s important that we remember these and continue to use them because actually they provide us with an awful lot of information and can be used wherever you are um even if you you don’t have a huge amount of resource there’s still a lot of information you can get from some very basic microbiology principles so I’m going to start by talking about microscopy um microscopy one of my favorite bits I have to say of bench microbiology is of course something we use in order to visualize bacterial and fungal cells if they are present in a clinical specimen and the how this helps us is because between bacteria and fungi different stains will be retained and lost which is based on the structure of the cell wall and we have some examples on the slide here and you can see gram positive gram negative there are differences microbacteria fungi some very clear differences in the cell wall and this provides us with some very initial identification information um so it can help to guide us initially in terms of diagnosis and empirical antimicrobial therapy and can also help to guide what further testing we need to do within the laboratory so let’s look at some examples here so gram negative compared to gram positive we’re going to look in a minute at the gram procedure but this is a staining technique that has been in existence for a very very long time and it’s based on the fact that there are key structural differences between ground positive bacteria and gram negative so when we talk about gram positive we’re thinking about organisms like stafi for gram negative thinking about organisms like eoli and the difference here is that grand positive bacteria have this lovely thick petly cell wall which helps to really retain stains when they’re exposed to them whereas gram negative bacteria have a much thinner W and additionally an outer membrane so they can actually lose stains quite quickly but will take up counter stains next slide please and that’s the basis of the gram staining procedure um so we get a sample for example positive blood culture drop on the slide heat fix it and then apply an initial stain and often uh the first stain applied is going to be Crystal Violet so we get a lovely purple color there we then need to apply something like iodine um which just helps in the process of of keeping that stain absorbed for the gr positives but then we want to see whether the bacterial cell is going to lose the stain so we apply alcohol wash and if we have gram negative bacteria in the sample this the gram positive Crystal Violet stain will be lost uh sorry will be retained but if we have a gram negative that stain will be lost and then we will apply a counter stain of a different color so saffrin for example and this allows very quickly to distinguish on microscopy between gram positive bacteria and gram negative bacteria so we’ve already differentiated from that sample what sort of bacteria we have and then next thing uh next slide please we can get some further information by looking at the cells and looking at the morphology so the shape as well as the staining and how they arrange themselves and we have the next slide please and I’ve put some examples here because that’s often the easiest way isn’t it to show how this uh particular test can be really helpful in providing us information so here’s some examples of common gram positive and gram negative bacteria and how just through microscopy you can identify them um it’s not a firm diagnosis but together with clinical information it’s certainly leading you towards the correct path of the identity of your pathogen so for example let’s look at our grand positive Oran organisms that have retained that St that stain there are clear differences staf lokai strep tocky both stain as Grand positive lovely Purple colors but morphologically look very different stafy Clump together like Bunches of grapes strep tocky prefer to form chains or sometimes pears so very quickly if you have a patient who for example presents with cellulitis then blood culture is positive you do the ground staining technique you’ve already got a very good idea of whether this infection is due to staus or streptococus there are other differences in morphology that you can pick up on for example the presence of spores the example of clostridia we can see those spores in the middle which are staining as pink rather than purple and with gram negatives you can get some really nice differences in the morphology which can be very classical so campy laaa has the appearance of a seagull it’s that lovely wave form vibrio nice curved rods very distinct from your usual gram negative pathogens that you see like eoli or klebsiella next slide please however not all bacteria will stain using the Gram stain method some don’t stay in very well at all because of differences in their cell wall micoplasma for example doesn’t have a cell wall so it’s not going to take up GR gram staining other organisms like micob bacteria have a very different structure because they have a very lipid Rich cell wall so the usual stains don’t penetrate so you have to use a process called acid alcohol fast staining there are other microsc op y methods as well such as dark field microscopy so lots of different ways that you can visualize organisms if you have for example a blood culture that’s flaged positive and you initially start with gr staining techniques and you can’t see anything in that sample along with the clinical details that may trigger a thought as to well maybe this is something that doesn’t stain by ground staining maybe I need to think about organisms like my mic bacteria or micoplasma next slide please fungi also can be visualized by microscopy earlier on one of the examples I showed of ground positive staining was candida Albans so candida will stain using that method but there are other methods available particularly when we’re thinking about our molds so there’s um one of my personal favorites which is the Scotch tape microscopy uh where when you have a growth on a plate of a lovely mold you can very simply use a bit of cell tape Sticky Side down to uh press over that Colony so you get some lovely bits of high feet on there that you can then stain and look at under the microscope and the nice thing about that is it keeps those structures intact it doesn’t damage them so you can get these really nice views um of the Hy and and other parts of the fungus which can help with identification IND your ink stains used to show capsules and calflor white uh which uses fluorochrome again used UV microscopy for this but helps to show those structures of fungi more now of course we may not have access to all of these things but there’s a range of methods there as you can see to help us visualize any fungal uh colonies that we have in our cultures next slide please so then let’s talk about culture because microscopy can be done directly from a sample such as blood uh that’s been taken for culture um but it’s not very useful if you’ve got samples that are non-sterile where you’re going to expect to see lots of bacteria there so what we want to be able to achieve is to get something in culture get a pure growth that we can then pick out the relevant organisms and do some more identification work on and that’s where culture is really helpful so culture is the use of artificial media to encourage the growth and therefore isolation of microbes which may be pathogenic in our patients and there are lots of different type of media available liquid solid here in the UK a long time ago we used to make our own AAR plates um that’s because of the volume has has very much gone away and we now buy them in from elsewhere but it is still something that you can do if you’ve got the available resources and there are different types of media you can have non-selective media which are just encouraging the growth of anything that’s in that sample um or more selective media which allows you because of the nutrients involved the chemicals that are present and antimicrobials that may be in the agar to allow particular organisms that you are interested in to grow through the method of inoculation of your plates is really important and here is um an example of what we’re taught to use in the UK and the reason it’s important is that what you want to do is try and get single colonies and so spreading out your test isolate across the plate should allow you to do that because it’s much better and easier to work with single colonies particularly if your culture may be mixed next slide please the incubation conditions for your culture are very very important because different microbes like to grow in different atmospheres or different temperatures crucially also the time that you allow the organisms to incubate for is important if you read a plate too early you may not get the results that you want if you leave a plate for too long you may get unnecessary overgrowth it then Shadows or clouds the important organisms so there are key things we need to think about the plates that we’re using so the media whether we’re using selective non-selective what sort of organisms we are interested in which be based on the clinical sample that we’ve received what sort of conditions those pathogenic organisms were worried about need to grow and at what time we need need to be reading those cultures um can we have the next slide please uh so selective media I just wanted to show you some examples of that obviously some Labs may not have access to all of these different types of media um some may be able to make their own uh these are examples particularly for enteric Flora where if you have a store sample of course you’re going to have a lot of bacteria in that sample but you want to be able to select out the ones that you’re worried about in terms of causing infection so this is an example of where selective media can be really really helpful to help prevent growth of anything you’re not interested in and promote growth of those pathogens you are interested in and this again all helps to identify the organisms causing the problems for the patient I always think about microbiology even more so than other branches of medicine being a bit like being a detective and trying to put the evidence together to find your culprit next slide please once you have a growth on a plate um you have microscopy which can give you information but there are other things as well that you can use in other tests to help identify further even to species level the organism that you have initially just looking at the culture plate and looking at the colonies themselves the colors the shape whether the colony have caused any hemolysis on the plate if you’re using um blood AAR looking at whether they’re mucco colonies or dry colonies all of this provides you with information but there are other tests you can do biochemical tests work on the basis of knowing what bacteria produce in terms of enzymes for example um and can be used to very quickly and easily identify an organism so for example you’ve got um a mucoid looking Colony on a plate it’s a sample that’s been uh say it’s a urine culture so you’re thinking you’ve probably got a ground negative organism causing the problem the most common organism to cause that type of infection would be ecoli so a very simple test would be something called the Indo test because ecoli other like other than um with the exception sorry eoli uh is indo positive whereas other colorforms or entact we’re going to use the proper name like ciella for example are not so immediately you’ve got some additional information about your identification for stafi staf cokus orus produces coagulase the other stafi which tend to be less pathogenic things like snaf is epidermidis usually just contaminants when we get them in most cultures do not so a simple coagulase test can differentiate that growth on the plate between staff orus and another type of staff for caucus for a long time and I always really enjoyed using these um there was some really nice kits the API kits that allowed you to do a whole host of biochemical tests very quickly in one go and that provide you an idea of the organism including to species level so um API stands for analytical profile index and it’s uh the the little strip you can see at the bottom with the different colors which contain uh different types of media um dehydrated media that have chemically defined compositions you add your solution containing your test isolate to it and look for reactions which to usually color mediated reactions this produces a score um which you can then submit to a database or maybe from a book which then because of a wide database of organism identities will tell you what the organism is so this is quite a rapid nice test to do if you have access to this bit of Kit and then in terms of media to the AAR that we’re growing our organisms on there are increasingly uh more and more chromogenic agar so agar that when you grow a particular organism the colonies will come out as a particular color so what we’ve got a picture of there is something called brilliant agar which is used when you have for example urine uh that you want to culture to see if there’s a pathogen eoli colonies will be pink and immediately you’ve got an identification um add that along with an indor positive test and you know you’ve got eoli very quick very simple there are also serological methods for identification which are based on particular antigens that may be present within the cell wall of certain bacteria and latex particles coated with an antibody when applied to a sample of the bacteria you’ll get a glutin again a very quick and simple test if you have access to those resources next slide please so um an example of how this would work we used the example of cellulitis before didn’t we so a blood blood culture is sent the clinical details say saitis that blood culture is incubated we get growth we do gram staining on a sample of that blood and we see gr positive organisms lovely and round um clumping together which immediately tells us that this is is stafl coccus now cellulitis common cause of of that staf coccus orus so we set up our culture plates and again this is a blood AAR very typical appearance of Staff crocosaurus on a blood AAR plate you can even see a bit of hemolysis in the background which again would be typical we think this is Staff caurus we want to do some further testing we know staff caurus produces C coagulase other stuff cocky do not so we can do coagula tests either a latex test or a free Unbound coagulase test the tests are positive and immediately we have our diagnosis so that’s how these methods using very simple bench microbiology can provide you with important results to guide the management of your patients next slide please of course there are other systems and it’s very variable as to what people have access to some of the tests that we’ve talked about in terms of um identification but also susceptibility testing can be done using automated systems and I’ve put uh on there pictures of two such systems which are very widely used throughout the world the BD Phoenix and the biom Mario vitec 2 and they have automated rule bases and databases that analyze that biochemical data and susceptibility data to give you an identity plus susceptibility results you still need to incubate the samples over a prolonged period of time so it’s not rapid um it’s an additional day on top of culturing your organism but it does give you those results increasingly in many areas of the world uh people are looking and using protonic techniques like Matrix assisted laser desorption ionization Tim of flight Mass spectrometry which is quite a mouthful so we all refer to it as mold off and this is where uh it’s actually looking at um instead of biochemical markers that will identify the organism it’s looking at particular proteins and using those proteins uh in Mass spectrometry to produce an identification next slide please and this is just an example of of sorry if we go back um you can see an example of of what you get so you get Peaks according to the presence of particular proteins um and that gives you an ID again a vast database which is regularly being updated but of course these methods they do cost money and resource so it’s not necessarily available to everybody mold it off is certainly much faster in terms of the results you can get a result within a few hours so same day um from a colony and with the right kits also Direct from positive blood cultures next slide please and of course we have to talk about molecular techniques increasingly being used in bacteriology um for a long time was mainly the domain of virology but we are now catching up and this allows much more rapid identification and in some instances can be used in a syndromic way so for example the bopi produced by biom Mario you can put a sample of CSF for example or blood and you do a rapid syndromic PCR which will identify key pathogens that you’re looking for they are expensive they require continuous resource but they are quick the downside is you will not be able to identify anything that the system is not programmed to look for so anything that you don’t have um the uh the particular reagent to look for so any new or emerging bacteria that may be causing a problem will not be identified by these agents next slide please so let’s move on to antibiotics because of course alongside identification we want to talk about susceptibility testing very quickly classification of antibiotics how do we classify them you’ll be aware there are lots of different groups of antibiotics and they can be classified in various ways the most common way is through their mechanism of action so whether they work on cell walls um such as betal laam antibiotics your glycopeptides such as fanyin whether they work directly on DNA or RNA synthesis such as fluoroquinolones whether they work on the ribosomes and then you can further divide that According to which subunit and this is just a really nice diagrammatic in uh example of that next slide please we have to mention about the beta lactams the biggest group of antibiotics that we have available to us and you can see there are multiple different uh beta lactams available some of which you may have access to some of which you won’t some of which are used regularly in clinical treatment others that are not so if I went through this list I would be able to pick off um a number that we have access into to in the UK but also a huge number that we don’t have access to but they are subdivided according to again differences um within their molecular makeup um so for example the keis borins really important to note that the keis borin are divided up into different Generations which Accord with their spectrum of activity next slide please antibiotics have also been classified according to whether they are bacteriocidal or bacteristatic in their action essentially what this means is bactericidal organisms as the name implies uh bacteriocidal antibiotics rather kill the bacterial cell whereas bacteria static antibiotics slow the growth of the bacteria but do not kill them and for a long time it was felt that bacteria static anti iotics were inferior to bacteria cidal there is um a very nice paper that came out uh a number of years ago now I think it was 2018 uh in clinical infectious diseases which was titled bosting the myth of static versus sidal and this is a systematic literature review looking at randomized control trials which found that the vast majority of those trials about 49 out of 56 found no significant difference between the outcomes of patients when you use bacteriocidal versus bacteristatic drugs the main characteristics that are important in successful treatment are optimal dosing pharmacokinetics and tissue penetration next slide please with all these vast antibiotics knowing how they work um knowing uh what their classification is is important but of course the most important thing for us as clinicians is their spectrum of activity because they are all different so another way in which we will classify antibiotics is according to that Spectrum do they have activity against Grand positive organisms Grand negative organisms do they have activity against Anor robes this uh table here is very good it’s not exhaustive but it shows some of the common susceptibility patterns of commonly used antimicrobials against significant pathogens and it’s really really important for all of us both within microbiology and outside to know some very basic um antibiotic spectrum of the antibiotics that we use on a regular basis next slide please so that brings us to antibiotic susceptibility testing which is my second well it’s actually joint favorite with microscopy part of microbiology so antimicrobial susceptibility testing of course the main function is to tell us how best to treat our patients we have a pathogen what is it susceptible to what is the best agent for for getting a good outcome for our patient it can also be used to help with the identity of an organism um if you’re aware of what the anticipated spectrum of activity is however Golden Rule you cannot truly and reliably interpret susceptibility testing unless you know the identity of the organism that you are testing a as as we often refer to it as is Guided by a number of very important points the anticipated susceptibility profiles of specific pathogens so are they intrinsically resistant to certain antibiotics should they in the main be susceptible to other antibiotics is also Guided by the availability of clinical break points by local and National empirical treatment guidelines so we want to test antimicrobials we have access to and that we use and so therefore antibiotic availability is also important next slide please there are different ways of testing antimicrobial susceptibility the gold standard is microb broth dilution um and this gives us something called the minimum inhibitory concentration the lowest concentration of an antimicrobial agent that inhibits the visible invitro growth of a microb and you can see um hopefully that nice diagrammatic representation of what that looks like you’re looking for the um the absence of growth on your agar plates or the smallest amount of growth at different concentrations of the antibiotic the minimum bactericidal concentration is the lowest concentration needed to kill and therefore get a completely clear no growth um at particular concentration of antibiotic and this can be done with AAR as well as broth and it is the gold standard next slide please however for ease um um the main way of testing for many many years in diagnostic busy diagnostic laboratories was disc diffusion testing uh where you have a suspension a standardized suspension of your organism that you then inoculate an AAR plate with so a lovely lawn that covers the plate apply the antibiotic discs that you want to test incubate check the plate the next day and you’re looking for a zone of inhibition which tells you whether you’ve got activity against that organism or not there is some variability in this in that for certain antibiotics that may have very large molecules you’re going to get much slower diffusion through AAR than you are for antibiotics with small that are smaller molecules and so just having a big Zone to an antibiotic doesn’t tell you necessarily that it’s susceptible there are um differences uh to be applied so for example vomisin is a very big molecule so you unlikely to get very big Zone sizes but a Zone size that is much smaller compared to to for example penicillin may still be a susceptible Zone size and that’s where you need clinical break points next slide please so susceptibility break point are um a a chosen concentration of an antibiotic which defines whether a species of bacteria is susceptible or resistant to that antibiotic when we talk about Zone sizes it’s the size of the zone so if the break point um you have a break point which will be in millimeters and if that zone size is larger than that break point it’s suceptible if it’s smaller it’s resistant other way around the minimum inhibitory concentration you want the lowest number possible not a high number so anything below that break point is susceptible different antibiotics um for different bugs we call them the drug bug combination may have different break points depending on the type of infection being treated so for example meningitis compared to non-meningitis because because one of the key elements of determining antimicrobial susceptibility is the penetration of the antibiotic to this site that you are trying to reach so when break points are put together it’s based on microbiological data it’s based on pharmacokinetic and pharmacodynamic data and also clinical study results so the mic The Zone size is really important but so is the type of infection that you’re treating and where you’re trying to get the antibiotic not all bacteria or drug bug combinations will have break points and in those situations it’s often uh decisions are based on whether there’s clinical experience of using a certain antibiotic in the treatment of a certain infection next slide please there are um two main clinical breakpoint guidelines that are used throughout the world and it varies from place to place what people use one is American the clinical and laboratory standards Institute College of American Pathologists or the clsi breakpoint and um the other which I will show a SL side of in a moment is the European version um now both are moving more and more towards a very individualized approach to susceptibility testing and that means looking not just at whether the organism shows susceptibility to an antibiotic but really taking on board things like the concentration of antibiotic achieved at different sites in the body so you will see that the traditional susceptible intermediate resistance are being replaced with categories such as susceptible dose dependent which means you’ve got a much higher likelihood of clinical success if you use higher doses this may be for particular drug bug combinations and certainly for different sites of infection so susceptibility testing is becoming more complicated and that is because of an acknowledgement about variability in methodology but also how drugs are metabolized and cleared by patients next slide please this is the European committee on antimicrobial susceptibility testing this is the one that we use in the United Kingdom um much like CSI it has some different categories which are based on something called exposure and exposure is just what we’ve been talking about it’s about how the antibiotic is administered how long you’re infusing it for what the metabolism and excre excretion of the agent is as well as the organism itself next side please so when setting up your antimicrobial susceptibility testing you have to take on board what bugs you’re testing what the susceptibility profile you anticipate should be what antimicrobials you have available to you but also what sort of resistance may you see so it’s important to know about your local epidemiology resistance detection it’s important to have indicator antibiotics so these are antibiotics that will be able to highlight the presence of a particular resistance mechanism of concern for example extended Spectrum betalactamase production in entact ales which would very significantly change the antibiotics your organism is susceptible to and therefore you should use in treatment of your patient next slide please so here’s an example um here are some organisms some antibiotics that are commonly used throughout the world and their expected susceptibility profiles so you’ll see cleal pneumoni should never be amoxicillin susceptible because it produces something called T betalactamase tem so it will never ever be a moxilin susceptible it will also not be susceptible to agents like vomisin that act on Grand positive organisms only Celler is a gr negative organism and metronidazol which has activity against Anor robes only so this is an expected susceptibility profile this is the sort of thing you would expect to see um we’ve got some other examples there staus ocus very specific intrinsic susceptibility pomonis only those agents with activity against sudon what we call the anti- sudon antibiotics are going to show any susceptibility here and bacteroides and anoro um in the main we can rely on Metro Idol susceptibility bit variable to some other antibiotics next slide please however some of these organisms can develop or acquire resistance and the use of indicator antibiotics will help to demonstrate that to us um and as you can see if we look at the example of an es producing E coli usually ecoli will be susceptible to a broad range of beta Lac antibiotics including keos gorin but if it’s an es producer it’s going to be resistant and indicator antibiotics like keod oxine although not as completely specific as we would like it to be certainly gives you an indication that we’ve got es production coupled with resistance to third generation korin like kef triaxone and keot taxine if we don’t test these agents we won’t pick up that resistance May treat the patient with the wrong antibiotic next slide please so which brings me on to antimicrobial resistance we’re all very very aware of increasing antimicrobial resistance particularly within those bacteria of significant pathogenic importance now antibiotic resistance very simply is an antibiotic not being uh effective against a particular organism we all have bacteria that will be resistant to certain types of antibiotic intrinsically so what happens when we use antibiotics is that we will select out any bacteria that are not susceptible to it and that can allow those resistant bacteria to multiply to flourish which then facilitates spread of antibiotic resistance and in our Hospital patients where bacteria can be shed into the environment through infected wounds for example through coughing um through diarrhea that antibiotic resistance can be spread within the environment or on the hands of Health Care staff to other vulnerable patients next slide please there are multiple there are four main mechanisms of resistance that we worry about impermeability so antibiotics not being able to get into the cell antibiotics being pumped out of the cell by e-lux modification of the antibiotic Target um so with betal lactans they target penicillin binding proteins in the cell wall if those proteins are modified by a mutation the betacon cannot bind to them and exert its effect and of course inactivating enzymes that break down that hydrolize our antibiotics rendering them ineffective now some of these mechanisms in some of these bacteria will be intrinsic which means that organism will never ever ever be susceptible to certain antibiotics for example stenram monus um this is an antibiotic that has intrinsic resistance to a number of different antibiotics including carop penams and that’s because it produces an enzyme called a carbapenamase and it will always produce that enzyme it doesn’t really transmit um to other uh senet because they all have it it’s intrinsic it’s built in what we worry about is the resistance that can be passed to other bacteria within the same species and even different species next slide please um this is just an example of some of those antibiotic targets and the antibiotics that that work that way for example cell wall agents like betalactams and the resistance mechanisms that we’ve also just talked about that will affect those antibiotics this is not an exhaustive list there are a huge number um but certainly within our betal laxm antibiotics which are the most frequently used Class of antibiotics it’s in inactivating enzymes that caus the biggest problem in terms of resistance next slide please it is important to recognize we’ve got different methods of resistance intrinsic I’ve I’ve mentioned already which is when where the organism will always be resistant and this is encoded at a chromosomal level but there are other forms of resistance mutational through DNA replication errors which can occur randomly but then the one that we really worry about which is that transferable resistance which is also mutational but is passed horizontally through different methods conjugation transformation or transduction next slide please the World Health Organization produced in 2017 a bacterial priority pathogen list and this is that list of agents that have acquired resistance increasingly so perhaps to multiple antimicrobials which is rendering them more and more difficult to treat and they pose a significant risk to patients in terms of morbidity and most importantly mortality and it’s important to be aware of those organisms and to know how to detect them in your laboratory by doing the right antimicrobial susceptibility testing now of course you may not see all of these resistant organisms in your own area that’s where knowing your epidemiology is essential for example we see very little carop penum resistant acin toaa in the United Kingdom but we will still always test carop penum susceptibility on these agents um to to look out for it because it’s also an agent we would use in treatment next slide please and on that theme I really want to highlight this if you haven’t read it which was a really groundbreaking piece of work published in the laned in um 2022 and this was the first really indepth analysis of the mortality toll caused by antimicrob resistance this is something called the gram report Global deaths attributable to and associated with bacterial antimicrobial resistance and hopefully what you will note on here first of all is that those top six pathogens causing death jeta antimicrobial resistance are all pathogens who were on the World Health Organization priority pathogen list it was quite striking this piece of work because it showed that nearly five million deaths world wide were associated antimicrobial resistance and actually when you looked at the numbers there were about 1.2 million deaths which they could say absolutely were attributed to bacterial antimicrobial resistance and this was more deaths than there were due to HIV and AIDS due to breast cancer and due to malaria in the same year so antimicrobial resistance is important and we need to ensure that within our Laboratory trees we are looking for it actively and detecting it next slide please so very finally um we’re going to talk about how we take this information and how we help in the management of the patient and this is a really really nice figure that’s used very often um about how we use Diagnostics to ensure appropriate treatment of our patients and this all comes in uh for us in microbiology as getting the right samples at the right time on the right patient and Performing the right diagnostic tests using what we have available to us and when we perform those tests making sure we have the skill set and the knowledge to be able to interpret those results and to have timely feedback of those results to our clinical colleagues to ensure that the patient gets the right anti antibiotic at the right time this improves patient outcome but also can be used to ensure we’re not overusing broadspectrum antibiotics next slide please so when we think about the process and getting those results what we have to consider is how those results are relayed back to the right person to affect the necessary changes in therapy so who’s getting those results and how are we getting them and how quickly we getting those results cross that’s looking at our own processes and what we can put in place if you have an electronic reporting system that’s great results can go out very quickly but then how do we know someone’s actually seen those results and acted on them telephoning we still do that absolutely uh phone people up give them the result can be difficult to get a hold of paper copies mailed out takes time it’s not it’s not enough but if you have a lot of samples it’s really about prioritizing which ones need to be um alerted to colleagues and how we share that information next slide please which also ties in with how we’re interpreting those results so it’s not really enough just to say we’ve grown this we also have to be able to say do we think it’s relevant do we think it’s significant to that patient in the context of the clinical signs and symptoms and the diagnosis is the result right have we made any diagnostic errors here because errors can occur sometimes you can get a mixed growth you look at the susceptability pattern and immediately you know it’s not right something’s gone wrong at the laboratory level is it useful is the information we’re providing going to make a material change to the patient so let’s have a look at how we might do that next slide please oh yes forgot very key word quality not just the quality of the processing and the results it’s the quality of the information we provide that makes the biggest difference to the patient next slide please so for example here we are this is um a very poor knockup of a microbiology result for a Midstream urine we can see we’ve got a purea there we’ve grown eoli we know that EOL is the commonest cause of urut trct infection we provided some susceptibility results so let’s go through this we want to be able to report antibiotics that one the clinicians have access to two are included in the empirical treatment guidelines and that’s because those patients that we’re treating may be on those drugs and we need to be able to tell the clinicians whether it’s the right drug or not so reporting resistance is just as important as reporting susceptibility but we also want to use as narrow Spectrum an agent as possible so on here erap penum has been reported but so is ke Xin erap penum is very very Broad in its spectrum of cover keex in much less so so why would we want to report erap penum which is unnecessarily broad has no advantage over over using kexin for the treatment of a UTI so that shouldn’t have been reported we have to release antibiotics that are appropriate for the clinical detail for example if it’s a simple humanly tract infection report nitrofur and toen if it’s a penitis nitrofur and tone doesn’t penetrate into the kidney so it’s a completely inappropriate agent to give so that shouldn’t be reported but alongside that let’s give comments to that effect let’s make sure the clinicians know why we’re reporting what we’re reporting what the thought process is ensure that we’ve got oral agents and IV agents if it’s somebody who’s in hospital if they’re an outpatient oral options are really what we want to be reporting and alternative options for allergy it does of course require clinical information the quality of the results and the interpretation of those results that are provided by the laboratory fully depend on the quality of the information that we are getting at the point of the test request so the more clinical information we have the better the result and the better the interpretation we can give to help the patient next slide please so antibotic steip and Reporting results go hand in hand um this is a snapshot from the World Health Organization antimicrobial uh stewardship program practical toolkit and the reporting of susceptibilities and sensitivities are hugely important to allow good outcomes for the patient but also to reduce unnecessary broadspectrum antibio crobial use which will select out for resistance if we don’t reduce the use of those agents when it’s not necessary to use them next slide please um this is just a paper that you may want to look up it was an interesting bit of work that looked at prescribing based on results being provided by a microbiology laboratory so sets of Junior doctors given scenarios with reports that either had antimicrobial um susceptibility results on or didn’t and what it found was that in a lot of cases particularly in non-acute settings if antimicrobial susceptibility results were not given antibiotics were frequently not changed and in some cases not even prescribed so for example wound swaps um that were taken and actually there was no real concern about clinical infection if antimicrobial results weren’t given Junior doctors didn’t prescribe if they were the junior doctors sort of thought it must be significant and would go down the route of prescribing so it’s important to acknowledge the behavior of uh the trained behavior of our clinicians if we’re giving a result and we’re giving an inter reptation and we give antimicrobials that can be seen as us saying this is significant treat it even if it may not be so we have to think very carefully about what we release next slide please so here are just a few examples uh leg wound swab growth of stafl cus orius we all know that can be a significant skin and soft tissue pathogen so we release antibiotics that would be used in the treatment that would be included in our treatment guidelines and for which we have available a ability for so I’ve included antimicrobials that we use in our trust I’ve also ensured that we’ve got IV and oral treatment options for if this is a patient in the hospital and given an alternative for penicillin allergy next slide please but then we have this circumstance where it’s a wound but it’s really mixed we’ve got lots of skin FL we’ve got lots of cola forms and what we know is that superficial swabs will pick up bacteria that may just be colonizing and may not be causing an infection and the more mixed it is the less likely these organisms are to be causing infection and we know that most of the time coliforms are not in the top three pathogens for causing uh your standard skin and soft tissue infection so with this and based on the information given I would not provide any further identification and I would not provide any further susceptibility results and I would provide a comment to explain what my thinking is and if the clinician has any concerns or questions about that they can then call and we can have a discussion next slide please still on the wound swabs because this is a common one for us I think uh ponus arenosa in the context of leg offers so this too may be a colonizer it may also be clinically significant I have to base this in my interpretation on the information that I’ve been given also looking back to see if we’ve had any past culture results is the patient in hospital are they not are they on antibiotics are they not and if this is the first time we’ve isolated it from someone who’s at home who’s otherwise reasonably well I wouldn’t provide any susceptibility results but again I would provide a comment to explain and to say call me if you have any concerns next slide please however if it’s a patient who’s in hospital they’re very unwell I can see they’ve had antibiotic treatment in the community this this may be more significant if they’re diabetic it certainly might be significant and I will release the relevant susceptibility results next slide please similar concept um for sputum sputum is not sterile you’re going to grow organisms that are in uh the normal respiratory tract but what we try to do in the lab is to encourage those that are clinically significant to grow through and certainly for somebody who’s got chronic obstru of a pulmonary disease hemophilus influenza is a recognized pathogen so it’s reasonable to provide susceptibility results and to provide antibiotics that we know are commonly used to treat this sort of infection so nothing broad spectrum nothing like maripan it’s not required but if you’ve got a patient who’s in hospital who has a hospital acquired infection maybe there on the Intensive Care Unit growth of an organism such as entaa May well be clinically signif ific it might be a colonizer and this is where we need to know a little bit more information and to produce relevant and timely antibiotics so for example gyin not great for the chest shouldn’t release that tiger cyclin we also don’t really use use for the chest shouldn’t release that release only appropriate antimicrobials for the sight of infection and for the patient next slide please lovely I’m sorry I’ve slightly run over I apologize Jean who’s now going to take us through some case studies and I’m going to stop talking thanks for your attention hi again yes I thought I would just uh present a few case studies to illustrate the value of the lab in diagnosing and treating infections so this is a 25-year-old girl who presents with a cuff and fevers for one week and she has green sputum she had been given an antibiotic by a doctor um but she hasn’t had any Improvement in her symptoms a chest x-ray shows in uh consolidation so there is definite pneumonia there she has admitted and given CF triaxone and a sputum sample as scent and quite surprisingly I suppose the sputum actually shows some gram negative rods um which may not have been treated with the antibiotic she was on she’s failing to improve on kef triaxon and we find in the lab that the sputum actually is growing an ESL producing kiella resistant to kef Tri but it is sensitive to cyof flosin and once the antibiotics change to this she improves so this is an example of how microscopy and sensitivity results assisted in the management of this particular patient and next slide please so the second patient is an 8-year-old man with cancer who’s admitted with fevers and flank PL Fain probably pylon nephritis um the patient has again started on kefri on and a urine sample Ascent uh the patient had been an inpatient recently and interestingly had had a course of meropenam for a similar presentation there’s no improvement this time on kefri aone so the treatments the patient’s treatment has escalated to meropenam but in fact the urine sample has grown a very resistant ecoli resistant in fact to meropenam and the eoli is producing a carbapenamase which makes it resistant to mol anti biotics tested however it is sensitive to Amic casin which is an aminoglycoside so that antibiotic is prescribed and the patient makes a good response to Amic casin and then the third case is a 40-year-old man admitted with a two- week history of fevers non-specific symptoms no obvious source of infection there’s a slight rash you can see there on the right as white cells are low he’s very very unwell very agitated it’s difficult to take blood cultures but they are taken on the third attempt he started on Kev triaxone and it’s just interestingly the blood cultures were unfilled the next day Grand positive cocky are seen in the blood in the Gram stain of the blood I think you can see them on the right there they’re identified as staff epidermus of doubtful significance probable contaminants the patient continues and kep tracks and with no improvement is transferred to intensive care but then it’s noticed on the on the agar plates the second colony is growing and a Gram stain of these show gram negative rods which are identified as salmonella Tye so the patient actually has typhoid fever and this particular strain is resistant to K triaxone but sensitive to aiyin so that antibiotic is given instead so I think these are three examples where the importance of sending specimens prior to starting antibiotics is really important and then once the organism is known and the sensitivity pattern of the organism is known the patient receives the correct um antibiotic thanks very much so I’ll hand over to Nikki again that’s great thank you so much Jean and Louise um I think we have some time now for uh panel discussion and some questions from um the attendees so if anyone has a question you’d like to ask any of us please do raise your hand and then we can um invite you to unmute yourselves thank you Nikki I don’t know whether you want to pick up um one of the chat questions actually now that we’ve got Gan and and Louise um not presenting so somebody asked about using a combination of ucast and um the clsi um methodologies in labs and what would your opinion be on that should I take that one um so people do um they certainly do uh even within my own Laboratory um we we do have that but I that’s where I’ve seen some difficulties with it and I would probably caution against it so for example we for everything that we do in terms of setting up our blood culture susceptibilities whether that’s dis ends or or through other methods um and our interpretation we use ucast but one of the bits of kit that we have which also does susceptibility testing for us is the vitec 2 automated system and that for some types of organisms and some types of uh bug drug combinations uses a mixture of ucast and clsi which one is just confusing in terms of interpretation for people and that can lead to error um that can lead to significant confusion from individuals uh and it’s something that we’re trying to sort out at the moment now it may be that for some drug com drug bug combinations there are only clinical break points available in one or other of those guidelines so clsi for example example does have break points for some drug bugs that ucast does not um for example we talk about AC toaa it’s got a much more extensive susceptibility profile same for Burk Aleria ucast doesn’t have any breakpoint data for Burk Aleria so you may have circumstances based on the organism where you might need to mix but in which case you would need to be very very clear so that people know know exactly how they’re interpreting those results and what they’re looking at in order to interpret them so I I think avoid it where possible but I recognize that there will be instances where you will need to mix and match a little bit but it’s just about Clarity within the laboratory and with your clinicians you know some clinicians are very switched on to the fact that you know you use the break points to interpret pharmacist particularly interpret your ing so it needs to be quite clear what you’re using so that people can interpret that information properly yeah I would I would agree with that um I think you in in the UK we’re encouraged to use ucast a lot and I think it’s probably only when we come across a drug bug combination which is uncovered by UK so we start looking at clsi and other options thanks we have a question from Stephen Stephen if you wouldd like to unmute yourself and ask your question thank you very much uh for the presentation and um I happen to work at the emergency uh setup one of the our problems has been managing very severe infections especially when we have situations where you have to manage SE sepsis and then septic shock and the challenge has been the issue about selecting the empiric antibiotic to manage these uh conditions however we have always been having the challenge of taking sample before the treatment begins what do you think would be the appropriate thing for uh situations like this and what you think we pharmacist involvement we do to make sure that the protocol is followed uh for an effective management of uh patients especially with sefy shock and cus um will I start maybe the discussion on this one I think yeah as you say it’s really important to get the specimens if if possible at all before you start giving the antibiotic particularly blood culture I would say you could probably leave some of the other samples until the patient has had one dose of antibiotics um as regards choice of antibiotics I suppose some of it is based on National protocols and some of it is based on local sensitivity data if that’s available uh because if you know that you’ve got a particular problem with antibiotic resistance then you may empirically go for some very broad spectrum antibiotic that you know is going to cover most of the expected organisms um uh obviously in the UK we’re trying to sort of rain back on that and go narrow Spectrum as much as we can um you know depending on our sensitivity pattern so we might need a com may use a combination of for example amoxicillin plus gentamycin which locally will treat most of the expected pathogens but if you are if you do have a lot of say es bacteria or carbapenam resistance locally then you may have to go for you know a more broad spectrum um for example a carop penum or even Broad respect one of the newo antibiotics to cover I don’t know Louise what you think about that yeah I think um so two things obviously starting with the the blood culture can I just say we have similar problems I think everybody has that that trying to get the samples taken at the right time is a struggle and they can you know the reasons for that are variable aren’t they and some of them may be very much situational um to what you’ve got got available within your department I mean we’ve occasionally I’ve had sort of calls from people saying we don’t have we don’t have the sample uh containers in the department what do we do you know there are multiple reasons behind it isn’t there and one of the things that I think is very useful is to try and address find out from the people who are dealing with those patients day in day out what what are the barriers um what are the things that make that more difficult to maybe get that blood culture done in a timely way there may be things that are easily identified that can then be modified that can be worked on to help bring about the effective change which is getting the blood cach taken as soon as possible um in cases where you’ve got somebody who’s come in septic of course there are multiple different things that as that treating clinician you need to do so you’ve got lots of competing things going on there um and I would say you know if you have to get the first dose of the antibiotic in great but as quickly as possible afterwards get that blood culture you’re not going to have killed off all your bacteria within five minutes of giving an antibiotic so maybe it’s about having that discussion finding out what some of the barriers are and coming to an understanding using a clear evidence base of well okay what time is acceptable what kind of time frame is acceptable to get those cultures done um secondly in terms of the empirical choice agree with with Gan absolutely that this really depends on your local epidemiology and and I’m I’m so boring because I say this all the time it’s pretty much my answer to most things because we’re all different and our situations are different and what you see in your area may be very different from what I see in mine and that’s where the microbiology data that you use to treat patients you should also be using and I’m sure that you are as best as you’re able when we’re all trying to do that aren’t we to get a picture of what you’re seeing in your hospital in your area and you build that picture to see what the pathogens are what your antimicrobial spectrum is so um in terms of your spectrum of of cover and resistance what are you seeing and that will help you if you can do a cumulative antibiogram for some of your major pathogens like your Gram negatives pull that together and you can see if you’ve got a lot of resistance to One agent well definitely don’t use that empirically but if you have a lot of susceptibility to another agent and you have access to that because availability has been an issue globally we’ve had lots of shortages of antibiotics and in some settings it’s really difficult to get hold of certain antibiotics so it’s looking at what you have available but what’s going to cover the majority of the pathogens causing septic shock in your patient population I hope that’s a reasonably helpful question Steph do you have anything that you want to pick up on there or come back with at all yeah I think you have addressed most of the issues and I’m very grateful um we believe we will change the things as you have actually some of the things you have suggested and then we look forward to a positive outcome thank you so much thanks Sten for your question it was a really good one we’ve got just three minutes left so I don’t know we’ve had a question in the Q&A I don’t if there’s a quick answer to this but I’m trying to use the disk reading template software Doo I think to produce reading templates for our partner Labs do you know of any more user friendly software or any that can produce PDFs Etc any thoughts that’s a really good question and despite the fact that we do use templates not allow I don’t I don’t know which software I think we put ours together ourselves or maybe I’m giving us too much credit that we did but yeah no I don’t but um I do think that’s a really good point the use of templates is is great particularly if you’ve got large volume samples a lot coming through that you have to read very quickly rather than getting the calipers out um is a really good idea but no Jean are you aware of of any I’m afraid I’m a bit useless on that question no we just uh use just the calipers and just you know record things manually you know so it’s quite oldfashioned really but I think it would be a good idea to to have some sort of electronic way of of uh reporting resistance obviously with something like Phoenix it’s all it’s all done for you already in the machine it’s sort of integrated but with the the disk testing um I don’t know of any system that’s actually used I mean they there I mean there are if you’ve got automated systems um like the wasp Copan for example or the KRA they they can there are methods you can do it for you but if in the lab you’re you’re doing dis diffusion yourself without automated methods I I I do think from a um productivity and efficiency point of view the templates are a really good way to do it um I think we probably would just need to find out this is probably a question I can ask my lab manager um what what we use because we do use them we use for a lot of direct susceptibility testing from blood cultures and it is it’s a nice quick way of doing it which is also fairly standardized as well there’s a little bit of of user interpretation isn’t there or limitation in it but for doing lots of those tests quickly if you don’t have access to these automated readers which a lot of people you know don’t use we don’t use them here currently and we just use templates and I think that’s a very good approach in the lab for dis diffusion testing so thank you so much I think we’ll have to wrap up there bang on time so um that just leads me to say a big thank you to our speakers Dr Gina Driscoll and Dr Lis Sweeny um thank you to our CPA colleagues and particularly CLA brandish who is our technical lead for the microbiology workstream and our colleagues at that and other Affiliates including Department of Health and flaming fund for their ongoing support for the CW pams program um thank you all for joining and also to page medical for tech support to facilitate these webinars um our next webinar will be on one Health and substandard falsified medicines in January so please keep an eye out for the invitation and we hope to see you all there thanks so much [Music] the Commonwealth pharmacist Association and the tropical health and education trust are pleased to announce the second round of grants for the Commonwealth Partnerships for microbal stewardship CW Palms to program funded by the UK Department of Health and Social care slaming fund the program will run from April 2023 to December 2024 and aims to develop new Partnerships as well as building on the success of established Partners encouraging sustainability and sharing of best practices through the development of in country hubs the projects are implemented by Health Partnerships between Healthcare institutions in eight African countries Ghana Kenya Malawi Nigeria C Leon Tanzania Uganda and Zambia and NHS and academic institutions byuk the increasing burden of Mr calls for more efforts to address the challenge and its consequences according to the gram report released in 2022 4.95 million deaths were associated with bacterial Mr in 2019 and 1.27 million deaths were directly linked to bacterial Mr the CW Pals program has proven effective in strengthening the capacity of the health work for some institions in Africa to address MRI challenges and creating opportunities for bir directional learning between institutions in the UK and Africa among other achievements the program facilitated over 6,500 lmic of care Staffing and microbial stewardship and infection prevention and control between 2019 and 2022 the second phase CW PS 2 aims to build on the success of the first space working with 24 Health Partnerships the program will focus on improving antimicrobial stewardship including surveillance building antimicrobial Pharmacy experties and capacity enhancing infection prevention and control improving the use of clinical microbiology and antimicrobial prescribing data to inform clinical decisions and encing the detection and reporting of sub substandard and falsified antimicrobial medicines supporting Community Pharmacy one of the ways we are doing this is by being in partnership with the exchange exchange an organization building Global health behavior science capacity by connecting health psychologist with health Partnerships we are exploring what behaviors are needed to change and what the the drivers and barriers of these behaviors are this partnership also assists with supporting intervention devopment to address these identified drivers and barriers and developing monitoring and evaluation tools to enable CW P’s Partnerships to understand what is changing why and how to achieve this we are excited to be supporting the delivery of the variety of projects in including supporting the development of antimicrobial stewardship Network to share learning and building capacity in antimicrobial stewardship in Ghana Mala Wells Pharmacy antimicrobial stewardship project Kaka Cambridge Health Partnership Kaka Country Center of Excellence in an microbial stewardship in Kenya strengthen Ms activities and establish a hub for quality control of antimicrobial medications at University of Nigeria teaching Hospital oala State Nigeria Cambridge at microbial stewardship in infection prevention in Uganda strengthening Ms atola teaching Hospital in Zambia strengthening Pharmacy leadership ship what M to ship and [Music] see
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