“Protect your good bacteria” a comic proposal from Med Student Educational Module

So, this is what happens if you set a Medical Student the task of creating something that communicates an important message in how antibiotics are used….

Slide1

(And if you’re interested – this isn’t just a fart joke…it’s an evidence-based piece of targeted work!

Poster presented FIS conference, Glasgow, 2015

For the literature behind the comic, read on…)

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Antimicrobial Resistance – Links to papers /resources

*** For any stewardship/education sessions – this post will serve as a resource for links to the evidence quoted- I’ll try and keep it up-to-date as I can***

“Hi, I’d really like an overview on where we are with antibiotic resistance!”  – recommend the CDC overview- colorful, diagramatic, comprehensive

“Hi, tell me about Carbapenem-Resistant Enterobacteriaceae (CRE)  and why everyone thinks this is seriously bad stuff” – great review in the Mayo Clinic Proceedings – Vasoo et al 2015

****Selection and transmission of resistance*****

Sub-lethal doses of antibiotic can select for resistance (eg wastewater…)  Gulberg  2011
Sublethal doses of biocide can select for resistance Forbes 2014
Resistance spread by the bacteriophage network – Modi 2013
Rapid spread of carbapenem resistance between multiple species (Klebsiella, Enterobacter, Serratia, E.coli… )  caused by jump of plasmid to multiple species – Mathers 2011, Conlan 2012 and  then jumping to high-fitness strains, evolving and spreading further.
Nepal MDR Klebsiella outbreak featuring horizontal gene transfer –Chung 2015
Antibiotic levels in wastewater above serum therapeutic levels –Larsson 2007
The widely-quoted correlation between antibiotic use on a population level and antibiotic resistance –Albrich 2004
Antibiotic resistance genes in cave microbiome Bhullar 2012
Is there a link between resistance in food-animals and resistance in humans? Examples:
Lazarus2015 Systematic review– plenty of studies saying probably, yes
More under the cut….

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Reflections from the front line: why doctors don’t listen to the ‘impending doom’ of antibiotic resistance

Using antibiotics to treat ‘medical uncertainty’, the ethics of patient vs population, and why the acute physician yawns every time you start talking Doomsday, up at Reflections on Infection Prevention and Control here!

Also highly recommend a great blog by Tom Lewis on using information to change minds, rather than just telling them what to do here  – Cognitive dissonance, and turning evidence into behaviour change in antibiotic stewardship.

ECCMID in a couple of hours!

“So I couldn’t go to ECCMID – what should I catch up on?”

If you didn’t manage to get to ECCMID this year at Copenhagen, this is designed to point you in the direction of a few of the outstanding talks I attended, or heard about. I was ‘on-call’ for my group, so the content very much represents their interests- resistance, genomics, microbiomes and oh yes more resistance…   Links to the ECCMID Live presentations included – a fabulous resource- kudos ECCMID!  Again, I’ve tried to be as accurate as I can, but please tell me if I’ve messed up attributions, names, science etc. – no co-authors or reviewers on this blog…

This isn’t in any particular order, in fact I’ve put the most important theme clinically (resistance) last, mainly as clinically it sort of dwarfs anything you say after it, even it is very relevant. Rather like telling someone that a tsunami is coming in 10 minutes to destroy us all, but in good news they’ve just managed to make the tsunami early-warning system 10% more reliable… but onwards…

THEME 1 – GENOMICS – Not ‘Coming Soon’ to Clinical Care – but ‘Advance previews already in theatres – general release imminent’

THEME 2 – MICROBIOMES – Witnessing a paradigm shift in human/bacterial ecology

THEME 3 – ANTIBIOTIC STEWARDSHIP – Its about hearts and minds and measuring your outcomes, however messy they may be

THEME 4 – RESISTANCE- superplasmids, super-everything, super-everywhere

continued….

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ECCMID Day 4 Roundup – Genomics and Microbiomes are here for clinical care

**Standard disclaimer: these are my notes taken during the sessions, as accurate as I can make them, please let me know if any inaccuracies. I’m putting them here as others have said they found them useful. However worth re-checking anything before you re-quote it. If this continues to be useful, I’ll continue. If it’s clear i’m not reaching the standards of accuracy I’m aiming for, I’ll review future posting plans.**

Final day at ECCMID! There was a very high quality Microbiome session, with two outstanding talks from the speakers, as overviews on the applications of microbiome research – highly recommended viewing and links below.

The massive highlight of the genomics session for me was a presentation by one of our collaborators – Phelim Bradley presenting the work done in the Iqbal group and Mykrobe – a tool that uses WGS data to predict antibiotic resistance. I’ll be right up and admit I work with these chaps, and I don’t want to appear biased, but I can only say that the first time I saw this working a few weeks ago I went Oh My GOD…

As fundamentally a clinician taking a ride in the fun world of genomics, this is the first time I’ve seen something involving genomic analysis I can see myself using on the ward. The user interface looked straight out of Apple & something I could teach my granny (/my senior much-respected Consultant population) how to use.  And validated on over 1000 Staph. aureus samples,  with major and very major error rates <1% compared with culture phenotype. TB and Gram-neg versions also developed. For any clinician agnostic about whether WGS is ready for direct use in patient treatment, the link for the 10 min presentation available at  ECCMID live : here  ( -worth a look even if you just skip to the demo!)

Updated: for a view of the  granny-friendly Apple-esque look – slides up at slideshare:

(ok maybe not granny, unless she’s a Microbiologically-literate elder, but given I’ve spent the last year in a field where people tell you they’ve written a really user-friendly genomic analysis interface which is super easy to use with just basic python scripting – I’m very grateful to any bioinformaticians who consider the intended end-user of their product… )

A very good question from the audience – given cost of sequencing and current times taken to extract DNA/analyse  –  how can it be used to treat patients (and what benefits over current clinical workflow). Agree – for that reason, I think at the present moment in time for routine diagnostics, in Staph. aureus it certainly would be hard to justify. But given TB takes weeks/months to phenotype, and the cost of sequencing is going down (and nanopore is looking increasingly promising…) incredibly exciting times.

Previous sessions posited that the use of WGS in day-to-day clinical practice was probably a few years away, and also suggested a key challenge is presenting WGS analysis in a way that can be used by non-specialists. The Mykrobe presentation suggested that perhaps we’re really much closer than previously thought…

Rest of the summaries  below.

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ECCMID Day 3 – Oh no, not more MDROs!

**Standard disclaimer: these are my notes taken during the sessions, as accurate as I can make them, please let me know if any inaccuracies. I’m putting them here as others have said they found them useful. However worth re-checking anything before you re-quote it. If this continues to be useful, I’ll continue. If it’s clear i’m not reaching the standards of accuracy I’m aiming for, I’ll review future posting plans.**

Take home message for me today – screening for carriage of Carbapenem-Resistant Enterobacteriaceae isn’t as easy as you might think/I thought/I hoped…

Some data presented suggesting CRE screening using culture alone may miss a lot of carbapenemase carriers that PCR can detect. Truly worrying for those using culture-based detection to stop transmission of resistance elements.

John Otter from St Marys, London  who has previously written about it: http://www.micro-blog.info/2015/03/cre-diagnosis-current-status/ had a poster where they  screened 816  admissions to a UK teaching hospitals with rectal swabs – found a very low carriage rate of CRE identified by culture (0.1%) but a considerably higher rate by PCR (2%)

http://eccmid.meetingexpert.net/ECCMID_546/poster_125278/program.aspx

There was also a very interesting study quoted on respiratory microbiome – where depleting the microbiome of mice with multiple antibiotics (poor mice!) appeared to be bad when they subsequently gave them Strep. pneumoniae pneumonia (it really is rubbish to be a mouse!) . More died, more lung inflammation  and the alveolar macrophages were bad at phagocytosing.  The respiratory microbiome appeared protective either at maintaining immune function or colonisation resistance or something else. Needs validation in clinical setting, but good message for the ‘don’t take antibiotics for viral infections just in case’ interventions if true.

The talk on the vaginal microbiome was hilarious. Was with one of my male colleagues who admitted  it made him Rather Uncomfortable. Especially when the presenter said that the best way to resolve recurrent bacterial vaginosis is circumcision of the partner. Drastic.

More below:

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ECCMID Day 2: I can’t believe it’s more MDRs

**Standard disclaimer: these are my notes taken during the sessions, as accurate as I can make them, please let me know if any inaccuracies. I’m putting them here as others have said they found them useful. However worth re-checking anything before you re-quote it. If this continues to be useful, I’ll continue. If it’s clear i’m not reaching the standards of accuracy I’m aiming for, I’ll review future posting plans.**

More of the same – mainly a report back on the MDRO sessions again,  especially some good looks at the wider picture and environmental/animal carriage.  If you want to  read two abstracts on MDROs I highly suggest two companion studies by the Tim Walsh group on `ESBLs and  carbapenem-resistance in Karachi  (90% faecal/site of infection swabs contain of CTX-M-15 ESBL beta-lactamase, approaching 50% NDM1 ).  And the accompanying environmental study sampling bugs, bird droppings, water, basically showing that this is everywhere.

http://eccmid.meetingexpert.net/ECCMID_546/poster_124965/program.aspx

http://eccmid.meetingexpert.net/ECCMID_546/poster_122365/program.aspx/anchor122365

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