Q & A with Professor Dilip Nathwani

Hello, everyone. Welcome to the end of the first week. It’s very hard to believe. This journey for me and the team has been more than a two-year journey from the ambition and the vision we created around how to produce something different that is truly interactive and engaging to the people that we want to learn with. And I’m very happy to be here. I think many of you have very enthusiastically engaged with us. You have posted a very large number of comments, which I hope we shared and we learned from. But you’ve also posted a large number of questions.

What I’ve tried to do over this week with my three other colleagues, David Jenkins, Mike Cooper, and Neil Woodford is try to answer your specific questions. But I think you’ll appreciate that on many occasions, some of the questions that you’ve asked are perhaps not entirely relevant to the context of the stewardship programme. For example, there are many questions that are related to daily clinical decision making and clinical decision practise. I applaud you for that, because this is what I do on a daily basis. But unfortunately, within the remit of what we’re given in terms of learning about stewardship, we’re not able to answer those questions.

So what I would suggest in these situations is that this is something that when we collectively come together at the end of the course is if there are enough of these questions, we’re actually thinking about perhaps the need for an additional educational resource that will allow you to think about how we manage clinical decision making process, for example, in a resource-limited setting, perhaps in a resource-rich setting, but also in areas where the levels of resistance are high and in areas where the levels of resistance are low. And we also perhaps need to think about how the team is involved in this overall decision-making process. So thank you very much for your comments. We have not ignored them.

And these will inspire us to go and do something more. But I would also then like to go on to say is that we also sense that you’re asking for a lot of information that you would find useful but perhaps is not directly related to week one. So I urge you to actually be patient. We’ve also just very recently posted the skeletal structure of what weeks two to week six will cover. And that will allow you to understand that if there’s a question related that you have, it actually may be covered in weeks three to week four to week five.

So please be cognizant of that because we will be addressing many of the questions that you’re posting in week one. However, if there are questions that are not related to that, what I’m very pleased to announce is the launch of the BSAC supported antimicrobial resource centre. Sally Bradley, our facilitator, has posted the link to ARC, or “arc,” at the end of this week. And what it will allow you to do– it’s a wonderful repository of PDFs, PowerPoints, videos, guidelines that will help you understand and inform many of the questions. But we wanted to be an evolving and dynamic website.

So what we also ask you is that you may use it for your own information, but if you actually have good resources that you think will help the understanding and learning around this subject, then we ask you to send this to us. We will have a quality assurance process. And if we think it’s appropriate and relevant, we will house it on this antimicrobial resource centre, which will then over time, will become a living repository, a rich, diverse repository of information and needs. Now let me come to the specific questions that you’ve posted. As you can imagine, there are so many questions that I– really, time would not allow me to be able to answer them.

I and my colleagues and Sally have tried very hard to address many of the questions by directly posting them, particularly from days two, three, and four. But what I aim to do today and now, over the next five to 10 minutes, is perhaps take six or seven thematic areas that you seem to be asking questions about and try to address them. I’ve already addressed the question about how one makes the clinical decision making process about what antibiotic to prescribe, what to expect from microbiology, when to deescalate, when to convince clinicians for stopping an antibiotic. And I’m suggesting that we actually may develop some specific resource to that kind of clinical decision making process in a different range of settings.

So I hope that you find that that’s something that we will do of interest. The second bit is that you’re asking about specific populations and stewardship needs. I’ve seen questions, for example, about immunocompromised patients. I remember a wonderful question about a patient with myeloma– no not myeloma, with splenectomy– who died or became very unwell with a pneumococcal infection. We have patients with cancer. We have neonatal infections. We have elderly patients. We have patients in long-term care facilities. And from the onset of our ambition, we’ve been very clear that this MOOC is the beginning of the journey.

And we perhaps will want to develop, maybe not a MOOC, but online resources that will look at the fundamentals, the principles, and the mechanics of stewardship in a range of these special settings. And I hope that you will continue to engage with that particular activity. And there’s clearly demand by the number of questions that you are posting. One of the other perhaps fundamental themes that is coming out from your questions is about how we respond to the overall agenda of antimicrobial resistance. And I think perhaps we should have made that much more clear at the onset of this MOOC. Antimicrobial resistance has essentially three solutions that we’re trying to address. One is infection control and prevention.

And I am so pleased that there’s so many infection prevention and control practitioners engaging with us, wanting to know about us. And believe me, we’re not undermining the importance of infection control and infection prevention, because it is a key strategy to reducing resistance and the transmission of resistant pathogens. The second is developing new drugs– the constant dilemma around preservation, which is stewardship, and innovation, which is new drugs. And again, it is not the remit of this MOOC. I’ve given you a range or directed you at least to a range of resources, the most wonderful one being the very recently published matter of two weeks ago of the report on the world of antibiotics in 2015.

It’ll talk about many of the issues in related to new drug discovery. So again, go ahead and read that report to address many of the questions that you’ve been asking. The third and important solution to antimicrobial resistance is preserving what we’ve got. We are a human race that has a tendency to deplete and abuse the wonderful resource that this planet has in terms of fossil fuels, in terms of water, in terms of green plantation. And antibiotics, that’s a resource that’s been given to us by a generation between from 1940s to 1990s. And we’re in a scenario that we’ve abused these wonderful agents and are now causing us problems. So this is at the heart of this MOOC.

But you also ask questions about the involvement of the use of antibiotics in livestock, in companion animals, in horticulture, in fisheries, in the waters and pollution of our waters with chemicals that contain antibiotics. And that signifies this one health, one world approach that we have to antimicrobial resistance. And I would encourage you to engage with that. And there’s a huge body of literature out there that will explain many of the things that are being done at the global, regional, and national level to address these problems. Finally, and perhaps the most importantly, many of you are asking specific questions about the availability of guidance, of policy, of good clinical practise.

And again, as I said earlier, that we hope that we will with the use of the antimicrobial resource centre, with the material that we’ve posted from this MOOC will be available on the antimicrobial resource centre. And over time we will have a community in which we will share much of this and I think obviously to depend on you to contextualise the relevance of the guidance and the policies that people have produced to your practise and to your health care setting. So I think in summary, it’s been now my pleasure. It’s been a wonderful week. And I have to say that as a clinician of many, many years, I have learned probably more than I have actually given.

Your questions have really stretched me, and I suspect my colleagues, into thinking about things that we don’t routinely think about. So thank you so much for that. Because for us, it’s been as much of a learning experience as I hope it’s been for you. Now, I also understand that many of you are from non-health-care professionals. And some of you work in perhaps some of the most challenging parts of the world. And I truly admire your ambition to be involved in this MOOC. You have asked fantastic questions. It must be very difficult to understand some of the jargon that we talk about when we come into a specialist area. And we are continuing to update our glossary.

Sally and I are trying very hard to make sure that some of these abbreviations– that you understand. So keep your comments coming. But also for those of you who are non-health-care professionals– some of you are in the public. Some of you are doing other things but interested in this area. I understand some of the technical language is difficult. But may I say to you, that if you want to understand about systems, organisational change, how you make implementation of care and process more effective. How do you measure the impact of what you want to do? How do you measure any unintended consequences? Because enthusiastically, we often do things we think is going to bring about a benefit.

But in certain systems it actually may have an unintended consequence, and we need to be cognizant of that, and we need to be able to actually evaluate that. How do you then share information? How do we influence change? How do we bring about behaviour change? And how do we learn from fantastic examples of success stories from across the world in different settings? And to me, who is very passionate about this subject, one of the key, true litmus tests for change is has that intervention been sustainable or durable? And I challenge you to find many examples of interventions that are durable and sustainable. Because at the end of the day, that’s what we want to do.

So not only the current generation of the public and patients, but future generation of public and patients would benefit from interventions. And for those of you at my age in their life, I may become or will definitely become a patient in the fullness of time. So I think that we need to be aware about sustainability and durability. So for all of you, well done. Keep going. And I think that weeks two to six are even going to be much more of a treat than you’ve been obliged to take part in so far. So thank you very much, and I hope that you enjoy the rest of course.