Gavin Barlow [Educator]

Gavin Barlow [Educator]

Gavin has been a consultant/hon. senior lecturer since 2004. Gavin’s main clinical interests are antimicrobial stewardship, orthopaedic infection, OPAT and complex bacterial infection.

Location I work at a 1400 bed two-site teaching hospital trust in Kingston-upon-Hull (aka 'ull) on the east coast of the UK. We do everything except transplantation and I have led the antimicrobial stewardship programme since 2005.

Activity

  • I hope you found the week useful - you will find future weeks will go into a bit more detail on specific areas of stewardship - enjoy!

  • How broad-spectrum any antibiotic is is relative to your local microbial epidemiology. In the UK, tetracyclines retain favourable activity against many Gram positive and respiratory bacteria, but are much less reliable against Gram negatives. They do appear to be relatively low risk for CDI - See this open access paper which has a very nice graph on the risk...

  • You can also watch the Hangout Mark and I did for the last run, which you may or may not find useful - https://www.futurelearn.com/courses/antimicrobial-stewardship/3/steps/96282

  • Thanks for all the posts - great to see so many emphasising the team approach - I think it's important we 'see' antibiotic prescriptions as being longitudinal with a beginning, middle and end (rather than one-off events) with doctors, pharmacists, nurses, patients and others contributing at various stages.

  • I agree Dennis - thanks for that.

  • Bars show the average difference in how good restrictive interventions were versus persuasive @ changing antibiotic prescribing (blue) & reducing the microbe of concern (red) at various times after starting interventions. The more above the axis the bar is the better restrictive interventions were. The more below the axis, the better persuasive were. The black...

  • Thanks for your many posts on this learners - really interesting - we should definitely aim to protect patients, antibiotics and the public!

  • Look out for the word cloud next week learners and discuss!

  • Yes I agree about the medical director being very active on stewardship - my own experience is that this was vital in 'kick-starting' our own programme over a decade ago now!

  • I really like "vibrant" too Sue - I think teams should aim for a positive approach whenever possible - even restrictive interventions can be presented positively!

  • I think this is a very tricky problem Frances with no easy answers, but I've always believed enthusiasm is much more important than expertise so if you can manage to identify/persuade a few enthusiasts locally to work with you then you have a chance to do something and make an impact even if you start very small and highly focused. See also my post in 2.17.

  • Hi Frances - I think with limited resources stewardship is very tricky, but I would encourage you to start small by, for example, identifying one key stewardship related problem locally (this could be education as Lesley suggests, but there may be other 'targets' too) - personally I would probably target something you can easily measure initially and use that...

  • Thanks Lesley - I like that too and may use it!

  • I think you touch on a very important global problem Frances without an easy answer - access to effective/appropriate therapy is the key issue in many low/middle income countries, which is something the UN have recognised this week.

  • Thanks Abraham - We too run an 'ALERT' antibiotic system - the following antibiotics can only be prescribed after microbiology or ID approval locally: azithromycin, aztreonam, chloramphenicol, ceftazidime, cefuroxime, ceftriaxone, cefotaxime, ceftolozane/tazobactam, ertapenem, fidaxomicin, fosfomycin, linezolid, meropenem, moxifloxacin, ofloxacin,...

  • Good luck with that David - I hope the course helps.

  • Thanks for all your posts - personally I think the language of stewardship is likely to be important - much of what we use at the moment feels like jargon to me with a limited chance of public understanding and perhaps only a moderate chance of professional understanding! Having said that, I certainly do not have the answers on this, but I think we do need to...

  • Thanks for all your posts - we usually post the word cloud at the end of the week or in week 3 so you should be able to see (and debate) what the final consensus is!

  • Just to point out to learners that it is the principle of low hanging fruit that is important here (i.e. start small with something 'easy' and be highly focused) not necessarily the actual interventions in the paper, which are USA orientated - interventions and how one implements them should be locality dependent - what works in one environment will not...

  • It is for me Aoife, but try this if it isn't for you: http://cid.oxfordjournals.org/content/early/2012/06/07/cid.cis494.full

  • Thanks Lesley for your excellent post - I'm not a microbiologist myself (ID/GIM), but completely agree with the above which are along the same lines as our own lab. For sensitive pathogens from 'good' specimens our local lab usually releases no more than two sensitivities (e.g. trimethoprim and nitrofurantoin for an E. coli from urine which is consistent with...

  • Great to see people emphasising the importance of the multidisciplinary approach although important to ensure this doesn't get in the way of rapid appropriate therapy for patients with life-threatening infection.

  • Definitely agree David that technology has a key role where available with many UK hospitals already using apps such as MicroGuide. This will undoubtedly evolve.

  • 'Wonder-mycin' - I like that!

  • Thanks Frances - you rightly highlight the need for the whole healthcare economy from primary care to the hospital to work together on stewardship, challenging as that is.

  • Great answer Jessica. Thanks for your post.

  • Thanks for your many insightful and impressively succinct posts - glad to see some emphasising the importance of involving the patient.

  • Thanks for taking the time to make the detailed posts below, which will be really useful to other course participants. Detailed analysis and understanding of the problems are key components of antibiotic stewardship. You can also look back at prior runs of this course to read what others have thought.

  • Great to see so many of you joining the discussion already. Mark and I are aware of the diversity of environments you are likely to be working in and also the range of experiences you will all bring to the course and this week. The week is very much a foundation or framework up on which, hopefully, you can build in the weeks to come. The course is set at...

  • Bars show the average difference in how good restrictive interventions were versus persuasive @ changing antibiotic prescribing (blue) & reducing the microbe of concern (red) at various times after starting interventions. The more above the axis the bar is the better restrictive interventions were. The more below the axis, the better persuasive were. The black...

  • The list of adverse effects of all antibiotics is long Ivy and some are certainly worrying. Metronidazole in my experience is probably one of the safer antimicrobials we commomly use especially when used as prophylaxis (usually less than 24 hours and often just one dose) and in short course therapy. One does need to monitor if prolonged use is planned.

  • That would be a long post! But I will give you an idea of how we use. In upper limb orthopaedics we use flucloxacillin only whereas in lower limb we use flucloxacillin plus gentamicin. In abdominal/pelvic we mostly use co-amoxiclav plus metronidazole. The teicoplanin with or without gentamicin (and sometimes metronidazole) depending on the procedure is for...

  • Apologies for this - probably a technical issue - it was made and I'm sure will arrive early next week so please do look back! Cheers, Gavin.

  • You make an excellent point Linda - I think there is a growing recognition this is an important area and I have seen one or two papers discussing this, but at the end of the day, as you say, it is all about having that open/honest discussion with the patient/relatives that is key.

  • I should point out that in the UK we don't have/use cefazolin (not sure why!), but I agree there is quite a bit of evidence to support its use for prophylaxis and given its spectrum of activity is less than the later cephalosporins I suspect the ecological impact is lower. In the UK, the excessive use of cefuroxime, ceftriaxone and cefotaxime was strongly...

  • I mentioned in a previous post that we have a 'heterogeneous' treatment guideline so our guideline predominantly recommends from benzylpenicillin, amoxicillin, flucloxacillin, co-amoxiclav, metronidazole, clarithromycin, doxycycline, trimethoprim, co-trimoxazole, teicoplanin and/or gentamicin for patients with mild to moderate infection across a range of...

  • You raise the cephalosporin debate - this is a rather UK centric view, but many hospitals have limited their use because of C. difficile in favour of other agents hence the disagreement with some guidelines. In my own organisation we use hardly any cephalosporins for either prophylaxis or therapy now.

  • Yes both very useful resources which I consult occasionally myself, but important to remember, as with all guidance, that it is orientated towards the writer's environment - in this case North America.

  • Thanks - perhaps the lack of guideline in your institution is a good starting point/focus for stewardship - one might say a low-hanging fruit - see later step!

  • Thanks for all your posts on this - Personally I think the language of stewardship is important, but has been somwhat neglected, and should be positive, simple and with clear meaning - we perhaps need more research on the optimum language to use in for example effecting behaviour change.

  • Thanks for all your thoughts on this.

  • Just to point out to that it is the principle of low-hanging fruit that Mark and I think is useful, not necessarily the interventions suggested in the paper, which may or may not be relevant to your environment - the fruit will likely be different from organisation to organisation, depend on what your targetted stewardship outcomes are and also where you are...

  • You are welcome.

  • Interesting questions. 1) One of my colleagues uses oral methenamine which acidifies the urine in patients with recurrent UTI, but the evidence is weak. 2) Where I work we use co-trimoxazole quite a bit for UTI and some other indications. Not sure about iodine washes though! As you may know povidine iodine has been shown to be inferior to chlorhexidine/alcohol...

  • That's a good question. In fact in my own hospital the Medical Director gave permission for unsolicited infection consultations including making changes (not just suggesting) to therapy some years ago which means we over-ride all the time. Interestingly, we never get any complaints about clinician autonomy on this - it is now accepted and in fact welcomed.

  • Thanks for your excellent contributions Giuseppe.

  • I think you highlight a major problem Sameh - the concept that some doctors have that broad-spectrum agents are the "best drug" compared to narrow-spectrum agents for bacteria that are sensitive to both - this concept is clearly erroneous, but tricky to eradicate!

  • Thanks for sharing all your ideas on this. You might want to have a look at the Google hangout Mark and I did for our first run of this MOOC last year in which we talk about how we first started our respective stewardship programmes amongst other things https://youtu.be/CNDAZ66zJ2g We'll be doing another hangout tomorrow so get your questions in!

  • Thanks Jose - I agree it's all about diagnosis, diagnosis, diagnosis and I think in the age of molecular medicine and CT/MRI/PET we have perhaps become lazy and deskilled at the basics. We should remember physiological assessment too in parallel I think.

  • I think you touch on a great point Rella - the challenge of the patient in front of us versus the wider interests of public health - not easy to resolve, but infection specialists in particular have a leadership responsibility in this area - personally I find paying particular attention to diagnosis and physiological assessment (how ill is this patient?) and...

  • Fantastic to read all your thoughts and perspectives on this.

  • I agree Farrah about the importance of community based stewardship - hospitals and primary care, doctors and veterinarians all need to integrate and work together on this - tricky in day to day practice.

  • I agree - stewardship is definitely more about controlling the situation than dealing with the underlying problem of resistance, which has always been there and probably always will be. Interesting that you should mention uniform prescribing - in my own hospital we have moved (about 3 years ago) to a much more heterogeneous antimicrobial guidance than...

  • Really good comments here - my work is done!

  • I really like this video too - Great job Mount Sinai

  • Great to see so many interesting posts and you responding to each other - I think this is perhaps the most important aspect of this course - the sharing of ideas and experiences so please post away and respond to each other! I know Mark and I always enjoy reading (as many as we can!), learn from and ascertain ideas from learners posts.

  • Agree - Antibiotic prophylaxis is not required for clean surgery (minor or major) unless there is clear high-quality research evidence to the contrary.

  • No - use in animals and other settings under the 'One Health' approach is important too - see my post about BSAC's recent statement on the use of antibiotics in humans and animals.

  • Completely agree - This is why some hospitals have integrated fully or partly both the IP&C and AS teams or at the very least the two teams should work closely together in day-to-day practice.

  • Hopefully you should get something out of week 5 Jonathan, which covers this area.

  • You may be interested in the British Society for Antimicrobial Chemotherapy's (BSAC) recent call for global measures to prevent the overuse of antibiotics in people and animals, which can be accessed via http://www.bsac.org.uk/bsac-calls-for-global-measures-to-prevent-the-overuse-of-antibiotics-in-people-and-animals/ The BSAC website is also a very useful...

  • Yes certainly in some countries this can contribute - low concentrations (than expected) of antibiotics can certainly facilitate resistance and of course may not fully treat the targetted infection, presuming an antibiotic is required in the first place. So robust regulatory pathways, whilst maintaining access for those in need, are important.

  • Many thanks for all your excellent questions so far - Mark and I will do our best to address some of these on Thursday and some will also be addressed as you go through the course. I hope you enjoy week 2 and please leave comments as both Mark and I and, more importantly, other learners will be informed by your own ideas and experiences to date.

  • Yes you could do that, but oral cefuroxime (if I remember correctly!) has poor oral bioavailability so lots will remain in the GI tract and this will promote resistance and C. difficile so from a stewardship point of view may not be the best switch strategy. If you have + microbiology and sensitivities to help the switch then I would always aim to switch to...

  • Thanks Shabber - great question - for me, it depends on the infection one is treating, whether there are any positive microbiological tests and what IV agent is currently prescribed (many IV agents as you know do not have an oral equivalent). Other factors such as oral bioavailability sometimes influence me - I do a lot of orthopaedic infection and use IV...

  • Yes hard to believe and we compared well to some other UK hospitals!! Ten years on and we have less in a year than we did in a month back then (3-5/month on average now). What has changed? Well, we prescribe less overall and far less cephalosporins and fluoroquinolones - more recently we've also made our antibiotic guidelines more heterogenous with, for...

  • Great to read your (very) interesting posts and your responses to one another - I'm sure you will learn from each other and Mark and I will learn from you. Many thanks.

  • Thanks Keith - That was really to make a point about 'empowering' the patient so that, for example, they feel comfortable to question when things don't feel right. We could probably do better on public education about antimicrobial resistance too I think.

  • Really interesting to see your responses as a word cloud and compare to our previous run in October - looks like broad/narrow antibiotics, hand-washing, cultures, IV to oral switch, sepsis and resistance are all strong themes.

  • Fantastic to see so many posts on this step now - Thanks learners. Please feel free to respond to each other in order to share your experiences and best practice and generate new ideas.

  • Antibiotic "conservation" - I really like that Sarah - Another more positive word for the stewardship vocabulary.

  • Thanks for all your posts learners - really interesting to read your thoughts and experiences.

  • Thanks Lisa - yes I agree - patient involvement needs to improve and arguably antibiotic stewardship committees should have patient representation.

  • I agree Joanne - accessibility is really important - many hospitals are now using apps - See http://www.horizonsp.co.uk/app-microguide.html as an example - I agree about the phone hygiene issue but realistically I doubt we can do much about that other than to promote hand hygiene before/after all patient contacts. We also have laminated posters on all wards.

  • I see the term "reserved" is being discussed. Perhaps a new antibiotic stewardship vocabulary is being created as we speak!

  • Yes I agree - Undergraduate courses have not done enough to address stewardship. If we embed the habit of appropriate prescribing early then it sticks for life (as do bad habits of course!).