I am a doctor with 25+ years of interest and experience in improving the use of antibiotics. Through better education, to promote better patient management and treatment.

Location I am a Infectious disease physician and Honorary Professor of Infection based at Ninewells Hospital and Medical School in Dundee, Scotland, UK.


  • Dear all,
    My apologies for not responding during week 1- this was due to some access difficulties. Hope you enjoyed the scene setting. Now you get into the details of antibiotic preservation /stewardship. The recent landmark UN resolution has given all countries 2 years to come up with a framework and action on key aspects of fighting AMR. Education and...

  • I have scanned many of your responses and occasionally commented; you are along the right direction and are identifying many of the things that were suboptimal here; we hope to come back to many of them and use them as a stimulus to help us think how we could do better and the science that supports this
    Keep up the great start- your learning journey has just...

  • What a high quality response; you have most of the key points we wishes for you to think about

  • Our problem is we have been less successful in the hospital

  • Actually, in the UK, there are fantastic protocols for prescribing and our increasing evidence is that GP's are doing very well in following this as antibiotic prescribing rates are coming down !

  • The challenging bit is how do we get professionals to adhere to guidance etc
    This will be discussed in more detail in week 5; critical to better implementation

  • Yep, all relevant.

  • Dear all
    Thanks for joining our course; in keeping with previous ones we continue to attract a diverse range of people, disciplines and countries. We hope you find our course helpful; your feedback in very important to us as we strive to improve and be relevant to your needs. good luck and keep up the hard work !!

  • just completed indian survey of stewardship education needs; interesting findings

  • welcome; much being done in veterinary amr now under the one world agenda; ours is entirely human focused but hope you find it helpful

  • Thank you for joining; we sincerely hope you enjoy this course
    keen to hear of your feedback

  • You certainly have a major problem but lots of good work in stewardship coming from south africa; refer you to the work of SAASP ; WELCOME

  • Welcome; first from lesotho; very commendable of you and hope we can work closely together with all our partners

  • Hello Gloria
    Thanks; as i said our programme is hospital focused; we do plan in the future to include community practice but there is much generic learning here also which i hope you find helpful
    please enjoy the course

  • Thank you for joining Esra- hope you find it helpful; week 6 share experience from less resource rich countries which i hope you find relevant; we do plan to evolve our course so it reflect broad needs of our participants; keen to from you and all others through feedback

  • Hi kirsty
    thanks for your interest; you may find this perhaps hospital focused but much generic learning also; suggest also go to SAPG website for scotland stewardship ; welcome and enjoy !

  • Hello
    Thanks for joining; there is a stewardship component to the semmeweis foundation confrence in march 2017 in budapest- you should check it out
    enjoy the course

  • welcome; we have lots of collaborations with australia; you guys are doing great work in stewardship; hope you enjoy the course

  • welcome
    we are participating in the ICAN africa meeting in joburg in september; looking particularly at role of nurses in stewardship in Africa

  • Welcome to our course; delighted to see this in germany- we will certainly look at this; enjoy the course and hope you find it helpful

  • see my comments above

  • How true Nyawira. I believe it is hightime the infection community stops agreeing what needs to be done within their own field, because we know, but engage with the clincians. I think 2 papers are a must read: refs :L Charani et al BMJ Quality Saf 2013; ):1-3 & JAC Rawson et al 2016; 71(2): 554-9; it talks wider and crosss specialty engagement

  • Thanks to all. I have seen more repsonses and they are alligned to what you will learn more about in the subsequent weeks. Thank you all for your discussions and enjoy the rest of the course.
    Look forward to reading more of your interactions with other participants and of course the educators.

    Welcome to week 2 .

  • Agree but more complex than what you outline. Weeks 2,3 and 5 will be valuable here

  • Agree, but not as easy to implement as you thhink; week 5 you will learn more

  • Thank you all for your comments. The scenation not only resonates with many of you but your are identifying the issues- exactly what we wanted and some of oyu are raising important additional questions that are relevant to the healtrcare setting, resource and geography you live or work in. We find these very instructive.

  • Good to see many of you discussing; looking forward to hearing from others

  • all very relevant concepts and need for the "one health approach"

  • Communication is fundamental; if you go to the Health Foundation uk website they have a paper and guidance on effective communication ; very relevant to stewardship and worth considering

  • I am pleased to see you are posting and responding ;the range of views is great and a basis for what we will embark upon later on in the course; keep it up

  • Not only infection control; if we did not prescribe antibiotics resistance would not happen or happen a lot less
    AMR needs a range of responses of which infection control is one key part

  • A theme about authority others have referred to; i have commented before and will be discussed again later

  • yes agree; many of these issues will be referred to as we go into more detail; please remember/re-refer to this scenario as we come back to it often through the MOOC

  • We accept not only the antibiotics in farming, but veterinary medicine, fisheries, waster- etc

    All part of the "one health " repsonse- we are addressing one small part of it

  • Spot on- got many of the key things

  • I note a great mixture of health care professionals and others ; hope you all get something out of this; please hang in there for the 6 week journey- it will be worth it!

    best wishes

  • Dear colleagues

    My most sincere welcome. from Baghdad, to Crete to Calgary to Kenya to Mexico to India etc etc and those at home in the UK its my pleasure to interact with you. I do hope you enjoy the course and the team and i look forward to learning with you.

  • I congratulate you on your work and ambition; i hope you engage with this course and encourage others to take part- you will learn of a lot of good practice is a range of countries and hopefully they will resonate with you
    well come and enjoy the course

  • Mandate v persuation/encouragement is a long standing debate' both have a place and something that will recur in our discussions

  • well made points and hard to argue against
    remember here its not only about nosocomial infection; its about all infections

  • So pleased you have all started- day 1 and already some very pertinent discussions
    thank you and enjoy the rest of the course; lots of good stuff yet to come

  • Clinician engagement and poor leadership are fundamental to effective stewardship programmes; a theme as we progress over the 6 weeks; hang in there and you will learn more and interact with some great learning
    thanks and welcome

  • I agree with your sentiments; the scenario tries to portray many challenges and poor practices

  • well done agree; some poor infection control practices !!

  • Not sure i completely agree with all your drivers- the evidence between iv -oral route as drivers of resistance per se is not convincing; using antibiotics not advised by a microbiologist is not always a driver either- think you will see many other prescribing drivers of resistance
    The infection control point is well made

  • The how to do it question is a key theme that i hear about- implementation and evaluation of what you have done is a major theme of this course- you will get this in weeks 5,6 and elsewhere;all your points are well made and i wholeheartedly support what you say re implementation
    Great start and welcome

  • very important points and relevant to your setting; the role of non medical professionals in stewardship such as pharmacists and nurses in key- something we will explore later

  • all very pertinent points and you will learn more in relation to most of these areas;
    while audit is useful the course in weeks 3 and 5 will lead you through some concepts of implementation science which will teach you other ways of collecting data and supporting change

  • Well done; you clearly are picking up on some of the key messages of poor practice we are trying to convey; great stuff and good start
    Audit of patient outcomes not easy in reality- which outcome will you use & how will you measure ? see week 3 !!!

  • Tracey your point about how we empower AMT's to influence the decision making is very important. you will learn more but even at this stage engagement with prescribers, getting their trust and confidence is key- we are at a stage in my organisation where they will allow the AMT members to change the actual prescription after discussion with the attending team;...

  • I agree that tazocin is used far to often empirically; in Scotland we have a similar problem and we have understood it more recentlu by undertaking a national point prevalence survey looking at tazocin- piperacillin-tazobactam) and carbapenem prescribing. This was we can try to understand what interventions we can put in place; you will learn about this as you...

  • Really enjoying reading the range of comments; some Themes emerging which are entirely alligned to our thinking
    Look forward to seeing more and as we go through this week some potential solutions based on learning from here

  • It is hard but basic to stewardship
    Hang in there !!

  • Good, we will in the fullness of time consider translations into major languages but this is sometime away

  • Really pleased we are into week 4 and you continue to remain engaged. Well done.

  • Really enjoying reading the responses; a lot of consistency

    well done

  • All the key references will be on the ARC website
    I alluded to this in my week 1 concluding video

  • I believe you have I missed the point of what I have been saying
    Many of the questions Te not entirely relevant to this subject matter
    I think we have tried in some way of answering all relevant questions or least direct you to a relevant resource

  • I will ask the team to uopload as did it yesterday


  • agree- non CF bronchiectasis and Pseudomonas infections is the model for al ot of work on immunotherapy as well as more traditonal antibiotics and work on biofilms and inhaled treatment.... sure we will see significant progress here ...

  • science fiction.. presently.... but such genomic combined with clinical and with rapid diagnostics will bring this age to reality--- personalised medicine

  • we really should and are explorin all avenues for treatment.... the traditional chemical approach is limited... for example look at the excellent response with faecal transplantation for recurrent C.difficile

  • Notb a miracle drug in myu view.... its of some value, usually in comibination for resistance Acinetobacter. spp infections of the lung for example and some resistant gram-negative ot polymicrobial intra-abdminial infections.

  • tihs is always challenging and perhaps a quesiton fir Sujuith Chand and Adrian Brink in week 6; - they talk about programmes in South Africa and India; there is also a paper looking at financial models/bussiness cases for stewardship

  • Many different models; you will learn aobut these in week 2 and 6

  • Fascinating and very petinent discussions; the mock scenario was deliberately chosen and constructed to show good and suboptimal practice and encourage debate from a range of perspectives. Really have enjoyed readingthem and will wet your appetite for future weeks! where the scenario is de-constructed around the theme of behaviour change, context and...

  • Great to see so many of you from different backgrounds. countries, healthcare shystems, cultures etc. Welcome and enjoy the course. Tell friends, colleagues- if someone missed this opportun ity we will run again in 2016, most likely Jan 2016 and May 2016 and September 2016

  • SorrY whilst i am delighted to try to answer such questions they are really not within the remit of this course and would make my capacity to answer the "brief" quesitons impossible.

  • Here the risk stratification based approach, adopted byu many guidelines, is reasonable. In htose patients with easrly nosocomial pneumona who have a low risk profile for likelihood of a MDR organism, i would go with narrow spectrum, often in combination, therapy. Your local antibiogram will also inform this process. How this proces correlates with fitness...

  • it is very hard to get positive cultures after such a long time; for some organisms you may consider prolonged culture incubation but otherwise you may wish to consider new non-culture based diagnostics if they are available to you

    Ultimately, the decision to treat should be guided by the clinical response and in many cases in the absence of microbiology...

  • great question- you will learn about the unintended consequence of any styewardship intervention- see week 2,3,,5, and 6

  • not an unsual response; we have to emphasise the increasingly fast evolution of knowledge and skills in medicine; increasingly the good clinician is the one who asks colleagues for informaiton and help when its not an area of their expertise - "it is not what you know but who to ask or where to look it up" that defines a good clinician in my view; this links...

  • team working is at the heart of the antimicrobial management team model but this model can be adapted for local resource. You will hear more in week 2,5 and 6 in relation to this.

  • a good quesiton- with the evolution of electronic presribing systems and sharing of patient records, that are available at the time the patient is seen in the surgery, is the way ahead. This will take time in most areas and until then asking aobut previous antibiotics, lookng at previous microbiolofy is an important part of risk assessment and should be...

  • Its a huge area of activity; please read the State of the Worlds antibiotics 2015 at the end of last step in week 1- a great update for you ; there is a lot of thinking outside the box of creating non- traditional chemical models of creating antimicrobials also

  • all this work in ongong- for example the longitudnal prize it to develop a point of care test that will do many and more of the things we need, especially in a resource limited setting

  • The patients response to treatment is determined by the host, microbial and antibitoic factors. In some patients despite high MIC the patient may respond because of source control, good dosing of antibiotics that may overcome an MIC, good penetration, the host may fond a favourable immune repsonse, the virulence of the bacteria may be low and other things....

  • i have looked at many questions

    It is clear that may of you are not sure what is covered in weeks 1-6

    i will ask Sally our facilitator to post the skeleton content framework of the 6 weeks

    we will do this by friday

  • difficult for me to answer as not sure how your hospital contracts expertise;

  • not my area- iwill see if my colleagues in week one can answer this

  • agree, the basis for a whole lot of public campaigns- their effectiveness has been variable and depends also on context and geography

  • week 4 question but i find it of variable value

  • No majic formula- a week 4 question!
    pk-pd evolving science but not enough studies linked to impact on outcomes
    think we need to dose our patients better as under-doing is a dirver for resistance and overdosing leads to toxicity

  • you raise an important and difficult questions- suggest week 5 on behaviour change is useful

    My view on name and shame is that its not the long term or sustainable approach to changing behaviour; there are other tthings we can do and in my practice have done

  • agree but we do use gentamicin as very effective; i think the ease of use of ceftriaxone etc has been one of the main reasons for its inappropriate or excessive use; there are other options

  • India is trying very hard against huge challenges to address this; we are working closely with them on a variety of fronts

  • agree; a terrible pathogen with great propensity for resistance
    & disease

  • very difficult but being looked at

    see the report on state of the antibiotics in the world 2015 - pdf end of week one and lancet review of AMR for more info

  • agree- not a an area of good practice; they need support to gain confidence about not worrying about this

  • while not the remit here there are a whole lot of areas for drug discovery outside conventional chemicals, not an area for discussion here though i am afraid

  • no; we need a multi-team/discplinary approach; however, the models and teams for stewardship can depend on local resource/expertise etc; do not get fixated on one model- its what works for you

    you will see in week 2 more of this and week 6 in South Africa a pharmacy led model

  • i believe we work as a team where the views of all should be heard; you are a professional and a potential patient" suggest that where possible you shohuld be an advocate for the patient; we are increasingly lookng at young professionals as change agents- see week 5
    you can influence behaviour thorugh participating in measurement, data, feedback etc- very...

  • too much "unecessary security" attached to iv drugs- we have great oral agents with excellent bioavailability- we need to promote their use with IV-oral: an underused and effective stewardship stragey- week 2 will refer to this

  • this should be part of the decision making process based on risk stratification; for example if the patient is unwell with sepsis or severe active co-morbidities i would certainly consider this important as part of the decision making process

  • i have referred to this in a previous question repsonse

  • will need to defer to my lab/microbiology colleagues here ?

  • think so, yes

  • this is a good point- we dont have specific guidelines protocols you can use posted here

    however, suggest you go to the new BSAC antimicrobial resource centre [ARC] where over the next few months a range of resource will be aviailable- iwill post the website details very soon

  • yes

    see the state of the world antibiotics in 2015 report pdf- last step of week 1