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Communicable takes on hot topics in infectious diseases and clinical microbiology. Hosted by the editors of CMI Communications, the open-access journal of ESCMID, the European Society of Clinical Microbiology & Infectious Diseases.
[00:00:00]
Angela: Hello and welcome to Communicable the podcast, brought to you by CMI communications estimates, open Access Journal, covering infectious diseases and clinical microbiology. My name is Angela Huttner and I am editor in chief of CMI comps and an infectious disease physician at the Geneva University Hospital in Switzerland.
Erin: And hello and welcome to breakpoints, the Society of Infectious Diseases Pharmacist Podcast. My name is Erin McCreary and I'm the Senior Director of Infectious Diseases Strategy at UPMC. Today we are bringing you our third, I can't believe it's, we've been doing this for over a year, which is awesome.
Collaboration podcast between communicable and break points. This time we'll tackle guidelines . And we're pulling back the curtain to learn how and why guideline panels are formed, how different organizations approach guideline development and how healthcare providers can implement guidelines in their clinical practice and research strategies across the globe.
So we're really excited for this [00:01:00] conversation. And our first guest is Dr. Benedict Hunter, the current unit, head of research, access Stewardship, and A MU surveillance, which is RSA in the Department of Antimicrobial Resistance of the World Health Organization. He previously served the WHO as Secretary of the Expert Committee on the selection and use of essential medicines and the team lead of essential medicines.
Dr. Huttner obtained his medical degree in Munich, Germany in 2001 and then moved to Switzerland where he went on to train in infectious diseases and serve in infection control and the division of infectious diseases of Geneva University Hospitals for over 15 years. Between 2010 and 2012, he completed a research fellowship in Salt Lake City where he obtained a master's degree in clinical research.
His research focused on antimicrobial resistance, antimicrobial stewardship, and appropriate use of medicines in general at the WHO. Dr. Huttner was instrumental in the development of the WHO Aware antibiotic book, and has participated in numerous WHO guideline steering committees. Before joining WHO, he was also a [00:02:00] member of the ESCMID Guidelines subcommittee from 2018 to 2021 and the Guidelines Committee of the Swiss Society for Infectious Diseases.
So just a wealth of experience. We're so lucky to have you. Welcome to Communicable and Break Points.
Benedikt: Thank you very much. Hi everybody. Very glad to be here.
Angela: Full disclosure, you may have noticed similarity in names. This man is my husband. We met at work, Bene and I met at work 20 years ago when we were infectious disease fellows in the same hospital in Zurich, Switzerland.
A lot of things have happened in the meantime, including three kids and some other collaborations. so I'm really, really thrilled to have Bene on communicable and break points, you might want to know that Bena was actually the, very first communicable listener, really our very first one.
He was the, he was forced to listen to our first recording before it was released, so I'm really excited to welcome him as a guest for the first time. So our next guest. Is Dr. Pranita Tamma. Pranita is a [00:03:00] professor of pediatrics at the University of Pennsylvania School of Medicine in the Children's Hospital of Philadelphia.
After having spent many years at Johns Hopkins. Her research focuses on elucidating the mechanisms of resistance and gram-negative organisms and identifying optimal treatment strategies for patients, infected with multi-drug resistant gram-negative infections.
Pranita is an editor at Antimicrobial Agents in Chemotherapy, a voting member of the Clinical Laboratory and Standards Institute, antibiotic susceptibility testing subgroup that provides international guidance on establishing antibiotic breakpoints and phenotypic and genotypic methods for identifying antimicrobial resistance.
And she's the lead author of The Infectious Diseases Society of America, antimicrobial Resistance Treatment Guidance. Pranita, welcome to Communicable.
Pranita: Thanks.
so much, Angela, and it's so nice to see all of you.
Hey Pranita, we're so excited to have you Pranita's a friend of Break Points for those who've listened before she's been on that pod, but I think making her first appearance on Communicable. So we're very excited for this conversation. [00:04:00] And as our listeners know, at Communicable, we start our episodes with a Get to Know You question, and then at Break points there's a beloved, I feel, nerdy segment, which we'll get to later in this episode.
Erin: But to start off, here's our get to know you. please tell us your favorite holiday and or holiday tradition, it can be from any time of year, so it can be any holiday. You can pick Groundhog Day
Pranita: thanks Erin. So, in the United States, we have Halloween.
it's a holiday where people dress up and kids in the neighborhood, knock on doors, ask for candy, and as adults you have to give it to them. so for me, and I should preface this by reminding everyone, I am a pediatrician. I do love being around children, but usually like one or two at a time. so in my neighborhood, I live in the suburbs.
it's a condo community. So these are like sort of small apartments. Most families have at least three children a piece. so on Halloween we're like swarmed by children. They're out in the wild. They like descend upon us. so me and my husband and our [00:05:00] neighbors who also don't have children, go to this Chinese restaurant every Halloween.
and it's just packed with people who are trying to escape the descent of the children. but it's, a super fun tradition for us and then we get to come back around 10:30 PM after all the Halloween festivities are over.
Erin: Pranita. I hate Halloween, so this like speaks to my soul. I hate Halloween and everyone always makes fun of me, and they're like, how can you hate it? I'm like, what's to like about it? And I just, that's so funny you should come to the store. I've never hidden in a Chinese restaurant, but I love that. So Bene, what yours?
Angela: . I'm thinking about it quite a lot and actually, it's quite funny because, when you come from a household where you have different cultures, you have different guidelines also how to deal with holidays.
So every year, for example, we have to struggle when to put up a tree because. In, German tradition, it would be on the 24th in America. It's sometimes already in October or
no, no,
my tree goes up November
1st. Yes it does. Oh my gosh. How does it
live?
[00:06:00] He's like, we have to do it on Christmas Eve.
Yeah.
So now we have a compromise and we do it somehow, mid-December, But, what I wanted to talk about is actually a Geneva tradition, because it just happened. So in Geneva, every year we have, ceremony for the Escalade.
So it's 1602. The Protestant Geneva has been attacked by the Savoyard, and, what happened, apparently it's apocryphal, but the soldiers were climbing up the walls and there was somebody called Mère Royaume, an old lady cooking her soup, and she then threw it on the soldiers. And what we do now, every year is there's these chocolate, cauldrons filled with, candy vegetables.
Angela: And, if you're in a group, you take the youngest and the oldest person, in the group, and then they smash, the cauldron together and say that's how the enemies of the republic perish.
So it's actually quite nice and it's not known far outside Geneva. And then there's like also big cottage of the, you know, people in traditional customs. So [00:07:00] yeah, that's, my tradition. It's.
it's a really big holiday here. They reenact it like grownups, like they do a whole parade. they put on the clothes from that day.
I mean, they were traumatized by this attack and they fought 'em off. They kept the independence of the city, but they were really traumatized by it. Yeah. And
they also run, 40,000 people run every year. Oh my gosh.
Big marathon. Yeah.
Erin: Okay. See this is why we do the get to know you question 'cause that was very cool.
I learned something about you both. Thank you for sharing. And Bene, I love that you put it in the context of families making holiday guidelines. ' maybe it would be less stressful if everyone had a playbook how to handle the holidays. I think that's half the battle. We need guidance.
And so it's a wonderful segue into our episode and let's start there. So, Ben, can you tell us. I mean, again, like to have order and not chaos, right? But why do organizations, different groups around the world, why do they develop guidelines or guidance in the first place? What really triggers this need?
Benedikt: So I think it's, really to assure that all patients receive the best possible care, right?[00:08:00]
And so it's about improving patient outcomes and based on evidence. So it's very much linked also to evidence-based medicine and to avoid harmful treatments. We saw it, you know, we are all still traumatized by COVID with all the treatments that were given without any real evidence. So I think that's, the basic, principle.
It obviously. It's a little more complicated than that because whenever you consider making a recommendation, you have to take into account the perspective of the individual patient. So what is the outcome of the individual patient? And then sometimes you also have to take into account what does it mean for society, be it in terms of resources.
I mean, we talk about infectious diseases, it's antimicrobial resistance. So there's always a balancing effect. And I think there are further, reasons to have guidelines. And, it becomes very apparent when you go to some, low middle income countries where there are absolutely no guidelines.
it becomes very difficult to assess the quality of care if you don't have any standards. Right? how do you chat if something is appropriate or not? You may want to reduce variability. I think it's also an equity issue. It's not, [00:09:00] equitable for some patients to be treated in a different way.
And, depending on where they seek care I think that's another issue that's very close to my heart that, it reduces cognitive load when we are on medical, service. You know, I was always talking about decision fatigue. you take so many decisions,
You should concentrate your mental energy on where it matters. And, a lot of the cases can be handled according to standard, uh, treatment guidelines. And obviously there are exceptions, but if you start discussing about every individual case how to do it, it's not effective.
it's tiring. So I think there's all these different aspects of why guidelines, are needed.
Erin: Awesome. That's really helpful context. I love framing it like that.
And then Pranita, I'm gonna come to you next because you are an author on quite a famous guidance document. something I think we needed around the world. Something that's been really valuable in the complexities of Gram negative, but also something that we've really emphasized. It's guidance, it's not a guideline.
And so Bene gave us a good framework for why we write guidelines. What's the [00:10:00] difference between a guideline and guidance and is the philosophy different? Does this distinction matter?
thanks Erin. it's funny 'cause we kind of. Made up the term with this document and said, let's call it a guidance.
Pranita: And part of it was that we, unlike guidelines which generally involve a methodologist, a librarian, a really formal systematic review of the literature evaluating each piece of, scientific literature for 'is this robust enough' to consider the evidence and formal GRADE criteria GRADE methodology with the guidance.
What we decided was with antimicrobial resistance, you know, particularly in the gram-negative space, it's a pretty rapidly evolving field. there's new studies coming out very regularly, new issues with resistance mechanisms, and a lot of the time we're sort of limited in the robustness of the data.
The trials we have are often like. New exciting drug versus Colistin, right? And people might say, [00:11:00] Colistin quote, 'best available therapy'. But of course we know it's not. So I feel like even if, we were gonna limit ourselves to trials, we would be focusing on, for the most part, sort of industry sponsored trials where there's a little bit of, you know, need to sort of put on your discriminatory hat to decide to weigh the evidence.
the nice thing with the quote 'guidance' is that it gives us the flexibility to evaluate the literature including smaller studies and preclinical data, and figure out how do we put this in the context of what might matter the most to clinicians, there's flaws with it because we end up missing
Pranita: important articles 'cause it's just a panel of six people. and that's when we turn to the audience. 'cause it's really helpful when they let us know we forgot to include something important and so forth. and of course then it does become largely opinion based because sometimes there's just a lot of gray areas where , very intelligent and well-meaning people have very different views on how to interpret the data, how to proceed [00:12:00] forward.
so there's pros and cons to the approach, but I think for a topic like gram negative resistance, where data does change quite quickly in contrast to something like Group A strep guidelines, I do think that this format actually works quite well for
this topic.
Angela: thanks Pranita. Bene, do you have, a different opinion or something else to say on that?
I'm not speaking for WHO, but WHO has a, definition of what is a guideline. It, essentially, it's any information product that contains recommendations for clinical practice or public health.
Benedikt: policy and recommendations are statement designed to help end users make informed decision on whether, when, and how to undertake specific actions such as clinical intervention, diagnostic tests, or public health methods with the aim of achieving the best possible individual or collective health outcomes.
So, in a way, whenever you make a recommendation on what to do or what not to do, that would be a guideline.
Angela: So WHO isn't necessarily saying that a guideline has to have GRADE methodology or different actors.
[00:13:00] yeah, yeah. But it implies in indirectly that if you do that, you need to use, GRADE methodology.
I like the idea though, like Pranita, has used in the past the idea of saying, okay, well a guidance allows a little more maybe creativity
maybe.
Benedikt: Yeah, no, maybe we have done that.
I mean, that way antibody book, for example, is guidance. There's not a guideline because it didn't follow the entire, GRADE approach. Yeah. So, there's also some, contradictions here, but, formally if you make a recommendation for WHO, it would be a guideline.
So I think that's a really interesting point. And I think one of the distinctions I'm hearing is. How structured or formal, I guess, and what wiggle room are we allowing for expert opinion, or I guess grace to say you didn't evaluate all 40,000 published articles on this, and so we're saying the word GRADE a lot.
Erin: Our listeners may have varying familiarity with what that is. So Bene, can you describe to us this GRADE framework? What does that mean? what is that acronym? and then how does that influence decision making or structure of guidelines or guidance?
Benedikt: Yeah. So, I always need to look also what the acronym means ' grading of recommendations, assessment, development and [00:14:00] evaluation'.
And it's been, developed, about 25 years ago. So since 2000, I think the first documents were established and the whole idea is, To make, systematic reviews and decisions regarding guidelines more transparent. So, really not just to have, you know, a group of old boys sitting around the table saying, oh, I do it always that way.
That's, why it should be done that way. But really to have a systematic assessment of the evidence and then also see how, based on the evidence, the recommendation was made, so it, assesses the quality and certainty of the evidence, which can have different levels from high to very low, can be upgraded, downgraded based on, some criteria.
and, the aim is to make it more transparent. But it has a disadvantage, I think, which has to be acknowledged, is that it's really quite complex. You need to have a certain expertise and it's really takes a few guidelines to understand how it's done.
It takes time, it takes money, and it doesn't obviously eliminate the requirement for personal judgment, right? It doesn't [00:15:00] make the decision for you. it's just a framework on how, how to assess the evidence and makes a recommendation. there're alternative frameworks like the strengths of recommendation, taxonomy, et cetera.
But most organizations nowadays use GRADE when they, uh, do a formal guideline process.
Angela: Pranita, what do you have to say about that? 'cause I have opinions.
Pranita: appreciate it. And you know, I should say, I'm also on the IDSA's intraabdominal guidelines and just as a contrast, I think we started working on that.
Over a decade ago, I mean, more than 10% of the panelists are not even alive anymore. I mean, it's just kind of like same-
Angela: Yeah. This is
the problem.
Pranita: It's like, and I think that because we're beholden to such rigorous criteria that, I'll be honest, I'm sometimes uncomfortable with some of the recommendations about using certain drugs that I know in clinical practice wouldn't be my first line.
but, but some things like maybe, ceftriaxone, metronidazole or something haven't been studied as rigorously as tigecycline, [00:16:00] for example. So I have to say, having been on sort of both sides of it as someone involved, as a panelist, the guidance process is much more. Fun.
It's much more flexible. we make it a point that we don't quote, recommend. We only suggest we suggest this treatment, suggest that treatment suggest this approach, just because we do understand that this is largely opinion based. and we're not using formal criteria, but I don't know, as an end user, all of us have taken care of patients.
I do think at the end of the day, to me at least, I'm thinking that this sort of format that a lot of different groups are starting to move towards where it's a little less formal might actually be just easier to translate into clinical practice. because it addresses some of the gray areas and not just the, data where it's like black and white decisions about duration for the best possible scenario with source control, et cetera, et cetera.
Angela: I think I'm a little bit traumatized by the GRADE approach because as Erin knows, [00:17:00] we've just, been doing the IDSA UTI guideline update, and it's oh my gosh.
It's so tough,
Angela: By the time you come out with the results, like, guess what? You're outdated. Like it's time to do another update. Yeah. Really
Pranita: outdated. It's true. We're outdated by the time it'll come out.
Benedikt: Maybe I can add for the WHO AWaRe antibiotic book, it contains, guidance on, 35 infections.
was a conscious decision, not to use GRADE, because if you do that, first of all, you need millions in funding and then you know, it, takes 10 years and by the time you're finished, it's completely outdated. So I think there is a trade off between flexibility and, and rigorousness and, it can be quite painful.
Benedikt: I agree,
Erin: for sure. And you, brought up something we wanted to ask about, so I'm glad you said it. I do wanna come back to the role of statisticians and methodology and Pranita you started to alluded to this, but I want to talk to you guys about how does the methodology. Guide what you can and cannot say in terms of recommend or, suggest.
But, Bene, you mentioned funding and I think that's something that I know as, a frontline clinician, I don't know that I necessarily think about all the time. What role do funders. [00:18:00] Sponsors, what have you play in guideline development, if any? are commercial entities allowed to fund these guidelines or are they, you know, public organizations and how does that influence the process?
Benedikt: there's a, large variation between different organizations and I mean, ideally the funder should not influence the actual recommendations, right? So the idea is to enable the guideline development, but it should stop there.
we need to talk also a little bit about the cost. It's quite difficult to find actually cost estimate. It depends also, you know, how do you take into account the time of the people who are on the panels and to do the actual work. But probably, a reasonably sized and detailed guideline is several hundred thousand US dollars. So, 200,000, 300,000, that's quite a chunk of money.
For WHO, there's a large variation between the funders. It can be governments, right? The government can give money, to develop a lot of the support guidelines. Sometimes it's non-governmental organizations. The Gates Foundation, for example, has funded a lot of work, in the area of HIV.
It can be the Global Fund, for example, malaria [00:19:00] guidelines, Unitaid, sometimes even universities, So it's quite large. What's very clear is that for a guideline to be credible, industry shouldn't fund a guideline and shouldn't play a role, right? I think that's, a clear no-no.
otherwise there's really a, a quite large, variation.
Erin: Cool. Thank you. And then Pranita along kind of the same vein of. We're getting started. How do we structure this process? We have funding, we have an approach. How do the panels get convened? You mentioned some of these interabdominal authors had been around quite some time and hanging out for a decade or so.
Is that normal or once you're on, you're on forever and you're committed to updating it for life as long as that may be? Or is it, do you serve a certain term and the update hopefully happens? And you know how if I was like, I really care about this subject, I wanna write a guideline, you know, where do people even get started?
Pranita: Yeah, I believe the process for IDSA, for example, is that there is a guidelines committee. just, people who are members will say, we think we need a guideline on this, a guideline on that. And the committee sort of decides what do we think are priorities are, who should share [00:20:00] this?
And then, you know, who should be on this panel? Usually they call for people to apply, to be part of the guidance or guidelines. and then there's some sort of selection committee after that that takes into account both your experience in that topic area, but also potential conflict of interest and so forth.
one point I wanna make with the guidance. It's interesting because there's no methodologists. There's no librarians. for the IDSA antimicrobial resistance one as an example, you know, it's six of us. We kind of lead our own zooms and we. Draft our own documents. So the truth is, it it costs our time.
Not that we get paid for our time to do it, and it's fine. We love doing it, but it's funny that no, there's not actually any dollar amount that's being exchanged, if that makes sense. It's more evenings and weekends people are spending working on this, which obviously is a cost, but in a different way.
And I guess that's different from the IDSA and, other organizations, more formal guidelines where there are sort of [00:21:00] quote, people who are sort of adhering to some rigorous methodology to pull articles, put the data together, do formal meta-analysis on the studies. so I guess from a business model point of view.
the guidance is a lot cheaper that way. I do though with the funding. think, and I don't know, Bene if you have other thoughts on this, but I do think because the types of people involved in guidance or guidelines are generally, have full-time jobs are, quite busy with being pulled in many other directions.
If there was some kind of model where panelists got a little bit of protective, like salary support for it or something protected time, I do think the process would probably move faster. because I do think that is often one of the rake limiting steps of finding time for everyone to meet.
And then, inevitably, even though everyone's incredibly well-meaning just the nudges required to get people to complete sections that, they were leading. do you know, Benedict? There are models of like. [00:22:00] Payment for panelists or if you have any thoughts on if that kind of helps move things quicker or not?
Benedikt: Well, I mean the WHO guideline, development group members are not paid. what happens is if their in-person meetings, obviously their expenses are paid, but there's no kind of salary support, I don't think, ESCMID pays . Who is paid is often the people who doing the systematic reviews, because that's like really the big chunk of the work.
So that's often, consultants who are hired and who are, who are paid to do that, or the methodologist may be hired, but the guideline panel members usually not. And maybe for the panel composition, it very much depends on the organization. So ESCMID has a guideline manual. I think it's a quite complicated process where one third of the panel is suggested by the guideline chair.
One third by the executive committee, the guideline director, the guideline steering group, and one third is an open call, WHO. there's no open call. It's essentially the guideline steering group, but paying attention, really that all geographic areas are represented. I mean, it's a big issue for a [00:23:00] global, organization that has gender balance.
And then there's also a lot of attention that all necessary expertise is presented. And one big issue is, for example, to have some people who are actually affected by the recommendations can be quite difficult, right? How do you choose a patient representative? Is that person really then the one speaking for the 2 million people with the condition?
but that's a requirement. And then depending on the issues that are cast, may be necessary to, for example, to have a health economist, some of the feasibility issues and implementation issues really, need some economic considerations. You may need ethicists. So it depends a lot. on the type of guideline, and another issue for the s then have people who actually will implement the recommendation.
You know, there may be, members of NGOs, even though for WHO if you're on a guideline panel, you are in your individual capacity. You don't represent the organization. But it's obviously helpful to have somebody who then will need to implement it or governments and, ministry of health. So it's, quite varying very quickly.
It can become quite large panels, which then again increases cost. But, yeah, [00:24:00] it's a science per se, how to choose a, good panel.
That's really interesting.
Erin: , So you both have talked about the spectrum. I think for Pranita your small but mighty tight knit group of friends that are volunteering on the weekends to write the gram negative guidance and then Bene, you talked about WHO can sponsor, a lot of money, a lot of time, a massive team, a commitment to a guideline document and with the GRADE methodology and strategy.
And so if the team is a little bigger and the methodology is perhaps more robust, Pranita, you had mentioned this too, that there can be a statistician involved, a methodologist involved, you know, specific people that have this specific role to do quite a bit of work on these documents. and we had talked about the grade structure being perhaps the most rigorous.
How does the methodology of the document and you know, whether or not you have these people involved, how does that shape what can be said as a conclusion? So can you maybe give us a few examples? I know often as clinicians we're a little confused, you know, what does it mean if you suggest versus recommend versus, versus the different words you can use and the strength of those words.
Erin: [00:25:00] And I know there's kind of some nuance there to say you can't say should, do you have to say consider, can you talk to us a little bit about word choice, I guess, and how the methodology shapes that word choice?
Pranita: it's very interesting 'cause I think with the formal guidelines. When there is a methodologist who, you know, the librarian pulls a lot of articles, many thousands, there's sort of a screening of titles and abstracts, and this whole formal process that occurs eventually, the methodologist with the, quote, best studies develops forest plots and odds ratios, and some things are significant and some aren't.
And then you're a little beholden just like you would with like a scientific manuscript of saying there's a significant difference or there was no difference. Basically there are some statistical tests that you have to kind of abide by to say, is there a difference or not? it's not just simply numerical differences in percentages.
For example. I think with the guidance, it's a little interesting 'cause we don't do any sort of formal statistics. And I'm not saying it's a good or [00:26:00] bad thing, but it's six people in the case of the, IDSA antimicrobial resistance one at least. as I was mentioning, we, try to use the word suggest because we do realize we're not applying rigorous definitions.
and our hope with terms like suggest is, Hey, we know these infections are hard to treat. We're six people who, practice infectious diseases, take care of patients with these kinds of infections. Also have an interest in sort of the research side of what's new, diagnostics, therapeutics, et cetera.
And if we had a patient in front of us with this issue, this is what we suggest doing. also, I like the word suggest because I hope it doesn't make people feel like they're in some sort of medical legal bind of having to do something because it's strongly recommended or do not do this.
we try very hard to avoid those kinds of words. 'cause we realize so much of the management of these kinds of infections, is a little more of an art than a science.
I think formulating the [00:27:00] recommendation is actually one of the most difficult aspects. And, that's actually, where also, the methodologist plays a role. It's not just, reviewing the evidence and interpreting the evidence, but it's also then how is the recommendation formulated, depending, is it a strong recommendation for, is it conditional?
Benedikt: every recommendation should always be accompanied by the certainty of the evidence and the strengths of the recommendation. So you need to be quite exact, right? What are you actually recommending compared to what, right. for what population? the problem, it's, maybe another issue that maybe, grade has is that that's not how people talk.
If you read, some of the recommendations and the great guidance, it becomes really, you have to huh?, yeah, you have to read it five times to understand what is actually said. So, that's a little bit of shortcoming but I still think it's quite important to be precise. Maybe there would be even a place to have like a simplified, for the average, physician who doesn't have time to go through all this.
, It's not simple to really formulate a clear recommendation. And there's a WHO handbook to [00:28:00] guidelines and it gives examples of, you know, different situations and how subverting is suggested.
Angela: So Bene, interesting that you bring up the point of GRADE language is not usually the language that we speak day to day. it makes me wonder, what do you both think?
What are the biggest barriers to uptake of guidelines? Why do you think people don't follow guidelines? Is it simply a language problem? Is it bigger than that? Are there multiple problems? And whatever you identify as those problems, what would you say are the solutions to those problems?
Benedikt: So, I mean it's obviously a key question and I think the first people to blame in a way are actually the guideline developers.
So also us, because the aspect of implementation is often neglected, right? You do your guideline, you publish it, and then, you know, fine. But, the thought about how is this actually then translated in practice, how is uptake facilitated is often not really considered very much and To be quite honest, it's one of the things that drove me nuts during COVID, right?
We spent hours and hours discussing, you know, the evidence, but then [00:29:00] instead of actually saying, okay, we have some national guidelines, maybe, how do we actually put them in place? Right? But that latter aspect often was completely neglected, and it's, you put out these documents and then your hopes that physicians and other healthcare workers, adopt them, which is not happening.
So, I think that's one thing, an important issue, I think, with many, for example, also infectious diseases physician, is that they consider medicine an art, right? because you're the expert, guidelines can be followed by everybody. So, you know, if you are an experienced, older, physician, I've witnessed this quite a lot of times, they had a certain disdain for guidelines, right?
That's for the younger physicians, they can follow the guidelines. I have so much personal experience, which obviously is, very risky because your experience is mostly anecdotal and we know even from well conducted, observational studies, how many biases they have. So I think that's one issue.
I think if you talk globally. There's much more. we have to create the conditions that the guidelines can actually be used. One issue that's often neglected is just the consultation time. If you look many low middle income countries, [00:30:00] you have like two, three minutes to see a patient.
just to implement all the guideline recommendations may actually. Take much longer than you have in a consultation. So we take, decisions very quickly, the availability of diagnostic tests and essential medicines. The financial aspects, right? I mean, you can very well tell you do a CRP for respiratory tract infections, but if the patient has to pay for these tests and an antibiotic costs just two or $3, this test is not going to be taken up.
Then very often, and I see it again and again, guidelines are produced in a very not user friendly format, right? You have these long texts and nobody's going to look at it at the point of care. You have to have, user friendly ways, algorithms, infographics, maybe some apps, but really the, healthcare worker can access a recommendation at the point of care.
So I think it's quite complicated, but I think there are many, many barriers that relate to the health system per se. That makes it difficult for prescribers to take up their recommendation. And then just so, so many recommendations. Right? It's not just infectious diseases. The patients [00:31:00] has chronic diseases, which you need to manage, they're always more medicines.
Medicine gets more and more complex. So I think they're also asking a lot of modern, healthcare workers, if you really want them to follow all guidelines, that's nearly an impossible job.
Angela: Wow. Lots to think about. Pranita, what do you think?
Pranita: Yeah, I mean, I think just said everything much better than I could.
I think an important point he mentioned is that often these end up being very long, extensive documents written in formal kind of jargon for a lot of people, that they're not end user friendly in the sense. If Erin is seeing a patient with like ESBL, intraabdominal abscess, not great source control, super sick, susceptible to a quinolone, is it okay for me to switch?
I mean, Erin's so smart, so she can like teach a course on that, but I think that it's not like they're designed to just plug in your patient's, specifications and spit out what do you do now, right? Like it actually does take a lot of time to sit and read all the [00:32:00] suggestions and all the data behind it, and then figure out, okay, how does this apply to my patient?
and that's the challenge. And then. Besides everything that Bene already said. I think the other issue is just this idea that it takes so much time to develop. By the time they're published, they're already a little outdated. so then it's embarrassing when like a really cool study comes out and you completely not addressed it, could turn the whole guidance or guidelines upside down.
so now people sort of lose faith in these documents.
Erin: It's so hard to keep up. And I wanna be very clear, yes, this pertains to low middle income countries, but, friends listening from the states, this pertains to your backyard.
So I work with 37 hospitals across three states and, you know, hospitals that have. Come into my health system over the last couple of years, and this is very, very, common now in the United States, in a post pandemic world, there are very few standalone hospitals. Everything is systemizing. And as we, bring critical access and, small rural and community hospitals that are [00:33:00] less than a hundred beds or so into our fold, we're finding they don't have onsite micro labs.
They send every single thing out because they can't find technicians skilled enough. We struggle with finding people who can perform a gram stain 24 7 and read it with competency, right? And so then it's like, oh, and then implement Pra nita's guideline.
I love you. But nita's guidance is like, do genetic testing to understand if you have a carbapenamase. Ideal. And I'm like, I can't read a gram stain Pranita. And so, you know, you have to do these things in a stepwise fashion. And yes, low middle income countries don't have access to novel antibiotics for years and years and years, and they're super expensive and there's all these barriers.
but I don't wanna fool us that in, resource rich countries there are resource poor areas people want to do the right thing and implement the guidance, and they're like, but I'm 17 steps behind. And then at that point, they kind of just give a hope. 'cause they're like, I'm never gonna be as smart as you are.
I'm never gonna be able to do this, so I'm just gonna crawl in a hole. And that's not how we want people to feel either. So I think that's why I'm so passionate about the work all of us do, is how do we empower people to say every little thing you do matters, and every little step you take forward to [00:34:00] get there is, important.
But I think more so what I actually wanted to get into, apologies for my personal tangent, was implementing recommendations. we are asking frontline clinicians say, Hey, read this very long document, interpret it and follow it.
But sometimes, there's the recommendation and it's this quality of evidence and it might be very low quality of evidence, but we had to make a recommendation, so we made one. But then you tease into it, and my favorite example of this was the 2019 polymyxin guidelines.
So you had 15 of the world's leaders on polymyxins. They had global meetings to write these guidance documents over years. They published the guidelines in 2019, and what I loved is they released the vote. So there were 15 people, There was a tie breaker vote. And for several of the recommendations in the polymyxin guidelines, the vote was eight to seven.
And you can see that in the document. And so they said, okay, we're gonna recommend monotherapy here and we're gonna recommend combination therapy here, eight to seven. And so basically it's a coin toss. And like they had to make a call, but what am I supposed to do with that when I read it? [00:35:00] And I say, oh, they said to give combo, but like basically it's 50 50 on whether they'd give combo or monotherapy.
So what the heck do I do for my patient? and I imagine this happens quite a bit and Pranita, you had mentioned earlier in the podcast that there's often very reasonable disagreement amongst very smart people. And so what do you guys think on, this kind of disagreement?
Is this disagreement amongst experts healthy? And then how does that fall into guideline development and implementation?
Pranita: Yeah, thanks Erin. I, actually love the poly mixing guidelines for doing that. 'cause I find it so funny, that they put the votes out there and you could see where the conflict is.
I like the idea, I mean, what ends up happening, even my interpretation. 'cause there's some things in that guideline. I agree with others. Maybe I would practice a little different. But I feel like I have this liberty, well, only like eight of the 15 thought this seven agreed with what I would do.
So I'm not gonna do that. Right? So I do feel like you end up interpreting it the way you want. what we've tried to do, and again, I think we are able to do this with the A MR treatment, but we're not able to do this with intraabdominal because of [00:36:00] this Kind of difference in, methodology. With the IDSA guidance
we do often have conflicts of, what can we use phosphomycin for? Can we use it beyond e coli? Or whatever the issue is. And if we have disagreements, we try to use language such as this approach is suggested, however, an alternative, reasonable approach could be blah, blah, blah. We try to do a, a bit of that.
and this time around the next version we're expecting to be published in, the first quarter, 2026. but I think that, we do have the flexibility with the guidance model of doing a little bit of that nuance of both of these approaches are considered acceptable.
There's a slight preference for this approach. but you're right, Aaron, I mean there's always internal conflict, always of course, friendly disagreements on the approaches to this.
Benedikt: So, from my side, I think, there are two issues. One is, the evidence base, and it may just be that the evidence, is, low, certainty or very low certainty. And for some of the [00:37:00] outcomes we look at, there may even be no studies or, low quality study. So that's, one situation.
But I think even if we had a situation where we really had perfect evidence, it doesn't mean everybody would agree. And I think the best example is, again, COVID, right? Because you look at different dimensions, it's a multi-dimensional space. If you want, you have individual patient outcomes, you have societal outcomes.
How do you weigh the death of, the elderly in nursing homes against the impact on the social and, interaction. Right. my mother, for example, was in a nursing home, was all stopped down. You know, it, probably contributed to her, deterioration or, school closures.
It's a completely different dimension. How do you weigh, these aspects And there is no simple answer. it's a decision. And I think it comes back to what David Hume said, right? The Scottish philosopher. It's a, is art problem just because we know what is, it doesn't follow automatically what we ought to do.
And I think that's where GRADE comes again, and at [00:38:00] at least tries to give a framework how the decision was taken. But it doesn't mean that everybody will take the same decision because. You may value these different aspects differently so it's normal, right? We have different values, we have different preferences.
We may even have different values and preference over the course of our life, right? Depending if you're in the situation. So I think it's, just normal and, that it's just part of, the way it is. And very often you have the combination of both, right? You have, not super good evidence and these very complex, trade-offs to consider.
So, you will have, divergent opinions, but the idea is to have a consensus and, you know, to make it very clear why that suggestion or recommendation was taken. And it doesn't mean it should always be adopted. I think, you know, especially for conditional strengths recommendation, it, you take into account your local setting, the values, the patient preferences to take into account and it can be adapted.
Erin: I really love that both of you said that.
I think it's really important for us as authors and [00:39:00] researchers, and. public health servants and as clinicians and as patients ourselves to know that there's humility in these things. I think when we try to make them black and white and when we introduce, dare I say, a degree of shame to these things, it's not constructive for anybody.
And I, really dislike and get quite uncomfortable when I'm at national talks or I see people online or whatever saying it says this, you have to do this. And then, and really just making people feel badly if they don't necessarily a hundred percent follow it or understand it. , again, Pranita I agree.
Like I loved seeing the vote in the polymyxin guidelines because it made me feel safe. In the 50 million times a day when I'm unsure of what I'm reading, how I'm interpreting it, I'll read it one night, sleep on it, read it again and be like, I think I've changed my mind. Or even just to your point, science evolves.
And so we do the best we could with what we have at the time. And if three years later we make a totally different decision 'cause we have more data, we have to have grace in that. And I think especially today, I feel like sometimes we lose ourselves a little bit and, and that's not okay. Right? We have to be kind and humble [00:40:00] and gracious with people as we all evolve.
'cause that's how we can stay in this space.
Angela: Okay, so you guys, now we're moving into some controversial territory. Here's a, slightly provocative question, potentially provocative. how should clinicians approach differences ultimately between international guidelines? For example, IDSA saying one thing versus an ESCMID guideline saying another thing versus WHO saying a different thing.
what are we to do as practitioners?
Erin: Pranita. it's like EUCAST vs CLSI dun dun dun.
Benedikt: Follow WHO. that's an easy answer. No, but I think it varies a lot. in some settings you have too many guidelines.
You may even have in a different country, different professional organizations issuing different guidelines. It's apart from being a waste of resources, it just creates confusion. but really the normal case in many settings is that there's absolutely no guidelines. And what sometimes then happens is that, guidelines that were developed for specific national setting, like the US are [00:41:00] taken to a setting that really doesn't have the same infrastructure healthcare system.
And it's actually something we struggle with because a lot of the opinion leaders, for example, have trained in the US they go back to the low middle income setting, and then they say, well, I'm used to following the US guidelines, but. They may not be adapted to the local setting. So I think it's always important to take into account for which setting was the guideline actually, developed.
You know, what's the health system like? What is the availability of medicines? I think for infectious diseases, it's really important to also take into account our antimicrobial stewardship principles considered. I think sometimes we have guidelines that recommend 10 different antibiotics of all different aware categories.
It's probably not the best, option, at least from an antimicrobial stewardship, perspective. the other issue we have is that in some countries as the perception that, for example, every hospital needs to develop their own guideline. Oh, no, no, no. Our patients are different. We have to develop our own guideline.
It's also a complete waste of resources because for most [00:42:00] situations you don't need that. Right. A national guideline, would probably be, suitable except very specific situations maybe in an ICU when you have a completely different epidemiology. yeah, I think it, really depends, but all too often we see a transfer from guidance that's not really adapted to the setting, to another setting, and that can actually create problems.
And then in some countries, obviously legal issues, so you may be obliged to follow your national guidelines. So if there's a legal case, you cannot say, well, but this as a guideline recommends a completely different approach.
Pranita: Yeah, it's a challenge and I think it puts clinicians in a tricky spot. antimicrobial resistance, for example, there's ESCMID, there's IDSA, there's many individual countries that now have very nice guidelines. So Mical Paul, who is the first author of the ESCMID AMR, guidelines, we get along very well.
We're good friends and we joke about some of the differences in the documents and we understand, I think at least all of us in the infectious disease space, I think that [00:43:00] tend to be very nice. People do-gooders, wanna do the best they can. So I think it's also important to remember that different groups might have disagreements, but it's not anything personal.
We all are trying to do what we think is, the best for our patients. Right? So that's like number one. but the biggest challenge, I think is the low middle income versus the not low middle income countries. And then, as Aaron said, even within the US, just using the United States as an example, there's so much variation between resources available to institutions.
So there's a, lot of humility involved in realizing that, these documents just may not be generalizable for many clinicians, period. I think that, for the IDSA guidance, we specifically mentioned for antimicrobial resistance, it's meant for the US because there's a lot of newer drugs mentioned that aren't available in other parts of the world.
The molecular epidemiology of resistance is quite different, for example. Then producing pseudomonas. Big problem in places [00:44:00] like Italy, Greece, lots of Latin America in the US, It's incredibly rare for us to encounter one of these. And if we did, perhaps the suggested treatment approach would be quite different, upfront for someone critically ill with pseudomonas in an ICU, all that.
So what I would say is that, it's good for there to be groups in different contexts with different epidemiology to develop these kinds of documents that are more tailored to what clinicians are seeing. And if you have something that's sort of more consistent with the types of patients you're encountering, it probably makes more sense.
I know there's a group, for example, in Latin America. who are considering developing guidance for AMR. And I think that that's great and it probably will be more applicable to them than the IDSA or even the ESCMID, guidance or guidelines. I, I think it's great when there's dissent, it forces all of us to step back and think about, well, why did we say it this way?
Are we missing something? [00:45:00] This other country using that IV phosphomycin example, have had this drug for a long time or have had these other drugs that we've never even thought about, maybe we're missing something important. So, at the end of the day, I think more of these kinds of documents are welcome.
I think conflict is good. It forces all of us to sort of think hard about what we're suggesting. and for clinicians, I would say for the end user clinicians, it's probably most applicable to see what's available, that represents the types of patients you're seeing in, in your practice.
Benedikt: Can I just add, ADD something to that because it's really close to my heart, and that's a local adaptation of guideline based on microbiology.
Well, yeah, it's, relates to the issue. how do you adapt your guidelines based on the local epidemiology of resistance? And that's something that comes up very often. And it's actually quite complicated because, in many countries the surveillance data are biased, right? there's only a minority of patients who actually get the test.
Often they may have been already on antibiotics. [00:46:00] it's, very often you don't have detailed contextual information to know, in what context a sample was taken. It's actually, quite difficult. And if it's done inappropriately, it can actually lead to, for example, recommending broader spectrum treatment than necessary.
So, we are actually going to work on a framework on how to do that. How do you take into account your local microbiology data to really adopt your guidelines? Because in some situations it may not be necessary. Right? When we talk about upper respiratory tract infections, most of them are viral, so you shouldn't treat, or if you need to treat, it's a pli.
You know, you can give amoxicillin, correctly dose. So there is no real issue in, adapting based on molecular epidemiology. Then when we talk about intrabdominal infections or urinary tract infections, it may be different, but I think what we need is a framework, and I'm very happy that WHO is now working on our framework on how to use local microbiology data and patient related data to adapt guidelines, for the local setting.
Angela: Yeah, that's interesting because for the recent Complicated UTI [00:47:00] update. we did end up deciding to allow use of an, a local antibiogram, I wasn't part of that working group, so I didn't get to be there for the really nitty gritty questions.
But I know that they really had to think very carefully about, well, how old can that antibiogram be? Like, how local should it be? Can it be your next door hospital's antibiogram, or must it be your own? And it'll be great if there's a framework for this kind of thing.
Obviously yes, like local epi should drive things and patients are different and.
Erin: Doing that without technology is hard enough, but technology actually can make it worse to implement it. Because I talked earlier about the systemization of healthcare, at least in the United States, and I do think globally this will become a thing. And I will tell you, you know, at least in the early years, the first five to 10 years of getting on a standardized electronic health record, we have one order set for community acquired pneumonia.
We have one order set for urinary tract infection. And if you wanna modify that order set for every hospital, you can't because then you have to build 37 order sets. And we don't have the resources for that. And quite frankly, we try to get away from that. We try to [00:48:00] get away from every site doing their own thing As much as possible following the same set of guidelines to treat patients. But I do have some hospitals where empirically for UTI, they could get away with something like cefuroxime based on their e coli susceptibilities. But other hospitals, quite frankly should probably be using a carbapenem 'cause they have a 30% ESBL rate.
And that is incredibly hard. And so basically we have ceftriaxone and we call it a day, but that's not great. So even if we wanted to individualize, being able to operationalize that is very challenging.
Angela: Yes. And all these problems. Bene and Pranita, you guys need to fix them. So all that, So one more question for both of you before we go into the I feel nerdy segment. Bene, you had mentioned before that one of the problems with implementing a guideline is that doctors don't always have a lot of time they have two, three minutes, per patient in some places.
So, I would imagine that is where AI might come in in the future and help out clinicians to [00:49:00] parse that guideline very quickly, and then help the clinician implement that guideline for that patient in front of them. Do you see this happening already? Do you think? Is there a place for that? What are the pitfalls of that?
, What do you guys think?
Benedikt: I'm a techno pessimist even though I use AI a lot in my daily work and actually believing we are running, something dangerous without knowing what happens. And I think it's quite difficult to make any statement about AI because even by February it potentially outdated.
I think it'll radically transform. Many things, including how healthcare is provided. as you know, it's a little bit a black box of what's actually happening. So I'm curious how it'll influence, how medical care is provided. But I think, what is more traditional are these clinical decision support system that are integrated in the electronic health record.
It's not really ai, right? It's not based on large language models. It just, take some parameters and may suggest the most appropriate treatment. I think if you look at the, literature and that's a randomized control trials often, they're quite, disappointing. And I have [00:50:00] participated in two who actually didn't really show.
large impact of these physician support tools. I think, physicians tend to be also quite reluctant, to use them. So it needs to be really easy to use. I think we are all used to very smooth applications, right? if it's developed in academic setting or in a, hospital, often they're a little bit clunky.
and I think what also often emerges is that sustainability is always an issue, right? I mean, if you do something in a study, you may see an impact, but then if you stop all the other attention you give, it may actually, return to baseline level. So I think anything alone is, probably just clinical decision support.
The system systems alone are not sufficient. how AI is going to transform that, that's unclear. I mean, for the guidelines, It'll potentially facilitate the development of the guidelines. You know, that whole evidence synthesis, which is now sucking up so much time and money, possibly AI will be able to do it faster and better, in the future.
but let's see. I think any predictions are, very dangerous
Pranita: Yeah, I can [00:51:00] barely connect like Bluetooth to my phone, so I'm probably not the right person to ask. But, I think I agree with, what Bene's saying, have to see what there is to come. I think though, the one thing with AI is it definitely can make the output, and maybe I'm just older, so I'm kind of hopeful that we still need humans, but I think that it still will take people doing good science, asking the right questions, doing the right studies to feed into what algorithm AI develops, right?
So hopefully this doesn't replace the sort of science, the clinical questions, all of that, that needs to happen first, to establish the evidence. And maybe AI can kind of help synthesizing that easier. but hopefully it won't replace all of us.
Okay, so with that, the time has come, break points faithful for, I feel nerdy. So I feel nerdy is meant to be a safe place and a closing segment for our panelists to nerd out over their favorite ID topics, quirks, and fun facts for today's, I feel [00:52:00] nerdy.
Erin: What would you say, in your opinion, was the most practice changing or the biggest guideline drop in the past 50 years?
Angela: Pranita, how about you go first?
Pranita: Um,
Erin: have I have stunned them into silence with my
Angela: I question. I know deer in the headlights
Erin: by the best question I've ever asked. Yeah.
Pranita: obviously I would love to say it's the I-D-S-A-A-M-R treatment guidance, but I know that is not true. you know, the truth is, I think it's, I don't, these aren't really guidelines at all, but I think it's a lot of public health campaigns, right?
Like the risks of smoking and how that dramatically reduced smoking levels around the world, frankly. Right? so I, I think that as much as we put value into these guidance guidelines, we develop, I think that things that go directly to the public. About wearing helmets and all of that is, probably probably the, the kind of, health campaigns that have been most meaningful.
and then I think from a medical point of view, it, it might not actually be in the infectious diseases [00:53:00] world. It might be something with, blood pressure control, lipid control, these things that have dramatically reduced cardiovascular disease, stroke risk. so as much as I love being in the infectious diseases world, I'm not sure that I can think of any specific infectious disease related guideline .
Oh
Erin: my gosh. I didn't even think to limit it to infectious diseases. I assumed he was going outside the box. Many, I assumed you'd take an ID one, but that was like, wow, that really, that was meaningful. I mean, it's like cars being regulated to have that beeping.
If you don't put your seatbelt on, you're right. Like those things, that's guidance that changes the world. Yeah.
Benedikt: Yeah, I actually struggled quite a lot with it, and I have a really nerdy answer for you that goes beyond the 50 years. And that's, also non-infectious disease.
It's actually the first, really guideline issued internationally in Geneva by the League of Nations at the time, so the predecessor of the United Nations. And it was about standardizing the classification of cervical cancer because at the time they were trying, you know, radiotherapy was available, but they realized there is [00:54:00] no even consensus on how to stage it.
So if you want to do studies, you have to actually have a framework on how you assess, you know, the state and then the impact. And that was in 1928. And I think it had a. Huge impact. It took a long time then, , to take off that evidence-based medicine, but it's actually nearly a hundred years ago. And with regard to infectious diseases, I actually, I mean, it's just something that, , gave me extreme pleasure as, somebody involved in antimicrobial stewardship is that the new, a TS guidelines say, less than five days of therapy for community acquired pneumonia.
I think it's a monumental change. at least three, but less than five. And, I think it's, really progress and I was very happy to see that.
Erin: Awesome.
Thank you both. yeah.
Angela: Thank you. Breakpoints just did a very nice episode on those guidelines. And yeah, on the one hand, the new duration guidance is great, but yeah, there might be some antibiotic consumption, occurring for other reasons in that guideline.
Erin: But, uh, yeah, you know, there's never been a good trial in that. And I was like, I don't know. People are very up in arms about the [00:55:00] 2025 guidelines saying give antibiotics for viruses, but they're better than the 2019 ones. I think people have lost sight of that. the 2019 guidelines said, give every patient with a virus antibiotics.
They did, and I think people just like missed that or whatever. But the 20, 25 ones at least risks stratify them, you know, at like, at least.
Angela: Yeah. that's very, that's very optimistic.
Erin, the original, I, I just,
Erin: people are all mad and I'm like. this is not a new recommendation. The the 20 19 1 said that I think people just kind of glossed over it.
so mm-hmm.
And it's recommended ceftaroline as first line therapy for CABP risk. So we actually wrote from WHO we wrote a, but
to your
Angela: point, we wrote a commentary on that.
Erin: Okay. to your point though, stewardship is important and I'm just being a contrarian. Obviously I don't give ceftaroline for CABP, but there is a more robust RCT showing the benefit of ceftaroline in CABP patients than there is for any other CABP therapy.
It is an evidence-based recommendation, so it's not a stewardly recommendation, but how do you not put in the guidelines, even RCT showing it's very effective therapy for CABP. So. It's tough.
Angela: Oh, but that comes back to the age old tension, right? Right. Between the [00:56:00] individual patient and the group.
Right. I know, I know. And it's super expensive. Mean the same reason, like same, same issue. Like I have to give Nitrofurantoin, and I know it's not the best drug for lower UTI. But I know I need to give it
Erin: right
Angela: first line because I've got a whole bunch of future patients to protect.
Erin: Yeah. I mean it's like these, these new drugs have to come the market, right? They have RCTs in the disease state. What are you gonna do? Whatcha are you gonna do? You say it's clinically proven efficacious, but it's expensive and broad. So I don't know. It's, it's really tough. It's really tough. Angie. I give Nitrofurantoin for UTI, 'cause you told me to not, use phosphomycin so I
Pranita: know I'm always You RCT my world now.
Angela: I was like, hey, you guys have guidelines that say that that was
Pranita: even, he was back in the, because of Huttner et al's RCT. That's why that was your
Erin: RCT
Angela: Uhhuh IDSA IDSA put Nitro first line in 2010. Yeah. Yeah.
But that's another example. For example, in many countries, Nitrofurantoin is not available.
Right. So you say follow the guidelines, but then you don't have Nitrofurantoin.
Erin: Well, I mean, that's the United States with Pivmecillinam. Right. They're in the guidelines. Yeah. Never been a drug that we've had. Now [00:57:00] we have the drug and no one will, don't have it. So
Pranita: no one know how to pronounce it or spell it or words.
I
Angela: know.
Erin: iTill, I practiced it a lot. Yeah. I'm really bad at pronouncing. I
Angela: just say PIV as if I actually know the drugs. But we have no access here, so.
Erin: Correct. Like, like he's coming to your holiday party. You know, your friend.
Angela: All right. Well thank you too for being so nerdy. I love it.
So yeah, thank you so much. we just always wanna give the opportunity at the very end if there's any final messages that you want our respective audiences to hear.
Bene, final thoughts.
Benedikt: Yeah, there was something I wanted to say, which I forgot to say, and that's, the criticism sometimes of evidence-based medicine. The famous parachute example, right? Saying, oh, you know, everything is clear. Why yes, no randomized control trial. And I think. most things and medicines are not like that, right?
You have moderate effects, you have many different outcomes. It's not so clear, you know, [00:58:00] it's not just determined by physics because, the parachute example is gravity and friction. we have biological systems that becomes complicated. If you talk about infectious diseases, you have all the issues with the different pathogens, complicating things.
So I think it's kind of an annoying, unfair example because most things in medicines are not like that, and that's why it's complicated.
Angela: fair enough. I like that observation. It's true that it, is a very powerful kind of obnoxious, demonstration of why guidelines are stupid, right?
But I agree. We aren't that simple. If only we were, then nobody would have any guidelines.
Pranita, any last thoughts,
Pranita: I just want people to know that I, don't hate children. Even though I don't like Halloween.
that's it. Thank you for, having this podcast and for inviting us.
Angela: thank you so much to our guests, Benedict Huttner in Geneva, Switzerland, and Pranita Tamma in Philadelphia, Pennsylvania, USA. And thank you to Erin McCreary in Pittsburgh.
Pennsylvania USA for co-hosting with me, Angela [00:59:00] Huttner in Geneva, Switzerland. Thank you for listening to Communicable the CMI Comms podcast and breakpoints, the Society of Infectious Diseases Pharmacists Podcast.
This episode was produced by Katie Hostetler Oy, Megan Klatt and Lacey Warden. It was edited by Katie Hostetler, oy. It was peer reviewed for Breakpoints by Lacey Warden and for Communicable by Ljiljana Lukić of the University Hospital for Infectious Diseases in Croatia.
The executive producer at Breakpoint is Lisa Dumkow, and its theme song was recorded by SIDP, member Steve Smoke. The executive producer of Communicable is Angela Huttner and Communicable Music was composed and performed by Joseph McDade.
You can subscribe to both Communicable and Breakpoint on Apple, Spotify, or wherever you get your podcast. Thank you for listening and helping CMI Comms and ESCMID move the conversation in ID and clinical microbiology further along and helping SIDP achieve our vision of safe and effective antimicrobials for now and the future.
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