Antibiotics: the ‘wicked’ questions

The Clinician Scientist Fellowships (CSF) is a world-first scheme open to medical, nursing and allied health clinicians from The Royal Children’s Hospital (RCH). It offers successful applicants a golden opportunity: protected research time.

It’s an investment in early and mid-career clinician researchers as they establish an independent research program.

Associate Professor Penelope Bryant was one of five in the first CSF intake and has just completed her second year of five. She is packing a mighty amount of research into her two days a week away from her clinical position as a paediatric infectious diseases physician.

She might still see patients during those days, however, because her clinical practice and research share a unifying theme; what Penelope described as ‘a wicked problem’. It is, in fact, an issue the World Health Organisation also has in its sights: antibiotic overuse and misuse.

“In my clinical practice, my patients include any child with an infection, from the straightforward like cellulitis to the complicated such as infections in cancer,” said Penelope. “My research is about helping healthy children not get infections, particularly antibiotic resistant infections.”

In Australia, about 50 per cent of children have had one course of antibiotics by the time they turn one, yet children are a neglected cohort in most studies of the subject. With antibiotics underpinning so much of our healthcare, it’s vital their usefulness is preserved by intervening early to prevent an explosion of resistance in children.

“At the RCH, we’re articulating a clear vision to develop best practice in antibiotic use,” continued Penelope, “treating the right patient with the right antibiotic at the right time in the right place.”

But where is that place? While children don’t commonly develop resistant infections, an unknown rate of colonisation with resistant bacteria in their nose and throat, skin and gut can spread these bugs to family members. Penelope and her team are developing a map to chart where childhood antibiotic resistance is primarily located in Australia to determine how that aligns with antibiotic use, hospitalisation rates and socio-economic levels.

“Antibiotic use can have downstream effects,” continued Penelope. “We’re just beginning to learn about the effects on the microbiome – the sum total of all the microorganisms that colonise the human body – and how these disruptive effects might lead to issues like obesity, for example.”

While the fellowship positions Penelope as a research leader, her research focus is sharpened through a number of other significant positions.

She’s the co-leader of the Clinical Infectious Diseases Flagship at Murdoch Children’s Research Institute (MCRI) and led its engagement with an international review to address the central problems in paediatric infectious diseases.

She is also the chair of the RCH Antimicrobial Stewardship Committee which oversees the use of antibiotics in the hospital, and the medical lead of the RCH’s Hospital-in-the-Home (HITH) program. The latter is by far the largest such paediatric program in Australasia and adds at least 50 virtual beds to the RCH with clinical staff paying daily visits.

“One of the things I’m most proud of is the oversight we’ve put into antibiotic use in Hospital-in-the-Home,” said Penelope. “Previously bone and joint infections might have been treated for six weeks, but children don’t need that.”

Although intravenous administration of antibiotics is the most common HITH treatment, Penelope is convinced that the other best medicine is simply being at home.

“Children do better psychologically staying within the family dynamics,” she said. “We particularly want to minimise hospital stays for children who spend a lot of time on the wards such as those with cancer or cystic fibrosis.”

So responsive is the HITH model that, for five years, it’s been offering a pathway out of the Emergency Department (ED) and straight home for treatment.

“The ED team liked the concept but questioned whether it was safe,” continued Penelope, “so we ran a world-first randomised control trial. For 188 children presenting to ED with severe cellulitis, we investigated the efficacy of intravenous treatment at home and found that it was in fact safer at home as well as a cost saving for the hospital.

“It’s about turning best evidence into best clinical practice.”

Penelope was mentored at the start of her fellowship by a senior MCRI clinician and now she’s in the mentor’s position. The baton is passed on and one of her priorities now is to build up early post-doctoral fellows.

“The fellowship tells people our research program is exciting,” she said. “Come and engage with us.

“There’s not just a need for collaboration between scientists and clinicians but a need for individuals fluent in both science and medicine to think about their patients differently. It makes them better clinicians. It makes me a better clinician.”