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Hello. Can you hear me? Yes, we can hear you. OK. Amazing. So I see that we've got about 20 people right now. So I'll just give it a couple more minutes and then we'll start. Um Can I just get a response from one of the audience members? If you guys can hear me, please just drop a message in the chat if you can. Yes. Amazing. Thank you. So yeah, I will start in about just a minute or two just to give people a couple more minutes to join. OK. No. OK. OK. Mhm. Mhm. Ok. Amazing. So we will get out then. So hi guys, welcome to teaching things and today we're doing all you need to know about antibiotics and sepsis. My name is Harish and I've got with me um Eleanor who will be doing the second half of this talk. So I'm gonna be starting off today with antibiotics. Um So welcome to things if you haven't been here before we do weekly tutorials open to everyone focused on core presentations and focus on teaching diagnostic technique. Um It's done completely by medical students. So myself and Elena are both fifth year medical students at UCL and we also have doctors who review our slides to ensure that we're giving you guys accurate information and we will keep you updated about our upcoming events via our email and group chats. So today we're gonna start off with antibiotics. So what we're gonna be covering is antibiotics. So we wanna talk about what they are, how they work some common classes of antibiotics. Um We're gonna be talking about types of bacteria and common antibiotics that you may use in certain common conditions and what to do when you have allergies such as penicillin, which is c can be quite common in clinical practice. We'd also like to talk about some of the important side effects and some high yield interactions between other drugs and some cases of how and when you might consider antibiotics within a GP setting. Ok. So before we start off, I'm just gonna do a quick poll of, I'm just gonna do a quick polish. So it should appear on your screen. So I just wanna get a rough grasp from you guys of how confident you are about currently about antibiotics, it's use is in common conditions and any side effects. Um So if you just fill in this poll when you can please as soon as possible, um we give about a minute or two. OK. Amazing. So I'm seeing a bit of a mixed response. Some of you are quite confident some of you have almost no, no idea. But a lot of you are kind of in the middle. So, ok, let's get started. So, first of all, what are antibiotics? So, antibiotics, they are drugs that we use to treat infections caused primarily by bacteria but sometimes other microorganisms such as fungi. Um They are made of chemical substances either produced by living organisms made in the soil bacteria and other fungi or some are also made synthetically. And how do they work? Um So there's five main mechanisms of antibiotics that control different classes and they work on different types of bacteria. Can anyone just give any ideas that they might have if you just drop it in the chart of any main mechanisms that you may have heard of, of how antibiotics work. See, yes, the slides will be available afterwards. And this whole presentation is also recorded. So you can rewatch it at any point you'd like. Yeah. OK. So, so let's go through some of the main mechanisms. So the first one is inhibiting cell wall synthesis of the bacteria like Hazara just said as well. And yeah, this is amazing. So you want this is targeting the structure around the bacteria. It breaks, it prevents the synthesis of the cell wall and therefore the structure kind of breaks down and you get cell lysis. Another mechanism is inhibition of protein synthesis, primarily interfering with the prokaryotic ribosomes. So this again prevents reproduction and prevents the bacteria from performing its actions, then we have injury to the plasma membrane. As we know, bacteria has a cell wall and a cell membrane. If you cause injury to the membrane, it increases the permeability. It can either cause loss of metabolites or it can cause um excess fluid to uh rush into the cell again, causing cellulitis. Finally, we have got two more. We've got inhibition of nucleic acid DNA or RNA synthesis. So this prevents again replication and transcription. So, bacteria can't produce as proteins or, and it can't reproduce. And finally, we have inhibition of synthesis of essential me metabolites and this causes competitive inhibition of key enzymes. Ok. So I'm gonna give you guys some examples now of some classes of antibiotics. Um Does anyone know any classes? And if they do, can you also give any examples, please? You just drop a message in the chat when you can? Yep. Amazing. So you've got beta lactams and an example of that is penicillins. Any other ideas? Yes. Good. Yep. So macrolide. So Erythromycin is a common one. Good. Amazing. So here are all the, some of the main classes of antibiotics. There are some other kind of niche and smaller ones which I haven't necessarily listed on here. But these are some of the common ones that you see used in clinical practice and are commonly prescribed for some common conditions which we'll get onto later. So we have your beta lactam. So this comprises of three different types. So this is your penicillins, your cephalosporins and your carbenin. So, penicillins, that includes your amoxicillin, your benzylpenicillin, uh Foxim penicillin as well. Cephalosporins. They always have the C ef um starting like the suffix. So your cefTRIAXone and cefuroxime and your carbapenem. So these end in penem. So meropenem teem, then we have your glycopeptides such as Vancomycin um aminoglycosides. Uh So this is your gentamicin neomycin. We also have macrolide. So, like um you guys said in the chart, so this is your Clarithromycin, Erythromycin and Azithromycin um Lincosamides, that's your clindamycin quinolones, uh Ciprofloxacin, levofloxacin Polymyxin B, which is kind of a category of antifungal and antibacterial. So that's antifungals, your fluconazole and your ketoconazoles. And then you have these other couples like sulfonamides and trimethoprim. OK. So this is a bit of a broad list. So you can use this Pneumonic. Um It's not the best in the world. So, you know, you may have your own that you've developed over the over your educational um in medicine. So, one that I've got here is Britain's got talent, always made live quick performances appear superbly tremendous or maybe the opposite as well if you, if you watch the show. Um So this kind of gives you a way to remember the broad classes of antibiotics and it's something that you can refer back to in the future. So I've got a kind of a match up here of trying to match the classes of antibiotics to the mechanisms of action. And as you can see, there's some of the classes are joined together. So, tetracyclines, macrolides, aminoglycosides, lincosamides, they all work in a very similar pattern. So if we go through it, does anyone know which class of antibiotics is uh responsible for inhibition of cell wall synthesis. One too quick. There anyone have any ideas? Ok. So inhibition of cell wall synthesis. So this is primarily the class of antibiotics that work in this way is primarily your beta lactams and your glycopeptides. Um So they both work kind of to target the cell wall. And how about next? So we've got inhibition of protein wall synthesis. Does anyone know which class of antibiotics? That one refers to any wild guesses at all? So, inhibition of protein more synthesis is c exactly. So that's your tetracyclines, macrolides, aminoglycosides and lincosamides. Um ok. So how about injury to plasma membranes? Any ideas for that one? Any guesses? So injury to plasma membrane, this is gonna be your Polymyxin B. So this is your kind of antifungal medi medications and your antibacterials. Amazing. And now we've got inhibition of nucleic acid synthesis. Um So does anyone have any ideas for this one? It's kind of a 5050. Yep. Amazing. So this one is a, so it's your quinolones and then finally, we have inhibition of synthesis of essential metabolites, which is gonna be your sulfonamides and trimethoprim. Amazing. So these are a broad class of antibiotics and rough and the kind of mechanisms in which they work. And this can be really important to kind of understand how antibiotics are targeting your bacteria. And it gives you a bit of understanding as to how and why we use those. And I'll get on to the next bit in a second. So this kind of diagram kind of broadly covers um these mechanisms and shows you where they're working. So your beta lactams targeting your um cell wall and your vancomycin, which is your glycopeptides. Again, looking at the cell wall, um some of them you can see are looking at the ribosomes, er the DNA the cell membrane and then just your enzymes in general. OK. So this is something you can refer back to and it gives you a kind of a broad summary of all your mechanisms. OK. So we're gonna talk about bacteria itself now. So as you sa lot of you may know bacteria is split into your gram positive and your gram negative bacteria, what this really means is looking at the cell wall structure of your bacteria and specifically the peptic peptidoglycan cell wall. Um So gram positive, when we look at gram positive bacteria, we find that it has a very thick peptidoglycan cell wall. Whereas your gram negative bacteria is a lot thinner. And what this means is that when you stain the bacteria with dye, it's retained a lot less than your gram negative because of that thinner cell wall. So the dye leaks a lot more. And then when you get your gram staining, which I'll show you an example of in a second, it can appear either pink or red. Um whereas dye, which is retained, whereas gram positive bacteria, it retains that dye a lot more. So it appears a lot darker and it appears with that purply color. And can anyone um tell me what investigation do we do to determine this information? So how we are assessing for bacteria? Well, there's one main investigation that you may know and the one thing I'm thinking of the most anyone have any ideas, drop the message in the chat. Yep. So we are doing gram staining but where are we getting that bacteria from? Amazing. Yeah. So we're doing blood cultures. So blood cultures are some of the most important investigations you'll do when you're assessing infections. Um and you're trying to work out which antibiotics to give. So blood cultures tell you three things. So firstly, it can tell you whether the bacteria is gram positive and gram negative. And this is actually identified first before you know what specific bacteria it is. So this for example, can tell you straight away that we have some gram negative rods in the blood um causing infection. Second to that you'll then find out what specific bacteria it is. So in this case, you could say we we've found out it's a gram negative rod. And now we know that, that actually this specific gram negative rod is Escherichia coli also e coli as most of you probably know it as. And then finally, after you found out the specific bacteria, which can take quite a few days to grow um fully to find out the exact one, we then can test that bacteria for its sensitivities and your resistances. Now this is really, really important and um because it tells you what antibiotics will actually work and what antibiotics that that specific strain of bacteria is resistant to. And this can vary depending on the area you live in. Um and the trust itself and what antibiotics they've used over the years. For example, some trusts may use one bacteria to treat a certain infection. However, in another area that specific strain is resistant to that antibiotic. So for example, um we're treating an infection with Clarithromycin. However, in village, a Clarithromycin can be used. However, in village b, that strain of bacteria is actually resistant to Clarithromycin. So therefore, they may use something like Erythromycin instead. So the sensitivities and resistances are really important so that you can direct your clinical practice and give you the best idea of what to what antibiotic to choose. Ok. Amazing. So some kind of facts that we know is that gram negative bacteria have a bit of a protective capsule and this prevents its ingestion from white blood cells. And this can mean it's not used in certain certain antibodies just don't work that well. And g bacteria in general can be found in either cocky bacilli or branching fam filaments. OK. So I'm gonna show you an example of these now. So we have this gram stain here. So we've got two different gram stains. One on the left and one on the right. Can anyone tell me which one would be gram positive and which one would be gram negative? So would you say this the purple one is gram positive or gram negative? Amazing. Yes. So gram positive, your gram positive bacteria appears purple and you can see quite a distinct difference in the color. So this one's a lot darker. Sometimes it appears a bit blurry. Um but the majority of the time it's purple, whereas on the right, you can see it's a lot more pink. OK? So here is a quick a little table of your main bacteria of your gram positive and gram negatives. So gram negative cocci, that's almost always Neer. And this can be either nicer meningitis or nicer gonorrhea. So you some primary causes are both gonorrhea and meningitis. Your gram positives. That's your staphylococcus, streptococcus and enterococcus. OK? And you can kind of go into a bit more. So for example, you can learn about group A and group B streptococci um and that's to do with your B to hemolytic B alpha hemolytic. But I'm not gonna go into that in too much detail right now. These are just ways to remember the broad categories. Um your gram positive bacilli, this is your actinomyces, your bacillus, uh clostridium, coryi, and listeria. So your corona, that's your common cause of diphtheria clostridium. You may know as C diff um or C diff facile bacillus, which is your common infection of um leftover rice or rice that's been warmed up multiple times. So these three kind of have these very specific bacteria. And as a general rule of thumb, obviously, it's not, I haven't put an exhaustive list of all the bacteria on here. Majority of other things and other bacteria will be a gram negative rod or a gram negative bacilli. So that includes a lot of your kind of gastrointestinal infections. So your salmonella, your e coli and other other things like klebsiella and hemo haemophilus, commonly found in a lot of respiratory infections. They are all gram negative rods. And so if you um if you can kind of remember some of these bacteria, it really helps with figuring out what antibiotic may work best depending on the infection. So w something I'll get onto in a second is antibiotics will cover gram positive bacteria, gram negative bacteria. Some will do both, some will do one better than the other. And so if you know whether it's a gram positive and gram negative, and if you know which antibiotics correlate to that, it can help you make an educated guess about what antibiotics to give, depending on what situation you're in. Ok. So if there's a table here that I'd like to show you, so this table which it might be a bit small on your screen. But if you just search antibiotic cov coverage on um Google, you'll find many of these tables. So these tables kind of show which antibiotics cover, which infection. So which kind of primary infections. So as you can see, for example, M RSA, that's only really covered by Vancomycin, Clindamycin and um Bactrim, they're very little whereas you can see some of the others are covered by many antibiotics and some have a broad spectrum and some have a very narrow spectrum. So many of you may have heard of broad spectrum antibiotics and when they mean broad spectrum, they mean it covers a lot of different bacteria. So something like your coamoxiclav or your ciprofloxacin, those they have a very wide range of bacteria that they can treat. And so when you don't have your sensitivities or you don't know you when you haven't had your blood culture results yet, so you don't know what specific bacteria it is, you wanna give a broad spectrum antibiotic so that it covers multiple different um infections so that you get uh some good coverage. In the meantime, um got a question about uh V RSA. Um so V RSA is Vancomycin resistant um Staphylococcus aureus and this is a very tricky infection because obviously M RSA which is commonly found in hospitals you usually want to treat with something like Vancomycin B RSA. Um, I'm not too sure about, but I let me just quickly have a look. Have a think. So. I believe from what I remember V RSA kind of, there are some other antibiotics which you can use. I think the main one that I can remember is something like Daptomycin. Um, I can't remember exactly which class potential link coamide. Um But in general, one thing which I want to know which I will get onto after as well, your antibiotics that you choose is always gonna be dependent on the trust and the hospital you work at. Each hospital has its own guidelines of which antibiotic they prefer to use. So for example, some, like I was saying before, some trusts prefer to use Clarithromycin over Erythromycin for whatever reason. Um One of the big reasons being the kind of sensitivities and resistances that are available that are common in that area. So each trust will have its own guidelines of which antibiotic to use. So for example, with the V RSA, it can just depend on, depend on which trust you are in. I have a picture here which shows the coverage of your br your main classes of antibiotics. So as you can see a lot of them have a lot positive and negative coverage, whereas aminoglycoside is the only one which is only gram negative and you can remember that by the no amine. No. Um so no, so gram negative and then you can see some of the other ones at the towards the bottom are only gram positive. So your macrolides, your lincosamides and your glycopeptides. What this means is that when you're unsure of which antibiotics to give, you can have a think and remember, OK, I know that macrolides. So your clarithromycin only covers gram positive bacteria. So in my patient who's got meningitis caused by nice meningitis, I know for a fact that macrolides are just not gonna work because they only have gram positive coverage. I hope that makes sense as to what I'm trying to hint at. OK. So I've got a quick question here which I'm gonna set a pole for. So a patient has come in with a gastrointestinal infection and blood cultures have been sent to identify the source of this infection. Results have pre preliminarily shown a gram negative bacteria. So which of the following antibiotic classes? Would you not choose to prescribe for this infection? So if you just take a second to answer this, Paul, OK. So I'm seeing some responses coming in, I'll just give it like 30 more seconds or so. OK. So I'm seeing a bit of a mix of answers. So I'm seeing some of you say aminoglycosides and some of you saying a macrolides, a few of you saying sulfonamides and other ones. OK. But I've seen the majority of you go for macrolides. Which amazing. Yes, you you are right. So macrolides is the correct answer. This is the only one that has gram positive coverage. So those of you who've chosen aminoglycosides, I think this is an important point to remember that you should always read the question carefully because it's saying which of the following antibiotic classes would you definitely not consider? Whereas aminoglycosides is the only one that's g only gram negative cover. So you may have fallen into that trap but just make sure to read the question carefully. And so just to highlight this, I'm gonna go back to the picture I showed you. So as you can see, macrolides is only a gram positive coverage. Whereas we know that in this question, it, they have found a gram negative bacteria and the other ones. So your tetracyclines, your quinolones and sulfonamides, they both have a gram positive and gram negative coverage. So you could consider, you could consider those depending on what the infection actually is. I see. So I'm gonna move on now. So I'm moving on to some common conditions that you see, which you will need to know the best antibiotic to give. So this ranges from your pneumonias, your uti s um to things like your sinusitis, your tonsillitis and your kind of gi infection. So your er c diff campylobacter meningitis, but I just wanna you reiterate that this is not an exhaustive list. It does not include all the infections from the UK MLA content map and definitely does not include all the infections that you need to know how to treat at this stage. Ok. So before we get on to some of these common conditions, which classes of antibiotics would you not consider giving to a patient who's allergic to penicillin? So I'm gonna start this poll now. So as you guys answer this, penicillin, allergy is very commonly seen. Um, in clinical practice, a lot of people come in with penicillin allergy and just as a kind of like, uh CPS, a osk tip. One thing with any allergy, whether this is penicillin, whether this is, um, nuts or anything, it's always important to rem remember to ask what reaction do you get when you take this medication or this drug or trigger whatever the allergen is? It's always always important to remem, ask what the trigger. What happens? Is this an anaphylactic rash? Is this just they get some rash? Is it sorry? Is this an anaphylactic shock? Is this just a rash or do they get some nausea and vomiting? So you want to know whether they are actually allergic to the drug or do they just have a common side effect nausea? Vomiting, like gi symptoms can be quite common with a lot of medications. So you want to know whether that is actually going on or are they actually allergic? Are they gonna have an anaphylactic reaction? And is that gonna be life threatening for them as a patient. Ok. So it's always important to remember if someone mentions any allergy, always check what the reaction actually is. And yes, amazing. A lot of you have got the correct answer here. Basal lactams should definitely not be given. If a patient is allergic to penicillin, penicillin is one of the three beta lactams. The other two are your cephalosporins and your carbapenems. And also those you would not really prescribe those either because there might be some cross reactivity you the others don't, you can't, you will be safe to give. Ok. So here, I've got a table of some of the common conditions and some of the first line antibiotics that you use for those conditions. So I'll let you just have a quick read of these. And as a general rule of thumb, if a patient is allergic to penicillin, you can give Clarithromycin or basically macrolide. So, Clarithromycin and Erythromycin are commonly used for patients who are allergic to penicillin. So as you can see some of the common ones here, we've got amoxicillin or co amoxiclav for communi community acquired pneumonia, whereas you tend to use your Clarithromycin for your kind of atypicals. Um So that's like your mycoplasma, your legionella. Um those kind of things. And then we have hospital acquired pneumonia or aspiration pneumonia. So, commonly seen in some of the more elderly patients or people who have difficulty swallowing, we use Coamoxiclav uti S the two common drugs antibodies we use is nitrofurantoin or trimethoprim cellulitis is typically flucloxacillin, tonsillitis is your phenoxymethylpenicillin and um otitis medium oxacillin, salmonella, ciprofloxacin, Campylobacter Clarithromycin C diff oral vancomycin and meningitis is cefTRIAXone. And I'd just like to highlight the importance of oral vancomycin for clostri idius. Um Clostri C diff, I can't really say that too well. Um Yeah. So I'd just like to highlight oral vancomycin should always be used for C diff because this prevents reduces the transmission through the fecal oral route. So it really, I is a much better way of targeting and killing that bacteria. And again, I'd just like to make an important note though, these are commonly prescribed, you should always always refer to things like a la or micro guide as a lot of you may know it for your local trust, specific guidelines for reasons that I've explained before. Ok. So now I'd just like to talk about some of the important side effects of antibiotics that you should remember. So this can come up in a lot of UK MLA questions and it's quite um it's just a good thing to understand and for whenever you're prescribing antibiotics, for things to kind of safety net to your patients. So, amoxicillin can commonly cause a rash with um infectious mononucleosis, coamoxiclav and flucloxacillin are both known to cause cholestasis. So gall uh gallstones, erythromycin, um and all macrolides are commonly known to cause um prolongation of QT intervals. And this is the one that really, really important. And can anyone tell me why a prolonged QT interval is really, is quite bad and quite dangerous. Can anyone tell me what it can um make a patient more susceptible to get you just drop it in the chart? Yes, amazing. So you guys have got it. So it's the, the funny named um arrhythmia. So to, to de point um prolonged QT can cause, yeah. So things like your ventricular arrhythmias, which can lead to TDP and this is a very, very dangerous. It's a very life threatening condition where if it isn't found quickly and treated correctly, um it can cause patients to die. So it's very, very important and very dangerous. And so you want to always make sure when you're prescribing something like Erythromycin, the patient isn't on any other medication which can cau which also causes prolonged QT intervals. So something like Citalopram, for example, now, then we have Ciprofloxacin. So this is known to lower your seizure threshold. So you have to be careful in someone who's got epilepsy and it was commonly also known to cause tendonitis. Specifically, a lot of patients who've been on Ciprofloxacin um have known to have achilles tendon rupture. It's a, it's have been quite common other things. So metroNIDAZOLE. So this can cause a disulfiram like reaction um which following alcohol. So you should never give metroNIDAZOLE is the one antibody. You should never never ingest with alcohol cos it can, the reaction can be quite poor, quite severe. Then we have photosensitivity for both doxycycline and trimethoprim and trimethoprim also causes some rashes and Prusis. OK? So definitely have a look through this table after this section is done to have a read through and to kind of learn some of these. OK. So just an another SBA now, so if you just have a quick read of this and answer what you think might be going on? No, sorry, I put the wrong one. OK? Give me quickly. OK? So I haven't, I haven't made this poll properly. So if you guys could just answer in the chat, what you think the answer might be for this one, please see if I can. OK? So I've got this poll up now. So if you could quickly just see if you can answer this, please, it should appear on your screens. OK? Yeah, amazing. So a lot of you are getting the right answer here. So you guys are right. So Erythromycin um can cause as I said just for now, Erythromycin or sorry, Erythromycin, in this case, ca a common side effect is your prolonged QT interval and I just have given you a couple of explanations here. So, Ciprofloxacin, like I said can be a cause of seizures, but it doesn't explain the prolonged QT metroNIDAZOLE as well. Can can be a cause of palpitations and that's part of your disulfiram like reaction um with alcohol, but it doesn't explain the seizures and your prolonged QT interval. Ok. So some important drug interactions that I want you guys to be very aware of. Um some of them can be life threatening and need immediate attention. So, does anyone have any important examples that they might um know already and they can let kind of put in the chat, any ideas? So there's three that I want to highlight. So we've got macrolides and statins, macrolides and Warfarin and trimethoprim and methotrexate. So, macrolides and statins. So this can cause an increased risk of rhabdomyolysis. Um and this is er rhabdomyolysis when your muscles break down and can then cause kidney damage, can lead to AK I and then d chronically kidney disease. So it's something that patients have to be aware of and they should usually statins should be stopped when they're signing a patient on um Clarithromycin and Erythromycin. The next one is Warfarin with your er Clarithromycin or macrolides. So, macrolides are ap 450 inhibitor. So P 450 is an enzyme that is, that typically breaks down warfarin. So if you have something that's inhibiting that enzyme, it's gonna increase your I nr which increases your bleeding risk of patients. So this makes patients more susceptible to any kind of bleeding, whether that's like hemorrhagic stroke, for example, or just if they get bruising and they start bleeding or cuts. Um So it's a very important thing to monitor carefully um in patients. And the last one that I want you guys to be aware of is trimethoprim and methotrexate. So methotrexate, as you might know, is commonly used in a lot of um rheumatoid conditions. So, rheumatoid arthritis, for example, and when given with trimethoprim, they both can cause myelo suppression, which can cause bone marrow aplasia and um can make a patient more susceptible to getting really poor bad infections. Ok. And so the last thing I want to talk about is how do you decide when to give antibiotics? So, in the GP setting, uh you have to consider when they might be indicated. And in these cases, we have certain scores which might be helpful. So for example, you have the fever pain score and the center criteria and the primary aim of both of these is to determine whether the infection is actually a bacterial cause or a viral cause. So the fever pain, does this quite well. It gives one point for each of the following. So a fever of over 38 degrees cent grade purulent such as some kind of exudate or pus. Um a quick onset severely inflamma inflamed tonsils and no cough or cries or symptoms. Whereas viral infections, you will typically have more of a low grade fever. You won't really see any exudate. It can be a bit of a slower onset and you almost always have kind of like a congested nose, a cough. It sounded like in influenza flu type symptoms that, um, a lot of people present with in winter and depending on your score, show is dependent on the likelihood of isolating, um, streptococci in this case. And this can help you then decide whether you, you should be giving antibiotics or whether you should just kind of safety. The end for viral er causes. The next one here is central criteria. So this is more specific for tonsillitis. And again, so it's looking for tonsillar exudate. It's looking for any tender anterior cervical lymphadenopathy. So around this region or any lymphadenitis, it's also looking at if there's a history of fever and again, no cough. Um We've got a chart saying there's a pneumonic placental. Uh Please do share if you've got. So we've got c for lack of cough. So if you guys have a read of the chat has asked very kindly giving us a pneumonic placental criteria and like we've said, a high center score suggests a strong likelihood of bacterial tonsillitis. Um And that's when you wanna start your medication. Ok. So again, I've, I've got one more SBA here before we finish off. So if you guys could try this out, please, I'm gonna start the poll now. Ok. So we've got some varied responses here. So we've got 73% of you went for option two. So essential score of three would, so you should give amoxicillin, whereas te 15% of you went for option four and 10% for option three. So the answer here is actually option four. So the patient actually has a center score of four. So you can see they've got a history of fevers and it's three days. So you know that it's a fairly short and acute onset, the patient doesn't complain of any cough. So there's absence of cough, we have tonsil exudate on examination and there is cervical Lyden. Um So overall, we've got a, a score of four. So we know the patient's got a score of four. We know that this is therefore, meaning it's very likely to be a tonsil bacterial tonsillitis and the first line antibiotic, which um which I mentioned a few slides back is actually phenoxymethylpenicillin. However, we've also got here notes that the patient has no known allergies. So if the patient was allergic to penicillin, we would actually consider Clarithromycin instead. Ok. So I hope that you guys can see how the question's got you to kind of pick apart and use the essential criteria to choose which, whether they decide whether this is a viral cause or not. Ok. And what is the biggest complication of infections? It is sepsis, which leads very nicely into the second half of the talk um by Eleanor. So I'm gonna hand over now. Hi guys, I'm just gonna get the presentation up. Give me one second. So as Eleanor does that, I'm just gonna send the feedback form now. So if you guys could please fill in the feedback form now and it will also come at the end of the session. Um Eleanor will also send it again. Uh It's really important for us like it really helps us to see how you guys have found the session and how you would want us to improve for future. So please do fill that in when you get a chance. Thank you. Just gonna let it load for a bit. Um Sorry whilst it does load, would you guys be able to just so I can get an idea of how much everyone knows about sepsis if you could answer the poll, please? Ok. So everyone's kind of midrange with this. So it connects very well to antibiotics because as Harris was saying, one of the biggest complications of infections is sepsis and of course, that is what we use antibiotics for. So I'm just gonna give this like two minutes to load properly. Sorry about this guys. Ok. Ok. I the OK. Ok. Ok. Yes. Ok. No, I OK. No. Ok. Ok. I I Mhm. Ok. So now that we're kind of loaded up, so I'm going to be talking about sepsis. And the reason why this is relevant is because it comes up in a range of AK stations. A KT S in the form of prescription tasks in the form of complications in the form of management. A two E management is a really common ay station when it comes to sepsis. So we're hoping in this tutorial to cover some of those common presentations and how you would go about spotting and managing sepsis. So for some definitions, firstly, sepsis and septic shock sometimes are used interchangeably. And the difference between them is that sepsis is a life threatening organ dysfunction caused by a dysregulated host response to the infection. Septic shock is essentially a worse form of this where the mortality risk is greater and to a cellular and um metabolic level. There are more abnormalities. Ok. You may have seen anyone who is currently working or on the wards. A lot may have seen these signs around and they are kind of to highlight the importance of spotting sepsis because as I mentioned previously, it comes with a very high mortality and to start us off, we have this little um SBA. So patient X, well, not SBA, this has one right answer. So the patient X is a 22 year old male admitted to the rest board for pneumonia over the last three days. He has been recovering steadily. But observations this morning show a Respi rate of 23 SAS of 94% BP of 95/80 pulse rate of 100 10 of 38.2 patient is alert. What is his news two score? I'm going to put up a poll um for this, I hope the um the news two chart isn't too small to see. I hope you guys can at least zoom in a little bit. Ok. Ok. I, you give it a few minutes? Yeah, I, ok. Ok. Ok. Ok. Ok. So we're kind of between six and seven, which is very reasonable because the answer is well, seven because they'd score two for their respirate one for the oxygen saturation because the patient is on air. We don't count the next two columns because therefore if the patient is on oxygen and still not saturating properly, um systolic BP scores two pulse rate scores one. I actually consciousness, the person is alert, so no issues there. Zero and the last one for temperature scores one and the total of all of those is going to come to seven. Now this chart here kind of highlights the protocol when sepsis is suspected. So if the new score is under five, then we're looking at ward based care perhaps a little bit more monitoring, 4 to 6 hourly monitoring. Um if it's a case where the patient scores three or above in one of those parameters. So for example, only temperature is scoring high or only respirate, just scoring high, then we're more trying to look at, you can kind of tell that there's more of a local issue going on as opposed to a fully metabolic system issue. So you would intervene accordingly to that. If the news starts to go above five, this is where you start getting concerned, alarm bells start going off. So above five, at this point, you're having very regular monitoring to make sure that we catch it early and intervene early above seven, which is where this patient is or rather seven or above, we need continuous monitoring. And at this point, it's going to also trigger the critical care outreach team as well. Um because at this point, it is an emergency and there's a very strong risk to the person's life. OK. Now, we have an SBA. So Mr X has a new score of seven, which is the patient that we're just talking about. And as the F one, you need to initiate the management algorithm. So what do you do? First, the pole is gonna go up? Um Now, OK, everyone seems to kind of be between assess airway or give him broad spectrum antibiotics or take his temperature. OK. We've got quite a mix of responses. Um Most of you have actually got it right. It is assessors airway. And the reason for that is like this is the biggest osk tip. A KT tip I can give in anything to do with an acutely unwell patient. The first step is to always, always assess the airway and then you would do your relevant interventions. But firstly, always a two E management and the a of course stands for assess his airway. We do take his temperature to make sure, but it's unlikely if the patient is being monitored that often that the temperature is wrong. B as I said, is the correct answer again. C we do give him broad spectrum antibiotics, but this question is asking for the initial management. So this isn't what we're doing. When we first see a patient to a septic, give him a blood transfusion. There's no indication for this at this stage. And with e exposure again, we'll come into the A two E assessment, but it's not our initial management. Ok. On to the next part. Now, the investigations and management for sepsis kind of go hand in hand. So we take a give three, take three approach when it comes to sepsis. That's kind of the catchphrase for it. So what do we give? There's three things broad spectrum antibiotics which as you will remember from Harris's lecture, um from his tutorial are we want the antibiotics that will cover a large amount of organisms? So, Coamoxiclav and Clarithromycin are always safe options to go for because they cover a lot of bacteria, fluids. They usually usually it will be 500 mils of 0.9% sodium chloride over 15 minutes for fluid resuscitation. That is just the standard. There'll be, there's some alterations to it which you will see later when we move on to the prescription stuff. Um In terms of oxygen, again, the usual catchphrase is high flow oxygen, 15 L per minute via non rebreathe mask. And it's important to say that it will be targeted to a target of 94 to 98%. Now, the interesting thing with this is going to be explained in the next question. Does anyone know how the oxygen requirement would change if this patient was um had COPD or was a carbon dioxide retainer pole is gonna go up now? Ok. Yeah. Yeah. Ok. Let's have a look. So the correct answer is C 88 to 92% via a venturing mask. Now, the reason why it's not A is because the target saturation for anyone who retains carbon dioxide. The main example of which is a patient with COPD, their, their body has kind of adapted to breathing with less oxygen. So what happens is if you give them too much oxygen, the brain all of a sudden thinks, OK, the muscles don't need to do enough work, do any work anymore and because they already have enough oxygen. So it kind of the hypoxic drive is the official name for it stops working and because the cells feel like they have enough oxygen, you stop breathing and that can obviously end very badly, which is why you need to lower the saturations for retainers. Um Option B it's wrong for two reasons. Firstly, it can't be that high saturation even in someone who isn't a retainer and Option B, it won't be through a non rebreath mask, it will be through a venturia because we want to be able to control the flow of oxygen better and option d pretty self explanatory. Um Yeah. OK. So like I was saying, the very common stations that come up with sepsis, a lot of the time want to do with the prescriptions. And in the we sorry, we give section, the give three section oxygen is one of them. And the key things to note here are always, always like at your, at your concentration. All of that stuff remember to circle the target saturation. That's very important to reasons I just explained um flow rate again, usually is 15 L for a minute. Always remember to sign that big loop. Um In the time section just means that the nurses or whoever's administering the oxygen will know that it's on continuous and it doesn't need to be taken off until you intervene and say, OK, that's enough. Um The next one is the fluids. Now, this is what I was mentioning with regards to extra considerations. As you can see here, this is the prescription for a standard um person who needs resuscitation, 0.9% sodium chloride, 500 mil put the duration at 15 root of IV. You should of course. Um If you like for resuscitation, you're not adding any drugs signature bleep. And all of that as usual, if this person is known to be fluid overloaded or has heart failure, the body is going to be able to pump that 500 extra mil all in one go and that's going to cause even worse issues. So to counter that we give 250 mil instead of the 500. And finally, we of course, have antibiotics and antibiotics go in the anti-infective section of the prescription chart and you always need to include the indication um in osk that is always worth a mark. So don't forget to do that when it comes to antibiotics like Coamoxiclav, um you need to write that you'd review after 48 hours and that's just to check if there's any interactions, like some of the ones that was mentioned in the previous tutorial because if there is, you need to obviously stop it, find something else. Um And just like Harish was saying, always remember to, sorry, we have a question. Would you do that loop on the prescription for oxygen in a CPSA situation? I'm pretty sure we did. Yeah, I would say do that. Um Yeah. So antiinfectives, where was I? Yeah, then check your guidelines usually like broad spectrum, right? In the anti-infective section, um indication sign time everything. And then that brings us on to the, we take three section of sepsis, which is we're taking blood cultures, um the urine output and the lactate. And when we take cultures where as well as culturing it also measuring FB ce clotting glucose, L FTC RP. This is a good panel to say in an Os situation. Um If you kind of want to specify what you're looking for. And this will generally tell you, you know, things to do with um all of the, like all of the stuff. And this is usually done when the cannula is inserted in the A to E section. So in the, in the sea circulation, but the cannula will be inserted and when it's going in, you have an opportunity to take blood. And that's usually when this will be done. Um the urine output insert a catheter, this should be over 0.5 mil per kilogram per hour and the lactate is something else you need to take and it's going to be under two. Um OK. That brings us on to our next question in the case of Mr X who is a 22 year old, which bacteria is it most important to assess the serology for during bud culture? Ak A what's the most important cause of atypical pneumonia? I'm going to put the pod up. OK. We've got much more of a mix of this. It seems to be a battle between mycoplasma and strep for very good reason. Um The answer is mycoplasma. This is the most common cause of atypical pneumonia, especially in younger people. And given that the patient is 22 years old, this makes it a very reasonable answer. C I can fully understand why people would have gone for that because this is the most common cause of community acquired pneumonia. Across all groups. But because the question specifically for atypical pneumonia, we're leaning towards mycoplasma legionella. It's not going to be because that's tested in urine, not blood urinary antigens and hemophilia. Um, it would be more, you'd be more thinking that way if the patient had a history of smoking or COPD. Ok. Now, what are some of the common complications of sepsis? We've, I kind of discussed septic shock earlier in the first slide. Um It's a complication of sepsis which has higher mortality. Others include acute respiratory distress syndrome odds for short, which is where you get a build up of fluid in the alveoli and it's going to need mechanical ventilation. Usually A KS um usually needing temporary dialysis and D IC which is kind of a mismatch between um a mismatch between like clotting and bleeding. Like your body is bleeding so much that it can't clot essentially. Um Yeah. So all of these are complications that can occur of sepsis and one final SBA which of the following is a red flag criteria for a patient suspected of sepsis. Um pole going up. Now, this one's a little bit tricky. So, yeah, have a read through it properly. Ok. This. Mhm. Yes. Mhm. Ok. So the answer is recent chemotherapy. Now all of these ones are flags for sepsis. They're just amber flags. You have to distinguish which is the red flag. So respiratory rate, it's a red flag if it's over 25 and this question, it's not. Um if they haven't passed urine in the last 18 hours, then it becomes a red flag. At this point. It's not recent chemotherapy. The reason it's a red flag is because this person already has an incredibly weak immune system and neutropenic sepsis has like its own kind of pathway there where hematologists will intervene and um there'll be a whole, a whole other process for it. For instance, they might need broader spectrum antibiotics and extra interventions. Um With the BP when it gets to under 90 that's when it becomes a red flag at this point. We're still between the 91 to 100 range and yeah, that is everything. Thank you everybody for watching. Please fill out the feedback form that was sent earlier. It really does help us out a lot. Um Yeah, we hope you enjoyed the tutorial. Yeah. Thank you guys for coming. If anyone has any questions, please feel free to drop a message in the chat. Um And yeah, I've, I've sent the feedback form again, so please do fill it out. Um Like I said, we really appreciate any feedback you guys have and as mentioned earlier, we will be uploading the slides so you can review them whenever you would like if you'd like to go back to any of the diagrams that we've had in. Yeah, thanks guys. OK, I'm gonna stop broadcasting.