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Can you give me a little high? If you can hear me, uh, in the chat. Okay. Hi, guys. How many days you been one of the co founders of the six PM Siris on. I work as a cute medical doctor. Trust grade in the Southwest. Today, what we're going to be covering is microbiology in terms of organisms and antibiotics was specifically going to be focusing on bacteria with a few viruses interspersed in between. So, as usual, just want to start by talking a little bit about social. So if you haven't done so already, please join our Instagram Facebook or Twitter page. It's how we keep you up to date with the latest information about the six PM Siris, including what Siris were running. What webinars we have coming up on in terms of content that released and also a way to console that you're learning because we post questions on there from time to time and if you haven't done it already, is well. Please join medal. As I've said, model is how we receive feedback. Is there anything that we ask for for free teaching helps in terms of our portfolios. But it's also where you can access slides and video content from previous webinars and a quick thank you to the MD you who are sponsoring us. Without the end, you would have been able to get the six PM Siris off the ground. Once you finish medical school and you work as a doctor, everybody is going to need sort of medical legal advice or medical indemnity insurance and some sort of other support in terms of contracts and other things. So if you're interested in that, there is a cure code in the bottom, right? Please have a look at you want to join, and if you do join, then you can get a prescribing booklet. Or you can get some flash cards for revision, which I use on. There's also the foundation program booklet. Okay, brilliant. So, uh, without further ado, let's get started. So you're 50. A medical student who is working in the emergency department. A 45 year old lady is admitted following a dog bite to the hand. There are otherwise well with no medical past medical history and no known drug allergies. The foundation year to doctor asks, Ask you of the mechanism of the antibiotic that would be prescribed. So what is the mechanism of the antibiotic that you prescribed in a dog? Bite on? Let's put up the pool. Okay, so the majority of you've answered correctly. The correct answer of the antibiotic that you prescribed in a dog bite is it inhibits cell wall synthesis. So when you get a dog bite, a doctor by contains a mixture of gram positive and grand negative back to him. So you have to give an antibiotic that covers both. And the first line with in the UK is cold box o'clock and co marks cavity nose combination of amoxicillin, which is a form of expecting penicillin. But it also contains an adjuvant called clavulanic acid, which helps protect against beetle. Act amazes. Penicillins will make some sort of typical. They're part of the Beetle act I'm group that contain this beetle Actim bring, and some bacteria produces enzymes called beetle Act amazes that destroy these rings and make the antibiotic ineffective. Eso with catatonic acid does is it inhibits. These beetle activities is amount amoxicillin to penetrate and soul destroying a cell wall, which is why it works, which is why I called Meloxicam have worked so well. So the first line antibiotic for someone who's none pen allergic would be calm. Oxygen clerk called amoxiclav, which contains a penicillin, penicillin, codeine, beat elect um, rooms and their mechanism. Action is destroying the sub. All goes and sell license. So, as I've mentioned in terms of Bites, the choice of antibiotics to cover both grand positive gram negative bacterium in terms of the spectrum of what's nasty in terms of bites, human bites on our seed and catfights cat back to an acid and dog bites. Think of it that way. So cat bite or a lot worse and dog bites. You give your lot more sort of like to get stronger antibiotics for a longer period of cat bites in your with dog bites. A common organisms that sort of isolated from animal bite is pasteurella, which is a grand negative facultative Anaerobe s so that's one to remember for exams. Ondas. I've mentioned comics comes the first line in non penicillin allergic patients, and it's amoxicillin plus clavulanic acid. Now we already talked about the class. It's a beetle act. Um, it's a broad spectrum coverage, grandpas the anger and negatives on in terms of side effects that you want to know about particular. So every antibiotic there's always going to be diarrhea, nausea and vomiting as a potential, but a little bit more specific to sort of calm oxycodone. It can cause Cody's Stasis on with any sort of broad spectrum. Just remember anything sort of broad spectrum. There's going to be increased risk of seed FSN Tree so there's increased risk of cdiff would call marks clubs. Well, fine. So just in terms of dog bites in terms of indications of given antibiotics, so if it requires Surgery Corp a house of antibiotics. If it's a wound in a sensitive area such as the handle face, give antibiotics. If the wounds close to a joint or the bone, give antibiotics if it's close to the bone. It's pretty deep if the wounds in immunocompromised patient, which could be something as simple as diabetes because you got to remember diabetes, does immuno compromised patients, um, to give antibiotics and, if the wound is deep or significant again, prescribe antibiotics. So moving on to question number two. So you are a 50 year medical student who is working in the emergency department a 32 year old alcoholic, presents with severe nausea and vomiting, requiring IV fluids. His blood's a normal. He has no raised key tones and has been drinking as he usually would open close inspection of his hand. You notice a dog bite. He has no other medical history is penicillin and these penicillin and allergic, he tells. He was started on some antibiotics yesterday for his dog bite. How does this antibiotic work? And that's been up to pull. Okay, so we've quite a mixture of answers, so this is quite tricky question, and that's sort of free parts to it. One is you need to know what the sort of UK guidance is for the antibiotic that you prescribe in dog bites for someone who's penicillin allergic. Then you also need to know the reaction that you'd have with alcohol because this is a reaction to clue. Here is it's a reaction with alcohol that you need to know how it works. So the correct answers inhibits sort of DNA synthesis. Sorry, Know, in a sense, it inhibits DNA synthesis. So what it is, it's metronidazole. So in dog bites, the second line antibiotic is doxycycline, plus metronidazole doctor. Cycling is broad spectrum, and metronidazole helps cover anaerobe. So in this, what you need to know is is a very sort of common reaction between an antibiotic and alcohol. So metronidazole plus alcohol causes. And I saw from like reaction, which is where you get increasing amount of albuterol that you produce, which causes this hangover effect, nausea and vomiting. So that's why this patient came in with nausea and vomiting. Now he is an alcoholic. So the reason why I specified that he'd been drinking as usual as well is that he is in in Madrid. All so that's what I'm getting towards either, just to make sure why I put that in the vignette. So let's talk a little bit about that. I saw from, like, reactions. So in the level I love talking about liver. So the liver's got two enzymes that you want to know about in terms of alcohol metabolism. And this is for the metabolism of toxic alcohol's a swell, which is so useful to know, because then you know, with how the treatments for toxic sort of how treating toxic alcohol's works. So you've got alcohol dehydrogenate. You've got Alabama hide dehydrogenase. So when you drink alcohol, alcohol dehydrogenase tension in to see the aldehyde and album I dehydrogenase since the CT acid and that can be passed sort of into the year and metabolized in the blood somewhere whatever. So what happens is when you have metronidazole. What happens inhibits aldehyde dehydrogenase. You get this buildup of albuterol or a seat I'll be height and build up of all the height equals a hangover. So that's why you get that vomiting, nausea, flushing palpitation that you did all that because it's it's It's just an access acetyl album because of albuterol and the hydrogen. It's inhibition. Do the metronidazole The reason it's no, not that I saw from, like reactions because of ah, drug where they notice the same effects with a drug called Drysol from. I don't quite remember how they saw from works, but that's where it sort of originates from on. Just another interesting tidbit I like to know. So I know in these two enzymes is useful in terms of toxic alcohol's because if you know the enzymes, you know how the treatments work. So, for instance, if someone's got efforting glycol poisoning, it's the metabolites that are poisonous. It's not really the medications itself. See need to stop the enzymes in the liver that metabolizer. So you've got two options. Either you saturate the pathway and sort of toxic alcohol you saturate apart from what I've been. Also, toxic alcohol can be metabolized enzymes, or you inhibit that enzyme. So one of the drugs that we use is called from epistle, and what it does is it inhibits alcohol, dehydrogenate and stop the metabolism of toxic alcohol's into it's toxic metabolites, which are the things that cause the downstream issues. So that's why I like to know about sort of the liver, enzymes and alcohol part of it, because also relates the metronidazole on the vessel from, like reaction so a little bit about metronidazole. So Metronidazole is very wide spectrum on its back to recycle, so kills bacteria. It's effect. It's particularly effective against anaerobe. So that's what you need to remember is useful in anaerobe good example of as he always using biliary sepsis as well on but also useful against protozoal organism such as trichomonas and guardian lamblia. So how it works diffuse into the bacteria, it creates toxic metabolites that damaged DNA Henson and inhibits DNA synthesis on As I've mentioned, typical sort of side effects. Nobody is nausea, diarrhea, vomiting for all antibiotics. It can occasionally cause dysgeusia this map metallic taste in the mouth and if it's used for more than one month. So you have to be careful in patients who you're giving long term antibiotics. If you're giving the metronidazole for more than a month, I don't know what the mechanism is, but it can cause the peripheral neuropathy. So that's something else to bear in mind. And obviously don't drink alcohol with it because it will cause that I saw from, like, reaction. Does anybody have any questions so far in the truck? I will take that as a no, and I'm gonna move on. So let's have a little look. So question number free. You are a 50 year medical student who is working in the emergency department. A 65 year old gentleman was admitted following a seizure. He has a history epilepsy and has been controlled for years with soda involved parade alone. He was recently hospitalized and developed a hospital, acquired pneumonia due to a pseudomonas infection on was told to compete than a lot course of antibiotics following discharge. Which antibiotic was it then? That's perfect. A pool. Okay, so the majority of you've answered correctly. The correct answer is separate fluxes, and so with a pseudomonas infection. What you want to know is which antibiotics have sort of our our work against pseudomonas because you have to make a specific set of antibiotics. So pseudomonas or gin oh, so is susceptible to college pennants. So I dropped like meropenem aminoglycoside, meaning gentamicin Kefalas sporin things like craft accents and quinolones, which includes ciprofloxacin as an example. So what you want to know in terms of quinolones is that they're associated with prolonged QT. Today can cause the kidneys tendonitis they can lower. A seizure threshold has happened with this patient, and they also increase the risk of a C diff infection as well. So a little bit about pseudomonas or Genesis. So it's a grand negative, A robot crowd. It's found in environments such as fresh water, and it's related to cause of multiple community acquired infections as well as non so comb your infections. It produces this sort of BioFoam, which makes it very robust on it's also problematic in CF patients in particular high. It's sort of highly implicated in infections in CF patients. And as I mentioned, it's susceptible. Teo compendiums aminoglycoside follow sports and quinolones so a little bit about quinolones. So So they're active against mostly grand negatives. But some of the newer quinolones such as Levofloxacin Mobile fluxes and are also active against gram positive bacterium and how they work is they inhibit DNA, dry rays, DNA gyrase. Um so in bacteria have these super cool DNA strands DNA gyrase helps loosen them up so that you can sort of have DNA synthesis. Wonderful. Where with it and Quinton nose are bacteria static so you don't actually kill bacteria? They stop. It's multiplication and potential side effects as usual. Diarrhea, nausea, vomiting again. Remember, it can lower that seizure threshold would be careful. Epileptic patients. You don't want to prescribe that and cause of prolonging of Q T S O. Make sure to look at the EKG because if the beauty gets too prolonged, remember that you have the increased risk of tarsus. The point, uh, which is also known as, uh, sort of poly. What's the word I'm looking for here? It's also known it's which is also a form of E. T, and that can potentially lead Teo sort of other arrhythmias such a sweetie and VF. So that's where you need to be so careful with it, Achilles tendonitis or something, you get snapped the kidneys, particularly many patients. You would be careful if you're describing, choosing to prescribe the quinolones and make sure they know about that. And again, there's that increased risk of seed if infection. So moving on to the next question a 24 year old gentleman presents to sexual health clinic with Syria and penile discharge. He states he had unprotected sex with a new partner in the last 10 days and had given urine sample had given a urine sample free days ago. Microbiology results indicate a committee infection. Which antibiotic do you describe? Thank you. That was the way I was looking for Katie. And that's but it. Okay, Brian, So majority of you answered correctly. The correct answer is doxycycline. So just in terms of why you wouldn't use the other antibiotics. So if you took since typically used in sort of staphylococcus induced infections, working on grand positives for the most part for, for my sin can be used. But it's safe for pregnant patients because it's safe in pregnancy on clindamycin, usually used to treat atypical organisms. You know, particularly Nemo in the context of pneumonias things such as legionella. So in terms of the management for chlamydia, at least in the UK, there's two sort of first lines that you can pick. So it could be between a seven day course of doxycycline, which given twice day. But it's not safe to use and pregnancy, and another option is azithromycin, which could be given over three days once daily. But again, it's not so safe in pregnancy. Erythromycin would be the choice of antibiotic in that case, little bit about comedy A truck, Um, artist. So it's gram negative. The most common bacterial SDI in the UK close with coronal gonorrhea. It's commonly asymptomatic course symptoms, sisters discharge on dysuria and the times of complications. So thinking ladies, you get pelvic inflammatory disease you can from the pelvic inflammatory disease, because information within sort of the abdomen and course fits shoes. Curtis syndrome, which is where you get on sort of strands of sort of scar strands of sort of adhesions to deliver because of the inflammation that goes on, you'll get proctitis. You can also get a reactive off writers you know, can't see compete kind of climate tree If you remember that for sort of these reactive type off, ritis is so in terms of tetracyclines, which is the class of antibiotic that doxycycline belongs too. So again, they're quite broad spectrum. They cover against grand negatives and grandpas itiveness, and it's back to your static eso again. It doesn't kill bacteria. It stops. The multiplication inhibits protein synthesis by acting on the 30 s ribosome or sub unit. Ribosome is being very important for protein synthesis in terms of sort of the mechanics of the neck and the the mechanics of the sort of structures in machine read are within the cell. It's not safe in pregnancy or breastfeeding on what you want to remember is it works similar to aminoglycoside and gentamicin, and then they also inhibit for it. Yes, in a little ball that will be in a little bit differently. They also inhibit the 30 s ribosome or sub units, so side effects again nausea, vomiting, diarrhea. It can also cause brandy or sometimes irritation of the esophagus as well, finding enough on sort of the spectrum of things, including sort of softened itis on erosions and ulcers. It can cause an animal discoloration on Also commonly, what's implicated as a side effect is photo sensitivity. A. Z well, so. But it's so we're gonna take a 32nd breaks that I can answer some questions If anybody has any questions. So far, it's been stunning the choir in the chart. It's so somebody asked if you will receive the slides. So if you complete the feedback, make sure you could catch up content. Slight. Um, posted tomorrow some slides for some or other lectures except for the nephrology two electoral available in a for allergy to like just slides and video be made available tonight on metal. Okay, fine. Well, uh, move straight on. So question number five a 42 year old gentleman presents to the E. D with significant shortness of significant shortness of breath and pyrexia. He has a history of HIV and has not been compliant with his entry. Retroviral therapy, which is we are, stands for for several years on chest X ray, he has global ground glass changes. The any doctor prescribes an antibiotic, and they ask you how it works or what is. Mechanism is. So let's put up the pool and then I can answer that question. I want to get about half of the people aren't so good the minutes I'm going to leave it for a little bit longer. Seems people stuck a little bit more on this question and the other ones Okay, so the majority of you've answered correctly. So the correct answer dehydrogenase folate reductase inhibitor in. So that's because the we recognize is this is a patient who's probably got a age. The finding illness, especially because the ground glass change in the chest X ray and with them having untreated Hey, try be for a number of years probably means that they've got Peter of Achy Infection, which also used to be known as Pneumocystis pneumonia or PCP. Eso. The treatment of choice for that is coach from mocks is all, and coach remarks is all the way it works. Inhibits metabolism of folate, buy directly targeting the de uh, the D hydrophobic reductase enzyme and dehydrated for the reductase this'll enzyme that's involved in for that metabolism and being able to use violate for DNA synthesis, which what it's so important for is also president in humans. But coach remarks is or certificate trimethoprim. And so from a from a focus, all have a almost fountain in the thousands times higher affinity towards the bacterial, some type of enzyme compared to the human enzyme. But nonetheless, that means there's still a risk of sort of causing issues with for that metabolism in in people as well. So it can, you know, cause high MVC MCV is causing it. A logical issues cause anemia and it can also, you know, shouldn't be used in pregnancy for that reason as well. Um, so let's have a little look what else? So keys for PCP and also toxoplasmosis. Ondas I've mentioned Dina Juries. Inhibition is rate the quinolones ldh is lactate lactate. Dehydrogenate is, which is an enzyme that converts likely to pyruvate, which is also important and, you know, in things like a model assist and other conditions carbonic 100 on hydration interested enzyme involved information of carbonic acid related to hydration. I owns and sort of bi carbon ions and oxygen on sort of water. That's why all of those are not the answer so little bit about HIV in aged, So hatred is retro virus that my CD four T plus helper cells once inside the use these reverse transcriptase to convert. So it's already two DNA to replicate itself multiple times over and fruit A. It destroys these T helper cells or display kidneys, CD four plus T helper cells and when there's a count less than 200 or this some sort of AIDS. The finding illness. This would mean that a patient has aides acquired immunodeficiency syndrome as a complication of HIV infection. So sort of AIDS. The finding illnesses, some of them There's a lot of them, but some of them to definitely know about is Peter of Wacky is what it's commonly known as it used to be known as a PCP, or Pneumocystis pneumonia composes sarcoma, which type of herpes virus. Burkitt's lymphoma, which is type of B cell, non Hodgkin lymphoma or a CD four plus count less than 200. A little bit about coach remarks is also, as I said, it's a combination of trimethoprim and sulfamethoxazole covers gram positives, grand negatives, but it also covers for PJ Back E and also commuting toxoplasmosis on, as I mentioned, inhibits folate metabolism. Common side effects include nausea, vomiting, diarrhea. You can get rashes with it on occasion hematologic or issues because it causes problems with Foley and, if you remember for later involved in DNA synthesis is also implicated in macrocytic on emails. When someone's fully deficient, as have previously mentioned, and, uh, for allergy lecture, it increases it. Also, when you give it, it can cause a rising creatinine. But not because it's causing an A k I, but rather because it's decreases the tube, the secretion of karate. There isn't an actual injuries, not something you have to know when you give someone trimethoprim. And if you're measuring, they're using these again. You need to take that into account. If you're if you're looking to measure, they using these for whatever reason. Okay, so question number six a 60 year old gentleman with decompensated liver failure secondary to our colleague liver disease is being managed in the I see you. He had a CT scan two days ago showing he was not an obstruction. Since then, his abdomen has become the standard. He has no open his bowels for four days. He suspected to be an idea to consultant prescribes Metoclopramide Metoclopramide, which have said access a prokinetic and another antibiotic. Another low dose antibiotics to clear which antibiotic was prescribed. Let's put up the pole, Okay, so let's have elected a majority of you answered correctly. So correct Answer is a referral license. So this is known that macrolides, which previously I might have mentioned before I can also Actos prokinetic, which is why they could be sometimes useful, not always, and you can use in patients with gastroparesis. And sometimes I'll yes, although the evidence and ideas is a bit patchy, but basically the actors motive, agonists and Moten in. As I said, this is a type of hormone where which sort of what's called encourages got movement, motive and meaning, you know, movement motor, however you want to remember or think about it so very briefly about macrolides. So macrolides, you know, include care for my sinner from icing. Is that from mice in on What they do is they instead of acting on the 30 s sub unit, which, if you remember aminoglycoside and tetracyclines do it acts on the 50 s subunit of of ribosome in bacteria. That's how it inhibits protein synthesis, and it's a bacteria static drug so it doesn't kill it. It stops perforation by stopping protein synthesis by acting on the 50th subunit on crime. Finical on clindamycin also act in similar manners. Um, so points to remember either azithromycin employed for mice and have a wide spectrum than a refer mycin and a low dose refer mice and can use is a pro, uh, kinetic. As I mentioned, motive. Acne is for patients of gastroparesis is sometimes used in patients. That I least with the evidence, is a bit patches and mentioned, but typically or broken up all mkreutz have some sort of prokinetic function, but erythromycin more so, and it's given in a lower dose and then usual important side effects to remember once again nausea, vomiting, diarrhea. No surprise on different. Remember about sort of the antibiotics. They all have it increased UTI risk by reformation. Our ward, um, has the highest risk of increasing the duty Prolong the QT interval on azithromycin is hepatotoxic, and as I've mentioned, is it from I said it not safe in pregnancy ever for mice and safe in pregnancy. Okay, moving on question number seven. So a 40 year old lady has recently traveled back from India. She is complaining of shortness of breath, pyrexia weight loss, night sweats or last month on Just like radar cavity, a tingly jin's visible in the A. P. C's of the lungs. What is the first line treatment for this condition? Let's read in the pool. Let's get a many people wants from the polls. We can Guys will give it a little bit longer about 15 more seconds. So the majority answered correctly. Still correct. Answer is ripe. Antibiotics from person, isoniazid, President light and even beautiful because we're treating TB so, uh, to treat TB, it's normally six month course on. For the first sort of two months, you're gonna get ripe and for the remainder to four months, you give them just one person and isoniazid little bit about microbacterium tuberculum OSIs. So it's acid phosphatase. It'll I staining that you want to do for it. A k zero niece and standing is what he used to be known as as mentioned to treat it with right antibiotics. So a little bit about TB. So it's an atypical bacteria. So when we talk about a typical bacteria a what it was referring to, it's. But it's gram stain, a bowl or not sort of bacteria. It's not gram stain a ble you can't see. Crime Staining is an atypical bacterial examples of clear legionella, Um, and a few others. I'm sure I can name off my head late from That's what a typical means. TV is very robust, so you know it's a visor. Macrophage is. And that's what causes caseating granulomas, caseating, meaning sort of looks like cheese When you cut through these granulomas aside mentioned how to die, how to sort of find It is acid fast, basal I staining make a zillion niece and staining. And as we've sort of already know, TV is a multi system disorders, looking effects, sort of multiple organs, and it can disseminate for out everywhere, and it can also be multi drug resistant as well. On as mentioned mentioned, managed right, see you give ripe, fantasizing eyes. It appears that might even be useful for the first two months and next 11 should give them just our i I, even from person and isoniazid and side effects remember fun person. Make sure orange. Make sure you're in common Orange. It's also a path toxic Isis Niacin is course, perform neuropathy and as well as I can cause an asymptomatic rise in your LFTs. Presented Might is teratogenic. So make sure not to give it to anybody pregnant, and it can also cause joint pain. And he found beautiful is sort of implicated in optic neuritis. Okay, brilliant. So we're onto the last question now, guys. So a 65 year lady presented weighed fever at 30.2 degrees and feeling on well, she has a history of small cell lung carcinoma and is being treated with chemotherapy on has no known drug allergies. Her neutrophil is on her. FBC are no point free, so she's neutropenic. Two days into her treatment, she improves but unfortunate developed diarrhea and abdominal pain, which for a peace where she prescribed by the consultant when she originally presented. And let's put up the pool a little bit of a spot of answers. But the majority of you've answered correctly, so the correct answer is be it's It's a Texas in which is, towards the back down plus pepper, a certain I can't ever pronounce it. So we need to know in specifically in terms of U K guidances, the person is presented with neutropenic sepsis. So patients sort of highest risk of neutral except our chemo for amputations. And it's typically 5 to 7 days off the Navy. Sort of received chemotherapy is when they're neutrophil count competitively. Drop now To get neutropenic sepsis, you have to have neutropenia s so I, you know, need for can't less than no 70.5 on a Z Well, is that what you need is a source of infection and typically neutropenic patients. It's it's It tends to be from within their own gut because when they're getting chemotherapy, they're high turnover of sort of cells on stuff, which is why to get side effects like diarrhea. And because that high sort of got cell turnover because of how the guts affected it can let sometimes something slip into the bloodstream. Eso that's typically the source of the bacteria, but not always on the first line, as mentioned status in in non allergic patients. And as it is obviously a very, very broad spectrum. Penicillin, you know, as with all penicillin, you know, It's typical side effects of sort of, you know, rashes and nausea, vomiting, diarrhea and all the other things that you really know about Palisson. But we need to know with these white spectrum antibiotics, as usual, as I've mentioned previously, is of a high risk of see death, which is what probably happened to this patient. So neutropenic sepsis. As I mentioned, temperature of more than 38 neutrophils last no 380.5 on some features of sepsis with a source of infection that you can find, Oh, I'll come back to your question towards the end are so, as I mentioned, typically sort of 5275 to 10 days. Post chemotherapy, but it can come in can occur up two months afterwards. The source of infection is not usually not from an outside source, so you know they often put these patients in the side room, and they say, you know they're worried about are spreading germs on to him. But it's not really about us. It's usually from sort of big, own gut organisms that's typically implicated in in sort of the course of organism. But as I mentioned always an example, Organisms again from the gut cold like I'm Sciele pseudomonas. Typically, first line is Tosteson second Line, CAFTA's idem, depending on your trust and third line meropenem. But again, it can depend on your trust in my trusted probably be tossin and then Mirapex and has a back some sort of similar to kabiljagic acid. Because has it is a combination of piperacillin Onda Tazorac Time was back, um, similar to Catholic acid in that inhibits the action of Beatle activities, which again helps make it broad spectrum. And Meropenem is a type of carbapenem and CAFTA's the names type of follow sports, so a little bit about see death. So C diff is a grandpas defraud. It's an aerobic, and it's four forming, which makes it so robust. And that's why in hospitals they have to be in a side room because the C diff sports can last and spread very easily and you do not want a C diff outbreak in your hospital causes big, big issues, and that's when you know you have to wash your hands I/O and be very careful with your infection. Sort of A. It's infection protocols when you're when you're dealing with these patients, and that's why they put into a side room. And as anybody who's sort of known to six PM stays for quite some time, you know that my favorite family of bacteria Mr Cost station for it because it contains so many problematic family members. You know, including See Tetany, which is what we get sort of vaccine again. Tetanus resources of the tonic, paralysis, botulinum flaccid processes we've mentioned Related is off the neuromuscular junction. Christian Provenge is, which is great to gas green infections and the next thing sort of fasciitis commonly associated back on antibiotics with C diff include clindamycin phallus, boring quinolones and sort of wide spectrum penicillins, which includes cold box of cabin tussin. It's a common common ones, remember, but finding of other things to also remember that implicated in it is PPI. So sometimes you have to be careful in patients newly starting PPI on. But it's it's all related or alteration of the got floor up, because if you give a wide spectrum antibiotic in your white part, the got fluoride that gives C diff and the other sort of problematic things the theophylline unity to colonize and and sort of brownish out and periphery a lot more because they're not was inhibited. There's not much competition because everything else has been wiped out on the gut problem with C. Difficile that it causes these sort of exotoxin source of toxins that cause the inflammation and cell death not particularly problematic. And when your screening for someone with seed, If you do a glutamate dehydrogenase test on date screens for inactive C diff. So that's what it's particularly sort of, sort of looking for. So were you tested for glutamate? Dehydrogenase. You want to test the presence of C diff and that see if can be active or inactive, and to know if that's enough, it's actively causing an infection problem in the diarrhea. You're looking for the toxins specifically with stocks and present and his G h positive. That means there's a scene of present, and it's active. If his GED, it's positive and it's toxin negative, the C diff, but it's not active, and if it's GED, it's negative. But and talks and negative. There's a new variety unlikely for someone to have a CD of colonization on. If G. H is negative, then it's, you know, again unlikely from five a. C. Diff you shouldn't be. Find the toxins basically in, generally speaking, okay on in terms of sort of complement, complicated complications. So you would have seen some of these horrible endoscopy pictures of the sort of membrane pockets and white and quite discussing. If you haven't seen C diff in sort of sort of endoscopy picture of a have a Google event that's called pseudomembranous colitis. Now we need to be really careful in patients where diarrhea, because of antibiotics, is giving them something to plug up the diarrhea. I use something like a paramedic or something to stop the diarrhea, because if you stop it and you don't let things come out are toxic, especially if it's see death, you put them at risk of toxic mega colon, and talks to make your mega colon can eventually need to more problems. It's just this sepsis and as well as that potential perforation and more issues down the line. So that's we're going to be really careful and patients with diarrhea antibiotics before giving anything toe. But anything up. If you even thinking about it, send off a sample, make sure it's negative on the first line treatment is oral metronidazole again. You want to give all things because you want it to get to the gut. And it's the only. It's specifically only case that I know of that you get or or vancomycin Uh, specifically, You know, um, again, it's only time when you give a little vancomycin because you want to be in the gut where the C diff is. Now if they've got sort of widespread sepsis weather and you think it's in the blood, it's in the blood. Positive blood culture is that you need to give you intravenous versions of these antibiotics. A Z Well, Britain. Fine. Um, I hope that made sense. Please fill out the feedback guys as usual because that helped me know what I need to add in on. Let me see what questions I can answer. And I'll put up the feedback ling first, actually. So, as I've mentioned, So it depends on how Let me answer the first question, actually, So the first question was repeat or bacteria go into the blood stream of Oh, yeah, You know what? Let me put up the feedback linker limp of the feedback in first, Just give me a second guys, and then I'll answer the questions. Uh, let's find a feedback link. So let's just send the feedback link. Here we go. Does the feedback link let me start sharing screen again? Uh, brilliant. Okay, So let's try. And also some of those questions that you have had And let's have a little look. So could you please, briefly, a peep.