dear students today we are going to talk about a very special clinical decision that how we use the use of clindamycine versus metronid use of clamy versus metronidazol in anerobic bacterial infections now why it is so important that we should know that when we are treating and aerobic bacterial infections we must know when to use clindamycin or where to use clindamycin and when to use metazol and where to use metazol so actually there's a very common clinical saying there's a very common clinical saying that if anerobic infections are above the diaphragm if anerobic infections are above the diaphragm usually doctors prefer to use clindamycine over metazol and if Anor robic infections are below the diaphragm if anerobic infections are below the diaphragm then doctors usually prefer to use metronidazol yes you prefer to use metronidazol over clamy now to get a rational of this clinical construct to get the logic behind this clinical saying we have to answer few questions right first of all let let me make a very basic diagram that okay here is someone and this this is a very simple diagram and here is your diaphragm right and Below force will take this now I think arms have gone too high okay what we are saying that clinically speaking when infection anerobic infection ctions are above the diaphragm we prefer cenda very good camine and when anerobic infections usually they are mixed infection they have multiple organisms so when anerobic infections are below the diaphragm usually we prefer to use Metro nidazole why it is so for this purpose we have to answer four questions at least we have to answer four questions at least question number one related first two question related with metol other two questions related with clend if we discuss metronidazol first we have to answer number one why metronidazol is is not considered as a monotherapy firstline drug for anerobic infections above the diaphragm so what is our first question first question is why metronidazol why metronidazol fails yes fails in anerobic infections above the diaphragm right question number one question number two why metazol is more successful metazol is more successful below the diaphragm infections anerobic infections question number three why clinda mine is more successful above the diaphragm and question number four why CLA why camine fails or not preferred below the diaphragm so these four questions we have to answer clinical saying is that usually while treating anerobic infections which are usually mixed infections poly microbial infections if infections are below the diaphragm we prefer metronidazol if infection is above the diaphragm we prefer clamy very good now what we have to answer number one why metronidazole above the diaphragm fails especially as a monotherapy and why metazol is usually more successful below the diaphragm anerobic infection while compared to compared to glendine third question focus on lyine why glendine is considered more successful above the diaphragm anerobic infections and why it fails below the diaphragm so let's first of all focus on Metron rather even before going for metrol let me tell you some very basic concept related with anerobic [Music] microbiology because the real answers will become clear when you are very very clear that microbiology of anob organism above the diaphragm is slightly different from microbiology below the diaphragm and also a very important concept you must be clear that which microbes which anerobic microbes are resistant to metronidazol and where they are and which microbes Anor robic microbes are resistant to clamy and where they are so let's talk about first anerobic microbes right so I will WR I will write it here first of all Anor robic microbes and then I will decide tell you what is the difference between anoro microbiology above the diaphragm and below the diaphragm first of all anerobic yes n aerobic gam negative rods anerobic gram negative rods right when we talk about this there are number I will only write clinically most important anerobic organisms right now anerobic rods first of all the very important is bacteroides bacteroides and one of its very big group is bacterioides fragiles fragilis and actually bacteriodes fragiles is two types number one bacteriodes fragiles secondly bacteriodes nonf fragiles non fragiles both of this group are slightly different from each other right then other is prella privo and then there is pory Monas Poyo Monas and both of them are pigment producing and then there is your friend yes that is fusobacterium Fuso bacterium bacterium one of the way to remember gram negative anob is a simple sentence you can remember that naughty naughty boy yes Naughty Boy places pink flower Naughty Boy places pink flower in virgins where virgin here right now notis stand for negative right gr negative anob and why stands for bacteroides remember bacteroides are two group bacteroid is fragiles and non fragiles and there is nauy places places for prella P for prella pink flower poromas and flower fusobacterium in virgin's hair virgin ha is basically this V this v stands for gram negative and aerobic coxide and that is vow Nella species Vella right so these are most important gram negative organisms right now here I want to tell you one thing that bacteroid is fragiles this is where one of the most important anerobic organism if you forget all anerobic bacteria at least remember bacteroid is fragiles bacteroid is fragiles yes bacteroid is fragil what is this this boyfriend he is ined blow the diaphragm I don't want to say anything more than that this boy friend bacter is fralis it is more common in anerobic infections below the diaphrag and bacteroid is non frous non fragilis which does not have F non fragilis that is common in orod Dental area Oro frenal microbiota right now this is something I want to stress on all of you if you don't remember anything about anerobic bacteria the minimum minimum you remember bacteroid is fragiles why friend commonly producing anerobic infections below the diaphragm right intraabdominal abscesses right abdominal infections even pelvic in infections in pelvis now this was about anerobic gr negative organisms let me write here anerobic gr positive organism an aerobic gram positive bacteria right now anerobic gram positive bacteria you can remember from clap c l a p clapping clapping c l a p i n g what in gr negative Naughty Boy places pink flower in virgins here I don't have hair very sad anyway but I hope you have so when when I'm saying when you go to anerobic world not boy places pink flower in virgin's hair this covers all gr negative important bacteria and gr positive are clapping ground positive AR clapping right clapping c stand for clidia clidia group right L stand for lactobacillus lecto basus and a stand for actino mes and this piece stands for propon bacterium propon bacterium which is now called it has a new name cue bacterium it is not cute at all because it produces eal garas right propionic bacterium and now recently it has changed the name yes QT QT bacterium so and this P these are gr negative B these are the rods these are gr positive sorry these are gram positive anerobic rods and this P now coxy and this piece stands for Pepto stto coxy please please don't confuse Pepto strepto cocai with micro aerophilic strepto cocai and aerobic strepto cocai facultative anerobic or aerobic strepto cocai is a different group that is different group they are not strictly anerobic those facultative anerobic strepto Coy like streptococus pyogenes like streptococus viridans like streptococus pneumoni these are not stri anoes they are facultative Anor right and don't confuse and there is another category micro aerophilic strepto cocai so please don't confuse these are three different category one category Pepto strepto cocay which are gr which are which are gr positive anerobic coxy then there are micro aerophilic strepto coai which are not strictly very anerobic and then there are facultative anerobic strepto cocy like streptococus penes which can uh grow and multiply in anerobic environment as well as aerobic environment now now these are the most important organisms anerobic organisms you should know now why it is so important that I have discussed all these organism the reason being that most of the anerobic infections are poly microbial infection most of the anerobic infections are for example if you have an anerobic obsession lung it will have multiple organisms and not only they have multiple anerobic organism they might have some aerobic also part of that right now let's put important thing I told you that from where these anerobic organism come in to produce infection answer is usually they don't come from somewhere else most of them are part of our normal microflora most of these organisms are part of our now we don't call microflora in new language we call it microbiota most of these anerobic organisms are part of our normal microbiota microbiota are the microorganisms including anerobic bacteria and other bacteria right which are present normally on our mucocutaneous surfaces for example if I talk about Oro fenial microbiota in Oro fenial in Oro fenial microbiota it is very very rich in anerobic organism right and Oro fenial suppose this is Oro frenal microbiota this is representing actually your whole oral cavity right even when you go down into especially lower gut lower git right alium lower alium or distal alium colog even in female genital tract all these mucous membranes they are painted with plastered with they are plastered with billions and billions of microorganisms and most of them are anerobic most of them are anerobic right for example now we start with first of all we divide anerobic infections above the diaphragm and below the diaphragm why this distinction is made actually infections above the diaphragm an IC infections above the diaphragm are mostly derived from Oro fenial and aerobic microbioma what I'm saying that infections above the diaphragm anerobic infections they are mostly derived from Oro fenial microbiota for example from this Oro fenial microbiota organism can produce orod Dental infection they can produce Oro deep neck infections they can produce orofacial infections even they can go up and produce brain obsesses there are lot of anerobic bacteria in mouth and oral area you know The Rao of anerobic to aerobic organism is an oral cavity the the ratio between anerobic to aerobic is 10 to 1 it means in oral cavity anerobic bacteria are 10 times more than the aerobic bacteria and if you go to ging crevices between the margin of the gums and the teeth there's relatively more anerobic environment you know there are so many Anon robes the ratio between anerobic to aerobic between the ging crevices is thousand is to one that is 1,000 is to 1 and if you go down remember our microbiota on the mucous membrane is abundantly abundantly anerobic aerobes are less right yes so what did I say that microbiota in oral cavity orial area ratio between aerobic anerobic anerobic two aerobic is 10 to 1 and in ging crevices ratio between anerobic to aerobic is yes, to 1 now there are lot of anerobic organism here there are lot of gram negative and gr positive anerobic organism here these organism are normally present on the mucous membrane in Oro frenal area but if there's a breach in the mucosa these organism go deeper and in deeper tissues when they are exposed there they are able to produce the path pathologic leens infections and obsesses right now from Oro frenel as I mentioned previously these organism can lead to orod Dental infections Oro facial infections deep neck infections even infections can go through the sinuses air sinuses to the central nervous system and can produce brain obsesses and if as a part of SLA yes if these are aspirated to the lungs right they can produce plur pulmonary infections now those plop pulmonary infection which are due to aspiration right they are having lot of Anor robes coming from Oro fenial microbiota right so the organisms which are in oral orial microbiota they are responsible most of the time for the Anor robic infections above the diaphragm right so next time someone asked you that what is the major source of microbes anerobic microbes anerobic microbes microbes infections above the diaphragm you say oringal microbiota now oral orial microbiota when we talk about about one thing is very important this they have almost all of these organisms but there is one very notable exception the very notable exception is bacteroid is fragiles boyfriend this is a kind of boyfriend is more interested below the diaphragm but in the oral cavity bacteroides are there but they are not fragiles so we call them bacterioides nonf fragil why this is so important to make a distinction because drugs for bacterioides fragiles are different and drugs for bacterioides non fragiles are different so what I'm saying that in the oral cavity all anerobic infections above the diaphragm are deriving their microbi an IC microbes mainly from orial microbiota and they usually have bacterioides non fragiles not not fragiles non fragiles and of course they do have prola poromas fusobacterium even they might have vonella but more important are bacteroides non fragiles prella por feromonas fusobacterium these organisms and clidia are less common in orral but some lecto leoas actinomyces are very common propionic bacteria there Pepto strepto cocay are there in Orel Pepto strepto cocay are there these are all anerobic so what did I highlight out of all these organisms out of all these gram positive and gram negative and gr positive anerobic infection you have to remember at least two things that in or of all two three things number one all anerobic infections above the diaphragm are mainly derived from orial microbiota number one number two thing in orral microbiota bacter is fragil is usually not there that is more common in colog we'll talk later number next even clidia are less common all other organisms are there but two special organisms are also very common in Oro frenal microbiota or infections which are derived from Oro frenal aspiration right when there's Oro frenal aspiration we say there is aspiration pneumonia or there's empa or there pulmonary obsesses right depending upon pathology that not only has Pepto cocai or propionic bacterium eomis sometimes leoas usually do not have clidia but they do have valona fusobacterium por Monas pivala bacteroid is non fragiles but they have two other organisms which are not strictly anerobic number one was micro aerophilic strepto cocai micro hero philic strepto Cai and number two is what are those streptococus pyogenes or we can say aerobic strepto which are also called because they can grow aerobically as well as anerobic so more commonly called not aerobic stto cocai it is more commonly called facultative right facultative anerobic strepto cocai this group now let's go back this is a major important things above the diaphragm right now I will tell you that why fagil I mean metronidazol is not considered a good choice not considered a a good choice for anobi infections above the diaphragm as monotherapy you know why