hello everyone welcome to part two of our online lecture for drugs used to treat infections today we're going to be discussing fungal infections and viral infections I'm Dr Cosby let's go ahead and get started with talking about fungal infections first any drug that's going to be used to treat a fungal infection is called an anti um an anti-fungal drug interestingly enough unlike our bacterial or bacteria which invade our body and have that hard kind of outlay outside well cell wall that becomes pretty unpenetrable by our immune system making our immune system ineffective at fighting it off our fungi are the opposite they have very similar characteristics to human cells biochemically and physically and so for those reasons our immune system if healthy for the most part is capable of fighting off most fungal infections now there are some things to consider a lot of the fungal systemic fungal infections that we encounter most often will have been caused by actually taking broad spectrum bacterial cytal antibiotic drugs so in other words we take this broad spectrum bacterial cytal drug which destroys all of the good things in our system that are capable of fighting off infection and so as a result there's this fungi lying dormant that now is allowed to manifest itself we call that a Supra infection a super a super or Supra infection is caused by it's an infection cause from taking another drug most often that other drug is an antibiotic and most often the antibiotic that causes that is a bond Spectrum bacterial cytal drug so you're taking this drug for seven to ten days destroying everything and anything that would be protective to you and as a result you have this fungi living here which normally the immune system would be able to keep in check that is now allowed to run rampant and so you develop a fungal infection and that's called super infection right it wouldn't have happened if you were not taking that antibiotic drug now we have two kinds of fungi that kind of exist the first is a is yeast yeast is a derivative of a fungus okay but the difference between yeast and most other fungi is yeast or unicellular and then your fungi are multicellular so there is a little bit of a different kind of biochemical makeup between the two but ultimately we have just like with bacteria we have no back healthy bacteria good bacteria that's circulating within the gastrointestinal tract similarly we have normal kind of fungal Flora circulating in two key areas in orally in our mouth and then uh in the vaginal region as well your candida is an example of that we have candida yeast in our mouth and in our vaginal reason again region again that's for Extra Protection in those two anatomical regions right but there are other ways of course to kind of develop a fungal infection we talked about taking antibiotics and how that increases the susceptibility to fungal infections but then it could just happen as a result of of invasion of the pathogen right either through an open wound in specific orifices right through contact with the human or I'm going to talk about animals as well which carry a lot of the fungi that jump off of them on onto you um it can happen from taking broad spectrum bacterial antibiotics we talked about that and then inhalation most often when we get to kind of respiratory drugs a patient who has asthma will be taking an inhaler in younger patient populations they don't know how to use the inhaler and they tilt the inhaler up towards the roof of the mouth and so the drug will start to stick and it will start to layer and it will cause a fungal infection in the mouth or a Candida infection in the mouth and so we'll talk about thrush in just a little while as an example of an over proliferation of a fungus in the actual mouth itself now just like bacteria bacterial drugs right antibiotics they can antibodies could be bacterial or a bacterial stat right similarly anti-fungal drugs can be fungicidal or fungistatic right fungicidal means they just destroy the the fungus and there is a passive role of the immune system fungi static means they inhibit the synthesis of thereby allowing the immune system to come along and kind of fight off that that fungal infection right so as we start to talk about the next types of fungal infection and believe me there are many I'm only talking about the ones that we will see as athletic trainers um all of the ones that we're getting ready to talk through on the next few slides are caused as a result of a specific type of fungi known as the no matter dermato fights you know Derm refers to skin in particular what they Thrive off of are the keratinocytes or the Keratin cells that live on our the external structures of our body they'll attach to the Keratin and then start to replicate themselves automatically so the next group of pathologies fungal pathologies we're going to talk through are the tinea group now in this bottom right hand corner I've given you kind of just examples of different types of antifungal agents that can either be used over-the-counter or that can be prescribed the common ones are in the bottom your Lamisil or your Tinactin so I'm using the trade name that's what we'll know it by Tinactin most often used for in the treatment of athlete's foot but you certainly have I mean if you have a patient a female who has a yeast infection for example she might get some type of Monistat which is an over-the-counter kind of vaginal suppository so we can see that antifungal drugs can be oral obviously it can be topical or can be inserted vaginally if needed and necessary to treat that particular treatment area so let's talk through types of antifungal diseases particularly the tinea diseases the first Tania disease we're going to talk about is tinea pedis and that is known as athlete's foot so athlete's foot as you can tell Will attack the plantar surface of the foot where we are rich in Keratin and so if we have an open wound if we're living in a moist hot environment sweaty environment like our shoes um if you have that open wound and that pathogen can start to eat away at the Keratin it will start to replicate itself the dermatophyte will start to replicate itself and what we'll see is something that looks like this a patient who presents to us with the cracking feed the itchy feet severe inflammation if it's wet there's an increased risk for the development of of a bacterial infection as well but most of the time over-the-counter anti-fungal medications will work so going back to this Slide the Lamisil the Tinactin those will work perfectly fine rub it on make it nice and creamy on the bottom of the foot have them put a sock on usually within seven to ten days it will resolve itself but that it is you always have the repeat patience right the ones who have have a resolve in their teenagers but then come back and have tinnitus all over again so what you're going to have to do is find a shoe that allows that foot to breathe right and now as we look at the shoe market the shoes are so breathable these days right patients who suffer from tinea pedious we want them to be wearing those breathable shoes as much as is possible the next forum of antifungal disease is tinea capitis as the name implies right cap meaning head right this is a fungus that attaches to the Keratin on the scalp right most often we see this in children particularly children who are in daycares who have terrible sanitization procedures a lot of jump houses right um we see that in children who've been in jump houses playing at a birthday party problem is is that the fungus will live on the surface their head will hit the surface and then it'll attach and start eating away at the Keratin so it's called capitis because it impacts the head what you'll start to see is the patient will develop some sort of like bald balding spot because instead of hair growing through the follicles that fungus has started to eat away at the the Keratin and so they'll develop a big large bald spot over time so it can happen with contact with surfaces Combs and brushes which is why it's so important to not allow yourself your peers your students Etc to share Combs and brushes believe it or not and also in contact with animals so you know how we like cuddle with our animals or we might meet someone else's dog and go oh so cute let's hug them don't do that they can actually transfer fungus from you to your scalp and then you'll develop a tinea capita so as you can see here what are the signs and symptoms big huge bald spot with maybe red sores so hair loss and then severe inflammation now this is an African-American patient so you're not going to see the inflammation here but until it might look more gray in nature and then obviously in your Caucasian or or more pale patients you'll start to see like a redness in that area as well so most often they're prescribed in oral anti-fungal you can put a topical on there but because of the hair it just gets really sticky and gooey and actually increases the risk for the development of an infection so oral antifungals are going to be the best treatment for this particular Patient next we have tinea corporis or AKA ringworm of this skin so this is where you have a fungal infection that starts to invade the Keratin on the actual skin in particular we see this most often on the face and in areas of folds or creases where it's warm so right in the fold of the elbow the posterior aspect or popularial fossa of the knee so it occurs as a result of direct contact with humans and animals or other objects impacted by microorganisms right so any of these things can cause what we see here again for ringworm where we see it most often is in wrestling again it has to do with how well are we sanitizing the maps that the face is actually laying on so we'll see the transferring of ringworm it's extremely contagious in fact patients are not allowed to participate it participate with it early on you'll find that you're not even allowed to put tape around it that's how infection it is so what are the sign symptoms um patient's going to present with something that looks like a ring and you can see that beautifully kind of here in this patient it'll look like a ring and so they'll have severe inflammation in that particular area lots of itching very contagious if I didn't say that treatment is most often going to be topical so they'll do some type of topical anti-fungal medication one area of concern for patients of color is as you start to put that antifungal medication on their face you might actually cause some discoloration so in patients of color what they typically will do sometimes isn't an oral anti-fungal medication to avoid skin discoloration after after treatment just something to consider when you have patients of color next is Tania curse as you can see here it is an inflammation of the The Jock region um particularly I guess we could call this like almost femoral triangle region if we wanted to be anatomically correct most often caused by like a tight fitting close or and by clothes that could be jeans that could be shorts that could also be panties or underwears that are just really really tight in that femoral crease and then warm environment wet environment so we see this a lot so like think about going swimming and having on like tight trunks tight bathing suit and then like you put your clothes on to go somewhere else and you don't change right that creates a tight warm moist environment and it's is right and ready for a fungal infection so be careful with that see this a lot in swimmers and then you're gonna see it a lot in football athletes who share jocks hate to say it that way but it actually does happen so be careful with that signs and symptoms are going to be what you see here kind of a ring in that femoral triangle region itching a raised Ash for example and the treatment is going to be the topical anti-fungal medication next to Nia that we see most often is tinea on GM as you can tell it um the fungus attacks the Keratin on the toenails so it starts to create a thickened discolored toenail which you can see here this treatment can be with topical or it can be with oral anti-fungal it depends on how many toes are being impacted the more toes being impacted typically they'll take an oral anti-fungal most often fungicidal approach so it doesn't spread to each of the toenails the biggest concern here is as the nail gets raised you start to see the risk of infection starts to develop pain it starts to push into the skin of the nail bed so there's lots of consequences for these patients tinea angium develops the same way that tinea pedis actually occurs so warm environments the other thing that we see in soccer athletes oftentimes you know how they wear those tight cleats and they start to butt their foot up against the actual cleat itself so then that nail will get irritated put them in a warm moist environment and they're ripe and ready for the development of tinea ungium as well so we associate that topically and or orally with anti-fungal medications the next um Tania that we're going to talk about is tinea vessel color which you can see here it's Versa color its name is honestly truly given by its the way that it presents itself it is a systemic fungal skin infection that causes discoloration of the skin so you can see these little blotches in um darker complex people of color those those skin blotches will be a little bit darker so they'll be more gray or a deeper Brown and so it really is like literally the fungi attaching to the skin Flora right just attaching and taking its place and replicating itself very quickly unfortunately there really isn't any type of treatment for the most part for the most part it isn't painful the skin does become discolored there is some itching associated with it and they'll have some dry scaly lesions but most patients can live live with this they aren't going to die from this particular pathology next um probably the more extremes of the types of fungal infections that we'll talk about are the candiasis diseases um the candiasis diseases can either be vaginal or oral if it's vaginal then essentially what we're referring to is a yeast infection if it's oral then what we're referring to is a mouth infection you can kind of see that here again remember I mentioned incorrect use usage of inhalers is usually the number one culprit which causes um oral types of fungal infection but of course you you y'all probably won't deal with this but as you start to have as you if you work with infants who are bottle feeding or nursing right if the mom there's like this tongue scraper because the milk will deposit on the back of the tongue and if we don't scrape the tongue then you'll start you can see the development of the oral candies candices if you don't have good oral hygiene in your infants the scary thing about oral candiasis is it is that it can absolutely if it starts to kind of develop and get thicker it can occlude the airway and so once again one of the things that we have to think about is how do we treat that if it's if it's vaginal we can do it orally specifically if um a few things if there's lots of itching and irritation in the vaginal region if they have discharge most often that's going to be oral but if you know the signs and symptoms are are relatively low then they'll just do a vaginal suppository and why am I talking about this in a farm class the reality is we have female athletes who will suffer from these things and oftentimes when they come to you and tell you there's just awkward like oh what are you talking about so let's just put it out there we're going to be able to help them and Coach them through whether or not they need to go get a prescription or or not they just need to go get an over-the-counter vaginal suppository right to reduce their signs and symptoms signs and symptoms regardless of where the candy candidasis actually occurs is itching either their throat will be really really itchy and then obviously discharge right that can be vaginally um or orally right you'll start to see this white putrid discharge and then also you could there's going to be a distinct smell either in the vaginal region or the oral region as well so for oral it's it can be it can be topical believe it or not so like you can rub something on the tongue or they can just literally just orally take that okay all right now as we move from our fungal infection group the next drug that we're going to talk about to treat infection going to be virus infections so the virus is a small very small of the three we've talked we're talking about is a small microorganism most often It's relatively benign but it can also lead to severe or fatal depending on its type right severe covid-19 fatal HIV which progresses into AIDS right which can be life-threatening and then you can have just the flu right that we can fight off in two or three days so you can see how there's this massive amount of of spectrum one scary thing with the virus is that they're going to act kind of by interfering with the viruses ability to synthesize DNA so we haven't talked about DNA in the last two but today we're actually going to talk about that so um for the flu we used to just let people live it out and essentially people were dying from the flu so there are anti-influenza drugs currently available they aren't readily prescribed right um just because of their side effect and if I had to guess probably their low therapeutic index or their increased risk for adverse side effects so the key thing with flu drugs is they have to be initiated within the 48 hours to be affected if not by then remember that that virus is just replicating itself so you're just going to let the patient live through those signs and symptoms and eventually what we see is that our immune system is capable of fighting that off right so what are the types of viruses that you probably will encounter or may encounter smallpox is going to be one of them very very rare now so many vaccines based on that chicken pops again if you're working with um a youth population it's possible but again very very rare shingles um ironically I had a 21 year old on the men's basketball team who actually suffered from shingles used to think it was an elderly population virus but it is starting to play younger students and I think stress has plays a role in that as well Hepatitis B is a common one that you can actually be exposed to so right that is a kind of blood to blood contact so making sure you're using your blood barrier um your blood barrier protectionary methods or your ppes that's what I'm gonna say and then the hard part with viruses is the chemical structure is similar um to RNA and DNA so in some cases these the smallpox of chickenpox the shingles or Hepatitis B makes it very difficult for the immune system to kind of recognize that it's actually foreign right it assumes that it's actually good because the chemical structure is so similar to our RNA and our DNA so they are more challenging to treat right um so what do we use with viruses we use an antiviral narrow Spectrum drug we have to identify it right we don't want to use a broad spectrum antiviral drug because there are so many adverse side effects associated with it and so when a virus invades our human body it brings with it only the necessary DNA and RNA to replicate so the capsid holding of the DNA RNA invades our body via some sort of Airborne mechanism or through an opening through the skin so bloodborne right we're thinking HIV blood to blood um maybe even fluid to fluid transmission right so it invades through that and then when it enters the body it finds a host cell and then it just starts to kind of um replicate itself within in that cell so much so that the body can't recognize that it's actually foreign isn't that scary it's like kind of a chameleon it changes its shape in its color making it very difficult for the body to actually fight off right so if if our virus takes over one of those human body cells then it becomes similar to the DNA and RNA again repetitive here but it makes it very hard to for our body to recognize that as foreign and so what it does is it just takes over and by the time the body recognizes recognizes that we have a foreign virus in our body it becomes very difficult to treat now we're talking about the extreme forms of those viruses so right like HIV smallpox shingles all of those we're not talking about the traditional influenza right so [Music] um with antiviral medications in particular they have the medium to low therapeutic index for the most part they're generally well tolerated but they have high risk for diet causing diarrhea nausea and obviously vomiting right so one thing that I want to talk about and sometimes we don't talk about it enough here but I think it's important as you all move away from Point Loma to this concept that the reality is that kids are becoming more sexually active earlier on in their lifespan so this is an encouragement of that but how do we help student athletes who present to us with sexually transmitted diseases the first thing that I want to do is kind of have you look at the number of sexually transmitted diseases in 2014 and then 2019 so you can at least just wrap your head around the fact that this is almost in and of itself kind of a pandemic right so in in 2014 about 1.9 million new reported cases and then we move to like I don't know all five so years later and we're at 2.6 million this is the most recent data we can imagine that there's still kind of this upward Trend right so if we go we add four more years to that we're probably at about three million new cases being reported each year in 2023 right so we have to be equipped to coach our athletes through how to live with sexually transmitted diseases right okay so let's talk risk factors the biggest risk factors for patients to develop sexually transmitted diseases is the number of sexual partners right the next thing is particularly with Mel's same sex partners are at a higher risk for developing sexually transmitted diseases particularly if it's male to male contact right so what am I saying here with this slide I want to say this to you all um that while we don't necessarily treat sexually transmitted diseases we have to be able to educate our patients on what the risks are and how catastrophic the development of a sexually transmitted disease can be and then we also have to be comfortable enough to have that that clinical conversation with the patient who might confide in us that they actually do have a sexually transmitted disease and understand what are the side effects let's go back to this side what are the side effects that they might present with if they're actually taking an antiviral drug and how do we help them through a season maybe being dehydrated because they have diarrhea maybe being dehydrated because they have nauseousness or vomiting right so those are all things that as clinicians we have to be able to have that that conversation right so um as we think through both anti-viral and anti-fungal medications understanding number one the routes of administration that can be oral can be topical most often they're not injected but those are the two main forms oral and or topical right so oral topical and intravenous is another one particular it just depends on the extremes of the signs and symptoms of the patient and then um you can do inhaled as well so what are some guidelines for athletic trainers that's what I want to talk about I think that's most important is like what are some of the guidelines that we should be considering in patients who kind of are taking these drugs right that's where we need to be ending this lecture so our big job is an identification right we have to identify do we need to refer them out to get treatment or is it something that they can fight off naturally right most viruses mine's the ones that were listed right a patient can fight off but the question just becomes and fungal infections for that matter but at what point in time when a patient has a bacterial fungal or viral infection do we actually need to refer out right that's the key specifically for um like let's say the influenza where we know that within the first 24 to 48 hours it's crucial if we actually do want them to take an oral medication right so those things become extremely important the other thing that we have to think about is the development of drug resistance right and we talk through that in the antibiotic component that they must finish taking all of the antibiotic medication if they don't then we typically see that they become resistant to that particular drug group and if I didn't say it I'm saying it now so um we know that with antibiotics at some point in time we start feeling better and usually we start feeling better before we're done with the prescription and the Temptation always is to stop taking the drug as soon as we feel better right but with antibiotics in particular one of the things that becomes extremely important is to make sure that the patient finishes taking that drug because if they don't they increase the risk to develop resistance to that drug if they were to ever take it again so this becomes extremely important in patient education the other thing to keep in mind particularly as we think about the sulfa drugs which really cause heightened adverse side effects is to ask a patient if they actually have a drug allergy most common penicillin and sulfa drugs are the two most common types of drugs that patients typically will have some sort of allergy to so knowing whether or not they have a drug allergy knowing whether or not they've been they had a poor reaction you're not going to be able to do much with that but to share it with the physician right so that they don't prescribe your patient a drug that they've had a reaction to and then the big thing for you identify and then making sure they're compliant so once they have the prescription knowing how long they're supposed to be taking it for and then you're the one that's going to see them every day their physician their nurse practitioner their um I don't know PA they're not going to see them every day but you are so your role is to make sure that they're compliant with taking that prescription drug particularly those antibiotic medications so I hope this has been helpful for your exam for your board of certification examination you need to know all of the tinea fungal infections which is why I spent so much time there as it relates to fungal and viral infections just understanding there's a short window of time that we have before the patient before the drug they're getting ready to take will no longer be effective and then becoming familiar with some of the over the counter drugs that are available to your your student athletes to treat most of the tinias right and then also recognizing will be an extremely important component and role in athletic trainers particularly as it relates to to infections caused by microorganisms I hope these two lectures have been pretty helpful in helping you understand the process by which the fungal and the viral and bacterial infections can actually occur and how we work together with other Healthcare clinicians to treat those over time