Transcript for:
Antimicrobial Treatments Overview

all right so let's get started with this chapter antimicrobial treatments we're going to talk about antimicrobial treatments as far as drugs but also alternatives to drugs uh and antibiotics that we've been using for a while okay so not so much the physical and mechanical stuff that we've been talking about so first of all this will make a great true false question hint hint there is no perfect or ideal drug there is always going to be some sort of pros and cons and those have to be weighed uh to figure out what is going to be best for the patient okay so if you have a raging infection that antibiotics are not working for but there is an antibiotic you could try but it has a high level of nephrotoxicity which means you could cause the patient kidneys to stop working You've Got Away the pros and cons of that what's going to be best for that particular patient right and if you have to you got to start them on that antibiotic and then deal with the nephrotoxicity later okay so there's no perfect uh ideal drug but here are the characteristics this is straight from your textbook these are the characteristics of the ideal drug that you do need to know about though okay so first it needs to be toxic to the microb but non-toxic to the host we're going to go into that in more detail because if you ever taken an antibiotic for example but you had nausea you had diarrhea vomiting something like that so that often happens when the target of that antibiotic is a little too close to your own cells okay so the further apart those are the better off you're going to be microbicidal rather than microb bistatic okay now this one can confuse students sometimes right so microb is better in this case because you're going to just kill off the bacteria instead of holding them off where potentially they could come back full force again right but remember which one's more toxic microbicidal exactly so even just with that right there you see that there's no 100% good versus bad there okay uh needs to be soluble in body fluids okay so you should be able to swallow it and let it dissolve in your stomach acid it could be injected into a vein into the blood that kind of thing remains potent long enough to act as it's not broken down or excreted prematurely so what if you have you're taking a pill goes into the stomach but because of the chemical your stomach acid and your stomach enzymes degraded completely but you have an intestinal infection it's not going to last long long enough be potent enough to get there in the first place to cause any effect um slow or non-existent development of antimicrobial resistance wouldn't it be great to have something with that where that could just be non-existent but it's rare to actually see that and that is a major thing that developers are keeping in mind when they're trying to come up with alternatives to antibiotics needs to complement or assist the activities of the host defenses okay so you your immune system is going to try its best to do the job and you don't want to give somebody something that's going to stop it from working very well okay kind of like what we were talking about have we talked about fevers before whether we should stop a fever or not that's the kind of thing I'm talking about okay um let's see remains active in tissues and body fluids that kind of uh is associated with the potency up there readily delivered to the site of infection okay so we got to consider if it's a skin infection do we use a cream or do we use a pill you know that kind of thing um does not disrupt the host's health by causing allergies or predisposing the host to other infections okay so when you guys are watching TV or you're watching a streaming service which is what most of us do nowadays and you've got one that there's no option to get rid of the commercials you have to watch the commercials whenever there's one for a new new drug pay attention to the little voice that goes real fast and says you know yeah may cause death may cause this infection may cause tuberculosis do not use if you're using Mo MOA Inhibitors and blah blah blah pay attention to those because a lot of times they are going to do just that okay so we got to be aware of that as well I always love it when they say it may cause death but they show like some female that's smiling and dancing through like the fields of flowers and stuff and you just s of Imagine them suddenly going and just dropping dad right but they don't show that part I've noticed okay anyway um antimicrobial antibiotic bactericidal bacteristatic again so those those Antics those uh definitions are going to be important okay um an antibiotic is actually the term used for a drug specifically targeting bacteria okay whereas antimicrobial it could be a fungus it could be a protozoan bacteria any of those okay we've already done Cal versus static and then we've got narrow Spectrum broad spectrum which I'm sure you guys have heard of before uh if you've done any sort of research into antibiotics either that you or family member is taking one of the things that I have sort of realized later than sooner is that the terms narrow versus broad really depends on who you're asking because even just looking at different resources for one particular antibiotic there can be some that say it's narrow spectrum and then others will say it's broad spectrum and it depends on where their gauge is right if it's just gram negatives and gram positive aerobic bacteria is that broad or is that narrow it really depends okay and actually that's one of the reasons why I gave you the handout today with the different antibiotics on it if you were ahead of yourself and you printed out the study guide before we got to this chapter your uh particular uh table at the end of the study guide check it if it says narrow spectrum and broad spectrum at the top of each of the boxes that's the old version because there was all of this differences I I'm not even going to test you on it it's just too dependent on the resource and you don't really need to memorize that anyway so I took that out of all of the boxes so the table you got today that's the new version it's up on bright space it's been up there for a couple of days at least uh that's what you should be using okay all right um so yeah this these definitions as far as like only against Grand positive or but yeah again those are different depending on where you're going now synthetic sounds like it's being made in the lab and it is thank goodness we've got something that's relatively straightforward semisynthetic means that they took a drug that came from a natural resource but they tweaked it a little bit either because the original was causing antibiotic resistance or because they wanted to make it more broad spectrum or more narrow Spectrum or what have you okay so um so yeah semi synthetic I've got some of those on there all right so natural sources that was a good segue right there uh so our two main sources you guys need to know this our two main natural sources are going to be fungi and other bacteria now the fungi most people know the how penicillin was originally discovered and you know that penicilium notatum is like bread mold right it's that green stuff that you can get on your um Fred so that secretes a chemical that is now penicillin okay so most people think it comes from fungi they sort of get that but other bacteria secrete these as well okay and this is where the microbial antagonism comes into play that's so important with those associations so if you have a limited amount of space a limited amount of nutrients you're going to be in competition if you're a bacteria you're going to be in competition with other bacteria and fungi and other things for those nutrients in that space so wouldn't it be a great Advantage if you secreted a chemical that diffused out into the environment that killed off your competitors and then all that space and nutrients was yours right that's what we're talking about here so we're going to talk about uh Alexander Fleming here in a second um this is just uh what I wanted to kind of present to you guys you don't as sort of a visual on where a lot of these are coming from you don't have to memorize anything on here but look through these and see if any of these sound familiar to you depending on maybe some antibiotics that you've taken in the in the past now panyin and sephos warin those are fungal okay um poly Mixon one of the antibiotics that we work with in the um micro lab that you've been working with is a polymixin and that actually comes from another bacteria there's atomy which is a specific category as well and then these are the synthetic ones over here quinolones and sulfonamides are the ones that we're going to be looking at a little bit more closely though but I want to get to and the lighting is not as good but that shows it a little bit better I think so there's the penicillin Colony this is a modern kind of version of what happened so you can see kind of where a Rough lawn was created with bacteria but there's that ring that zone of inhibition that's around that exactly good you made that oops the story of the discovery of penicillin okay so Alexander Fleming Scottish researcher discovered penicillin in 1928 I want you guys to remember jot this down somewhere if you don't have uh the Powerpoints in front of you 1928 okay that's extremely important for something that's coming up 1928 and what's crazy is that's almost a hundred years ago now and that crazy that's that's wild okay so here's the here's the story he was basically doing uh research and I have some of the quotes here that's been going on uh he was looking uh and trying to grow different types of stao coxy um on his plates and he now remember these are labs in the 1920s no heap of filtration systems there's a lot of different like molds and and fungi and other bacteria just floating around in the air right so it was really easy to inoculate some media plates and there be contamination right like we only see one or two spots every once in a while but there was a lot of it back then so he comes in and he's looking at his plates and he's really kind of ticked off because the his plates have contamination he can't use them for his experiments so he just starts throwing them away basically but he all of a sudden he starts to notice a pattern and it caught his eye so he comes back and he looks at the plates digs them out of The Biohazard trash from back then and he starts looking at him and he notices that there is a clearing of the bacteria that he had plated around where the mold is so this is one of his actual plates so here's the penicilium colony right right here and you can see it's mostly dark and then the colonies get larger and larger as you go away from it so when he start seeing this clearing around it he's like well wait a minute why didn't the bacteria grow in those areas what if the mold is giving off some sort of a chemical that's diffusing through the media and it's killing the bacteria right so think of that nothing had been known about this previous to this people are dying by the millions really of BAC IAL infections now here's the thing he gave a speech got the Nobel Prize for this in 1945 it's a long distance from 1928 right so he knew what was going on but he actually wasn't successful in isolating the compound itself so other researchers carried on and were actually able to come up with Penicillin as an antibiotic and 19 1945 was right around World War II and so they were able to use these for people that had wounds that were dying of infections after they got shot or what have you right so it saved millions of lives back then so the combination of all of them got together and they got the Nobel Prize for this I'm not even giving you the names of the other people because quite frankly you wouldn't recognize them anyway they're just not famous for anything else nobody knows them Unfortunately they everybody knows uh fliming however okay so he said it arose simply from a fortunate occurrence which happened when I was working on a purely academic bacteriological problem which had nothing to do with antagonism or molds or antiseptics or antibiotics so it just happened to come up because of this okay yeah so that kind like or not call yeah it's like it's like the very first ever zone of inhibition yeah exactly and the picture is too small up there ction okay so again remember 1928 okay all right now there are three factors to know before antibiotic treatment is given so if you are coming into the ER with a really really raging infection of something the doctor is not going to immediately give you a prescription for it or a shot or whatever he has to consider or she or they have to consider all these different factors before they prescribe something if possible you need to at least narrow down what the organism might be it could be simple gr staining You' at least know whether it was gram positive or gram negative okay and hope that it's not microbacterium but those would be very specific types of um infections so you can take samples of body fluids sputum urine stool whatever so you can do some gram staining immediately obviously the lab would do this not the doctors um then then they can also make an educated guess based on the most common infectious agents the patients history and their life info so if somebody comes in and stepped on a rusty nail out on a farm somewhere you'd want to look for claustrum botulinum and tetanus and things like that because those are frequent um types of bacteria that would do that and they could be very serious know the microb susceptibility or sensitivity to various drugs so we are going to be looking at the Curby bow or disc diffusion method you guys already did a small version of this in the lab with your Nova biasin opticin and basrin antibiotic discs uh the week before we had our midterm okay and then understand the overall health medical condition age of the patient obviously if somebody is pregnant or very young or the elderly cany liver disease do they have an allergy to penicillin you know all of that has to be taken into account and then you have to kind of you know try to make a best guess as to what might actually work now um at the end of the semester we talked about doing the milk lab and then we're going to do the antibiotic lab slash antimicrobial agents like your sprays from home and things like that but we are actually going to take these plates are almost to the correct size I freaking love these plates they're this big these are not your standard Petri plates you almost feel like you're miniature like you shrunk down when you hold one of these things it's awesome so it's a big plate and look how many antibiotic discs okay those are the same size that we've worked with before so it give you an idea of size right of of those so we're going to put a whole bunch of them on this is an actual photo taken from the lab you guys are going to be doing okay so we can put all these antibiotic discs on there and then we can do this with three different bacteria and we look at these different zones of inhibition and when we measured them last couple of weeks we just said is it sensitive or isn't resistant but there's a little bit more to it that we're going to go into when we get into this one okay now real quick studying wise I want you guys to pay attention to two things this is the name that I use the Kirby Bower technique okay that's the one that's used I think most often the non-name part is dis diffusion test but Kirby Bower is what I want you guys to learn primarily okay that's what I'm going to be using on quizzes and exams is Kirby bow named after two people one named Kirby and one named bow okay the augur is a special type of augur it's not tsoy like we used last time so this is going to be Mueller hint and augur and we're going to talk more about that in a second here okay two completely different names Mueller and Hinton do not get those pairs confused with each other okay all right so let's move forward here ah so this should look familiar especially if you're in my lab so here's our anotic dis and we measure across the center to get our zone of inhibition and then we're going to compare that to a table to figure out is that zone of inhibition going to be sensitive intermediate or resistant so there's an intermediate class now okay so the major thing is here if you're not taking microlab right now the major thing to understand is just because there's a zone of inhibition doesn't mean the bacteria is sensitive to the antibiotic that's a major misconception you have to compare it to tables that have been published okay so here are some different ones we're going to be looking at aromasin gyin neomin penicillin G which is one of the first penicillin that was made strepto bomin and they all have different numbers they can either be if they're less than this number so if it was like six or seven it would be resistant okay toos if it was 9 10 11 or 12 we would consider that intermediate and then if it's uh greater than 12 so 13 14 15 and on then it's going to be sensitive okay so I want to do a quick uh exercise with you guys right here to make sure we're all in the same page okay so let's say that we are testing those drugs against staff or and these are our Lawns okay our zones of inhibition that we've got on our Lawns okay so if we have 15 millim would that be resistant intermediate or sensitive intermediate intermediate good okay because it's between 13 and 18 now there are some antibiotics where there is no intermediate okay so if it's less than 12 or greater than 12 then this is what you get so if we have 16 sensitive okay all right so what if we have 12 millimeters for this next one neomy intermediate good okay how about the next one 10 millim resistant okay how about 11 mm for this next one intermediate good how about 15 millim sens sensitive good okay so you should be able to do this on a quiz or on a test right okay don't over complicate it okay now I said it wasn't the same as t- soy here's how it's different uh I'm going to talk about U Hinton here in a second but this was developed in 1941 okay uh originally as a way to neria species and neria is a cause of Gonorrhea as well as Menin menitis you're going to find that there was a lot of researchers back in the 1920s 30s 40s where their research was primarily geared towards STDs like syphilis and gonorrhea and things like that okay so there was a lot of that back then apparently um they were just using it for neria but it turned out to be a perfect medium to do this antibiotic testing and now it's the gold standard so it actually contains beef extract as well as starch starch like you would have like corn starch something like that right so the starch is going to absorb any sort of toxic metabolites that the bacteria give off so that those don't interfere with growth so you want to make sure that anything that's killing the bacteria it's coming from the antibiotic and nothing nothing that either the bacteria or anything else is generating at all okay and it can also be broken down into glucose and use as an energy source so starch is a really cool thing to have in there um there are also it's going to have less augur in it now remember augur is a solidifying agent right well that's a blast from the past right we haven't done uh chapter 3 in a long time so there's less augur so it's less dense it's less solid now when you guys inoculate this you guys aren't going to notice a difference but there is less augur in it and that is so when you do put an antibiotic disc on there that antibiotic has no problem diffusing out in a very prescribed rate out uh around itself right if it's really tight augur if there's too much augur in there it's not going to go very far and it's going to affect your zone of inhibition that's why the IM henion augur if everybody around the world loses the same mu hension augur they'll get the exact same zones of inhibition okay so that's important all right now here's what I absolutely love micro teachers and and a lot of people assume that all of these researchers these names that we come up with we never know if they're male or female or what nationality they are with we don't know but everybody assumes it was some white guy right so this is a shout out to Dr Jane Hinton who was a black woman and you got to imagine what things were like back when she was alive as far as how races were treated she was born in 1919 in Massachusetts New England folks okay so here's the deal though and I actually found out some extra information about her that I thought was really interesting her father was actually pretty successful and had enough money that he sent his daughters he had two daughters uh sent them to Europe to become educated because it was easier for blacks to get an education in Europe than it was in the United States right she graduated high school at 16 and was pretty much done with college by 20 she had a mind like she definitely got her from her dad I think too now her father was a very successful bacteriologist and pathologist he had to go into lab science because he wasn't allowed to become a doctor because he was black so he did research instead but he was the first African-American teacher at Harvard because that's how smart he was um and he was the first African-American author of a textbook any textbook he was the first author and at the time Jane was unable to take a medical lab technique course is that wild like just taking micrb if you were female there was a time where you weren't allowed to take that class it's insane right so because he had the clout he was able to start a medical lab techniques course that was open to women for the first time and his daughter was able to take the class from him okay and she worked in his lab for a while in the bacteriology lab but he had a colleague named John Mueller who was working on the neria stuff and he took her on as a labtech and together they created Mueller Hinton augur the fact that she was even able to put her name on the augur back then it's phenomenal right otherwise it would just be Mueller auger and that's all you guys would know okay um just a little bit more about her she was not a lab tech for a very long time um the war was going on in the early 1940s and she was able to actually become a medical lab tech let me write that let I wrote that one down yeah so during World War II she worked as a medical tech for the US war department in Arizona not sure why Arizona but uh yeah so she did that from 1942 to 1945 when she was done with that she decided she wanted to become a vet but it was really hard to be a vet as a black woman as well so she became one of the very first two African-American veterinarians in the country okay which I thought was pretty darn cool so she was a small animal vet in Massachusetts for a while and then she joined the Department of Agriculture as an inspector so she investigated disease outbreaks in livestock just kind of interesting she did research as with that as well she was able to retire Folks at the age of 41 the rest of the time she played in her garden and enjoyed life and she died at 83 not phenomenal she lived more by the age of 41 than most of us will in our entire lifetimes it's just absolutely amazing I love this woman she's fantastic all right anyway I hope you guys like that now for the boring stuff okay selective toxicity and therapeutic index um the definitions of these are really really important okay definitely selective toxicity can be a little bit confusing so if something is selectively toxic it means that it's not just going to cause Flatout toxicity of everything it's going to be very selective about what kind of damage it causes okay so the more selectively toxic something is the better it is because that will help you avoid problems that it might otherwise cause so if somebody has k kidney disease you want to make sure that it's not going to be selectively toxic towards kidneys right all right um now this is really important as well fact let me Circle this so the more alike the pathogen and host cell are the greater the toxicity and the greater the side effects I touched on this earlier okay so remember I said that if you take an antibiotic and you get a lot of side effects from it like diarrhea and other things then it means that it doesn't just Target the bacteria it's also targeting your cells as well because the structures are a little bit too close together think about ribosomes okay so the only difference between the ribosomes is one is 70s and one is 8s so if you got an antibiotic that targets ribosomes you're going to have some side effects to it they're just too close together unless there's one specific part of the ribosome that's completely different okay so think about this way back when I talked about cell structure remember I said review that I said that pepti tolyan which was in the cell walls of gr positive and gr negative that was your thick Sponge versus your thin sponge right that the only place on the entire planet where you can find that molecule is in bacteria cell walls nowhere else so doesn't that sound like a beautiful Target for antibiotics and it is okay so that will give little to no side effects now penicillin luckily targets pepto glycan and that's why it became such an amazing and fantastic antibiotic to start off with okay but if it targets a cell membrane that's found in all cells that's going to cause side effects okay now there is an index called the ti therapeutic index okay so what you guys need to know is that the the number the better off you're going to be so it's going to be less toxic so higher is better so if I give you two numbers and I ask you you know which one is more toxic you should be able to figure out the answer from that okay all right so we've got five main targets for our antimicrobial drugs really our antibiotics here and we're going to look at each of these a little bit more closely uh we've got our first cell wall synthesis so that's our pepid glycan that we have talked about before definitely review the structure of that if you need to uh way back in that chapter 4 with procaryotic structure we've got protein synthesis so we've got the main job of ribosomes that are going to be targeted for that one folic acid synthesis that's going to involve a series of chemical reactions that occur in the cytoplasm fourth we've got the cytoplasmic or cell membranes I really should get rid of that last parenthesis right there I know I'm refractionist sorry cytoplasmic or cell membranes themselves can be targeted uh and then nucleic acid which can be DNA or it could also be RNA now we are getting it into the point of the semester where you're going to have a lot more memorization to do and if I give you one of these antimicrobial drugs that I've got listed here you should be able to tell me recognize which of the five main targets that it has okay so we have this diagram that comes out of your book and there's a larger version of it that you could print out on the next slide there's uh more antibiotics there um on that diagram then I need you to know so I've picked out the ones that I think are the most important so I did reduce the amount of memorization a little bit here for you um but these are definitely the ones that you guys need to study now as you look through this list some of these may look familiar to you uh it may be that you took one of these antibiotics or a family member had to take one of these antibiotics before if we look at cell wall synthesis one of those should be very familiar to you from lab and that is baset Trin so that was one of our antibiotic discs that we we did uh in unit 12 uh if we keep looking through some of these something else from microlab should look familiar here so if we're looking at number four the cytoplasmic cell membranes uh polymixin is sort of a larger group of um antibiotics kistin falls into that category and if you look under the nucleic acids you have uh listed here nalidixic acid so as you guys probably I hope remember your CNA blood auger that's literally what the CNA stands for it's kistin and nalidixic acid so that is your CNA blood augur and you know that that augur is selective uh for GR positive caucus bacteria you cannot grow gr positive billus or any gr negative bacteria on it and it is because of these antibiotics that are in it so that is what makes it selective okay so the first one that we are going to be looking at is going to be our cell wall synthesis this one is especially important um because it's actually uh the target for um penicilin which is the first antibiotic that was discovered and what's great about um this particular group of antibiotics is that it targets the cell wall and 90% of bacteria are going to have a cell wall so that means we've got a lot of targets that we can aim for now cell walls typically are there they can help maintain shape they can give protection from osmotic pressure uh we know that if we can damage the cell wall somehow that usually will change the osmotic pressure and your bacteria can lose its integrity and water can flood in cytoplasm can leak out and then the cell basically falls apart one of the most important things about the cell wall is this right here it is made of Pepto glycan remember that's a combination of uh protein and sugar and what makes this particularly special is that this is the um compound that I said the only place on the entire planet that you can find peptidoglycan is in the cell walls of bacteria that is extremely important for this selective toxicity so if you are targeting something that is only found in bacteria then it's not going to affect uh the Mion cells you know your human cells which means means you're going to have less side effects and that is always going to be a good thing side effects can be uh damaging uh it can be permanent and uh it can also have patients stopping their antibiotic before it completely kills off an infection and then you can end up getting uh an antibiotic resistant infection from that so having something that is very unique to bacteria is going to be the best uh form of antibiotic that we can actually get all right so good Target for antibiotics the cons however um yes you can develop an allergy to it we are going to be studying the immune system and you're going to know that an allergy is basically uh your response your immune systems response going a little bit Haywire um it's not a direct effect of the antibiotic itself um but also drug resistant forms are going to be common now I asked you guys to pay attention to the year that penicillin was first discovered and if you did that then you should remember that penicillin was first discovered in 1928 okay now the first antibiotic resistant form uh of penicillin came about in 19 29 see that now you guys have to understand that this antibiotic resistance started forming before they had even fully developed the antibiotic itself to give out to patients so that took a few more years to actually do but in the labs they were already seeing penicillin resistant strains so this was already an issue but it wasn't until much later that we really saw how big of a problem it was going to be now although we've studied peptag glycan before or PG for short um let's look a little bit closer at what this really looks like at the molecular level so we've got our nag and N compounds here and this is what we call them for short because the full names are sort of ridiculous to say so uh n acetal glucosamine that's nag and N aetl muramic acid is nam and when you look at the chemical structures of these they always cross link to each other and they have these rings that should look familiar to you guys because these are actually five carbon sugars that are actually glucoses so you can see that a little bit better there uh these are just glucoses but they have extra groups that are attached onto them that give them the fancy names now these are the sugars just the sugars so you're going to have rows and rows of these um these glycans nag and N nag and N over and over and over again and if you have a gram negative cell wall that's the one that has just a small layer that's about one to two layers of these nagam molecules in a gr positive cell wall however you guys know that's the thicker one now you're looking at anywhere from 50 to 100 layers and they end up getting crosslin with each other to create a really strong wall with these amino acids okay so together this is what makes the pepti glycan U itself all right so there are enzymes that are just on the outside of the cytoplasmic membrane those are going to help um catalyze the reaction where these layers of nagam are cross- Lin with each other so these peptidoglycan cell walls are synthesized in three basic stages and I want you guys to pay attention up here we've got our gr positive and gr negative bacteria next to each other let me add a couple of things here so we fully know what's going on so here is the plasma membrane but remember we call this the cytoplasmic membrane because this is the one that's closest to the cytoplasm so that means okay so that means that the cytoplasm is down here so this is going to be the inside of the cell all right and there are going to be some enzymes that are right around here okay all right so here's how it's built the nag and N those molecules are actually built here in the cytoplasm okay so that's the first stage they're built inside second these are going to be transferred across the cytoplasmic membrane to be incorporated into the peptic glycan on this side of it okay so they're going to be transferred over from one side to the other finally these enzymes right here that I made little Circles of red here those are called trans peptidases okay or also penicillin binding proteins we pretty much called them that because that's what the antibiotic is going to bind to okay to actually fight these bacteria all right so once again nagam is made in the cytoplasm stage one stage two they get transferred across the cytoplasmic membrane to the other side uh and then stage um three those are going to be cross-link using these enzymes and that's where these little bridges are actually created just like this to make the Pepto glycan layer now there's a couple different groups of back of antibiotics here we have our non beta lactams vco myosin and Bacitracin so that's actually going to Target number two so that's going to Target where they're actually transferred from one side to the other and then our beta lactams those antibiotics penicillins is going to be one of these is going to Target number three where these enzymes right here are going to start linking them together okay so what in the world is a beta lactam to begin with it sounds like it's an organic chemistry term and you're basically correct on that so we have this little square right here in the basic chemical structure and that square is called a beta lactam ring I know that sounds weird that there's a square that we call a ring but we just got to go with it because it's organic and organic doesn't necessarily make sense all the time if you ever take an organic chemistry class you'll understand what I mean so we just happened upon or really Fleming uh happened upon the most diverse most commonly used chemical structure that we have for these antibiotics that work so darn well okay now if we look at the basic chemical structures here's penicillin right here okay now I'm not making you guys memorize the individual chemical structures that you see in this box this is this is really just for um interest sake okay so interest not on exam but you can see that they all have that common betalactam ring or that square involved in their chemical structure so here we've got penicillin another one that's pretty common is the syphilis sporin that may seem familiar to you and then another one that you may or may not be familiar with is the carbapenams down here I don't know if I'm pronouncing that correctly but that's how I'm pronouncing it uh those are kind of the most common ones that you might come across so let's look at how these antibiotics U like penicillin can actually fight the infection so I can tell you it's really hard to find just a basic diagram for these kinds of things um this is really the best one that I could find but let's Orient ourselves here a little bit before we get into this so what we are looking here at here is a gr negative cell wall so we're going to have our cytoplasm down here the inside of the cell okay and then we have our plasma membrane or the cytoplasmic membrane right here okay here are these penicillin binding um proteins which are transpeptidases right here actually let me go ahead and write that in as well so those are trans peptidases okay cytoplasm let's recall this the cytoplasmic membrane okay uh here is our pep glycan layer right here so remember there's only one or two layers uh in a gr Nega cell wall and then last we have our outer membrane which is out here okay now remember we're not building the cell wall right now we are looking at how you're giving a a patient penicillin um as that antibiotic how is that antibiotic going to try to kill the bacteria okay and in this case a gr negative bacterium so our beta lactam up here let's just just go ahead and call this um penicillin okay so the penicillin is going to be these little boxes which remember these are betal lactams based on that ring structure right there the most basic kind so it's going to come in from the outside okay because it's going to be in the bloodstream it's going to get into um the spaces between the cells and these are not Magic Bullets so they are going to go throughout the body and you're going to have the betalactam it's going to be able to go through these porin proteins that are in the outer membrane they're actually going to go through the peptidoglycan layer and they are going to bind to these penicillin binding proteins over here okay hence the name penicillin binding protein it's weird because it's being named after the antibiotic that fights it and that can really throw people off quite a bit uh so if you just want to call it transpeptidases you know absolutely go for it so the penicillin is going to come in it's going to bind to the transpeptidases um and when it blocks it it's going to prevent it from doing any sort of cross-linking um of the peptidoglycan layer okay now we've said before that bacteria are going to be most susceptible when they are actively growing and dividing right and now I think you guys can see why so if we have just a static bacteria it's made its Pepto glycan layer and it's just sitting there then having penicillin come in and block those transpeptidases is really not going to matter a whole lot right but when the bacteria is actively growing it's getting larger in size because it's about to divide by by fision it's going to need to be actively creating more pepti glycan which means that those transpeptidases are going to be needed to do the cross-linking if they don't get crosslin now you're going to lose Integrity of the bacterial cell wall and the bacteria is going to fall apart and die lice at that point okay now let's look at how this looks with a gr positive cell wall so here's our gr positive cell wall notice we don't have a um outer membrane that we need to go through we do have a thicker layer of peptidoglycan but the betal lactam your penicillin is going to go through this and once again bind to the penicillin binding proteins okay now I want you guys to pay attention uh to these differences between the gram negative and gram positive cell walls uh because we are going to be looking at later how these bacteria can sort of defeat and become resistant to these penicillin uh and betal lactam antibiotics so keep this in the back of your head now the next Target of our antibiotics is protein synthesis and I really hope at this point that you guys remember that protein synthesis is translation and that's being done in the cytoplasm by ribosomes okay so ribosomes are really going to be the target for all of these antibiotics but how it actually targets uh the ribosome where it targets it what process uh what part of the process of making that protein that is going to interfere with that can all be different okay now remember we've got a large subunit and a small subunit so for our bacteria we have 50s subunits and 30s subunits I also want you guys to remember that both procaryotes and ukar are going to have ribosomes the shape the size they are going to be slightly different from each other okay and but we're still going to have a little bit more of a problem here uh depending on what part of the ribosome is targeted we're we're talking about something that both types of cells share so you're going to have a much greater chance of side effects with these type of antibiotics okay now let's look at some of these ways that it can actually um be blocked and you can kind of see that over here on the right hand side so I made a little list over here as well so this first one is block initiation so when the ribosome is not actively translating something these subunits are apart they're all by themselves okay so they only come together uh and fit with that messenger RNA if you're going to initiate translation so if you block them coming together then you're not going to make any protein whatsoever the second one is a misreading of the messenger RNA leading to a faulty protein now there's some different ways that this can happen but I want you guys to remember that shape is everything to a protein ability to function correctly and the shape is going to be dictated by the chain and sequence of amino acids so if you misread the messenger RNA you're going to be putting different amino acids together you may make it shorter you may make it long I mean all kinds of weird things can actually happen with it so if you change the sequence you're going to change the shape and that's going to lead to a faulty protein and depending on how important that protein is you could definitely damage the bacteria okay all right the next one is to block peptide bonds from being formed so in the large subunit there's going to be part of it that acts like an enzyme and it is going to um make the amino acids uh make the peptide bond between the individual amino acids one at a time as the messenger RNA is being read so if you block that ability then they're not going to be able to come together to form any type of protein next one t RNA is blocked from joining the ribosome so remember the TR RNA or transfer RNA is going to be what's actually bringing the individual amino acids to the ribosome so that they can be linked to together if those don't arrive then nothing's going to happen and then we've got ribosome prevented from translocating and remember that means that it's going to read one codeon and then it's going to shift over to read the next one and then it shifts over to read the next one so if you are physically blocked from doing that uh if it gets locked in place so to speak then again you're not going to make any type of protein okay so all of these are really really important to have a functioning viable protein and you have to have proteins in order for a bacterial cell to survive and if you think about it you have to have this happen for any cell to actually survive so the specific types of antibiotics that I want you guys to look at for here we have our aminoglycosides uh here we've got aminoglycosides up here so that's going to be one of the ones that causes the messenger to be misread and that's going to include streptomycin uh we've got tetracycline right here so that's one of the ones that blocks the TRNA from coming in and then our aromasin that was super common when I was younger and then it developed into aiyin that's going to be one of the ones that stops the translocation from actually occurring now this is just another diagram that I found um it's a little bit bit bigger but it can show you uh different ways that a lot of these drugs can inhibit protein synthesis okay so remember this is translation so I wanted to go a little bit more in depth with a couple of these protein synthesis um antibiotics so we're not in a new category here we're still at what is it number two protein synthesis as far as this is going Okay so we've got aminoglycosides okay and uh some members of the aminoglycosides these usually end in m with a y m with an i or just sin uh c i n so streptomycin is uh the most common one that we were just looking at before uh also gentamycin and toyin um are also going to fall into this category now streptomycin was uh first discovered from a streptomyces bacteria this is not the same as a streptococus bacteria okay so streptomyces is a different uh genus that we're looking at here but they still occur in Chains which is where the strepto comes from okay now these are typically used with another antibiotic um to kind of widen the Spectrum a little bit or uh they have sort of a synergistic quality where if you give uh it with another one it sort of enhances the quality of both of them this one um in particular these are only administered parenterally so that means that by injection Under the Skin uh through IV something like that okay the targets are usually your Gram negative aerobic bili and if you look at some of these they should look familiar to you because we are using species um of some of these and eoli as well in the micro lab okay this uh these aminoglycosides are rapidly bactericidal so instead of stopping the growth they are going to just kill the bacteria outright and that's uh really what you want more than anything usually these are reserved for more serious infections okay which you can probably figure out from the parenteral injections as well so gentamycin can be used for infective endocarditis so we're talking about an infection of the lining of the heart uh more complicated urinary tract in infections um septicemia uh where you've got bacteria that are um growing in the bloodstream uh pneumonia things like that there are some pretty serious adverse reactions however which is another reason why it's reserved for serious infections so ototoxicity uh when you see oo you're talking about the ears uh vertigo tentis which is a ringing of the ears uh hearing loss but also nephrotoxicity and if you remember me talking about that before um that's we're talking about um kidney toxicity okay so kidney damage now sometimes that kidney damage can be reversed and sometimes it can't be next we have Tetra cycling uh when I was young this one was a really common one that was used um now is bacteriostatic or bacteristatic so it's going to Halt the growth but it's not going to um kill the bacteria outright this does mean that it has slightly less toxic side effects absorbs well orally so this is not one that has to be injected okay shows pretty good distribution around the body so it can make it to the liver and kidneys it can Target both gram positive and gram NE negative aerobic bacteria usually used for everything from acne to uh STDs like chlamydia uh Lyme disease which can be carried by ticks all kinds of things now the main and kind of the most famous adverse reaction for Tetra cycling is going to be this uh kind of graying of the teeth up here um and this normally happens if the tetracycline is being taken when the teeth are actively being formed uh which which is why it's contraindicated in uh children that are still growing as well as pregnant women so even in the womb uh you've you've got teeth starting to you know form in the gums and uh it can cause the staining of the teeth that is 100% permanent so if you think some um some uh Crest White Strips are going to take care of that uh you got another thing coming it's it's permanent all right so now we're at our third target which is folic acid synthesis and you may that that folic acid um may seem familiar to you you've probably heard that before um it's also called folate okay um and when uh a woman becomes pregnant they often take uh vitamins that include folic acid so it's very important for um form of various things uh especially nucleotides for making DNA and that is really the target for these bacteria as well so you can imagine with folic acid synthesis we are talking about something that could affect both procaryotic and eukaryotic cells okay um so there is uh enzymatic activity in these metabolic um chains of chemical reactions and it can be inhibited so stopped completely by something called competitive inhibition which is something that I wanted you to go back and study for enzymes and if we look over here just to give you a little bit of a review here so here's a typical enzyme and you know that it's a lock and key type of deal where the substrate has to fit perfectly inside the active site of the enzyme in order for the chemical reaction to actually occur now there are chemicals that can have the same general shape or one that's close enough to it that can compete for the substrate um and if they come in and are sort of the winners of that competition and block that substrate uh from coming in then the enzyme can no longer function correctly okay um if we're talking about a non-competitive inhibitor just to do a quick review that means that it is changing the shape uh causing def uh deformation at some other site which changes the shape of the active site so the substrate can no longer bind but what we are talking about here is this right here okay all right so our sulfa drugs or sulfonamides are usually ones that do this they are going to compete with um a chemical called paba which is short for par aminobenzoic acid and it's just one of the substrates that's needed in the chain of chemical reactions leading to um folic acid and folic acid is a vitamin or co-enzyme that is let me highlight that instead so folic acid is a vitamin or Co enzyme needed to create purine and peragine nucleotides as well as some types of amino acids so if you look over here towards the end of that series of chemical reactions um that's what we're looking at and obviously you need to have uh DNA um to be able to do DNA replication uh and be able to divide yourself and do binary fion so if we look a little bit deeper at the sulfonamides or sulfat antibiotics um we see that these were actually the first synthetic antibiotics and remember that if an antibiotic is said to be synthetic that means that it was made completely in the laboratory okay uh an example of a sulfa drug would be sulfamethoxazol and it's often combined with something called trimethoprim as well really shows good GI absorption good distri distribution around the body so these things can be taken orally they are renally excreted so that's going to be through the kidneys it can be both bacteristatic and bacterio cyal which uh can actually be good A little bit of both targets are going to be usually your gr positive aerobic bacteria like strep pyogenes remember that's the one that can cause strep throat as well as causing all kinds of really bad things to happen in the body um and then gram negative aerobes as well like eoli shagel salmonella neria typically these are going to be used for urinary tract infections uh that's where eoli can get from the gut over to the urinary tract as one possible example uh sinusitis otitis media again that's involving the ears and an ear infection uh chlamidia leria Toxoplasma all kinds of things now what kind of adverse reactions are we looking at here um Again part of this is because of the fact that we all need folic acid synthesis uh nausea and vomiting diarrhea uh stev Johnson syndrome which is this really rare um side effect where the scin the scin the skin blisters really badly um and it can also be a teratogen uh if you don't know what that means that means um that it can cause birth defects through mutations so not a good thing which is why this is contraindicated if you are pregnant so here we have our fourth Target which is the cell membrane and I kind of want to change this a little bit um I want to maybe here at least while I'm explaining it let's really just make this the phospholipid by layer this is going to be a little bit different than we were looking at before so this is not just going to Target the cytoplasmic membrane okay and that would actually be right down here this is the cytoplasmic membrane okay and here they're calling it the inner plasma membrane all right it's not just going to Target that it's going to Target phospho layer phospholipid bilayers in general which means it's not just going to Target the cytoplasmic membrane but it's also going to Target the outer membrane as well which we find in our gram negative bacteria okay so in gram positive bacteria it will only target the cytoplasmic membrane in gram negative bacteria it will Target both the cytoplasmic membrane as well as the outer membrane okay just take out plasma so it doesn't confuse you guys all right so the outer membrane as well now how is it going to do this it is going to do this by acting like a cat ionic detergent ah so here we're bringing in a little bit from that chapter 11 now these cationic detergents were like surfactants okay these are like amphipathic molecules where that kind of acts like a phospholipid in of itself one end of it is going to be hydrophobic one of it is going one side of it is going to be um hydrophilic and it's going to insert itself into the membrane um in just as if it was a phospholipid but it ends up not doing a great job of it on purpose and it starts to break up the phospholipids from each other which can make the cell very very leaky and once you make a cell leaky water runs in cytoplasma runs out and the cell is going to fall apart okay so that is going to be a super huge deal now obviously that is going to make it bactericidal okay bactericidal so it's actually going to destroy the bacterial cell not stop it in its tracks okay um now this one also actually has an added benefit and something that we have not seen with the other um antibiotics we've looked at before so these can actually bind to and neutralize LPS now LPS is an endotoxin it's believed to be the only endotoxin that we know of and these are these molecules that stick out of the outer membrane in gram negative bacteria the these LPS molecules as you're going to see more in the next chapter can do a lot of damage even if you destroy the bacteria itself and you make the outer membrane fall apart you do not want LPS suddenly being released in large quantities into the bloodstream if you do that it's actually going to then just turn into a toxin um and it's going to start destroying tissues okay and you can have something that's like toxic shock syndrome associated with this so it's not a good thing so the added benefit of these is that they not only just make the bacteria die and fall apart but they also bind the LPS up and Surround it so that it doesn't cause tissue damage and you don't get the toxic shock that's associated with it now as you can imagine uh it sounds like this is a pretty serious antibiotic and it is this is usually a um Last Resort antibiotic okay um it's got a very small therapeutic index so remember the larger the therapeutic index the better so if you have something where the host and the bacteria the pathogen have similar structures you're going to have a small ratio and that means it's going to be more toxic so the bigger the ti the better unfortunately in this case it's not just bacteria that have fossil lipid Bayers we do as well around every single freaking cell so nephrotoxicity again involving the kidneys is going to be a serious issue here okay now it can be used in creams and used topically um a little bit gets absorbed by the skin but not a lot but if somebody has a pretty massive skin infection and other antibiotics have failed um this one is sort of a safer option to go with um types of these antibiotics include polymixin and there's a bunch of different polymixin that all have a different letter at the end uh polymixin B is uh pretty common and then look here we have kisten now another name for kisten is polymixin e but you can just learn it as kistin and this is one of the ones that we had in our CNA blood augur okay in our CNA blood augur and if you remember uh CNA blood augur will uh kill any gram negative bacteria right so that kind of shows you a little bit more about why and how it does that um and then finally the last one is nucleic acid uh synthesis so there's all kinds of different points within DNA replication as well as transcription where you're making a an RNA copy of the DNA strand uh where this could actually these different kinds of antibiotics can come in so uh we were just talking talking toxic we were just talking in lab about one of the antibiotics that you guys are using this week in unit 12 the antibiotic discs that you put on the different augur plates blood augur plates and one of them targets DNA gyas which is right here and so if it stops that enzyme from being able to relieve super coiling then the DNA essentially has to stop it can't get it gets to a point where it can't open the DNA strands any longer to allow other enzymes to come in and make a copy and if you can't copy your DNA then you fail in doing binary fision which means that you're not going to replicate at at all okay and then for transcription um it can affect different antib can affect that as well and then you can't make any messenger RNA which means you can't make any proteins if you can't make any proteins then it's going to stop everything happening at that point and your cell can either die or just static at that point so now diic acid there's that one it's Naros Spectrum really it's only used for UTI um and in this case cypro is the broad spectrum one it's a type of quinolone or we also call them floral quinolones for these um and other Topo isomerases like too 4 is another one that it can actually affect so have any of you guys ever taken cypro before yeah so that's the yeah it's it's not fun to take CYO so um every time I see the word cypro it brings back bad memories for me in particular so I in my late teens early 20s I had a run on just recurring urinary tract infections just like every month I was having one and it got to the point where the bacteria was becoming resistant to the antibiotic and I was very compliant I took my full 10 day 14 day whatever it was at the time um speaking of feeling old uh you know routine of it I took all of the pills I was supposed to but it always always came back and so I don't even remember what the original antibiotics were that they gave me but they really didn't help for very long until they put me on cypro and they told me at the time that once the bacteria is immune to cypro or resistant to cypro I was going to be in trouble because they didn't really have anything else at the time to try to give me so that really set me into a into a little bit of a panic so I was living in Soro at the time so very small college town down there if you've ever been there uh tried being there for 15 years of your life um and I had gone to pretty much every healthc care provider every doctor that happened to be down there and nobody really could help me so as a last resort I had heard about this uh herbalist that had gotten her biology degree from uh New Mexico Tech where I went to school and uh or actually she was biochemistry I think it was anyway enough of the information told me all right I'm going to go check this out I have nothing to lose whatsoever so I went to go see her and I wasn't into any sort of alternative medicine or Easter medicine nothing like that so um you know I was only like 19 at the time so I went to go see her and the first thing she did was she spent an hour and a half talking to me and taking down all of my information and we talked about the fact that I had passed a rather large kid Stone like a year and a half before and uh and if any of you know what a goat head is yeah you know what if you step on it so my stone looked like a goe head it had spikes on it so it took me a full 30 days to try to pass it it was absolutely Agony I can tell you it is more painful than childbirth um so that that's that's true so anyway she took all this information she said I think what's happening is that you are um actually releasing smaller crystals that are very easy to pass but they are sharp enough that it is nicking or irritating the lining of the bladder and that is where the ecoli or whatever bacteria that I had because they never even tested to see what bacteria I had was latching on basically so um so she gave me a tea to drink had four things in it and some of it was to was to resolve the crystals and then the other parts of it was to just soothe and heal the in lining of the bladder right never had another bladder infection never so um I also never passed another kidney stone thank God and they told me that my kidney stones were inherited and therefore there's nothing I could do about it and I was going to pass one every two years so that's real great to hear uh also um so yeah that that's every time I see cpro I get I get like this little tensing happening so anyway a little bit more uh here so this especially the example of cypro here and there are second third fourth generations of these for quinolones cypro is actually second generation which is all they had when I was younger there's now third and fourth Generations which are supposed to help better and be less toxic but in general these are really absorbed well they can distribute all across the the body um so they can be used for different types of infection even though they usually are used for uh UTI but pneumonia is another one and STDs here we see chlamydia again chamia is like in all of these um but some Grand positive caucus can be uh affected gr Nega bacillus like eoli salmonella camonis and micoplasma as well whenever I saw you know again some of these that we use in lab I wanted to kind of put them up here for you guys but look at the list of adverse reaction actions right so it's it's very long and I remember some of this just from taking cypro myself so thank God I didn't have nausea or vomiting but I had um several of these others did not have hallucination or seizures that's pretty rare um but you can even get arthropathy so weightbearing joints like your knees uh it degrades the cartilage and so you kind of get arthritis from a very young age if you start taking this very young contra indicated in children you can also get tendonopathy and tendon rupture and one of the worst pains besides passing a kidney stone is also having your Achilles tendon rupture anybody in here have that done oh gosh so I watched it happen to a friend of mine he stepped off the sidewalk wrong and there was like a little bit of a dip and he ruptured his ailles tendon it was only his second day on the job by the way um and I am never seen anybody in so much pain before he actually started vomiting he was in so much pain and he was screaming at the top of his lungs and they had to get an ambulance to come and get him and he was homebound for six months it took that long for him to actually recover so how long did it take you to recover so I actually was was college basketball oh yeah myed as well as oh gosh the loud pop that yeah like just talking about it like yeah I know yeah so one of one of the ways that uh practically anybody can tell if the Achilles tendon ruptured like you don't even have to have a doctor look at it but because that's holding your calf muscle in place the gastrus it will roll up like a blind that's been you know that's been let go like if I were let just goes up in the ceiling like that that's basically what happens you get this big bulge right at the top part of the the calf I will stop talking about now I promise sorry uh let's move on it's making mine hurt and I didn't even do anything um so just a little reminder back to Charles Darwin here um it's not the strongest of the species that survives nor the most intelligent but those most responsive to change by Charles Darwin so that also applies to bacteria uh and viruses as well well so next we're going to look at ways that drugs can become resistant to all of these antibiotics that we've got and so here again you can see the Kirby B method here using the um uh different antibiotic disc that we're testing so um the main the main concern um is the fact that resistance can actually happen fairly quickly and I want you guys to know noticed that on this bullet I say that resistance is f was first seen ever in 1929 now when was Penicillin discovered 28 and it wasn't even really developed as uh like widespread use for a few years after that but just from working with it in the lab trying to develop a drug for this they were already seeing bacteria becoming resistant to penic so it is um yeah now it didn't become a major concern until the 1980s and and 90s when they were starting to see more and more widespread um bacteria that were resistant Mera is the most uh popular one and a lot of experts have predicted that deaths from uh infections are going to outweigh cancer by the year 2050 and this was a prediction that was made oh gosh maybe 15 20 years ago and still today day they're making the exact same prediction so it's not getting any better unfortunately so this is if you're going into Healthcare whether it's um you know in the hospital or a doctor's office or uh especially in Dental as well dental offices uh you're GNA you're going to see this happening quite a lot so um I've told you guys before that uh a descendant of um liser Dr Phil um was also following his family line in um studying microbiology and his research was in antibiotic resistance and so uh he gave uh he gives talks um all over the the world and he's also head of a special group in NIH that is looking at antibiotic resistance as well and ways to find it so he's still very much involved in it even though he's the dean of our um school now um um but he often gives this case study and uh and I asked him if it was okay if I borrowed it and he said absolutely so this is one that he kind of put together but one of the things that I want to get across to you guys is when I nitpick with you guys about being detail oriented and reading things really carefully think about that when we talk when we talk about this that there's a reason why I'm nitpicky okay um all right so University of Miami Hospital is actually really famous uh worldwide uh it's one of the top places to go to if you need any sort of an organ transplant so they have very specialized areas that do this um that also means though that people from all over the world that need an organ transplant are coming into that hospital and into the United States um it with you know varying degrees of antibiotic resistance so we know that um in order to get a prescription for antibiotics you know you have to get that from a from a healthcare provider we can't just go to the store and grab some antibiotics off the shelf but that is not the case across the world so there's many many countries where you can go to your local pharmacy like we could go to CVS and get penicillin off of the off of the shelf or any other kind of um any other kind of antibiotic and so a lot of people self medicate because of that even though they may have a viral infection so anytime that happens you're increasing the risk of having antibiotic resistant bacteria so um a person came uh I'm not going to say what country that they came from but it was uh pretty far away and they came this person came in for a transplant and uh in his admission file all the paperwork that came with them and since he needed a transplant you can imagine his file was pretty thick but even on the first page it specifically said xdr and xdr means extensively drug resistant so now we're talking about kind of worldwide being resistant in this case so these are the most dangerous bacteria on the planet and specifically he had clella pneumonia okay now this is the most deadly KP that exists out there now we play with KP in our microlabs but we purposely get and purchase the most non-pathogenic we Poss possibly can okay um but anytime that we work with it and we grow it we're putting that bacteria in a situation where we might put some environmental pressures on it and there might be a mutation to where it becomes more antibiotic resistant so anytime we play with bacteria we're going to have that possibility happening so anyway on his file it specifically said xdr for K Pon and everybody overlooked it they just kind of glanced at his incoming paperwork they knew what he was coming in there for they knew about the transplant and everything else and that was it so read everything and pay attention to details this is where that comes into play several people missed this because they didn't follow through and look at his file very uh closely now when you're going into a hospital for a um organ transplant it's not a you know come in for a few days have the procedure leave for a few days you're done they are in the hospital for months and months okay depending on what the transplant is so if you're going to the urgency Miami Hospital these are where some of the trickiest and most difficult transplants are going to happen like a double lung transplant for example so uh anyway the information was ignored um and by the time they figured out what was going on because suddenly more people were coming up with infections and they were trying to trace it back to you know person zero person zero um they realized that this person had xdr Club Sal of pneumonia and by the time they sequestered this person because he'd been out talking to people you know whatever else yeah yeah he was sick but he was still well enough to walk around and you know do whatever so um by the time they figured it out and sequestered him and isolated him the damage had already been done so nine more patients were infected over this 3mon period and that may not seem like a lot but it is um and then the final clinical impact from this five patients uh not this particular person but five other patients died and they found xdr Cale pneumonia in their bloodstream so they had bacteremia okay we're going to talk about the difference between septicemia bmia and all that kind of stuff later two survived but they had kidney failure that means that the drugs that they used trying to kill the Cale pneumonia was nephrotoxic and then three survived without kidney failure they were able to get them kind of uh back from the nephrotoxicity but they still had uh long lived issues medically for the rest of their lives so all of this just because a few people at the admissions area the first nurses the first doctors just didn't look to see that they had this so it's going to be a very um very serious thing so all right so with drug resistance we we got three things that are actually working uh against this and I got this um particular figure from uh Phil as well um so first resistance to new drugs evolves extremely rapidly um so I already showed you that it only took less than a year of just working with u penicillin gosh I know what I was thinking penin allowed before resistance was starting to happen um the pipeline of new drugs is dwindling so we may think that there's all these really great antibiotics that are still in you know the depths of the Amazon rainforest and stuff but they really not finding much anymore unfortunately um and there's more pan resistant bacteria so pan kind of like pandemic means all across the world so that is also an issue and you can see that the antibiotic development you know has been um absolutely decreasing as we get closer and this is just 2008 to 2012 I mean we're in 2024 now so this is even smaller um at this point that we've got yeah so there's two main Pathways of how a drug gets resistant in the first place one is just spontaneous mutations so anytime again that you have bacteria that are actively growing so if we're going to put a bacteria on a augur dish and grow it in the lab that is actively going to start going through fision and uh going through DNA replication and anytime you've got DNA replication going on you're going to have mistakes being made in copying the DNA and depending on what organism you are uh as human beings we you know we talked about this before that we've got enzymes we've got um methods to be able to find and notice and excise out the bad um DNA uh nucleotides and put in the right ones but even that's not 100% for us and there's a lot more that happens with bacteria so those are not often caught or fixed either so anytime we're doing that we have the possibility of introducing just spontaneous mutations like errors and DNA polyas putting the right um nucleotide matching together to build a new strand uh number two gaining resistance through genes uh through horizontal Gene transfer so we talked about conjugation transduction and transformation before and this is one of the reasons why we were going into it so remember that in conjugation that's where we have the sex pilli that comes in and connects two cells together and that puts them close enough that they can exchange um DNA could be plasmids it could be um a strand of DNA from the um main chromosome uh you've got transduction which uh is going to be kind of transferred through viruses bacterial FES and transformation and transformation is one where you may have bacteria that are dying and their DNA the cells has have degraded and Fallen apart and the DNA has fallen apart into these small little pieces but a bacteria near there can actually take up some of that DNA and then integrate it into its own um chromosome or it can pick up plasmas also then we've got our transposons or tees remember te means transposable element let me write that back on there because we haven't seen that for a while same thing as a transpose on or jumping genes um so that's when you've got part of the DNA kind of excises itself out and puts itself inside another part of the Strand and that can inactivate genes or can change genes as well um or you can even have um this happen without any prior exposure to the drug whatsoever that's kind of the scariest thing so picking up a plasmid for uh resistance to penicillin can happen without penicilin ever being in the area so there's less um pressure that way when you're talking about evolution of this all right so here's some specific ways um that this can happen so if there's genetic changes that can lead to cell changes so you can make possibly a new enzyme um that could actually break that beta lactam ring so there's that square with the double uh bonded oxygen right there remember that's a beta lapam ring so if you got an enzyme that could come in and just break that Bond right there you have now changed the antibiotic structure to a point where it will no longer function correctly that's a very easy thing to do actually so there enzymes are just called bapes okay um there's penicillinase sepor a those are very specific for those particular antibiotics and it just inactivates it so it doesn't even work anymore so most strains of sta oras um that we know from meylin resistant staff oreas are no longer susceptible to any penicillin today um and there are greater than 500 enzymes that are now known that all basically do the same thing destroying that structure so that the penicillin doesn't work anymore or that uh section of antibiotics doesn't work anymore so and this is what MRSA looks like I mean it looks very innocent from the outside right okay number two um permeability or uptake of the drug into bacterium is decreased so remember that some of the ways that the um antibiotic actually gets into the bacteria where it can do the damage damage it has to come through membrane proteins okay transport proteins this goes all the way back to when you guys studied the phospholipid Bayer and you have those proteins right that are embedded within it if you change the structure of those proteins then you can actually close it to a point where the antibiotic can no longer go inside and if it can't go inside if it needs to go inside to actually disrupt the bacteria then it's ineffective completely at that point so that's a major thing that can happen as well and it doesn't take much to change the shape of a protein because again one mutation in the right place for one nucleotide can change the um amino acid that it codes for and depending on whether it the R Group is positively charged negatively charged hydrop hydrophobic whatever that can completely change the shape okay uh or this one's kind of scary um the drug is immediately eliminated so as soon as the drug kind of comes inside through those membrane proteins it just Chucks it back out again so this kind of reminds me of like you know if you're chucking a grenade at an enemy and they pick it up and throw it right back at you that's kind of what this reminds me of so uh it's not going to harm them whatsoever and it's just going to get pumped out and and not work so that's another issue that's takes a little bit more um nuances genetically for that to happen but it do so um for GR positives we've seen this in staff and strep pathogens and gram negatives we've seen it with ponus and eoli so and all four of those are some that we work with in the lab the fourth uh change that could happen um you could have a change in the site where the uh drug is actually going to attach to in order to take place so if you've got you've got all these different parts of the ribosomes for example and we looked at how all those different little um antibiotics that Target protein synthesis can stop protein synthesis in certain ways they could bind to the small subunit to the large subunit they could bind to the messenger RNA all that kind of stuff but if you are changing those binding sites in any way shape or form then the antibiotic can't bind anymore and it's going to be completely useless and then finally um an affected metabolic pathway is shut down or an alternative pathway is used so if you have a chain of reactions and we've studied this with glycolysis right so it's it's a series of 10 different chemical reactions and as soon as you make the product of one that becomes the substrate for the next and so on and so forth so if you have a drug that needs to act here between B and C between those then what the bacterium could do is simply go all right well I'm not going to use C any more I'm going to use this C sub one and I'm going to go in this direction around it so this kind of reminds me of basically Albuquerque Whenever there is a car accident somewhere you know so if this is I25 and there's an accident there we simply go around it and use the side streets that's kind of what they do with the metabolism okay so we saw this diagram before when we were looking at how penicillin actually works to disrupt a gram negative and then a gr positive organism now we are going to look at how the bacteria can actually um fight against this and stop penicillin from coming in and disrupting it so how do we get some resistance uh from this for it well if you are a gram negative there are actually three targets uh that you can use to prevent um being destroyed by penisy uh number one you can stop the POR in proteins from allowing penicillin in in the first place so you can close those up or change the shape enough uh or make it too narrow so that the penicillin um will not be able to actually come in so it just stops it completely at the front door all right so let's call that number one the second uh place where it can do this is at the pbps or transpeptidases themselves so penicillin can come in but then when it reaches these guys down here these enzymes these transpeptidases maybe it changes the shape of those just enough that now penicillin can no longer bind to them so if they can't bind to them can't bind to the penicilin binding proteins then you're not going to um be able to stop the trans linking crosslinking um of your nagm and the Pepto glycans not going to get disrupted that kind of thing all right so let's call that number two and number three the structure of peny in itself you have that betal lactam ring which is kind of like a square so if you can actually disrupt and break open that chain just destroy that chemical structure somehow then you can also stop penicillin right there as well so those are three spots three targets that the bacteria can actually use okay now notice here with a gram positive bacterial cell wall we really only have um two Targets in this case okay so we can either change the shape of the pbps okay so make that number one or you can destroy that beta lactam ring of penicillin itself all right so there is no blocking of any porins or anything like that there's only two Targets here en yeah and they can be made interior and then exported out okay so it's actually Harder Than You Think to find a really good diagram for antibiotic resistance and um so this is a a fine one um but I'm actually going to just do it with my iPad so let me do a little drawing here to kind of represent this cuz when I first saw something like this it really kind of drove it home to me um let's let's do this okay so let's say that um this is bacteria on the skin let's say so each of these green dots that I'm doing it's actually pretty fun each of these Green Dots is a good bacteria okay supposed to be there okay and let's say that right there and right there some genetic mutation happens to where these are now anotic resistant so red is bad green is good okay so somebody takes an antibiotic well actually let me say this first so if it just stays like this there is enough of the good guys to crowd out the red so that the red don't go crazy there's a limited amount of space there's a limited amount of nutrients okay so as long as the green outweigh the red it's fine they will keep them in check okay so a lot of people have for example uh cloes dial SE diff in their intestines you might have some SEI cells in your gut right now and you don't know it but you don't have a ciff infection because they're being kept in check by all the good bacteria that you have in your gut like eoli and about 50,000 others okay a lot more than we thought actually let's switch from the skin and go to the gut let's do it like this okay so let's say the red is CDE okay and the green is like eoli so you have an infection uh it could be anywhere but you've been given an oral antibiotic okay so that antibiotic if it comes through and wipes out these or at least most of these but the red one stay away or stay stay there because it's resistant then all of a sudden these are going to start replicating themselves because now it's like Disneyland with no lines so they just go to town now they've got all the nutrients and especially if and this is what sometimes happens if the red has a faster rate of binary fusion faster rate of reproduction then even the green ones that were remaining can't get up to a high enough population to stop the red from going crazy to stop SEI so now this person has a SEI infection and that wasn't even what they had initially it could have been like a sinus infection that they they took this antibiotic for and now they've got a ciff infection from it right so this is mostly what happens with that all right now let's talk about some strategies against this so we have some that actually do still involve antibiotics so we are trying to slow resistance from developing that's why uh when you if you've got some sort of an ailment and you go to the doctor they're going to be less inclined to prescribe you an antibiotic even though most patients do not have a microbiology background they don't know the difference between a virus and a bacterium God knows we saw that at beginning of covid didn't we just the amount of of ignorance just from not having a proper background led to millions of deaths and led to the pandemic that we've got it just wasn't recognized soon enough so if you go to the doctor you make the appointment you pay your co-pay you go in you expect for something to be done to help you and if the doctor just says drink lots of fluids and rest you're that doctor's going to get yelled at basically it happens a lot so for fear of that that actually led a lot of doctors to prescribing antibiotics even though they knew it wasn't going to help anything because at least they were doing something and showing they were doing something and the patient would go away and not bother them okay so fear of Confrontation is one of the problems but now there's so much antibiotic resistance that doctors are finally trying to get education out there to patients as well now there are things called secondary infections so we may start off with a cold but if you've had that cold and now you've got severe sinus pain you know that kind of thing and if the symptoms look like it's a bacterial infection that's when you can get antibiotics for it a lot of times that's spiral as well uh patients need to be more compliant taking the full course of antibiotics so if you don't take the full amount you may even though you feel a lot better or you're totally back to health by like the fourth or fifth day if you leave some of those cells behind and again if they develop antibiotic resistance uh then it's going to come back and be much much more difficult to fight and then we need other countries to start limiting those overthe counter antibiotics for sure uh use a combination of antibiotics and Other Drugs so that can help as well um and then we need to try to focus on using antibiotics that Target specific virulence factors rather than the entire cells so stay away from those that are like the cytoplasmic membrane that a lot of these cells have and things like that because also as soon as the patient starts having nausea and vomiting for the antibiotic they're going to stop taking it right so as soon as they feel better for sure so it's another thing to kind of think about okay so these are new ones that you may or may not have heard of before um now crisper has nine so you guys have heard of that before right so you had that Ted Talk from uh Jennifer DNA and she actually won the Nobel Prize uh for medicine for this and so we might be able to use that tool to Target pathogen specific DNA and RNA sequences okay so if we're able to do that then you'll have very low side effects from it um and then you'll be able to just chop up okay or cut up the DNA or the RNA and the cell is not going to be able to survive at that point the problem here is getting the crisper c nine to the cells that actually need it so that's the hardest part so a lot of the first crisper cnine uh kind of experiments or clinical trials targets the blood because then all you have to do is inject it into the bloodstream it's right there so if you have a very specific infection that is away from the bloodstream a little bit more it's going to be harder to do um probiotics and prebiotics you guys are going to have to tell the difference between these two and this is one of the big areas that students get wrong on exams so there's probiotics those are actually bacteria okay prebiotics is the food you give to them that are already there okay so you've got good bacteria already in your gut so if you take a Prebiotic you're giving them uh basically you know chocolate cake and pizza and anything that it wants so it stays very happy and multiplies at a good rate and tamps down uh prevents any pathogens from going crazy so you would take this before that's what pre means before it gets to the bacteria for probiotics I want you guys to think of pro carots bacteria okay so probiotics are the bacteria themselves prebiotics is the food that you give them so that's a big difference between those um bacterial FES and F therapy I'm going to talk about this one a little bit more now the research into using these viruses that only infect bacteria they do not infect human cells whatsoever they only target bacteria the research began 1911 to 1912 that was a long time before penicillin came about 1928 right the problem is um each bacterio Fage can only infect one species of bacteria that's it and this research takes a ton of time so they were making some Headway but then as soon as penicillin came out every everybody's research switched to those kinds of methods the antibiotics were supposed to be the wonder drug the perfect drug that was going to solve all infections on the planet they expected every bacteria to be wiped out by penicilin so it just was timing it was a timing issue okay but it's very difficult research to actually do we're going to talk a little bit more about that in a second um anti-quorum sensing molecules so if you remember from Bonnie basser's uh Ted talk so a lot of these pathogens will only kill or mount an attack against the host if they get to a certain population level so if they're only one or two troops they're not going to go you know say war against the the person they know they're going to not you know succeed at doing that so these little molecules that tell each other okay there's more of us around because remember they're blind they don't have eyes so this is their way of telling how many of them are around in that area so once they get to a certain population level then they attack but if they all think that they're the only ones in the room they'll never mount an attack so they all think they're the only ones around so that actually has some really cool consequences that we're seeing and then my favorite fecal transplants well we're going to talk more about that too okay so F therapy now when I was first researching this online my alma mon came up New Mexico Tech and on their um biology page um I kind of uh copied this over from it but there is a 40 State Consortium with 200 colleges including New Mexico Tech that are part of this C fases program standing for Science Education Alliance F Hunters advancing genomics and evolutionary science so whoever came up with that one wow uh but part of the Howard Hughes Medical Institute anything that you see that has Howard Hughes Medical Institute stamp on it it is of the highest level you can trust it take it to the bank good stuff okay it's a big big big deal so what this program is because there's not enough researchers uh around the world to be able to because these things are so specific for a bacteria there's not enough people to do the research the research itself takes a while but it's not that hard so they're actually recruiting undergraduates like any of you could go down to New Mexico Tech and do this so they're recruiting uh undergraduates everybody takes one type of bacteria Fage for that one bacteria and studies it and then they compile all the data in this gigantic database to be able to come up with hopefully FJ drugs for the future which are really cool so if you know what the bacteria is that's causing the infection Ah that's the hard part right we were talking about that before but if you can figure that out like if it's strep pyogenes for example then you can pick the Fage that targets spy and get it there somehow and it will destroy the bacteria it'll literally blow it up okay which is kind of cool and this is one of the things um that they do so this was a lawn of bacteria and then some bacterio fages that Target that bacteria were put on top in a solution that absorbed into it so every one of these it's not a zone of inhibition it's a called a plaque and so every spot was where One bacter ofage landed and killed all the bacteria that was in its immediate area which is really cool is there not concern about the bacteria developing resistance toes there is yeah yeah because if you remember bacter ofage recognizes the bacteria through those membrane proteins so if those change then it's not going to be able to attach any longer the good thing though about F therapy is that is going to take mostly random luck rather than developing because there's bacteria fages there because the bacteria fages kill very quickly so it doesn't really have time to form a specific resistance against it but if there's a mutation that changes those membranes proteins then yeah it's going to not work anymore all right this one's chrisper cas9 uh I'm going to kind of leave you to look at that uh in a little while I think your heads will explode if I try to go into that we basically already talked about it uh probiotics I basically have mixed feelings about probiotics um I'm a little afraid that this is sort of like a health fad um that's going to come and go when probiotics were first put on the market it wasn't really clear what kind of natural bacteria there actually were in the intestines um and by taking probiotics you could be causing an imbalance of natural microbes that are there already um so I think these came out a little bit too early and also some of the first probiotics that came out you were spending and absolute fortune on these pills and tablets and everything and the problem was as soon as they made it into your stomach your stomach acid and the enzymes were destroying the bacteria so that very few of them actually were able to make it alive all the way to get to your intestines to repopulate it or do whatever health benefit you were looking for um this is one reason why natural foods that have probiotics in them are better they have sort of a natural way way that's been evolutionarily tested to be able to survive to get into the intestines um and because they've been used for hundreds and thousands of years uh by humans um a lot of those that are found in like fermented foods for example are naturally found in uh your intestines so it's these kind of pure form of probiotics that I guess I'm a little bit more wary of um but a lot more research has gone into it in recent years so as long as you do your homework um you know then this can actually have some sort of a benefit okay and the GI tract is one thing it's very complicated it it can have a lot of repercussions as far as hormones and there's a you know gut brain axis connection there to be aware of um now just like um diets uh are can be good and bad for human beings that are also diets that can be good and bad for your probiotics your live microbes so prebiotics are going to be the foods uh for these microbes to actually use them um carbs um usually non-digestible food ingredients are pretty good for these I did look up what has presently been established as good natural foods that we take in that are good u prebiotics u besides again like dietary supplements and such whenever you can get real food involved it's going to be much better than some sort of a supplement but um banana onion garlic leaks raw oats chickory root Jerusalem Arch OES legumes like beans denline greens berries apples things like that are all going to have um a lot of plant-based fiber in it and a lot of carbs and uh it's going to be good food for those microbes okay seu infections here's where I want to go before we leave um so SE actually affects half a million people per year in the United States and causes 15,000 deaths so it it it can be deadly okay and my best friend from um middle school and Grade School uh I started talking to her again after a really long time and she battles with seiff all the time and she got it because she took antibiotics for a sinus infection so the thing we were just showing with the dots that literally happened to her so I was thinking about her while we were doing that uh and she came very close to dying because of it as well she had so much diarrhea that she almost died of dehydration so uh now claustrum defil that used to be the genus for this and it was a heck of a lot easier to pronounce and so we had claustrum defil and we had the anthis and we had botul we had all those kind of together as a group now they have called it clides dial I don't know why anyway um endospore forming Grand positive bacteria found naturally oil air and water also found naturally in the guts this is what it looks like so flula all over the place do you guys remember what arrangement of Flaga this is called what was it parat tras yes good Mr per trius um this is actually the wall of uh the intestine none of that yellow should be there it should look like very nice pink tissue like you kind of see right over here but the this is all SE right there that has just caked itself on the walls now I found this cartoon um and at first I just thought it was a kind of like a a joke kind of cartoon but it's actually not it's very very educational this is actually what we would show somebody that didn't have a microbiology background kind of what was happening so um normal gut floor is altered by broadspectrum antibiotics most notably clomin sosin ampicillin amoxicilin and Fu quinon okay so that's why he's saying oops over here and that allowed the C diff to flourish within the colon and those are going to cause those yellow plaques formed and damage the epithelium so that you end up getting a lot of diarrhea as a result can't control the water so two main sources already talked about the opportunistic infection that's what we were just talking talking about um but any uh anybody that has a C diff infection in a hospital nursing home whatever it can also be spread fairly easily so I know a lot of you guys are nodding your head yes because you can work in some of these places and you know that you usually once they know they have a seiff infection usually have to gown up glove everything like super super so that it doesn't get spread from one person to another uh risk factors uh imos supressed over 65 or using inhibitor pump drugs for like um heart heartburn and um holes in the stomach ulcers why am I having trouble with that I don't know um yeah okay uh difficult to treat even using very strong uh antibiotics it often will uh come back because it's an endospore farmer so that's not good at all um probiotics have been uh used to try to help this uh has moderately certain after a 2017 analysis of 31 studies that it can reduce the risk of C diff okay so if you can give all that really yummy good stuff to the good bacteria and keep those levels up that's the best thing to happen so often times if you are going on an antibiotic for some infection and you really do need the antibiotic they will often tell you make sure that you're eating well you're taking prebiotics that kind of stuff or even probiotics to replace the bacteria that are killed by the antibiotic after uh after the round of antibiotics is over that can actually help as well as well but look at my last line here FAL transplants can cure cure and the word cure is not you know just thrown out there it's kind of like using a fact it's like a four-letter word in in science it can cure SEI infections within one day of treat is that incredible now these are not altogether um known about by doctors and my guess is the first time you saw a fecal transplant you thought it was ridiculous right like how could something like that work so a lot of people are not on board with this yet but time and time again it has been shown to cure so my friend was one day away from finally being able to get a feal transplant and the antibiotic that she was on finally put her in remission so she hasn't had another tack yet but the next time she does she's making her doctor uh set her up for one of these fecal transplants there's only certain places around the United States that will do it so they have to get feal Manor from certain uh of these companies that will take care of it so technically it's called fmt FAL microbiota transplant so um at the beginning when they were first trying this stuff out they took somebody that had absolutely normal gut everything looks good you know colonoscopy get some of that really good fecal manner well I guess you don't do that for a colonoscopy they don't clean it out first though okay so it's not really a colonoscopy but they still use the same kind of Machinery uh I guess devices to uh grab some fecal matter um and then they simply put that through the same kind of procedure into the person with SE diff so it was literally just a feal transplant from one person to another um and that again showed cures within 24 hours it was like you were seeding the that area with really really really good nutritious and and good bacteria and everything that comes along with it from that person's diet um now they're a little more careful with it because they want to make sure they're not also transplanting something that maybe the person didn't know that they had something that could cause an issue so they're much more careful about it and they've also gotten to the point where um instead of inserting it in that way you can actually take a pill and it has the processed fecal matter in the pill so you don't taste it or anything my issue with that and I'm I'm sure this has been thought of and everything but that has to get past your stomach acid right so um I'm not really sure sure how they take care of that issue but same as probiotics right yeah yeah it would be the same as probiotics yeah you're right um so anyway here's a link if you're interested 2022 so fairly recent FAL microbiotic transplantation as the new therapy that Avenue for human diseases so once they saw how great it worked for seed it they started looking at other things so GI diseases liver diseases inflam inflam inflammatory diseases autoimmune brain disorders obesity metabolic syndrome obesity is a major one that they're showing progress with by the way by simply changing the bacteria in your gut you can make somebody lose weight is that fascinating so that's that's got a lot of promise to it okay now it doesn't mean you get to eat pizza every day or that chocolate cake but um now brain disorders why would your gut have anything to do with your brain that has the microbiome it yeah the micro iome one of the benefits is it actually will give off chemicals like neurotransmitters so what you eat can affect your brain so they're looking at links to Alzheimer's and Perkinson and all those kinds of things with the microbiota of your gut and that gives Avenues of treatment which is very very exciting yeah very very exciting all right so here's a little bit more about that so here's somebody in the lab and there's the sample the feal matter and that's what they're kind of uh processing right there so yeah they can do it through a a through a capsule or from doing a type of colonoscopy okay um all right so side effects of antimicrobials so we've already talked about some of this already but the three major side effects is toxicity to tissues allergic reactions we're going to talk more about that when you get to the immune system and then just damage to your natural microbiome okay so we talked a little bit about nephrotoxicity hot toxicity so there's some notes we've actually talked about some of the stuff already but this is sort of a summary of all of that that you guys can look at a little bit more about allergic reactions here so penicillin is kind of the main one that people think about allergies when you go to the doctor they always ask you a question like are you allergic to penicillin are you allergic to any medications that so an allergen is technically any foreign material that can stimulate the immune system in some way um and so here's a link to penicillin allergies uh that you guys might be interested in looking at so remember with allergies your first exposure can sensitize the body but you won't have any symptoms but it's the second and on exposures that could lead to further reactions like hives a rash uh all the way up to anaphylaxis which is where your your uh throat can close up you can stop breathing and you can die from that all right and last but not least damage to Natural B microbiome so the SE diff we were talking about is a type of super infection and you guys have already looked at Super infections and the far UVC light uh in one of the TED Talks that we've got so here's a couple of examples of those as well this talks a little bit more about the the SE down here too um the example number one here is kind of interesting so if you take a seis Forin for a UTI it not only kills off hopefully the bacteria causing the UTI but it also kills off the lapto bacillus and some other really beneficial bacteria that are in the vaginal canal and the vaginal canal in order for it to not have an infection needs to say stay at a very nice particular pH and if any of that gets thrown balance then you can have a yeast infection the yeast kind of takes over at that point and then causes an issue so um I remember that um I had this one really great nurse Midwife and stuff and she had to give me some antibiotics for something and she's like okay I want you to go buy some yogurt any flavor you want put it on a tampon and put it inside your vagina really yep that's cool so that the lapto basill that's in yogurt could repopulate the the vaginal canal and prevent a yeast infection I didn't know a lot about microbiology at the time so I thought that was kind of ridiculous all I can say is wait for the yogurt to come the room temperature say she told you to eat yogurt yeah no she she she had a very much more direct approach to things I've noticed so all right we're you guys