infection, what anti-infective agent do we take?

For how long do we take it?

And do we even need to take something?

Stay with us.

As we talk with pharmacist doctor Angela Sandlin about the proper use of antibiotics, antivirals and antifungal medications.

Next on Kentucky health.

>> Kentucky health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> Since the discovery of penicillin in 1928, the average lifespan in the United States has increased from 56 years to almost 80.

While not all of this is solely attributable to the use of antibiotics, clearly the control of infectious agents with medications has had a significant impact on medical advances and subsequent improved outcomes.

As is true in so many cases, success may breed complacency, and in this case we have developed an overreliance upon drug treatments for infections.

The consequences for overreliance on anti-infectious medications includes the development of strains of bacteria and fungi that are resistant to these agents, and unforeseen complications from the medications themselves.

Anti-infectious medications include antibiotics, which are indicated for bacterial infections, antiviral medications for the treatment of viruses, and antifungal drugs which are for fungal infections.

Choosing the right agent is predicated upon identifying the right infectious agent and ensuring that it is sensitive to the medication, often to the frustration of some patients.

It is not always necessary to treat infections with an anti-infectious agent.

Equally important is compliance, such that if a medication is started, we must neither take them too long nor start them prior to completing the course of treatment.

To help us get a better understanding of antibiotics, antivirals and antifungals, the differences in how to use them, we have as our guest today, Doctor Angela Sandlin.

Doctor Sandlin is a graduate of the College of Pharmacy at University of Kentucky and is the pharmacy director at Baptist Health Lagrange.

Doctor Sandlin, Angela is glad to have you again with us.

It's always a pleasure.

>> Always a pleasure for me as well.

Thank you.

>> How did you get started in the world of pharmacy?

>> Oh, that goes back to high school.

Just a fascination with medications and chemistry and all the things that go along with that.

And there was an older gentleman that worked at a pharmacy in my hometown in Shelbyville, and he just inspired me that he he said, this might be this might fit you.

So I worked there in high school and worked there in college, and I just loved it.

So I love the way medications can help people live better lives and be more healthy.

>> Is this still a good time for someone to go into, I guess hospital pharmacy or retail pharmacy?

>> I, I absolutely love pharmacy and more than ever.

And you know this doctor Tuckson more than ever.

There are more medications to help us build better lives.

Things that maybe my grandparents passed away from, we can now cure or at least mitigate so that they can live longer, better lives.

So there's never been a time that was better to go into pharmacy, and I, I practice in a hospital, but there's wonderful opportunities for pharmacists and all the things they can do in so many different disciplines.

>> Well that's cool.

I'm glad to hear that.

I talk about Anti-infectious agents, but I guess this includes the antibiotics, antivirals and antifungal agents.

>> Yes it does.

>> What are they and what are the differences?

>> Wow, that's a great question.

And I think to understand the differences it helps to understand what those different organisms are and how they differ from human cells.

For example, a bacteria is a one cell organism and it's a living organism differing from a human body cell.

It has a cell wall, a rigid structure that it uses for protection and to keep it together, if you will.

And we can take advantage of the differences between a human cell and a bacterial cell when we are trying to eradicate an infection.

But now bacteria aren't all bad.

We have bacteria in our gut and on our skin that are absolutely so important to us for our health.

Everything from in our in our intestines, making vitamins like vitamin K and vitamin B, that it's actually manufacturing in the gut.

It helps us absorb nutrients and metabolize or utilize carbohydrates and other things.

And it so importantly keeps the infectious organisms that are down there at bay.

So we have a normal flora of bacteria that live in our gut and do just well and do us no harm.

And in fact, without them, it can lead to all kinds of trouble.

>> So you're saying that when we talk about antibiotics, we're talking about something that's just working on the bacteria and that these bacteria have this wall around?

Yes.

>> Well, and so we take advantage of that wall when we're developing antibiotics, some antibiotics break that wall and all their contents of the bacterial cell leak out.

Sometimes the antibiotic goes into the cell and it stops a process that the bacteria needs to live, like making proteins or enzymes or even its reproduction, its DNA.

So antibiotics work in all these different ways.

And then, of course, the bacteria, as you alluded to, have ways of becoming resistant.

Now, you talked about viruses there.

There's a lot of debate on this among scientists.

Is it even a living organism?

A virus cannot live on its own like a bacteria.

They're in soil and they can live on their own.

A virus has to have a human host, not a human host.

It has to have some kind of host, and it has to get into that cell.

And that's where it grows and reproduces.

So we have to treat it differently.

And that's why, as you say, an antiviral agent will not get rid of a bacterial infection and a antibiotic.

Bacteria killing organism medicine will not kill a virus.

We have to attack that differently.

And the same with with fungi.

The they have a cell wall, but it's different than the bacteria one.

It's made of a different it's constructed differently.

So we can break into that cell wall with antifungals.

But it won't work.

An antibacterial will not work on a fungus.

So we take advantage of the differences between these three types of organisms and the differences they have versus human cells.

And that's how we target and make antibiotics, antivirals and antifungal agents.

>> What determines the effectiveness of an antibiotic against a bacteria?

>> You know, the most important thing, if we just talk about bacteria for a minute, is that you've got the right drug for the right bug, because even among bacteria, they're different.

There are what they call gram positives and gram negatives, different shapes, different makeups and antibiotics target different parts and different organisms.

An antibiotic that works against a gram positive might only have minimal or no effectiveness against a gram negative bacteria.

So the most important thing, and what makes it effective, is that it is just what you said.

It is targeted to kill the bacteria that is causing the infection.

And then there are other things that pharmacists, as we talk about, whether it's an antibiotic, sometimes needs to be taken on an empty stomach, or maybe it needs to be taken with food.

You know, there's things like that, some other medicines that you take, like iron tablets or an antacid that has calcium and magnesium in it.

If you've taken a certain kind of medication, like a quinolone like Levaquin or Cipro, and that's in your stomach, and you also take an iron tablet on top of that, or a dose of an antacid.

It binds the antacid or whatever binds to that medication while it's still in your stomach, keeps it from being absorbed and makes it somewhat ineffective or a lot less effective.

So there's so many tips and tricks that you can use, so many ways that other drugs interact.

We can use that to our advantage, and it can also cause us problems, which is why when your doctor tells you take that with food or take that on an empty stomach, or don't take it when you're taking an antacid, don't take those at exactly the same time.

There's reasons for what we're talking about.

>> So so there's these drug to drug interactions that are going on.

But tell me about bacteria to drug interactions such that the antibiotic doesn't affect the bacteria.

What's happening.

>> That's that's typically where either there's a characteristic of that bacteria that makes it unable to be attacked by that by that antibiotic.

And we talked about the antibiotic typically has to either get inside the bacterial cell or it has to break that cell wall down so that the bacterial contents leak out.

And bacteria have a way of they're pretty smart for something without a brain, right.

They are able to adapt the more we expose them to the antibiotic, we kill off the ones that are not adaptable, but we these ones that have an adaptation, like they change their wall so that the bacteria so that the antibiotic cannot get into it, or they change something inside the target, or they make an enzyme that breaks the antibiotic down as soon as it gets in.

So they're very adaptable.

And that affects whether the antibiotic works well for you or not.

But you make a good point that it's it's not the person that's resistant to the antibiotic.

It's that bacteria.

It's the bacteria that's causing that infection.

And the more you're exposed to those antibiotics, especially doctor, unnecessarily.

And that's why you need to trust your doctor the more times you're exposed to that, if it's unnecessary, then you are increasing the chance of that bacteria becoming resistant, and the next time you need to be treated for that infection, the antibiotic from before will not work, and you may spread that same kind of bacteria to other people, and then it won't work for them.

So that's where we've found ourselves.

We we found a good thing in penicillin.

And it was really it saved lives.

And we are you're correct.

It's saving lives today more than ever.

But we use too much of a good thing.

>> We sometimes hear, even in the public discourse, in what methicillin resistant staph aureus.

Is that how this sort of thing?

That's a.

>> Perfect example.

Yes it is.

That is methicillin resistant.

We have staph aureus.

It's on your skin.

It's in nature.

It's it's everywhere.

And by continual exposure to to penicillin type medications and later methicillin, it's become what we call methicillin resistant, which means it.

Now there's a whole host of antibiotics that do not work against it that will not kill it.

So if you have a wound infection with that, or you have a lung infection with that, our typical antibiotics are no longer effective and we have to bring out medications like vancomycin, which still has some ability to take care of that.

>> That's one of those bacteria, though, that scares the devil out of everybody in the hospital because it can run rampant.

>> Yes, it can spread.

And now, compared to when I first started practicing in a hospital, to now those percents of our staph infections that have gone up to be methicillin resistant, the ones that when we first study them, they are has gone up tremendously to 50% sometimes where we won't get a staph that we can take care of with a more simple antibiotic or one of our more basic ones.

>> Now, you alluded to the relationship between bacteria and good bacteria, bad bacteria in the body.

But when we sometimes give these antibiotics, we're knocking off.

Again, I think you alluded to this.

We knock off the good ones that are keeping the bad ones in check so we can get some over some superinfections.

That's right.

Like we see what?

Pseudomembranous enterocolitis.

>> Yes.

Clostridium difficile is the organism.

You've got all these wonderful bacteria.

>> And you get diarrhea and all this other foolishness.

>> Yes.

And repeated exposure to that antibiotic kills off that normal flora that we talked about.

And it lets that Clostridium difficile overgrow, and it produces a toxin that aggravates the lining.

And it's like you said, it can cause pseudomembranous colitis.

It causes horrific diarrhea.

And that bacteria is very hard to kill.

And we have to again bring out the oral vancomycin.

We have to bring out some dificid, some other medications sometimes, and even fecal transplants to restore that normal flora after we've killed off.

>> You even get thrush in the tongue when you get that stuff on your tongue.

>> Absolutely.

That is a candida.

So you've got now you've got a fungus that normally lives with all the bacteria in your mouth and everything is coexisting.

Okay.

But you take an antibiotic, it's killing off that normal flora again.

And the fungus overgrows, and it gives you that white tongue.

And it's just very, no pun intended, distasteful.

And then we need an anti-fungal agent to take care of that.

It can be a lozenge that we that you can suck on that is, has clotrimazole an antifungal in it.

If that doesn't work, sometimes we have to go to an oral medication like fluconazole to get rid of that.

But it's more likely to occur if you don't practice good oral hygiene.

Sometimes people whose immune system is lessened or they're being treated, they have to be treated with antibiotics for a long time, for a very long standing infection, or they might be going through cancer treatment or something, and their immune system is compromised because your body wants to fight those kinds of things.

Sometimes it needs antibiotic help to do that or an antifungal, and that's kind of where it comes from.

>> Well, let's let's go and.

>> Talk about antifungal agents.

So what are you know, how you talked about what's going on as far as the bacteria.

So how are the antifungals.

And you've mentioned a couple of drugs already.

But how are they working.

>> Yes, they work differently from an antibiotic that takes care of bacteria, but they still target different things inside that fungal cell.

The fungal cell has that cell wall.

So some medications there's actually one called polymyxin or colistin that acts like a soap.

And it just breaks open that fungal cell wall.

And all the contents of that fungal cell leak out and then it dies.

There are some that again affect the DNA, affect the reproduction of a fungal cell.

There are some that affect protein that the cell needs to live, that the fungal cell needs to live.

So we can target it in different ways.

But there's many different classes of antifungals.

Some are used to treat like fungal infection of the nail or the skin.

And then there can be more serious lung infections like aspergillosis.

And we need a different class of of of antifungals to treat that.

Because of the nature of those different fungal organisms.

>> Now, you mentioned that bacteria are single celled organisms, but fungi.

>> Are multicellular.

>> Yes, sir.

>> They are.

Does that make it more difficult in your approach.

>> To treatment?

It does it.

They are slower to grow, but they are harder to treat and it tends to take longer.

So if you want to look at an antifungals that is responsible sometimes for the side effects or the adverse effects we get from antifungals is the fact that we if you have a nail fungus that has to be treated for quite a long time sometimes, and it's that it's that exposure over time that causes you to have more trouble.

But yes, they are multicellular cellular organisms.

The fungi are, and that does in some ways make them harder to treat.

>> What makes these drugs increase the risk of complications?

>> Yes.

Part of it is the nature of the medication.

It's it's like we said, we want to affect the bacterial or fungal cell, but we don't want to affect the human cell.

So we're taking advantage of the differences in those two cell types.

But when you have to take an antifungal for a long period of time, or when it's able to break up those multicellular fungi, it's going to naturally cause more side effects and more danger.

But it doesn't mean that you should stop taking it.

You should only take it.

I'll go back to this.

Only take what you need, when you need for the amount of time that you should take it.

And that's true of any of those, whether it's a bacterial agent or an antiviral or an antifungal agent.

>> Do you tend to see more problems with fungal infections?

When we've had people on antibiotics for long term?

Yes.

And then all of a sudden the fungi just kind of takes over.

>> That is correct.

And again, it will be people.

It will tend to be folks that are immunocompromised or have a weakened immune system for some reason.

Or maybe they have a viral, a long term viral infection that can't be cured, like HIV.

Yes.

So they're being they're taking antivirals and they're they're immunocompromised.

So that's when that fungus will tend to overgrow sometimes older folks or that have been exposed to many courses of antibiotics where you've maybe been in the hospital for a while with a serious infection, and then the fungus will show up after we're trying to beat back the bacteria.

Then we sometimes see the fungi and they grow slower, but they're they're hard to treat sometimes.

They really are.

>> You mentioned the antivirals.

So tell me, we go from the single organism, single cell organism, bacteria, multicellular organ, fungi to no cellular.

>> Organ cellular.

>> So what do you do with this thing?

>> It's so true.

It's really I just call it a protein bag of genetic material is the way for me because.

And like I said, scientists are they won't even hardly call it living because it can't live on its own.

It can be dormant on a surface or for a while, but it can't live on its own.

It can't reproduce unless it invades a host cell.

So it's really, in a way, it's a parasite.

It has to get into a cell.

And so we have to treat it differently.

It doesn't have a cell wall, so we can't attack that.

It doesn't have it doesn't have a nucleus.

It doesn't have some of the things that we can easily do that way.

So we have to attack a lot of times they reproduce very rapidly.

Viruses do.

So we take advantage of that and we can attack them by getting into that viral organism, if you want to call it that and stopping it from reproducing, you can find medications that affect the the DNA or the RNA of that virus and put in a fake piece that causes it to not be able to reproduce, and then it dies.

So we've got to stop it from reproducing.

We've got to stop it from growing.

And whether it's attacking a protein that it must have to live or whether it's keeping it from reproducing so that that one dies and there aren't more, that's how we tackle that with antivirals.

Some viruses we can cure with an antiviral, you know, and whether you use a medicine or not, a cold, you'll eventually get over it.

Some viruses like hepatitis B or HIV, we can control them, but we cannot eradicate them.

At this point.

I can say that now in 2025, 2026, we don't have that technology yet.

So part of it is because they're protected by those human cells there in the human cells.

So we have to find a way to attack them without destroying the human cell.

>> Which is a question I was going to ask.

Do we kill the cell that's harboring the virus, or can we be that specific?

>> Oh that's tough.

I think a lot of times that cell will be sacrificed.

You know, we can't really extract the virus many times.

But you have other cells, you know, billions of cells.

So you're trying to kill the ones that are affected by the virus and then just stop it from replicating is generally the way it's done.

You know, in general.

>> You know.

>> When we looked at because of Covid.

As opposed to a lot of other things.

So I guess the the best thing here is when we talk about viral infections is to vaccinations.

To keep from getting is the best way.

>> To go.

>> Especially with viruses getting a proper vaccinations.

And honestly, clean hands, you know, washing your hands.

You know, it sounds simple.

If it was, if it was difficult, we you know, it would be a different matter.

But washing your hands, getting vaccinated, getting vaccination, whether it's for a bacterial or a viral agent, there are vaccines for many different to help protect us.

And you're not only protecting yourself, but you're protecting your community because you're not allowing that to spread from person to person.

Handling food properly.

Raw meat a lot of times, you know, it can cause infection.

So you want to cook things properly, you want to refrigerate leftovers and those kind of things.

And I think another thing you can do to prevent this is be aware of your own body.

Be aware of when you're feeling ill, and don't go out and spread that to others.

Be aware if it's if how you're feeling, talk to your doctor.

You know.

Make an appointment if it feels like it's getting serious.

Some things can be things that your body can fight on its own, and you don't need an antibiotic.

But there are times when you do and there's times we watchfully wait.

>> You know.

>> What about timing?

One of the things which we got again out of the Covid thing was with Paxlovid.

They say within the first five days of onset of symptoms and stuff, use it.

But after that, no where does timing fit in with some of.

>> The antiviral.

>> And think about that.

A patient with HIV, you're getting on these things early, whether it's Covid or whether it's HIV or some other things.

The longer we remember, it reproduces very quickly.

And so the sooner you can get to it with antiviral medications, you do two things.

You keep yourself from getting worse, and you also prevent resistance because that's why for HIV right now we're typically using like three different medications, three different antivirals with three different mechanisms.

Because over time the that that organism has evolved, if you will, it's it's mutated to such that it takes a coming at it a bunch of different ways to, to control it.

And so getting the timing is an excellent point because sooner rather than later, especially with viruses.

>> One thing we oftentimes hear, especially with antibiotics, is someone says they have an allergy to the medication.

Is there something going on with antibiotics, antivirals and antibiotics and anti-infectious agents that increase their risk of causing someone allergic reactions?

>> We do know that there's some commonalities with folks.

We know that that there are some people that are more tend to be allergic, you know, that have allergic reactions.

But we also know that a lot of times, folks, what they say is an allergy, what they deem when they tell us as a pharmacist or they tell their doctor, I'm allergic to this.

>> Yeah.

>> It's really not an allergy.

It's an adverse reaction.

So it's important to know.

>> The difference.

Yeah.

>> It's super important because if it's causing nausea or sometimes just a common diarrhea or just feeling tired or fatigued, those aren't allergic reactions.

But a lot of times when we're in the hospital, folks will tell us that, oh, I'm allergic to that.

I can't take, for example, they'll say penicillin.

And as it turns out, when you lock yourself out of penicillin and other what we call beta lactams like these cephalosporins, cefuroxim, ceftriaxone, when you say, oh, I can't take those, you are sometimes forcing your doctor to pick a less effective or a more inferior agent, or one that has more side effects than what the more straightforward answer would be, because beta lactam antibiotics that are relatives of penicillin are still the workhorses in a lot of ways, and we don't want to lock a person into that unnecessarily.

So there's adverse reactions, and then there are true hypersensitivity reactions, the most serious of which is mediated by Ige, an immunoglobulin Ige.

And that would happen within an hour of taking the medication.

>> So is there.

>> A way I can test somebody to say, hey.

Yes sir.

This is allergic okay.

>> Yes.

And that's a that's a great recommendation.

A great idea is if, for example, my mother used to announce to our doctor when she would take me to our family, she's not allergic to penicillin.

She had penicillin.

She's not.

And that was a that was a thing like when I was growing up.

But even people that were said to be allergic to penicillin aren't necessarily, for one thing, in ten years, you that allergy can dissipate.

So you can an allergist can test can do skin tests and be able to tell if you really are allergic to penicillin.

So I think more and more when you're you're you're facing a need for antibiotics.

And you know, the longer we go and the longer people are living, it's going to be super important to know if you're really allergic.

And another thing that I think is interesting is that the relatives of penicillin, those cephalosporins, there are so many of those.

And what makes you allergic to penicillin is something we call a side chain.

So it's just like an arm on the molecule.

And they don't all have that same arm.

So just because you can't take one doesn't mean you can't take the other.

And we have a we have a. Beautiful graph that.

>> We use.

>> That is such good information.

>> Yeah.

>> I hate.

>> I want.

>> To thank you for being with us.

I'd like to thank you for being with us today.

I hope that you now have a greater appreciation for the types of anti-infective medications, along with their indications, complications, and functions.

You probably also understand the importance of having a good relationship with your pharmacist and your health care providers.

To discuss these, if you wish to watch this show again or watch an archived version of past shows, please go to ket.org.

If you have a question or comment about this or other shows, we can be reached at KY health at ket.org.

I look forward to seeing you on the next Kentucky Health.

And remember, all antifungals, antibiotics, and antivirals aren't the same.

Use them if you need them, and if you don't need them, use something else.

That's it.

Orange juice.

>> Kentucky health is funded in part by a grant from the Foundation for