Doczilla
03-15-2015, 10:20
I sent this out to our 18Ds after a recent NTM. Keep in mind that many are not perfect solutions, but workable for those constrained in the operational environment and by budgets.
____________
I wanted to send you some guidelines that will help you pick antibiotics for your missions that will maximize capability with minimal equipment. I realize you have a lot of choices, and I've made this list with cost and availability and broad utility in mind. I've listed some drugs in the guide that I didn't mention in my go-to list because you may find you have something on hand that is not listed or may have to get something on the local economy. If you are in a pinch and comms are available, you can always consult with me or the PAs.
A pocket Sanford Guide to Antimicrobial Therapy would be very helpful to have on hand. Jay Sanford was an SF doc who was the dean at one point at USUHS. He created this guide which lives on to this day and will run you only a few dollars.
If you had only a few antibiotics to carry, this is what I would carry:
Amoxicillin or augmentin (amox/clav) PO
Azithromycin PO
Ciprofloxacin (cheap) or moxifloxacin (pricey) PO
Flagyl (metronidazole) PO
Gentamycin or tobramycin ophthalmic drops. Overkill for a lot of conjunctivitis, but necessary if your casualty wears contacts in order to cover pseudomonas. Also can be used for otitis externa instead of carrying a separate bottle of ciprodex.
Rocephin (ceftriaxone). Alternates include Invanz (ertapenem), Merrem (meropenem), Mefoxin (cefoxitin). Ampicillin or Unasyn can be used in a pinch but probably won’t give you all the coverage you need for a gut shot without adding metronidazole. These can all be given as an injection and don’t require an infusion. With Rocephin, not a bad idea to add flagyl for abdominal issues.
Doxycycline has gotten so expensive lately that I use it less, but since we have to carry it for malaria prophylaxis, you might have it on hand.
As long as the patient is not in shock, or has some issue that would prevent absorption, oral medication works about as fast as IV, and most of the ones listed have very high bioavailability when given PO.
Combat injuries
Primary: Ertapenem, cefoxitin, ceftriaxone + flagyl, moxifloxacin. Avelox (moxifloxacin) PO is nearly 100% bioavailable, so you can give this PO instead of IV if you have it.
Alternate: 3g Ancef for clean wounds that don’t involve the gut
Contingency: Oral antibiotics. Cipro + flagyl, Levaquin + Flagyl, Avelox, amox + flagyl, doxycycline + flagyl
Emergency: Anything. The Battle of Mogadishu saw a 38% wound infection rate, even though it was less than 18 hours from wounding to definitive care. Early antibiotics matter.
Upper respiratory (sinusitis, strep throat, facial cellulitis, otitis media)
Most of this stuff does not need antibiotics.
Primary: Amoxicillin or Azithromycin
Alternate: Doxycycline
Contingency: Ceftriaxone IV + azithromycin for patients who are not responding or are very ill.
Conjunctivitis and orbital cellulitis
Primary: Gentamycin drops
Alternate: gatifloxacin, moxifloxacin, erythromycin, sulfacetamide drops
Contingency: Oral antibiotics for peri orbital cellulitis. Amox, azithro, clinda, doxy.
Emergency: Ceftriaxone, clindamycin, or levofloxacin IV for serious eye infections. Consider this if gonorrhea or chlamydia is likely.
Pneumonia
Consider this with chest pain or cough plus high fever, shortness of breath, or significantly systemically ill.
Primary: Azithromycin + amoxicillin. Amoxicillin will cover your strep/staph, while the azithromycin will cover atypicals like H. influenzae and M. catarrhalis. Doxycycline is another good choice.
Alternate: Respiratory fluoroquinolone (levofloxacin or moxifloxacin, NOT ciprofloxacin)
Contingency: Ceftriaxone IV + azithromycin for the very ill. Or any of the injectables listed above.
Bronchitis
Primary: Suck it up. This doesn’t need antibiotics.
Acute diarrhea
Most common traveler’s diarrhea is E. coli. Even with viral etiologies, a short course of antibiotics can lessen duration and severity of symptoms if they have >6 stools per day, blood, mucous, or tenesmus (constant feeling like they have to shit).
Primary: Damn near anything. Azithro, any fluorquinolone, bactrim, doxy
Alternate: Consider metronidazole if they’ve been drinking water from streams (giardia, cryptosporidium)
Contingency: Consider a serious intraabdominal problem if they have significant fever, localized pain, etc. (appendicitis, colitis, perforated ulcer). IV antibiotics necessary, and surgical eval.
Abdominal issues
Though we tend to operate quickly on appendicitis here in the US, that’s not the case elsewhere. They get IV antibiotics and cool down for a few days, then go back for operative management later. You can do the same if surgical eval not immediately available.
Primary: Moxifloxacin, ertapenem, ceftriaxone + metronidazole
Alternate: Cipro + flagyl, levaquin + flagyl
Contingency: Oral antibiotics. Cipro + flagyl, Levaquin + Flagyl, Avelox, amox + flagyl, doxycycline + flagyl
Emergency: Perforated viscus requires immediate surgical management. Severe pain (particularly with a sudden onset) or sepsis indicates this.
Urinary tract infection
Lots of antibiotics work for this.
Primary: Ciprofloxacin or levaquin (NOT avelox), azithromycin, cephalexin (Keflex)
Alternate: IV ceftriaxone if they are sick
Contingency: Almost anything that has some gram negative coverage. Cephazolin is not the best, but does cover some e.coli.
STDs
Gonorrhea and chlamydia are the big ones. Herpes sucks, but emergent treatment often unnecessary. Syphilis is another scary one, which should be considered with a full body rash that follows a genital lesion. Syphilis is very responsive to ceftriaxone, just penicillin, or anything related.
Primary: Ceftriaxone IM + 1g azithromycin
Alternate: 2g azithromycin if allergic to ceftriaxone. This will cause nausea, so you may want to have them space it out over a couple of hours.
Contingency: Ciprofloxacin
Emergency: Don't sleep with hookers.
Cellulitis and abscess
Abscesses just need drainage, and without significant associated cellulitis, nothing else is needed. Keflex is actually not a great drug for cellulitis since it fails to get decent soft tissue concentration, so avoid it. Bactrim is used a lot CONUS because it covers MRSA. HOWEVER it does not do a great job covering other causes of skin infections (Staph epi, group A beta hemolytic strep), so should be prescribed in conjunction with something like amoxicillin or should be given as 2 DS tabs BID.
Primary: Amox, doxy, azithro, clinda, bactrim IF you give 2 tabs BID instead of 1
Alternate: Freshwater exposure: any fluoroquinolone or bactrim
Contingency: Foot infections often associated with aeromonas, which responds to cipro.
Emergency: If really sick, give ceftriaxone. A lot of your injectables listed above will work.
MRSA (mostly CONUS urban environments): Clindamycin, doxy, bactrim + amox, or bactrim DS 2 tabs BID
Animal bites
Good wound cleaning, with copious irrigation, is key. Dog bites are the typical, but cat bites are actually more likely to get quickly infected. Prophylaxis with antibiotics should be initiated with animal bites downrange. Rabies is a big deal outside the US, and carries a 100% mortality rate. That’s why we want you to get the shots. If you’ve had them, you only need one rabies shot <48 hours after contact. Contact with bats should be ASSUMED to have rabies. Foxes and raccoons are also likely carriers. Rodents, not so much.
Primary: Augmentin, doxy
Alternate: Clindamycin + (cipro or bactrim)
Contingency: IV ceftriaxone
Otitis externa
Primary: Ciprodex otic
Alternate: Can use the ocular topicals like gatifloxacin, tobramycin
Ancef (Cephazolin): Very popular in orthopedics. Has not great gram negative coverage, so not the first choice for anything that is contaminated with soil, or anything in the gut or urinary tract. Limited applicability for combat injuries but if that’s all you’ve got, add ciprofloxacin.
Keflex (cephalexin): Useful for UTIs and upper respiratory infections. Not all it’s cracked up to be for cellulitis.
Fluoroquinolones: Similar coverage, but know there are some exceptions. Cipro (ciprofloxacin) is great for gut, soft tissue, urine, but not pneumonia. Avelox (moxifloxacin) is great for gut and combat injuries and pneumonia, but not UTIs. Levaquin (levofloxacin) works well on all of these.
Penicillins: Old fashioned PCN is pretty great in the third world, particularly in higher doses. Amoxicillin has broader coverage, and augmentin has coverage for resistant bugs you are more likely to encounter
Bactrim (Trimethaprim/sulfamethoxazole): Good for MRSA and a variety of other things, but note the dosing: Bactrim DS is given BID, but should give 2 tabs BID for certain issues described above, such as skin/soft tissue infections.
Hope this helps.
V/R,
j.r.
____________
I wanted to send you some guidelines that will help you pick antibiotics for your missions that will maximize capability with minimal equipment. I realize you have a lot of choices, and I've made this list with cost and availability and broad utility in mind. I've listed some drugs in the guide that I didn't mention in my go-to list because you may find you have something on hand that is not listed or may have to get something on the local economy. If you are in a pinch and comms are available, you can always consult with me or the PAs.
A pocket Sanford Guide to Antimicrobial Therapy would be very helpful to have on hand. Jay Sanford was an SF doc who was the dean at one point at USUHS. He created this guide which lives on to this day and will run you only a few dollars.
If you had only a few antibiotics to carry, this is what I would carry:
Amoxicillin or augmentin (amox/clav) PO
Azithromycin PO
Ciprofloxacin (cheap) or moxifloxacin (pricey) PO
Flagyl (metronidazole) PO
Gentamycin or tobramycin ophthalmic drops. Overkill for a lot of conjunctivitis, but necessary if your casualty wears contacts in order to cover pseudomonas. Also can be used for otitis externa instead of carrying a separate bottle of ciprodex.
Rocephin (ceftriaxone). Alternates include Invanz (ertapenem), Merrem (meropenem), Mefoxin (cefoxitin). Ampicillin or Unasyn can be used in a pinch but probably won’t give you all the coverage you need for a gut shot without adding metronidazole. These can all be given as an injection and don’t require an infusion. With Rocephin, not a bad idea to add flagyl for abdominal issues.
Doxycycline has gotten so expensive lately that I use it less, but since we have to carry it for malaria prophylaxis, you might have it on hand.
As long as the patient is not in shock, or has some issue that would prevent absorption, oral medication works about as fast as IV, and most of the ones listed have very high bioavailability when given PO.
Combat injuries
Primary: Ertapenem, cefoxitin, ceftriaxone + flagyl, moxifloxacin. Avelox (moxifloxacin) PO is nearly 100% bioavailable, so you can give this PO instead of IV if you have it.
Alternate: 3g Ancef for clean wounds that don’t involve the gut
Contingency: Oral antibiotics. Cipro + flagyl, Levaquin + Flagyl, Avelox, amox + flagyl, doxycycline + flagyl
Emergency: Anything. The Battle of Mogadishu saw a 38% wound infection rate, even though it was less than 18 hours from wounding to definitive care. Early antibiotics matter.
Upper respiratory (sinusitis, strep throat, facial cellulitis, otitis media)
Most of this stuff does not need antibiotics.
Primary: Amoxicillin or Azithromycin
Alternate: Doxycycline
Contingency: Ceftriaxone IV + azithromycin for patients who are not responding or are very ill.
Conjunctivitis and orbital cellulitis
Primary: Gentamycin drops
Alternate: gatifloxacin, moxifloxacin, erythromycin, sulfacetamide drops
Contingency: Oral antibiotics for peri orbital cellulitis. Amox, azithro, clinda, doxy.
Emergency: Ceftriaxone, clindamycin, or levofloxacin IV for serious eye infections. Consider this if gonorrhea or chlamydia is likely.
Pneumonia
Consider this with chest pain or cough plus high fever, shortness of breath, or significantly systemically ill.
Primary: Azithromycin + amoxicillin. Amoxicillin will cover your strep/staph, while the azithromycin will cover atypicals like H. influenzae and M. catarrhalis. Doxycycline is another good choice.
Alternate: Respiratory fluoroquinolone (levofloxacin or moxifloxacin, NOT ciprofloxacin)
Contingency: Ceftriaxone IV + azithromycin for the very ill. Or any of the injectables listed above.
Bronchitis
Primary: Suck it up. This doesn’t need antibiotics.
Acute diarrhea
Most common traveler’s diarrhea is E. coli. Even with viral etiologies, a short course of antibiotics can lessen duration and severity of symptoms if they have >6 stools per day, blood, mucous, or tenesmus (constant feeling like they have to shit).
Primary: Damn near anything. Azithro, any fluorquinolone, bactrim, doxy
Alternate: Consider metronidazole if they’ve been drinking water from streams (giardia, cryptosporidium)
Contingency: Consider a serious intraabdominal problem if they have significant fever, localized pain, etc. (appendicitis, colitis, perforated ulcer). IV antibiotics necessary, and surgical eval.
Abdominal issues
Though we tend to operate quickly on appendicitis here in the US, that’s not the case elsewhere. They get IV antibiotics and cool down for a few days, then go back for operative management later. You can do the same if surgical eval not immediately available.
Primary: Moxifloxacin, ertapenem, ceftriaxone + metronidazole
Alternate: Cipro + flagyl, levaquin + flagyl
Contingency: Oral antibiotics. Cipro + flagyl, Levaquin + Flagyl, Avelox, amox + flagyl, doxycycline + flagyl
Emergency: Perforated viscus requires immediate surgical management. Severe pain (particularly with a sudden onset) or sepsis indicates this.
Urinary tract infection
Lots of antibiotics work for this.
Primary: Ciprofloxacin or levaquin (NOT avelox), azithromycin, cephalexin (Keflex)
Alternate: IV ceftriaxone if they are sick
Contingency: Almost anything that has some gram negative coverage. Cephazolin is not the best, but does cover some e.coli.
STDs
Gonorrhea and chlamydia are the big ones. Herpes sucks, but emergent treatment often unnecessary. Syphilis is another scary one, which should be considered with a full body rash that follows a genital lesion. Syphilis is very responsive to ceftriaxone, just penicillin, or anything related.
Primary: Ceftriaxone IM + 1g azithromycin
Alternate: 2g azithromycin if allergic to ceftriaxone. This will cause nausea, so you may want to have them space it out over a couple of hours.
Contingency: Ciprofloxacin
Emergency: Don't sleep with hookers.
Cellulitis and abscess
Abscesses just need drainage, and without significant associated cellulitis, nothing else is needed. Keflex is actually not a great drug for cellulitis since it fails to get decent soft tissue concentration, so avoid it. Bactrim is used a lot CONUS because it covers MRSA. HOWEVER it does not do a great job covering other causes of skin infections (Staph epi, group A beta hemolytic strep), so should be prescribed in conjunction with something like amoxicillin or should be given as 2 DS tabs BID.
Primary: Amox, doxy, azithro, clinda, bactrim IF you give 2 tabs BID instead of 1
Alternate: Freshwater exposure: any fluoroquinolone or bactrim
Contingency: Foot infections often associated with aeromonas, which responds to cipro.
Emergency: If really sick, give ceftriaxone. A lot of your injectables listed above will work.
MRSA (mostly CONUS urban environments): Clindamycin, doxy, bactrim + amox, or bactrim DS 2 tabs BID
Animal bites
Good wound cleaning, with copious irrigation, is key. Dog bites are the typical, but cat bites are actually more likely to get quickly infected. Prophylaxis with antibiotics should be initiated with animal bites downrange. Rabies is a big deal outside the US, and carries a 100% mortality rate. That’s why we want you to get the shots. If you’ve had them, you only need one rabies shot <48 hours after contact. Contact with bats should be ASSUMED to have rabies. Foxes and raccoons are also likely carriers. Rodents, not so much.
Primary: Augmentin, doxy
Alternate: Clindamycin + (cipro or bactrim)
Contingency: IV ceftriaxone
Otitis externa
Primary: Ciprodex otic
Alternate: Can use the ocular topicals like gatifloxacin, tobramycin
Ancef (Cephazolin): Very popular in orthopedics. Has not great gram negative coverage, so not the first choice for anything that is contaminated with soil, or anything in the gut or urinary tract. Limited applicability for combat injuries but if that’s all you’ve got, add ciprofloxacin.
Keflex (cephalexin): Useful for UTIs and upper respiratory infections. Not all it’s cracked up to be for cellulitis.
Fluoroquinolones: Similar coverage, but know there are some exceptions. Cipro (ciprofloxacin) is great for gut, soft tissue, urine, but not pneumonia. Avelox (moxifloxacin) is great for gut and combat injuries and pneumonia, but not UTIs. Levaquin (levofloxacin) works well on all of these.
Penicillins: Old fashioned PCN is pretty great in the third world, particularly in higher doses. Amoxicillin has broader coverage, and augmentin has coverage for resistant bugs you are more likely to encounter
Bactrim (Trimethaprim/sulfamethoxazole): Good for MRSA and a variety of other things, but note the dosing: Bactrim DS is given BID, but should give 2 tabs BID for certain issues described above, such as skin/soft tissue infections.
Hope this helps.
V/R,
j.r.