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Old 03-15-2015, 10:20   #1
Doczilla
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Antibiotics for the operational medic

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 wonít give you all the coverage you need for a gut shot without adding metronidazole. These can all be given as an injection and donít 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 donít 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 doesnít need antibiotics.

Acute diarrhea
Most common travelerís 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 theyíve 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, thatís 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. Thatís why we want you to get the shots. If youíve 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 thatís all youíve got, add ciprofloxacin.
Keflex (cephalexin): Useful for UTIs and upper respiratory infections. Not all itís 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.
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Last edited by Doczilla; 04-01-2015 at 18:37. Reason: Update on use of gatifloxacin for otitis externa
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Old 03-15-2015, 11:44   #2
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Great stuff. Thanks.
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Old 03-15-2015, 11:48   #3
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Great stuff. Thanks.
No doubt !!!!

Thanks Doc !!!!!!


... and, highlight, right click, save and print.
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Old 03-15-2015, 21:02   #4
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Good primer for the antibiotic train. Thanks Doc

As for combat antibiotics go, I carried C-fox (cefoxitan). It's a Gorillacilin, and it is priced well. There are some slightly better but much more pricey. In combat, I actually pumped it on most of my combat wounded, if I had time prior to MEDEVAC.

When in South America (or put your groups honey pot location here), make sure you carry plenty of Rocephin for your silly Brovos that don't like wearing condoms. Don't forget to treat for Clamydia too! There's always one that goes in after PCOD And comes crying to you three days before redeployment. Not your job to be his pastor or mommy, just get them home clean.

Love doxy, bactrim, metro, azithro.

Other awesome drugs in my bag. Lidocaine, promethazine, narcan, some type of pain med depending on location, morphine, nubain, toradol and ultram(PO).

All of these will actually fit in your aidbag in small quantities. The majority stays in your boxes or whatever you guys have nowadays and I always gave my guys their own little baggies with their malaria proph, Motrin, sudafed and cough meds, etc.
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Old 03-15-2015, 21:07   #5
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I agree on the cefoxitin (Mefoxin). Another good one for trauma.
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Old 04-01-2015, 18:39   #6
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Edit to original post: You can use the ophthalmic solutions gatifloxacin or tobramycin for otitis externa, so you can carry just that instead of a separate bottle of ciprodex.
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Old 04-01-2015, 20:43   #7
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The Group Surgeon told me that Doxycycline is only being made by a single manufacturer and he said prices were through the roof.

IIRC, he said $1500 per bottle, but I might be wrong.

TR
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Old 05-04-2015, 21:27   #8
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Questions regarding a few other treatments

My wife and I work with tribal people, and she does do medical work here. So that list of all the different meds for different problems is a big help.
Have a couple of questions.
What do you carry for malaria for SE Asia? We think our area is Chloroquine Phosphate resistant.

What sort of antifungal meds do you use for foot rot? The tribal people often get foot rot, and cannot get rid of it for an entire rainy season.

One last question, is that we have several of our tribal friends, men, who have been carrying heavy for years, so they have a tremendous amount of mileage on their knees. The inside of the back of their knee hurts, possibly the PCL. The obvious answer is to get them to an orthopedic surgeon and get an MRI, but that isn't very easy to do, mostly because they are scared to go to Manila, and terrified of an operation if needed. So any ideas?

Thanks for any help. My son is in the pipeline for SF, right now waiting to get into the next SOPC slot.
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Old 05-05-2015, 08:24   #9
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Quote:
Originally Posted by Doczilla View Post
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 wonít give you all the coverage you need for a gut shot without adding metronidazole. These can all be given as an injection and donít 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 donít 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 doesnít need antibiotics.

Acute diarrhea
Most common travelerís 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 theyíve 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, thatís 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. Thatís why we want you to get the shots. If youíve 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 thatís all youíve got, add ciprofloxacin.
Keflex (cephalexin): Useful for UTIs and upper respiratory infections. Not all itís 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.
Doc, I am helping a friend who is in the process of acquiring a nano-technology that can be applied to antibiotic formulations. The idea is to enhance bioavailability (lower dosages) in PO formulations. Also reduce adverse event occurrence (reduced toxicity). The initial target market will be military applications.

The preliminary data is very encouraging.

If you were to select any of the existing antibiotics (older ones too) that could be re-purposed, what would those be and why?

Any of you active 18Ds please chime in too.

Thanks,

JDT
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Old 05-05-2015, 08:26   #10
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Originally Posted by Trapper John View Post
Doc, I am helping a friend who is in the process of acquiring a nano-technology that can be applied to antibiotic formulations. The idea is to enhance bioavailability (lower dosages) in PO formulations. Also reduce adverse event occurrence (reduced toxicity). The initial target market will be military applications.

The preliminary data is very encouraging.

If you were to select any of the existing antibiotics (older ones too) that could be re-purposed, what would those be and why?

Any of you active 18Ds please chime in too.

Thanks,

JDT
Sine Pari
Is the technology for oral or IV formulations?
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Old 05-05-2015, 08:31   #11
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PedOncDoc-

Can be either, but I think they are focusing on oral first.
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Old 05-11-2015, 18:12   #12
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Doc, I am helping a friend who is in the process of acquiring a nano-technology that can be applied to antibiotic formulations. The idea is to enhance bioavailability (lower dosages) in PO formulations. Also reduce adverse event occurrence (reduced toxicity). The initial target market will be military applications.

The preliminary data is very encouraging.

If you were to select any of the existing antibiotics (older ones too) that could be re-purposed, what would those be and why?

Any of you active 18Ds please chime in too.

Thanks,

JDT
Sine Pari
I'd go with vancomycin or daptomycin. Right now linezolid is really the only oral drug for treatment of serious MRSA infections, and the treatment for things like endocarditis often goes on for weeks. Having a couple of more PO options would save a lot of time, effort, and money.

Ceftriaxone would be another option due to its frequent use in pneumonia as well as gonorrhea.

For military applications, I'd consider imipenem. If the technology improves absorption and bioavailability in shock states, this could be useful in the prolonged care setting. A limiting factor on oral moxifloxacin absorption in that environment is poor perfusion of the gut in a seriously injured trauma patient.


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Old 05-12-2015, 05:38   #13
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Thanks Doc. I will pass this advice along.
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