Welcome back to part 2 of this short series that looks at the use of antibiotics within expedition medicine.
Please note that this article is intended for medical professionals and/or prescribers. Remember that you should always seek adequate pre-travel advice and have appropriate cover in place. Please see my full medical disclaimer here
As we discussed last time in part one, antimicrobial resistance (AMR) is a significant global public health concern and when we work on expeditions there are a whole range of factors that influence our prescribing behaviours and threshold to prescribe antibiotics.
Today we will look at how we might put together a comprehensive antibiotic package, and this will need to fulfil several important criteria:
Be able to treat common bacterial infections
Be able to treat rarer/tropical infections
Be suitable for people with allergies
Be able to treat a "Big Sick" patient
Be portable and not too heavy
Be affordable!
It sounds tricky right, but read on to get my top tips and get an idea of the sorts of medications I would consider to be essential. These are just my opinion and I'm sure lots of you may have other ideas- please comment below!
To start this process, firstly consider the types of infections you might see whilst away. Secondly have a look at the antimicrobial policy where you work, as there will be a degree of overlap.
It is also important to check for resistance patterns which can be done through websites such as https://travelhealthpro.org.uk/ or through local contacts.
It is helpful to use a systems based set-up when planning our inventory and we can work through this using a head to toe approach. It is worth considering which antibiotics have multiple uses as this will help you to save weight and cost. I have not included doses here as these will vary depending on the indication.
Head (i.e. brain)
Meningitis can happen anywhere and expeditions are no exception. Having a third generation cephalosporin, usually IV Ceftriaxone, is really important to treat both suspected meningitis and also to give if you have a "Big Sick" septic patient.
Eyes
The majority of superficial eye infections are viral in aetiology, however it is important to take a topical antibiotic preparation within your medical kit. Chloramphenicol drops or ointment is an ideal first line option.
If a patient has more of a peri-orbital cellulitis presentation, you may wish to give Flucloxacillin tables, however these patients should also be evacuated to definitive care.
Ears
Ear infections are common, particularly if you are working on a dive expedition. These can either be outer ear infections (Otitis Externa) or middle ear infections (Otitis Media).
Otitis Externa is usually treated with ciprofloxacin drops, unless the patient is known to have resistance, in which case they should have a personalised management plan. In contrast Otitis Media, is usually viral, however if it persists, it is potentially worth giving a trial of Amoxicillin or Clarithromycin.
Both of these would usually be a staple within most expedition medicine kits.
Tonsils
Despite what the public might have you believe, the majority of tonsillitis is viral. You can use the Centor or Fever Pain scores (available within the excellent MDCalc App) to calculate the probability of a bacterial infection and if you suspect this you should given Penicillin or Clarithromycin, NOT amoxicillin or co-amoxiclav as it can cause a potentially scarring rash.
Teeth
For all things dental check out https://wildernessdentistry.com/
Chest
Common things are common. It is obviously important to try and distinguish between viral URTIs and participants with genuine chest infections.
The later should be given amoxicillin, clarithromycin or doxycycline and it would be reasonable to expect to have all three of these in your kit.
Abdominal
A range of infections come under the heading of abdominal and many of these will require surgical evaluation which is only possible with evacuation, however if you have a prolonged evacuation, prompt administration of antibiotics may be indicated whilst you travel to definitive care.
Your choice of antibiotic would obviously depend on what you suspect is most likely, however something board spectrum such as co-amoxiclav, cefalexin or ciprofloxacin would be a sensible option in this scenario.
Diarrheoa (Dysentery)
The majority of travellers diarrhoea is viral, however if there are persistent symptoms, high fever, bloody stools or the participant is systemically unwell, it can be beneficial to try a short course of antibiotics.
Ciprofloxacin used to be first line, however there is now widespread resistance in certain parts of the world and Azithromycin is now preferable.
Genito-Urinary
Urine infections are common, especially in women and taking a supply of either Trimethoprim or Nitrofurantoin is sensible. Remember that men can also get UTIs and that they will need a longer course.
Women may present with vaginal discharge that is suggestive of Bacterial Vaginosis, in which case a course of Metronidazole can be beneficial.
Men may also present with epididymitis, orchitis or prostatitis. Depending on their age, this is usually either due to E Coli or it is the result of an STI. Usually a patient with testicular pain would require further workup in the expedition setting, however you may wish to give a stat dose of a board spectrum antibiotic such as ciprofloxacin whilst this is being arranged.
Skin
Skin infections are probably the most common infection you will see on expedition as wounds are often hard to keep clean in austere environments.
Conversely, the majority of "infected bites" are not usually infected and usually just look red and inflamed due to localised histamine release. These usually improve significantly with antihistamine tablets.
If you are treating a skin infection, Flucloxacillin or Clarithromycin are your best firstline options and marking the affected area, as in the picture, can help you monitor the success of your treatment.
Other Considerations
When we travel to exciting places, we can also expose ourselves to opportunistic infections. There are obviously entire diplomas and MScs on this topic and I am not going to try and do this justice here, however there are two common infections that are worth mentioning:
Lymes Disease
Transmitted by ticks, this appears to be on the increase in many countries. It is often accompanied by a bulls eye rash known as Erythema Migrans, however not all patients will get this. If a participant presents with non-specific symptoms with a history of tick bite in an area of high prevalence, in the expedition context I would have a low threshold to give a course of doxycycline or amoxicillin.
Leptospirosis
This is a water-borne infection that is spread in the urine of it's animal reservoir, usually rats. It again presents with fairly non-specific symptoms and can be treated with doxycycline. It is important to note that patients can become very unwell with this and progress to multiple organ failure so it is important to have a low threshold for evacuation for further workup.
I hope that this short article has been useful.
Do you agree with my choices?What else would you take? Would you leave some things out?Comment below...
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