1 Survival Medicine Antibiotic Use in the Austere Environment Part 1, Upper Respiratory.html

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Antibiotic

Use

in

the

Austere

Environment:

Part

1,

Upper

Respiratory

WarnerAnderson,MDJSpecOperationsMed,v2n1,Winter2002

THEPROBLEM

Specialoperationsforces(SOF)fieldmedicalcareisacompositeofseveralmissionderivedapplications.

Forinstance,directaction(DA)medicalcareisalmostentirelytraumarelated,whileforeigninternal

defenseliesattheotherendofthespectrum,withillnesscareforbothsoldiersandindigenous

personnel.Ofcourse,thereisalotofoverlap,andtheuncertaintyofsupplyandresupplyprovidesmuch

ofthechallenge:howmuchisjustenough?

Afresh

look

at

along

neglected

component

of

unconventional

warfare,

the

guerrilla

hospital

("G

hospital"),offersavaluableopportunitytorefineandredefinemedicalskillsandappropriate

applicationsofcare.Standardsofcaremust,insofaraspossible,upholdtopqualitypracticeregardless

oflocationandcircumstances.

Atthe2001SpecialOperationsMedicalAssociationmeeting,ColonelWarner(Rocky)Farrandthe

USASOCstaffpresentedanoverviewofseveralhistoricalexamplesofguerrillamedicalcare,with

discussionofhowtheycouldbeusedtodevelopdoctrineforfutureoperationalneeds.However,while

thehistoricaldatayieldvaluablelessonsoncentralizationversusdecentralization,organization,security,

andevenlogistics,littleisavailabletoguideclinicalprotocolsandpractices.Whatdoesthemedicdoin

thefield,

by

kerosene

lamp,

with

apressure

cooker

for

an

autoclave?

Ifwestartwiththepremisethatqualityhealthcareisessentiallythesameregardlessofsetting,it

followsthatanevidencebasedreviewofcertainclinicalpracticescanoffer

1)valuableimprovementsintherapy,

2)decreasedadverseeffects,and3)efficientuseofscarceresources.

Inotherwords,morepeoplewillgetbetterbecauseoftherapy,fewerwillgetsickbecauseofit,andthis

canallhappenintheausterehealthcaresetting.Acommonmisconceptionholdsthatthedifference

betweenagoodclinicianandapooroneisthatagoodclinicianknowswhentouseaparticulardrugor

interventionfor

the

patient's

problem.

The

reality

is

that

agood

clinician

is

one

who

knows

when

not

to

useadrugorintervention.Forexample,commonpracticeprescribesantibioticsforalargenumberof

conditionsinwhichtheantibioticsclearlyareofnouse,andmayactuallybeharmful.Themedic's

challengeistoovercometheintellectualinertiathatleadstothispracticeandprotectthepatientfrom

badmedicine.


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Inspecialoperationsmedicine,thecorollarybenefitwillbeahugereductionintheresourcesusedin

themissionthus,lesstonnageandfewercubicfeetofsupplies,andlessdemandonresupply.

So,thequestionis:whatchangescanSOFmedicinemaketoprovidemoreandbetterqualitycareinthe

austereenvironment?Tofindtheanswer,wecanlooktotheliteratureoncommonproblems

encounteredin

SOF

medicine.

THEANSWER

ArecentconsensuspapersponsoredbytheAmericanCollegeofPhysicians(internalmedicine),the

AmericanAcademyofFamilyPractice,theAmericanCollegeofEmergencyPhysiciansandtheCenters

forDiseaseControlandPreventionwarnedthatphysiciansandothercliniciansaredoinggreatharmto

theirpatientsbyprescribingantibioticsforconditionsinwhichtheyarenotwarranted,(1)

Sinusitis

Cliniciansoverdiagnosebacterialsinusitisbyabout250%.Inotherwords,foreveryfivecases

diagnosed,onlytwoarereallybacterial.Thediagnosisisactuallydifficult,sincenoonewantstohavea

bigneedlepokedintohissinustohavethepussuckedoutforculture.Mostcliniciansaretaughtthat

sinusXrayswillshowanairfluidlevel,oratleastmucosalthickeninginsinusitis,butthesearealso

commonfindingsduringthefirstweekofthecommoncold.Morerecentteachingsuggeststhatsinus

filmsmisssomesinusitis,andthataCTscanisnecessarytoruleitout.However,CThasbeenshownto

beoverlysensitiveinscreeningforsinusitis,withahighfalsepositiverate.Certainly,diagnosing

bacterialsinusitis

on

the

basis

of

congestion,

sinus

tenderness,

purulent

nasal

discharge

and

fever

will

leadtoahugewastingofantibiotics.InaSOF/UWsituation,antibioticsarebestconsideredforsinusitis

onlywhentheURIhasbeenseriousformorethansevendaysortakesasuddenturnfortheworselate

initsexpectedcourse,withdocumentedfever,bloodypurulentnasaldischarge,andexquisite(notmild

tomoderate)sinuspercussiontenderness.Ofcourse,erythemaorswellingoverasinusshouldprompt

antibiotics,andoneshouldprobablypulltheantibiotictriggeronfrontalsinusitisquickerthanmaxillary,

simplybecausefrontalsinusescanrarelyruptureposteriorlyintothebrain.Pseudoephedrine,nasal

decongestantspray(nottoexceedfivedays),andanalgesiacangoalongwaytomaketherecovery

processmoretolerable.

SoreThroat

Noclinicianwantstomissastrepthroatthatmightleadtorheumaticfeverandalmostnoonedoes.

Clinicianswhobegintestingwithrapidstreptestsareusuallysurprisedathowmanyapparentstrep

pharyngitiscasesarenegative,i.e.nonstreptococcal.Sincepenicillintherapyshortensthedurationof

thestrepinfectionbyonlyabouttwelvehours,it'shardlyworthitforsuspected(butunconfirmed)

cases.


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Manycliniciansusesuchclinicalindicatorsaspainfulswallowing(asopposedtosorethroat),tender

cervicallymphadenopathy,feverandcrypticredswollentonsilswithpurulentexudatestotrytomore

accuratelyguesswhetherasorethroatisstrep;however,theywillbeaccurateonly1030%ofthetime.

Furthermore,strep

throat

is

almost

unknown

in

children

under

two

years

old,

and

after

about

thirty

yearsofagethechancesofnewrheumaticfeverareaboutzero.

SOF/UWmedicsshouldadministerpenicillin(500mgBID)foranadultsizepatientwithsorethroatand

historyofrheumaticfever.Otherwise,antibioticssuchaswithgoodanaerobiccoveragesuchas

clindamycinshouldbegivenforperitonsillarabscess(plussurgicaldrainage),peritonsillarcellulitis,or

sorethroatthatdoesnotlooklikeaviralURIorstreppharyngitis(Ludwig'sangina,retropharyngeal

abscess,etc.).

Asorethroat,evenwithredandswollentonsils,doesnotreallymeritantibiotictreatment,butitmay

meritlots

of

liquids,

NSAIDs

and

codeine.

Bronchitis

Whenapatientpresentswithabothersomecoughperhapswithmusculoskeletalpainandnosleep

fromcoughingallnight,purulentsputum,feverandhoarsenessthetemptationtoreachforthe

antibioticsisgreat.However,patientswhoareundersixtyyearsold,havecompetentimmunesystems

anddonotsmokecanreliablybeconsideredtohaveaviralcondition.Ofcourse,Moraxellaand

Chlamydiapneumoniaecancausebronchitis,buttheseseemtobeselflimiting,anyway.

TheSOF/UWmedicshouldtreatalmostallbronchitisastheviralinfectionitis,andprovidecough

suppressionandanalgesiawithcodeine.Pseudoephedrinemayhelp,butantihistamineswillnot.Inthe

field,rustysputum,tachypneagreaterthattwenty/minute,heartrategreaterthanone

hundred/minute,and/orrales(notwheezes)shouldpromptazithromycinorlevofloxacintherapy,

especiallyifpulseoximetryshowssaturationlessthanninetypercent.

Otitismedia

Most

otitis

media,

whether

in

children

or

adults,

will

get

better

in

seventy

two

hours

with,

or

without,

antibiotics.First,thediagnosisofotitismediaishardtomake,andhaslittletodowitharedeardrum.

Instead,thediagnosisismadewithpneumaticotoscopy,reflectancetympanometry,ortympanogram

(sure,thedoctorlooksinyourkid'sear,butunlesshepumpsinairhe'sjustfoolingyou).

TheSOFmedicmay,bydefault,relyonanasymmetryofrednessbetweentheeardrums.Sinceany

cryingkid(andprobablycryingadults,Idon'treallyknow)haveredeardrums,themedicwillneedto


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comparethetwo.Afterall,thereasonhumansarebuiltsymmetricallyissothemediccancomparea

pairedstructuretotheothersideforabnormality.

IntheNetherlands,otitismediaistreatedwithmyringotomy.Easytotalkaboutbutscarytodo,

myringotomyimmediatelyrelievesthepressurebehindtheTMandletsthepusdrain.

Sincethedefinitionofanabscessisacollectionofpusinalocalizedarea,thenitfollowsthatotitis

mediaisatypeofabscess.Andifthetreatmentforanabscessisdrainage,notantibiotics,thenjudicious

myringotomymakesgoodsense.Inexperiencedhands,andinanantibioticpoorenvironment,itcan

provideimmediaterelieffortheboththesufferingchildandthefrazzledparent.However,without

antibioticsandwithoutmyringotomy,mostallotitismediagetsbetterandthepainrespondsto

acetaminophen,ibuprofenorcodeine.

Conclusions

Sometimesittakesagreatdealofintelligence,courageandpersonalintegritytoavoid,ratherthan

reachfor,thestockbottleofantibiotics.ButSOFmedicsarechosenforintelligence,courageand

integrity.Minimizingantibioticuseinanaustereenvironment,justlikeinarichone,isscientifically

correct,judicious,morallyrightandinexpensive.Andnoonegetsarash,anaphylaxis,orresistancefrom

theantibioticthatyoudidn'tuse.Ifthemedic,PAandphysicianrefrainfrompromiscuoususeof

antibioticsintheclinicandthefield,theywillbeingoodcompany:theACP,AAFP,ACEP,CDCandthe

InfectiousDiseasesSocietyofAmerica.Notbadatall.

SeetheSpringEditionforPartTwo

Reference

1.AnnalsofInternalMedicine.2001;134:479517.(Seealso,AnnalsofEmergencyMedicine.2001;Vol.

37,No.6.foridenticalarticles)

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1 Survival Medicine Antibiotic Use in the Austere Environment Part 1, Upper Respiratory.html