AntibioticUseintheAustereEnvironment:Part1,UpperRespiratory

WarnerAnderson,MDJSpecOperationsMed,v2n1,Winter2002

THEPROBLEM

Specialoperationsforces(SOF)fieldmedicalcareisacompositeofseveralmissionderivedapplications.
Forinstance,directaction(DA)medicalcareisalmostentirelytraumarelated,whileforeigninternal
defenseliesattheotherendofthespectrum,withillnesscareforbothsoldiersandindigenous
personnel.Ofcourse,thereisalotofoverlap,andtheuncertaintyofsupplyandresupplyprovidesmuch
ofthechallenge:howmuchisjustenough?

Afreshlookatalongneglectedcomponentofunconventionalwarfare,theguerrillahospital("G
hospital"),offersavaluableopportunitytorefineandredefinemedicalskillsandappropriate
applicationsofcare.Standardsofcaremust,insofaraspossible,upholdtopqualitypracticeregardless
oflocationandcircumstances.

Atthe2001SpecialOperationsMedicalAssociationmeeting,ColonelWarner(Rocky)Farrandthe
USASOCstaffpresentedanoverviewofseveralhistoricalexamplesofguerrillamedicalcare,with
discussionofhowtheycouldbeusedtodevelopdoctrineforfutureoperationalneeds.However,while
thehistoricaldatayieldvaluablelessonsoncentralizationversusdecentralization,organization,security,
andevenlogistics,littleisavailabletoguideclinicalprotocolsandpractices.Whatdoesthemedicdoin
thefield,bykerosenelamp,withapressurecookerforanautoclave?

Ifwestartwiththepremisethatqualityhealthcareisessentiallythesameregardlessofsetting,it
followsthatanevidencebasedreviewofcertainclinicalpracticescanoffer
1)valuableimprovementsintherapy,
2)decreasedadverseeffects,and3)efficientuseofscarceresources.

Inotherwords,morepeoplewillgetbetterbecauseoftherapy,fewerwillgetsickbecauseofit,andthis
canallhappenintheausterehealthcaresetting.Acommonmisconceptionholdsthatthedifference
betweenagoodclinicianandapooroneisthatagoodclinicianknowswhentouseaparticulardrugor
interventionforthepatient'sproblem.Therealityisthatagoodclinicianisonewhoknowswhennotto
useadrugorintervention.Forexample,commonpracticeprescribesantibioticsforalargenumberof
conditionsinwhichtheantibioticsclearlyareofnouse,andmayactuallybeharmful.Themedic's
challengeistoovercometheintellectualinertiathatleadstothispracticeandprotectthepatientfrom
badmedicine.

Inspecialoperationsmedicine,thecorollarybenefitwillbeahugereductionintheresourcesusedin
themissionthus,lesstonnageandfewercubicfeetofsupplies,andlessdemandonresupply.

So,thequestionis:whatchangescanSOFmedicinemaketoprovidemoreandbetterqualitycareinthe
austereenvironment?Tofindtheanswer,wecanlooktotheliteratureoncommonproblems
encounteredinSOFmedicine.

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
bacterialsinusitisonthebasisofcongestion,sinustenderness,purulentnasaldischargeandfeverwill
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.


Manycliniciansusesuchclinicalindicatorsaspainfulswallowing(asopposedtosorethroat),tender
cervicallymphadenopathy,feverandcrypticredswollentonsilswithpurulentexudatestotrytomore
accuratelyguesswhetherasorethroatisstrep;however,theywillbeaccurateonly1030%ofthetime.

Furthermore,strepthroatisalmostunknowninchildrenundertwoyearsold,andafteraboutthirty
yearsofagethechancesofnewrheumaticfeverareaboutzero.

SOF/UWmedicsshouldadministerpenicillin(500mgBID)foranadultsizepatientwithsorethroatand
historyofrheumaticfever.Otherwise,antibioticssuchaswithgoodanaerobiccoveragesuchas
clindamycinshouldbegivenforperitonsillarabscess(plussurgicaldrainage),peritonsillarcellulitis,or
sorethroatthatdoesnotlooklikeaviralURIorstreppharyngitis(Ludwig'sangina,retropharyngeal
abscess,etc.).

Asorethroat,evenwithredandswollentonsils,doesnotreallymeritantibiotictreatment,butitmay
meritlotsofliquids,NSAIDsandcodeine.

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

Mostotitismedia,whetherinchildrenoradults,willgetbetterinseventytwohourswith,orwithout,
antibiotics.First,thediagnosisofotitismediaishardtomake,andhaslittletodowitharedeardrum.
Instead,thediagnosisismadewithpneumaticotoscopy,reflectancetympanometry,ortympanogram
(sure,thedoctorlooksinyourkid'sear,butunlesshepumpsinairhe'sjustfoolingyou).

TheSOFmedicmay,bydefault,relyonanasymmetryofrednessbetweentheeardrums.Sinceany
cryingkid(andprobablycryingadults,Idon'treallyknow)haveredeardrums,themedicwillneedto

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)