The Grand Round was “Desert Island Drugs” and featured a GP, an Elderly Care Physician and a General Medicine Consultant (who I happened to work for). The basic premise was “what drugs would you take with you if you were to be marooned on a desert island and why?”
So based on my memories of the Grand Round (which appear in sepia tones through rose-tinted glasses) I will approach the question about what antibiotics to take on holiday with the premise “less is more”.
Where are you going? What are you doing?
My first response to those asking me what to take is to find out more about where they are going and what they are going to be doing.
On the other hand, if you are going deep into the wilderness, days from medical support, then you need a much more comprehensive medical kit AND the skill and knowledge to use it. The skill and knowledge is critical; there is no point carrying a hospital worth of medical kit if you have no idea how to use it… it’s just so much baggage!
So having decided what type of trip this is going to be what is the next bit of information I want to know?
Who is going?
If you are going as a family then it is very likely you will know a detailed medical history of everyone on the trip and whether they have any drug allergies. In this situation you only really need a small number of antibiotics as you don’t have to be able to cope with any unpredictable situations in terms of people not being able to take your 1st line treatments; you choose to take 1st line treatments everyone can take. The same caveat applies though; if they are family then you shouldn’t really be treating them anyway.
On the other hand, if you are responsible for a group of people who all have different past medical histories then you need to be prepared to modify your treatments to provide for possible allergies. In this situation you need to have a 2nd line option to supplement your normal 1st line.
What clinical conditions do you need to cover?
So having decided where and who, the next question is what? What are the common infections you need to be able to treat PLUS are there any uncommon infections/conditions/situations that you must be able to treat or at least manage until conventional treatment is available.
You cannot carry a medical kit that will cover every possible eventuality, that’s unrealistic, and not to mention heavy, so it’s important to be aware of what you should and can treat.
The common infections and their causes, which I think it is reasonable, to be able to treat include:
- Pneumonia – caused by Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae and Chlamydia spp.
- Otitis media - caused by Streptococcus pneumoniae and Haemophilus influenzae
- Otitis externa – caused by Staphylococcus aureus and Beta-haemolytic Streptococcus groups A, C and G
- Sinusitis – caused by Staphylococcus aureus and Beta-haemolytic Streptococcus groups A, C and G, Streptococcus pneumoniae and Haemophilus influenzae
- Urinary tract infection (UTI) – caused by Escherichia coli, Klebsiella spp. and Proteus spp.
- Cellulitis - caused by Staphylococcus aureus and Beta-haemolytic Streptococcus groups A, C and G
- Bites – caused by mixed bacteria from the oral flora of whatever did the biting and don’t forget rabies!
- Giardiasis – caused by the parasite Giardia lamblia
On top of this I think it is also a good idea to be able to provide at least partial treatment to patients with the following whilst they are being evacuated to a comprehensive health care facility:
- Severe gastroenteritis or enteric fever – caused by Salmonella spp. (including S. typhi and S. paratyphi), Campylobacter spp. and enteroinvasive and toxigenic E. coli
- Sepsis or severe infection of unknown origin – arising from any body system and caused by almost any bacterium
So how do you cover ALL of these possible infections with a minimum number of antibiotics? Well, you do this by keeping it simple and looking for antibiotics that cover the same microorganisms that these infections have in common.
In order to cover all of the common infections, and their causes, that I would be likely to see on “an expedition” (to remote wilderness areas… wherever they are) I would need to take ONLY FIVE different antibiotics:
This would give me a 1st line treatment and a suitable 2nd line if the patient was unable to take the 1st line for some reason e.g. allergy. I would also have an option for what to give if the initial treatment wasn’t working. Although at this stage I would be looking to evacuate the patient to a more comprehensive health care facility as well; antibiotics in these situations are to buy time to transfer the patient safely.
If I was only going away with the Editor Chief in Charge (aka Jenny, my wife, who actually plans and books all my fantastic adventures!!) then I would only need to take the three antibiotics highlighted in yellow (Doxycycline, Ciprofloxacin and Metronidazole) to give me a decent treatment option for each infection; I’d be confident we could get further help if we needed it (although 5 packs of Refreshers® and a big bag of Haribo® will also be essential for keeping up morale).
So I can hear you shouting alternatives at your screen and yes there are a number of antibiotics I considered but decided not to take as I wanted to limit myself to only five. However if there was more room (never discard the morale boasts though, they are essential treatments) then I might consider taking these and in the following order of preference. I have also indicated why I rejected them.
- Amoxicillin – excellent 1st line treatment for pneumonia, otitis media, otitis externa and urinary tract infections (UTI); narrow spectrum and therefore less likely to cause side-effects than many other antibiotics. REJECTED because same active ingredient as Co-amoxiclav and therefore if allergic to one then allergic to both, plus the antibiotics chosen are better options for the most common infections
- Co-trimoxazole – good broad spectrum cover 1st line for UTIs as well as 2nd line cover for pneumonia, otitis media, otitis externa, sinusitis and cellulitis. REJECTED because alternatives for 1st line treatments available and bacterial resistance in many countries can be a problem
- Flucloxacillin - narrow spectrum treatment 1st line for cellulitis. REJECTED because it is only really of use in this one condition, for which the antibiotics chosen are good alternatives
So there you have it, my expedition antimicrobial choices and why I would take them. However, any medical kit is only as good as the skill and knowledge of the person using it and there is nothing as good as seeking help from a competent professional in whatever destination you have travelled to. If in doubt seek medical help, and if you or the patient is very unwell then don’t hesitate about evacuating to somewhere where that help is readily available… it can save a life.
NB sweets, although essential in any kit, can only treat defects in morale in an emergency and not actually treat infections or illnesses!