Guerrilla Hospital Quality of Care: Part 2
J Spec Operations Med, v2n2, Spring 2002

In the last edition I wrote about the recent
recommendations by several professional societies
and government agencies regarding antibiotic use.
Universally, they recommend less, rather than more,
antibiotic use. Specifically, most cases of otitis
media, sinusitis, sore throat, and bronchitis in other-
wise-healthy adults will get better without antibi-
otics, although supportive therapy with analgesics
and sometimes decongestants is recommended.

Some other common outpatient problems
are traditionally treated with antibiotics in the
United States, in spite of strong evidence that
antibiotic use does not help, and indeed may harm,
the patient. In addition, many bacterial infections
which are known to respond to antibiotics are treat-
ed for much longer (more unneeded doses; more
side effects) than required. For example, an infec-
tion which may usually require three days of antibi-
otics may be treated for ten or even fourteen days.
In an austere environment, the foolishness of this
thoughtless superstition is most evident.

Skin infections represent a big antibiotic
requirement in an austere environment, or any other
operational environment. Ranging from impetigo to
abscesses to cellulitis, they can interfere with oper-
ational readiness and, improperly treated, even lead
to death. An environment with poor sanitation,
where it is difficult to wash the infected area or
one's hands, sets the soldier up for such problems
and makes them even harder to treat and contain.

A localized area of impetigo is adequately
treated with regular applications of bacitracin, twice
or three times a day, after a good scrub. To avoid
spread of the infection, it is sometimes best for the
medic to provide 2x2 or 4x4 gauze sponges which
can be discarded after each scrub. Any soap works
about as well as povidone iodine (Betadine©), so
there is no real reason to dig into the medic's stocks
of that. The lesion should be covered with a Band-
Aid© or similar simple dressing when possible; this
prevents lesion-to-nose colonization. Similarly, if

the patient has any insect bites, poison ivy or other
sites that are prone to scratching, covering them
with a minimal dressing can prevent infection
spread.

More widespread impetigo, three or more
lesions, calls for the big guns. Although the chain of
assumption has traditionally been "impetigo =
Group A Streptococcus pyogenes, therefore ten
days' treatment," in fact it's more often staphylococ-
cus. In any event, treating with a good anti-strep,
anti-staph antibiotic such as cephalexin for three to
five days is usually enough to clean up the lesions
for natural defenses to complete the job with half
the total doses. And no antibiotic is going to ade-
quately substitute for poor hygiene.

An abscess is a bit of a peculiar lesion, in
that many practitioners load the patient with antibi-
otics for days prior to draining it, in the supersti
tious hope that it will resolve without the applica-
tion of stainless steel. In fact, a well-localized
abscess can be drained without antibiotics prior or
after drainage. I would give a patient antibiotics
orally - again cephalexin is a good choice - if the
abscess were extensive and septated, requiring a lot
of exploration and adhesions to be disrupted. But if
you cut it with a scalpel blade and the pus runs out
without a lot of poking and prodding, the packing
will prove curative and the antibiotic a waste of
resources.

Cellulitis is a pretty solid indication for
antibiotics. Basically, if the patient could fight the
infection without antibiotics, he wouldn't have the
cellulitis to begin with. The question is really a mat-
ter of timing. If the patient is febrile (>100 degrees)
then the antibiotics should be given until the patient
has been afebrile for 24 - 48 hours. An already-
afebrile patient probably has a less serious infec-
tion, still requiring antibiotics, but the duration can
be abbreviated. Draw a line around the advancing
edge of the cellulitis; when the redness begins to
retreat, continue treatment for another day ort two.
In any case, do not forget warm compresses to
increase circulation to the affected part - but do not
let the skin macerate from too much moisture.

Diarrhea may rarely require antibiotic treat-
ment. Fever and purulent stool are usually thought
to be signs of invasive disease, and most would treat
this type of diarrhea empirically with antibiotics.
Salmonella, however, may actually be made worse
with antibiotic therapy. Importantly, these symptoms
in a patient recently treated with antibiotics should
prompt consideration of pseudomembranous colitis
- a condition that is often fatal and can be hard to
treat.

Turista, which occurs in travelers to the U.S.
almost as often as in Americans traveling abroad,
usually responds to loperamide (Imodium®) and
bismuth subsalicylate (Pepto-Bismol©). However, if
the diarrhea is disabling, three days of ciprofloxacin
500 mg bid is a reasonable intervention. A longer
course for turista is probably a waste.

Urinary tract infection in women can be
thought of as either pyelonephritis or cystitis,
although there are a few other less-common condi
tions, such as hemorrhagic cystitis or urethritis to
keep in mind. However, a woman with a fever and
constitutional symptoms such as vomiting, along
with a positive urinalysis, usually can be assumed to
have pyelonephritis. If vomiting is a problem then
intravenous or intramuscular antibiotics are needed.
However, if the patient can keep down oral medica-
tion, ciprofloxacin 500 mg bid alone or with
cephalexin will almost always be adequate, without
the need for IV fluid.

A woman with dysuria and no fever or vom-
iting and catheterized dirty urine can be considered
to have cystitis. Numerous studies have shown that
these patients will resolve with either a single dose
of medication, such as gentamicin 80 mg IM, or a
large dose of amoxicillin, such as three grams orally
at one dose. Slightly better results are obtained from
three days of cephalexin 500 mg qid for three days,

or TMP-SMX DS bid for three days. If symptoms
do not improve within the three days, then extension
to seven or ten days is, warranted, or the antibiotic
should be changed.

In trichomonas vaginitis, the medic can
chose from two standard therapies. He can give
metronidazole 500 mg bid for seven days, totaling
fourteen tablets, or he can give a single dose of two
grams po stat, a total of four tablets. However, the
incidence of vomiting is high in the single dose ther-
apy, meaning that the savings may be illusory. If
twenty percent of women vomit, then for every
twenty tablets given, four will be wasted, and the
one who vomits will need the bid for seven days
regimen. However, treating those same five women
with fourteen doses of metronidazole will cost a
total of ninety-eight tablets. So the total metronida-
zole used in treating five women with single-dose
therapy turns out to be about thirty-four tablets ver-
sus the longer regimen's cost of ninty-eight tablets -
about a third of the cost in resources.

Again, saving a bottle of tablets may seem
insignificant to the practitioner sitting behind the
desk in a comfortable TMC or sick bay, but when
everything has to be air dropped into the AO in the
middle of the night and rucked to the G hospital,
seemingly minor savings can become a big deal.

The SOF team medic usually enjoys one
advantage that other health care personnel do not
have - they are in contact with their team members
on a daily basis. Thus, instead of giving antibiotics
for some mindless and irrational interval, he can
provide them a dose or two at a time and watch for
the desired result. When the patient's infection is
resolving, then there is often little to be gained by
pouring more antibiotics down the black hole.