Antibiotic Use in the Austere Environment: Part 1, Upper Respiratory
Warner Anderson, MD
J Spec Operations Med, v2n1, Winter 2002

THE PROBLEM

Special operations forces (SOF) field med-
ical care is a composite of several mission-derived
applications. For instance, direct action (DA) med
ical care is almost entirely trauma-related, while
foreign internal defense lies at the other end of the
spectrum, with illness care for both soldiers and
indigenous personnel. Of course, there is a lot of
overlap, and the uncertainty of supply and resupply
provides much of the challenge: how much is just enough?

A fresh look at a long-neglected component
of unconventional warfare, the guerrilla hospital
("G hospital"), offers a valuable opportunity to
refine and redefine medical skills and appropriate
applications of care. Standards of care must, insofar
as possible, uphold top-quality practice regardless
of location and circumstances.

At the 2001 Special Operations Medical
Association meeting, Colonel Warner (Rocky) Farr
and the USASOC staff presented an overview of
several historical examples of guerrilla medical
care, with discussion of how they could be used to
develop doctrine for future operational needs.
However, while the historical data yield valuable
lessons on centralization versus decentralization,
organization, security, and even logistics, little is
available to guide clinical protocols and practices.
What does the medic do in the field, by kerosene
lamp, with a pressure cooker for an autoclave?

If we start with the premise that quality
health care is essentially the same regardless of set-
ting, it follows that an evidence-based review of
certain clinical practices can offer 1) valuable
improvements in therapy, 2) decreased adverse
effects, and 3) efficient use of scarce resources.

In other words, more people will get better
because of therapy, fewer will get sick because of it,
and this can all happen in the austere health care setting.
A common misconception holds that the

difference between a good clinician and a poor one
is that a good clinician knows when to use a partic-
ular drug or intervention for the patient's problem.
The reality is that a good clinician is one who
knows when not to use a drug or intervention. For
example, common practice prescribes antibiotics
for a large number of conditions in which the antibi-
otics clearly are of no use, and may actually be
harmful. The medic's challenge is to overcome the
intellectual inertia that leads to this practice and
protect the patient from bad medicine.

In special operations medicine, the corol-
lary benefit will be a huge reduction in the
resources used in the mission - thus, less tonnage
and fewer cubic feet of supplies, and less demand
on resupply.

So, the question is: what changes can SOF
medicine make to provide more and better quality
care in the austere environment? To find the answer,
we can look to the literature on common problems
encountered in SOF medicine.

THE ANSWER

A recent consensus paper sponsored by the
American College of Physicians (internal medi-
cine), the American Academy of Family Practice,
the American College of Emergency Physicians and
the Centers for Disease Control and Prevention
warned that physicians and other clinicians are
doing great harm to their patients by prescribing
antibiotics for conditions in which they are not warranted,(1)

Sinusitis

Clinicians over-diagnose bacterial sinusitis
by about 250%. In other words, for every five cases
diagnosed, only two are really bacterial. The diag
nosis is actually difficult, since no one wants to
have a big needle poked into his sinus to have the
pus sucked out for culture. Most clinicians are
taught that sinus X-rays will show an air-fluid level,
or at least mucosal thickening in sinusitis, but these
are also common findings during the first week of
the common cold. More recent teaching suggests
that sinus films miss some sinusitis, and that a CT
scan is necessary to rule it out. However, CT has
been shown to be overly sensitive in screening for
sinusitis, with a high false-positive rate. Certainly,
diagnosing bacterial sinusitis on the basis of con-
gestion, sinus tenderness, purulent nasal discharge
and fever will lead to a huge wasting of antibiotics.
In a SOF/UW situation, antibiotics are best
considered for sinusitis only when the URI has been
serious for more than seven days or takes a sudden
turn for the worse late in its expected course, with
documented fever, bloody-purulent nasal discharge,
and exquisite (not mild-to-moderate) sinus percus-
sion tenderness. Of course, erythema or swelling
over a sinus should prompt antibiotics, and one
should probably pull the antibiotic trigger on frontal
sinusitis quicker than maxillary, simply because
frontal sinuses can rarely rupture posteriorly into the brain.
Pseudoephedrine, nasal decongestant spray
(not to exceed five days), and analgesia can go a long
way to make the recovery process more tolerable.

Sore Throat

No clinician wants to miss a strep throat that
might lead to rheumatic fever - and almost no one
does. Clinicians who begin testing with rapid strep
tests are usually surprised at how many apparent
strep pharyngitis cases are negative, i.e. non-strepto-
coccal. Since penicillin therapy shortens the duration
of the strep infection by only about twelve hours, it's
hardly worth it for suspected (but unconfirmed) cases.

Many clinicians use such clinical indicators
as painful swallowing (as opposed to sore throat),
tender cervical lymphadenopathy, fever and cryptic
red swollen tonsils with purulent exudates to try to
more accurately guess whether a sore throat is strep;
however, they will be accurate only 10 - 30% of the time.

Furthermore, strep throat is almost unknown
in children under two years old, and after about thir-
ty years of age the chances of new rheumatic fever
are about zero.

SOF/UW medics should administer peni-
cillin (500 mg BID) for an adult-size patient with
sore throat and history of rheumatic fever.
Otherwise, antibiotics such as with good anaerobic
coverage such as clindamycin should be given for
peritonsillar abscess (plus surgical drainage), peri-
tonsillar cellulitis, or sore throat that does not look
like a viral URI or strep pharyngitis (Ludwig's angi-
na, retropharyngeal abscess, etc.).

A sore throat, even with red and swollen ton-
sils, does not really merit antibiotic treatment, but it
may merit lots of liquids, NSAIDs and codeine.

Bronchitis

When a patient presents with a bothersome
cough - perhaps with musculoskeletal pain and no

sleep from coughing all night, purulent sputum,
fever and hoarseness - the temptation to reach for
the antibiotics is great. However, patients who are
under sixty years old, have competent immune sys-
tems and do not smoke can reliably be considered to
have a viral condition. Of course, Moraxella and
Chlamydia pneumoniae can cause bronchitis, but
these seem to be self-limiting, anyway.

The SOF/UW medic should treat almost all
bronchitis as the viral infection it is, and provide
cough suppression and analgesia with codeine.
Pseudoephedrine may help, but antihistamines will not.
In the field, rusty sputum, tachypnea greater
that twenty/minute, heart rate greater than one hun-
dred/minute, and/or rales (not wheezes) should
prompt azithromycin or levofloxacin therapy, espe-
cially if pulse oximetry shows saturation less than
ninety percent.

Otitis media

Most otitis media, whether in children or
adults, will get better in seventy-two hours with, or
without, antibiotics. First, the diagnosis of otitis
media is hard to make, and has little to do with a red
eardrum. Instead, the diagnosis is made with pneu-
matic otoscopy, reflectance tympanometry, or tym-
panogram (sure, the doctor looks in your kid's ear,
but unless he pumps in air he's just fooling you).

The SOF medic may, by default, rely on an
asymmetry of redness between the ear drums. Since
any crying kid (and probably crying adults, I don't
really know) have red ear drums, the medic will
need to compare the two. After all, the reason
humans are built symmetrically is so the medic can
compare a paired structure to the other side for
abnormality.

In the Netherlands, otitis media is treated
with myringotomy. Easy to talk about but scary to
do, myringotomy immediately relieves the pressure
behind the TM and lets the pus drain.

Since the definition of an abscess is a col-
lection of pus in a localized area, then it follows that
otitis media is a type of abscess. And if the treatment
for an abscess is drainage, not antibiotics, then judi-
cious myringotomy makes good sense. In experi-
enced hands, and in an antibiotic-poor environment,
it can provide immediate relief for the both the suf-
fering child and the frazzled parent. However, with-
out antibiotics and without myringotomy, most all
otitis media gets better and the pain responds to
acetaminophen, ibuprofen or codeine.

Conclusions

Sometimes it takes a great deal of intelli-
gence, courage and personal integrity to avoid,
rather than reach for, the stock bottle of antibiotics.
But SOF medics are chosen for intelligence,
courage and integrity. Minimizing antibiotic use in
an austere environment, just like in a rich one, is
scientifically correct, judicious, morally right and
inexpensive. And no one gets a rash, anaphylaxis,

or resistance from the antibiotic that you didn't use.
If the medic, PA and physician refrain from promis-
cuous use of antibiotics in the clinic and the field,
they will be in good company: the ACP, AAFP,
ACEP, CDC and the Infectious Diseases Society of
America. Not bad at all.

See the Spring Edition for Part Two

Reference

1. Annals of Internal Medicine. 2001;134:479-517. (See also,
Annals of Emergency Medicine. 2001; Vol. 37, No. 6. for iden-
tical articles)