Purell instead of Triple Antibiotic Ointment?

"Hey sorry — just wondering if you were referring to deep tissue infection with MRSA or nasal colonization"

No offense taken-all part of give and take in the forums. I was referring to both nasal and deep tissue, but it was my first and, I hope last, experience with the little buggers.

"I hope last, experience with the little buggers." I think that's the idea behind the eradication strategies. Smart to be prepared just in case.

Well, all the books do say that the only intervention PROVEN to reduce infection in minor lacerations is copious irrigation. Not antibiotics, be they topical, enteral, or parenteral. (Restated: If you've got pebbles in the wound it WILL become infected, no matter what antibiotic you're using…) That said, I carry a triple antibiotic ointment. Hygiene is just a bit unreliable in the wilderness, and I am unaware of any clinically significant issues with neomycin-resistant strains.

I will say that I think Bactroban is a bit overkill, unless you have a solid MRSA history or something. If you react to neomycin just get straight Bacitracin. I really don't see much point in getting the prescription stuff- it's a lot of hassle for trivial gain, excepting MRSA.

(And, as was INTENSELY discussed in these forums a while ago- I too carry a fluoroquinolone as my general-purpose enteral antibiotic. The tendon rupture thing isn't realistically going to manifest with two days or so of use.)

Paul Auerbach was a little late on talking about the black box warning, but here it is. Yep, mostly takes about a week to develop tendon issues.

http://www.healthline.com/blogs/outdoor_health/2009/05/fluroquinolone-antibiotics-and-tendon.html

Acrosome — like the username.

The newer fluoroquinolones (levofloxicin and others) are very rapidly absorbed — many equivalent to IV administration of a drug. High levels are reached very quickly. While the incidence of tendon rupture might be small, IMO it would be a serious consequence. Would be interesting to know whether risk increases in a tendon under stress (backpacking) — based on the mechanism, I would suspect it would. There are reports of Achilles rupture during/after single 5 and 7 day (quite typical) courses. It's a black box I don't take lightly. I have and would use drugs in this class. But each time I pop one (typically for pneumonia, upper respiratory stuff), I do consider the risk I am taking. It takes pretty good evidence to earn a black box and the powerful pharmaceutical companies fight like hell to avoid it.

Maybe I'm missing something obvious, but why not take a penicillin/clav acid combination like Augmentin Duo Forte or a cephalosporin like cephalexin?

That should cover your gram positives like staph and have enough gram negative coverage for most common things (e.g. E.Coli). Should be enough for pneumonia, cellulitis, utis and most things you could encounter on the trail.

They are cheaper and don't have the tendonitis side effect.
Apologies for the medical jargon.

Good question. You can easily look up the coverages of these antibiotics and their resistance patterns.

But I will say a couple things I remember off the top of my head. Penicillins and cephalosporins are no longer good drugs for empiric (when you don't know what the bug is) treatment of pneumonia since about half of pneumococcus is now resistant. Penicillins do not cover Mycoplasma, often called "walking pneumonia" — probably the most common pneumonia in young healthy people. Newer fluoroquinolones (cipro is "older" btw) have excellent coverage against pneumococcus, mycoplasma, legionella and anthrax. Much broader coverage of enteric gram negatives. Covers most common causes of urinary tract infections plus gonorrhea, chlamydia. Newer fluorquinolones should adequately cover pseudomonas — lives in sneakers and gets into skin when you step on a sharp and it goes through the shoe — a real nasty.

Speed of onset. Many of the newer generation fluoroquinolones reach high levels in the blood and tissues very quickly when taken orally — as quickly as an IV drug in some cases. Once a day dosing. Usually shorter courses. Sometimes a single tablet in a female with run of the mill UTI — cystitis. 5 days for pneumonia. Very well tolerated and compliance is good.

Doxycycline would be an excellent choice for a trail kit. You can look up the indications/coverage. Very cheap. Does tend to cause some photosensitivity so keep the skin covered. Reaches high levels in the skin which is good if that is where the problem is. Resistant organisms do not emerge as quickly. Bactrim has some of what you want but sulfa sensitivity is common.

Penicillin allergy is somewhat common — chance of allergy increases with more frequent exposure.

What drugs are used in a clinical setting has a lot to do with how hard the drug companies are marketing them! Fluoroquinolones have been pushed very hard by their manufacturers — mega marketing budgets. A fair bit of resistance to them is now emerging as would be expected.

I think Patrick touched on some antibiotic issues — would be worth having a look. Take his word over mine or better yet look it up.

Thanks- the username goes back to college. A story for another time…

To address the question about why I prefer fluoroquinolones:

Fluoroquinolones are cheap, have great coverage, are very shelf stable, have oral bioavailability equivalent to their IV formulations, and few people have allergies to them. (I do think of the possibility of needing to give the antibiotics I packed to someone else.) But also- most of them are only taken once a day. I'd much rather carry two pills than eight.

The tendon rupture issue was what I meant when I said that my carrying fluoroquinolones was "intensely discussed" in an earlier thread, Hartley. I could dig it up if you like. Basically, I acknowledge the severity of the black-box warning, but maintain that the risk for a short course is manageable. I'm a provider in the US Army and we give TONS of fluoroquinolones to young and VERY active individuals (arguably professional athletes) for short courses with no significant problems. And before some zealous individual jumps all over me- note I am not saying "NO problems".

Anyway, I challenge anyone to produce a case report of a major tendon rupture in an individual who has only taken one or two doses of fluoroquinolone. (I.e. long enough to hike out.) There may be one, but I'm unaware of it.

I will admit that I tend to get huffy with people who expect risk-free medications. But that said I acknowledge that the prospect of an Achilles rupture is especially terrifying to an avid hiker, so I won't begrudge anyone who decides that they want to avoid fluoroquinolones.

By the way, the REI near where I live has packets of single-use triple-antibiotic ointment. A pack of 10 costs $4. Each packet weighs 1/32 of an ounce.

These drugs penetrate the bone very quickly and bind the bone matrix very strongly which is why they can be very useful in osteomyelitis. They are contraindicated in those under 18 because of problems with bone development. The drug stays in the bone long after you finish a 5 or 7 day course. Such penetration can weaken the attachment of the bone to the tendon for a prolonged period after discontinuation. Tendonitis and tendon rupture can occur. A black box warning IS a big deal, period. A drug really has to earn it! And one would be wise to avoid stressing a tender Achilles while taking this drug! This is a good drug. There are suitable alternatives for those who are not willing to chance it — doxycycline for one. BTW, some people here travel in areas where they could not be evacuated in two days if at all.

Cheap? What and where are you getting it? Cheap compared to what? BTW, Cipro is simply inadequate coverage for an all purpose antibiotic. Gut and the urinary tract, OK. Gaiti and Moxi are probably the preferred. Levo, OK.

I doubt anyone is at great loss heading into the backcountry without a 4th generation fluoroquinolone. I've got lots of the stuff. I carry it. I've taken it. I DO worry about it. If I had even a slightly sore Achilles in the months following a 5 day administration, I'd seek medical attention immediately. Something for people without health insurance to think about — do you really want to foot the bill for an ortho consult and an MRI to evaluate possible tendonitis. Especially when good old doxy probably would have been just fine. :)

A couple have been removed from the market and the rest have black boxes for this reason. Black box is a big deal! These drugs are increasingly being avoided in professional athletes as there are almost always better options.

I'm sure this thread is boring everybody else to death, but wow I can't believe you use moxi and gatiflox etc. We reserve those as last line and they are super expensive here. We just tend to have cipro and norflox and they are first line for an oral antipsuedomonal agent here but as stated their coverage against gram positives isn't great (perhaps non existent is a better term).

Our resistence patterns in Australia are much less so we tend to get away with narrower spectrum antibiotics. We also have pneumococcal vaccination free for everybody so we don't have to worry about it as much.

Besides it doesn't matter what antibiotics you're taking as long as their the lightest right? ;)

Took about 1/8" deep by 1" disc or flesh off my heel. Some blood, but lots of deep epidermis exposed. Pored some alcohol on it, and then have been using BFI powder and neosporin, but lots of walking in fresh saltwater makes impossible to keep dry/clean. No sign of infection yet. I have a 30-day supply of cipro 500mg with me. Bad idea to take prophylactically to keep anything bad from starting?

> Bad idea to take prophylactically to keep anything bad from starting?
Definitely bad.

Your body is coping just fine with the problem – why interfere? Why bomb out your gut flora needlessly? Why not let your immune system do what it is meant to be doing?

Hey – the salt water is probably half the cure anyhow!

Cheers

Figured this might apply somewhat.
Couple years back I had an accident on a motocross track with an ATV. Went over the front end off a large jump, was run over by the atv, and was dragged underneath until it stopped. I had road rash over the entire left side of my back from the butt cheek to the shoulder blade, from hard red clay. EMTs were at the track, but simply didn't have enough sterile water to even begin to clean it out. They gave me instructions of what to do at home.
First, the initial cleaning required scrubbing until I got all the dirt and clay out: no soap. Then I had the whole area irrigated with STERILE water (waterfall water still has bacteria; noticed a few mentioned that; boil water for irrigation). After that, we used a product called 2nd Skin to dress it, its like a water gel pad – semi permeable membrane. Tegaderm would be the choice for backpacking (self adhesive, stays very well, and waterproof). Replaced the dressing daily, irrigating with sterile water every time. No ointments or soap or anti-septic of any kind. The EMTs (and my general practitioner agreed) said most things will simply damage the skin, or slow the healing process (ointments will seal the wound, defeating the purpose of the semi-permeable membrane).
Wound was totally healed after about a month, scarring wasn't too bad, especially considering how deep it was (the lower left area of my back has no feeling anymore from nerve damage).