202010021053野外醫學 登山/戶外醫藥包需準備哪一種抗生素

(參考資料 WMS 偏遠地區基本傷口處置指引 )
(之前寫的筆記: 傷口清洗 傷口處置 傷口清理)
(另一篇筆記 傷口處置需要用優碘嗎?)

傷口處置, 最重要的是沖洗 irrigation 清創 debridement, 沖洗
所有開放性傷口都會有細菌生長, 但有細菌不代表一定有感染, 傷口即使培養出細菌, 多數不會造成問題
傷口沖洗與清創的重要性遠大於全身性抗生素治療
人咬傷的傷口, 預防性抗生素可降低感染率, 貓狗咬傷的傷口, 除了手部, 預防性使用抗生素不會降低感染率
沒有任何一種抗生素, 在不同狀況都能比其他抗生素好, 不同狀況應選擇不同類型抗生素, 因此, 如果醫藥箱想放抗生素, 建議選擇口服的第一代頭孢素, 做為預防性全身性抗生素, 理由是方便、便宜、易取得

那些傷口應預防性使用全身性抗生素
1. 開放性骨折
2. 人咬傷
3. 貓狗咬傷手部
4. 燙傷不需要使用全身性抗生素

systemic antibiotics 全身性抗生素, 包括口服, 肌肉注射, 靜脈注射

Infection Prophylaxis And Prevention
An overall principle of wound management is that whether or not prophylactic antibiotics are given, wounds should be monitored closely. Complications can develop rapidly or in an indolent manner. These include local secondary infection, undetected penetration of deeper structures, and systemic illnesses that can result from hematogenous seeding of organisms inoculated into the wound.
With the exception of certain specific wound categories, there is scant evidence to support the routine use of systemic antibiotics for prophylaxis against wound infection. A notable exception is an open fracture, in which acute antibiotic administration significantly lowers the rate of infection.54, 122 This is of particular significance given the substantial morbidity associated with subsequent osteomyelitis.
Virtually all open wounds are colonized with microorganisms, but this is usually without clinical consequences.123 The presence of colonizing bacteria does not constitute infection.
A systematic review of mammalian bites showed a statistically significant reduction in the rate of infection with the use of prophylactic antibiotics after bites by humans but not after bites by cats or dogs, except bites of the hand.124 There was a statistically significant reduction in the rate of infection with the use of prophylactic antibiotics after mammalian bites to the hand.
Although dated, there is evidence to support the use of topical antibiotics to promote wound healing and decrease infection.125, 126, 127

Recommendation 開放性骨折應使用全身性抗生素
Treatment with systemic antibiotics is indicated in the presence of open fractures. Recommendation grade: 1A.
Recommendation 人咬傷應使用全身性抗生素 (傷口接觸到牙齒)
Treatment with systemic antibiotics is indicated in the presence of human bites. Recommendation grade: 1B.
Recommendation 哺乳動物咬傷手部應使用全身性抗生素
Treatment with systemic antibiotics is indicated in the presence of mammalian bites to the hand. Recommendation grade: 1B.
Recommendation 如果無藥物過敏疑慮, 局部抗生素可改善傷口癒合, 減少感染率, 
Use of topical antibiotics may promote wound healing and decrease the incidence of infection, with little downside risk in the nonallergic patient. Recommendation grade: 2C.
燒燙傷的傷口是否需要預防性給予抗生素, 目前研究仍不足, 有一篇系統性回顧文獻, 使用磺胺銀, 相較於傷口換藥或人工皮, 會顯著增加傷口感染率, 這篇研究說, 因資料不足, 對於全身性抗生素目前無法給予建議. 
There is little compelling evidence to support the prophylactic use of antibiotics for burn wounds. One systematic review concluded that the use of topical silver sulfadiazine is associated with a significant increase in the rate of burn wound infections when compared with dressings or skin substitutes. The same review concluded that there was not enough evidence to enable reliable conclusions to be drawn regarding the use of systemic antibiotics. Another systematic review concluded that there was insufficient evidence to support the use of silver-containing dressings or other topical agents in the prevention of infection.129

Recommendation 燙傷的傷口不建議預防性使用全身性抗生素
Treatment with systemic antibiotics is not indicated for prophylactic use in burn wounds. Recommendation grade: 1C.
Recommendation 磺胺銀對於傷口癒合有不良效果 (不建議使用)
Silver sulfadiazine may negatively affect wound healing and may increase infection rate. Recommendation grade: 1A.

 

(參考資料 WMS Field Wound Care: Prophylactic Antibiotics)
下面這一篇有些段落看的不是很懂. 所以沒有全文逐字翻譯. 就寫個心得筆記

在野外受傷, 最重要的是清洗傷口及清創(移除壞死組織), 另外, 傷口縫合, 包紮, 追蹤也很重要

不管受傷當下使用廣效抗生素或窄效抗生素, 之後從傷口分離出抗藥性細菌的機率相同

短期的抗生素選擇性壓力, 是否會間接造成損傷延長(傷口延遲癒合), 目前仍無定論

伊拉克的一篇研究發現, 傷口清創比使用抗生素更重要, 兩者結合能產生更好的療效, 不過研究所使用的抗生素是先用 ceftriaxone (肌肉/靜脈注射), 或口服的 fluoroquinolones, 之後使用第一代頭孢素或augmentin. 抗生素治療時間是 7-10 天
傷口沒有適當處理, 感染率 70%
經過適當清創但不使用抗生素, 感染率17%
使用抗生素但不清創會將感染率下降到 40%
經過適當清創並使用抗生素, 感染率 2.6%

加沙一篇 2001-2003 年的研究, 收錄 109 位傷患, 受傷後 29 分鐘(+/- 11 分鐘), 最長在60分鐘內, 傷口處理後使用第一代頭孢素 + metranidazole, 11位病患出現傷口感染(沒有鑑定菌種), 2位病患傷口化膿需再次清創

註解: antimicrobial selection pressure 抗生素之選擇性壓力: 使用抗生素之後, 一部分細菌被殺死, 但另一部份具抗藥性的細菌變的強勢, 最後存活下來的菌群只剩下有抗藥性的

Based on the Ranger point-of-injury antimicrobial data and results of the Trauma Infectious Disease Outcome Study that indicated no difference between rates of subsequent isolation of resistant-bacteria after broad- versus narrow-spectrum antimicrobial coverage at the time of injury, it is unclear that short-duration antimicrobial selection pressure leads to collateral prolonged damage within the trauma population (unpublished data).62

It is important to note that the current regimens appear to modify the commonly encountered infections with Streptococcus species and Clostridium species that have directed field wound antimicrobials in the past. However, other factors may be involved, including differences in the environment of injury or host colonization, in contrast to other wars.82 

Gas gangrene resulted in 3 of 15 deaths among warfare-related limb injury in the Chinese military.83 The Chinese also reported cases associated with Wenchuan earthquake victims.84 A modifiable weighted matrix was previously published for the indications of various IV/IM medication, including ertapenem, for point-of-injury care in tactical combat casualty care to augment the CoTCCC recommendation of cefotetan (Table 3).85 Since that publication, data support that ertapenem can be delivered with a 5-minute infusion.86 Also, intraosseous and IM delivery of ertapenem appear to be adequate.26 Use of ertapenem and cefotetan in colorectal surgeries has been compared, with better outcomes with ertapenem.87 Overall, activity of ertapenem is enhanced in comparison to cefotetan for streptococcal, MSSA, gram-negative bacteria, and anaerobic bacteria. Although ertapenem has limited activity against P aeruginosa, versus none with cefotetan, ertapenem is not an agent recommended for P aeruginosa because of high resistance rates.

Foundational to therapy is determining when benefits of systemic antimicrobials outweigh the associated risks: potential antimicrobial-resistance pressure, C difficile-associated diarrhea; allergic reactions; drug-specific toxicities, including cardiac, hepatic, renal, and hematopoietic; and drug interactions. It also must be understood that timely irrigation and debridement is paramount to successful wound management. Appropriate closure of open wounds, bandaging, and close follow-up are also key.

A study in Iraq of the role of antimicrobials and irrigation, which included 53 wounds, noted the lowest infection rates (2.6%) with the combination of antibiotics and irrigation. Wounds that received no antimicrobial but were irrigated had a 17% infection rate. Those with antimicrobials and no irrigation had a 40% infection rate, and neither therapy resulted in a 70% infection rate.88 The agents used were parenteral ceftriaxone and/or oral fluoroquinolones predominantly, followed by second-generation cephalosporins or amoxicillin/clavulanate. Antibiotic course duration ranged from 7 to 10 days. One has to be cautious in the application of this study results given the use of 10 days of antimicrobials because it implies ongoing infection and not wound colonization, as well as the small numbers evaluated. However, the findings are intriguing given the field nature of care.

An examination of the use of early cephalexin and metronidazole in 2001–2003 in Gaza City is reported for 109 patients who received initial oral antibiotics and wound management soon after injury (29±11 minutes, maximum 60 minutes) with strict exclusion criteria.74 Eleven had an infection, although the type of bacteria was not reported. Of those 11, 2 had purulence requiring redebridement.

單純依靠抗生素治療, 沒有好好做傷口清創或沖洗, 會帶來更多感染及死亡

第二次世界大戰, 使用磺胺藥粉代替適度清創, 反而增加傷口感染率

1973年贖罪日戰爭, 使用高劑量抗生素消毒傷口, 不再依靠良好的手術技巧, 給予醫師和傷患一種虛假的安全感

紅十字會說, 良好的手術才是最好的抗生素

It has been recognized repeatedly over time that reliance on antimicrobial therapy instead of good wound debridement and irrigation leads to excess morbidity and mortality. During World War I, Alexander Fleming stated, “All the great success of primary wound treatment have been due to efficient surgery, and it seems a pity that the surgeon should wish to share his glory with a chemical antiseptic of more than doubtful utility.”70 During World War II, topical sulfanilamide became part of the standard of care after a lecture series about its success was attended by a team of Army and Navy medical personnel stationed in Hawaii just 36 hours before the attack on Pearl Harbor. However, this reliance on sulfanilamide powder replaced appropriate debridement, which had to be corrected after increased rates of infection were noted.71 During the Yom Kippur War, the overemphasis on antimicrobials led authors to state that “this leads towards the temptation to ‘sterilize’ the wound with massive doses of antibiotics and favors a false security with less reliance on good surgical technique.”72 The ICRC states that “the best antibiotic is good surgery.”5 As such, it is paramount to risk stratify the wound’s potential for infection based on parameters addressed by the epidemiologic triangle, along with access to appropriate wound care and surgical intervention, if need be.

Recommendations regarding antimicrobials include those by the IDSA, ICRC, WMS, NPS, CoTCCC, WHO, and combat-related injury infection prevention guidelines (Table 1).73 In comparison, Israelis reportedly use moxifloxacin, ceftriaxone, cephalexin, and/or metronidazole, while the British recommend penicillin or amoxicillin/clavulanate for cases that include abdominal injuries.74, 75, 76, 77 These recommendations are based on factors reflected within the epidemiologic triangle. The differences in choices are based on availability of supplies, evacuation chains, severity of injury, site of injury, and so on. As such, there is a difference between the benefits of point-of-injury antimicrobials for a severe open injury with prolonged evacuation to care and a minor injury with surgical care available in 20 minutes. Risk stratification for field care or point-of-injury antimicrobials must take into account many factors, including if the care is provided by a physician, a medic, or the person himself or herself; severity of the injury; and timely access to appropriate wound care.

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