I recently saw a patient who told me he had a cold. As usual I asked if he was taking any medicine. Yes. He was taking cipro, cephclor, arinate and tinidazole.

He was right, he did have a cold. So why was he taking 3 antibiotics and an antimalarial?

In Europe antibiotic use is a hot issue. A recent meeting of EU ministers of health discussed the estimate that 80% of antibiotics prescribed for respiratory infections are prescribed for no reason. They agreed top start a campaign directed mostly at doctors to reduce prescribing of unnecessary antibiotics.

75% of the world’s population never sees a doctor in their entire life, yet somehow they survive. I find that many of the refugees I see have never in their lives swallowed an antibiotic. Nor have they had acupuncture, homeopathy, hypnotherapy, reflexology or Chinese herbs. (They have had aromatherapy: cow dung is a common therapy in many areas. But you just can’t get good cow dung in Kampala) If someone in the family is dead it was most likely from trauma, not disease. How? Why? Unless most diseases get better without treatment?

So what are antibiotics, and when are they needed, and which ones should travelers carry for emergency use?

All true antibiotics by definition are “natural” most are derived from soil fungi. Some are not, in which case they are “chemotherapeutic agents”. The correct term is antibacterials, but I am going to call them all antibiotics. Antibiotics kill bacteria. Or at least slow them down so that our immune systems can gobble them up. As we have learnt from the AIDS epidemic, without an immune system, germ killers alone don’t work.

Other drugs kill viruses (antivirals) or fungi (antifungals) or parasites (antiprotozoals) Many are multipurpose, e.g. the antibiotic doxycyclin also kills malaria and clindamycin kills toxoplasmosis.

Some antibiotics are narrow spectrum killing only a small group of bacteria, for example penicillin these days mostly only kills streptococcus. Some kill mostly bacteria that live in the gut. Others mostly those who live on the skin. Others kill only those bacteria who like oxygen, others only anaerobes. Some are broad spectrum, killing a wide variety of different bacteria. All antibiotics are indiscriminate, killing good and bad bacteria with equal joy.

Our immune system on the other hand leaves harmless bacteria alone, or regulates their numbers or their habitat. A much better option.

So who needs an antibiotic?

The answer is very few people indeed.

Logic rules. You only absolutely need an antibiotic if it is necessary to kill a particular bacteria that otherwise is going to kill you. For example bacteria in the brain, meningitis. Or a real pneumonia. Or active TB. Or rare skin diseases such as streptococcus necrotans.

What about relative need? 

Here there are a wide variety of diseases that are almost certainly going to get better on their own but an antibiotic is going to get you better faster, or prevent disability. For example acute shigella or salmonella diarrhoea. It will get better in 5 days on its own. Or 24 hours with the correct antibiotic. I’ve got better things to do than sit on the loo for 5 days so I swallow some norfloxacin. Skin infections could leave you with horrible disfiguring scars or large chronic open ulcers for life, or you can get better in a few days with flucloxacillin. A strep throat gets better on its own. But is some cases can cause a crippling or even fatal kidney or heart or joint disease. Better to take penicillin

What about no need?

Antibiotics do not kill viruses. Most fevers, most sore throats and most coughs are due to a virus. Antibiotics are going to kill off a load of harmless bacteria, and do nothing at all for your cough and sore throat. They can even make it worse by encouraging other bacteria, viruses or yeast to grow. Every woman knows antibiotics give you thrush. Do you know why?

The vagina is supposed to be acidic. The acid stops yeast and most bacteria from growing. Otherwise a moist, warm, dark tube full of nutrients would be a bacterial culture paradise. The acidity comes from the lactobacillus, the same bacterium that turns milk into yoghurt. The immune system allows lactobacillus to grow in some places, like a vagina and a gut. Kill off the lactobacillus, which almost any antibiotic can do, and the vagina loses its acidity. So other bacteria and yeast can now grow, and you get a yeast infection, which is itchy and cheesy, or bacterial vaginosis, which is sore and smells like fish. That is why plain live yoghurt can cure a yeast infection. A similar situation explains why antibiotics can cause diarrhoea.

Even when a bacteria is growing, this does not mean an antibiotic is going to do any good. Most bacteria grow on mucous but may not be causing the mucous. For example a chronic bronchitis or a discharging ear, or yellow muck from the nose. Culture it and you will grow all sorts of lovely bacteria, all enjoying a nice environment with good food. But they are not causing it. They are simply enjoying it. Antibiotics are not going to do any good at all. All of us have learnt that throwing antibiotics at these chronic discharges is very frustrating. You kill the E. Coli and you grow pseudomonas. Change antibiotics and kill the pseudomonas and it grows heamophilus. You can go on chasing culture reports forever.

One thing that is inevitable is antibiotic resistance.

Take for example staphylococcus, the common cause of boils. Back in the 50’s a dose of penicillin and they all rolled over and died. All the horrible skin and joint and bone infections were cured like a miracle. When streptomycin, another soil fungus came along and cured all the TB doctors thought they were going to be out of a job.

The euphoria didn’t last long. All the penicillin sensitive bacteria died. A few resistant ones didn’t. They learnt to produce their own chemical that killed the penicillin, called penicillinase. Or they learnt how to pump the drug out of their bodies. The resistant strains were weaker, and on a level playing field were overcome in the struggle to survive by the wild strain. But keep giving penicillin and the sensitive ones all die. The resistance ones now become the dominant strain, and take over. At first science simply produced more and more antibiotics. The bacteria simply became more and more resistant. Now we have MRSA: resistant to everything. Except our immune systems. I once medivac’d a nasty gunshot wound back to UK, I think the royal or national orthopaedic hospital or some such prestigious sounding name. They were worried the patient may have MRSA and arriving on a Saturday when they only had “a skeleton staff on duty”. I fell about laughing that the orthopaedic hospital had a skeleton staff, but they didn’t think it was funny.

So what should a traveller in Uganda do?

Carry with you 2 antibiotics. Flucloxacillin and Norfloxacin

Here are the rules for a healthy gut, vagina and skin.

1) Don’t take antibiotics unless there is a real need.

2) A common cold does not require antibiotics. All colds develop yellow snot and green phlegm. Antibiotics don’t help. Nor does smoking. Malt whisky does, but only a really expensive single malt.

A real pneumonia means fever pain and coughing blood and pus in an adult. Children are trickier. Breathing over 60 times a minute is a better guide.

3) If you cough for over 3 weeks see a doctor. You may have a rare pneumonia that requires specific antibiotics, such as chlamydia or TB.

Rare means not very likely.

4) Meningitis is rare and requires specific antibiotics very quickly indeed. Meningitis is not a bit of a stiff neck and a headache. It is very ill with a rigid neck. See a doctor. Fast.

5) If you have a discharge 5 days after sex see a doctor. Many of the drugs in the books for gonorrhoea don’t work in Uganda any more, so don’t try self-treatment.

6) If you have boils or a spreading skin infection take flucloxacillin 2 capsules 3 times a day until it is better.

7) If you have acute diarrhoea with fever or blood or pus in the stools, take norfloxacin 2 tabs right away and then 1 twice a day until better. 3 or 4 doses are usually enough.

8) If you have pain passing urine and you are a woman, try drinking a lot of fruit juice. If it doesn’t work try norfloxacin, though it is not first choice. If you are not a woman see 5 above.

9) If you are given antimalarials and an antibiotic other than doxycyclin at the same time, ask why? You are not likely to be suffering from 2 diseases at one time. Like the example at the beginning you may not need either.

10) Er…

11) That’s it