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Doxycycline (Fish-Doxy)

Doxycline is an antibiotic that is a member of the Tetracycline family of drugs. Like so many other bacteria, the tetracyclines come from a soil fungus and were discovered in the 1940’s. Or maybe it’s more accurate to say tetracyclines were rediscovered then because bone analysis of Nubian people who lived about 350AD show they ingested tetracycline likely in a locally brewed beer.

The tetracyclines work by binding to and deactivating the ribosomes inside the bacterial cell. Ribosomes are the bacteria’s protein factories, and without it they cannot produce the proteins they need to stay alive. Ribosomal deactivation happens in both gram positive and gram negative bacteria, though sometimes the antibiotic has a little more trouble getting into Gram positive cells with their thicker cell walls. Some bacteria have also developed resistance to the tetracyclines usually by developing a pump that spits the antibiotic out of the cell and thereby protecting the ribosomes on the inside.

As it treats a large number of bacteria, Doxycycline is considered a broad spectrum antibiotic. Doxycycline is the preferred agent in treating Chlamydia, Rickettsial infections spread by ticks (Typhus and Rocky Mountain Spotted Fever), and Cholera. It will also work against walking pneumonia (caused by Mycoplasma pneumonia, though technically Azithromycin is a better choice but there is no Fish-Azithro), most strains of Gonorrhea, and early Syphilis infections. Doxy will also work against Anthrax, Plague, Tularemia, and Legionnaires disease. While not FDA approved for this, it will also treat Lyme disease. It will also treat sinus infections, pneumonia, and ear infections, but it is generally a second or third line choice for these. Doxy is generally a poor choice for the streps and staph, as their thicker cell walls are harder to penetrate.

Unlike most antibiotics, Doxycycline is also active against certain parasites of the protozoal class. It can help prevent malaria and is often used as a prophylactic for people visiting malarial areas. However, it is poor in treating malaria once the disease is already established.

Doxycycline is best taken on an empty stomach, though it can be taken with foods as long as they don’t contain calcium (milk), iron (red meats), or aluminum or magnesium (antacids). Calcium, iron, aluminum, and magnesium bind to the antibiotic, decreasing its absorption. Doxycycline should not be taken by children under age 8 or by pregnant women, as it can cause staining of pre-emergent teeth. Unlike Tetracycline, expired Doxycycline does not cause kidney damage.

Trimethoprim-Sulfamethoxizole (Bird-Sulfa)

Trimethoprim-Sulfamethoxizole (a.k.a Bactrim, Septra, or co-trimoxazole and abreviated as TMP-SMX) is a combination of two different weaker antibiotics that when added together seem to be greater than the sum of their parts. Sulfamethoxizole is a sulfa-based antibiotic that works best against Gram-positive bacteria (like strep and staphs) as well as many anaerobic bacteria. Trimethoprim is a man-made antibiotic that works against aerobic bacteria. They are combined in a ratio of one part Trimethoprim to five parts sulfamethoxizole, so the dosing will often be listed as 80mg/400mg or 160mg/800mg. Both act by disrupting the bacteria’s ability to process folate, which stops DNA production and a host of other processes resulting in bacterial cell death.

TMP-SMX is considered a broad spectrum antibiotic. Trimethoprim-Sulfamethoxizole (TMP-SMX) is not a terribly effective antibiotic, and a lot of people have unpleasant reactions to its use. The worst case scenario is that TMP-SMX has a known risk of causing Stevens-Johnson Syndrome (SJS). SJS is a life-threatening reaction that causes your skin to peel off your body. Yeah, it’s as unpleasant as it sounds. Because of these problems, the use of TMP-SMX declined through the 80’s and in some countries it was even banned.

So why do we use it today? It’s four little letters– MRSA. As MRSA (Methycillin-Resistant Staph Aureus) began to spread across the world and began showing up in more and more infections, the medical community began looking for effective treatments. Doctors discovered there are two different types of MRSA. One is more common in hospital settings and is resistant to almost everything and can only be treated with IV antibiotics in the hospital. The other was termed community acquired Methycillin resistant Staph aureus (CA-MRSA) and only two oral antibiotics were found to kill it on a regular basis. These two antibiotics were TMP-SMX and Clindamycin. And so, TMP-SMX came roaring back into the medical mainstream.

While TMP-SMX is a broad spectrum antibiotic, cautious use is recommended due to the potential side effects and interactions with other medications. It is a first line agent for CA-MRSA. It is also considered first line for most all urinary tract infections, as it treats the top five causes of UTI’s (E.coli, proteus, klebsiella, enterobacter, and staph saprophyticus). It is also the first line agent for cat scratch disease. It will also treat most other streps and staphs, but other antibiotics will do the same with fewer side effects. It can be used for ear infections, pneumonia, chlamydia, ghonnorhea, toxoplasmosis, plague, cholera, travelers diarrhea, and many others. However, once again, there is usually a better choice. Interestingly, it does not do well against strep throat.

Because it can mess with your own folate metabolism, it should not be used in pregnancy.

Metronidazole (Fish-Zole)

Metronidazole(better known under its trade name, Flagyl) is a very interesting and unique antibiotic. Invented in France in the 1950’s, it is part of the Nitroimidazole family of antibiotics.

Metronidazole only works after being reduced (a chemistry term for “adding electrons”), and in the case of Metronidazole this reduction only occurs inside Anaerobic bacteria. Because of this, it is not toxic to human cells, which are aerobic. Once reduced, Metronidazole interferes with bacterial DNA replication, making the cell unable to reproduce or make needed proteins, resulting in cell death. Metronidazole is considered a broad-spectrum antibiotic.

As you likely figured out, Metronidazole is best against anaerobic bacteria. Most of your gut bacteria and STD’s are anaerobes, and so Metronidazole is a good choice for those infections. Metronidazole is also able to kill one of the most resistant bacteria in your gut– Clostridium difficile. Clostridium difficile (or C. diff, as it is often abbreviated) is thought to be present in the intestines of about 5% of the population. C. diff usually only causes a problem when all the other gut bacterial have been wiped out by another antibiotic, allowing C.diff to overgrow and cause problems. Metronidazole is one of only two antibiotics in common usage that will kill it.

Metronidazole is also interesting because it is one of the few antibacterial that also acts as an anti-protist and anti-helminthic. This means it can kill some parasites. In America, it is often used to treat Giardia lamblia (sometimes called Beaver Fever, due to its common presence in water that has been contaminated by beaver feces. Giardia is an anaerobic waterborne protozoa that causes abdominal pain, bloating, and fever with a watery diarrhea that can last for six weeks or longer). It is also used to treat Trichomonas vaginalis (a protozoa that is transmitted through sex and while rarely affecting men can cause a frothy greenish fishy smelling vaginal discharge in women), and Entamoeba histolytica (an anaerobic protozoa of the Amoeba family that causes amoebic dysentery and amoebic liver abscesses).

Metronidazole is generally considered the first line drug for the protozoal infections noted above, C. diff colitis, and infections suspected to be caused by anaerobes (dental abscesses, pelvic inflammatory disease, bacterial vaginosis, aspiration pneumonia, intra-abdominal infections, lung abscesses, stomach ulcers caused by the bacteria Heliobacter pylori, and tetanus. It is a poor choice for treatment of streps and staphs, as they are both aerobic bacteria. Metronidazole penetrates the blood-brain barrier better than any other antibiotic and so is a good choice for meningitis caused by anaerobic bacteria. (Unfortunately, most meningitis cases are caused by aerobes.)

Side effects are common, and many complain of belly aches or a metallic taste in their mouth while taking this drug. You should also not drink alcohol while on this drug, as it interferes with your body’s ability to metabolize alcohol and will give you an unpleasant though harmless reaction.

Clindamycin (Fish-Cin)

Clindamycin is a member of the lincosamide family of antibiotics, which were isolated from a member of the Streptomyces bacteria family.

Clindamycin works by binding to the ribosome (protein factory) of the bacteria making the bacteria unable to produce the proteins it needs to stay alive.

Clindamycin is a very broad-spectrum antibiotic able to kill a wide variety of both aerobic gram positive (streps and staphs) and anaerobic gram negative bacteria, but gram negative aerobes (like C. diff) are resistant. While resistance to Clinda is rare, it is increasing. Most strains of CA-MRSA are killed by Clinda, but resistance becomes more common the farther west you travel in the USA.

Clindamycin is the antibiotic most often associated with the development of C. diff colitis. Clinda does not kill C. diff but does kill all its competition, allowing it to overgrow, which leads to illness. C. diff colitis presents as abdominal pain, initial watery stools that eventually can become bloody, fevers that can reach 105 degrees, and stools that smell like horse manure. There will almost always be a history of the person having recently taken a broad spectrum antibiotic. Imodium will significantly worsen the symptoms. Treatment is with Metronidazole or a fecal transplant. (Google that, if you dare.)

Clinda is considered a first line agent for skin and soft tissue infections (streps and staphs), pelvic infections, intra-abdominal infections (like peritonitis and diverticulitis), lung infections caused by Strep pneumo (lung abscesses, pneumonia, and empyema), bacterial vaginosis, and CA-MRSA.

A Word On Medication Allergies

Medication allergies are something we constantly worry about in the medical community. Lots of people claim to be allergic to this antibiotic or that antibiotic. The antibiotics people are most often allergic to are the penicillins and the sulfa family of antibiotics. Now I understand some people have very significant and real allergies; if you have had hives or other signs of anaphylaxis, you are likely allergic to the antibiotic you had taken just prior to the reaction.

However, many people think they have an allergy because they had a more minor reaction while taking the antibiotic. I can’t tell you how many patients I have seen who think they are allergic because they had a rash when they were three years old or the antibiotic upset their stomach one time. This was probably just a non-allergic side effect of the antibiotic or the illness and not a true allergy. An interesting study was recently performed at the Mayo Clinic in Florida. Three hundred eighty-four people with self-reported penicillin allergy had penicillin allergy testing performed. Guess what? Of those, 94% were negative.

In the modern medical world, allergies to an antibiotic are not that big a deal. There are lots of alternative antibiotics we can use if you are allergic. “Allergic to penicillin? Fine. We’ll use a cephalosporin. Allergic to that, too?! Fine. We will use something else.” However, in a post-apocalyptic scenario, the only antibiotic you may be able to get may be the one you have always thought you were allergic to. Will you take it? It probably depends on how ill you are and how bad the reaction you had to the antibiotic was.

Might I suggest that those of you who think you have an allergy to an antibiotic go see your doctor and have an allergy test BEFORE the SHTF. Then you will know what you are really allergic to and what you aren’t.

How Do Antibiotics Work? (continued)

Antibiotics work in a number of different ways, but perhaps it would just be easier to talk about each one individually. I will focus on the pet antibiotics, since these are the ones most of us can stockpile easily. Again trying to make this as simple as I can, I have omitted many technical details. (A cellular biologist may take exception to what I say, saying “He didn’t even discuss peptidoglycan cross linkages by the DD-transpeptidase enzyme!! Who does he think he is!!??” However, I think most of the prepper army will appreciate omission of the technical fluff.)

Penicillin (Fish-Pen)

Penicillin was the first really effective antibiotic discovered and the starting point from which other antibiotics were developed. The original penicillin worked best if injected, but eventually an oral preparation was developed (called Penicillin VK or phenoxymethylpenicillin potassium), and this is what you get when you buy Fish-Pen.

The penicillin antibiotics are part of the beta-lactam family of antibiotics due to a chemical structure common to these antibiotics called a beta-lactam ring. Other members of the beta-lactam family are the Cephalosporins. Penicillin (and the other beta-lactams) function by deactivating an essential cell wall-building enzyme in the bacteria. With the bacteria unable to repair its cell wall, the cell wall begins to break down and the bacteria literally pops and dies.

Penicillin once treated a wide variety of bacteria, but overuse allowed most bacteria to develop resistance. The most common form of resistance to penicillin is the beta-lactamase enzyme, which cuts the beta-lactam ring, which deactivates the penicillin and renders it harmless to the bacteria. This caused penicillin’s spectrum to become more and more narrow over time as fewer and fewer pathogens responded to it. Today, penicillin is only used as first choice for one infection– strep throat. That’s it. Penicillin’s spectrum is so narrow (because so many things are resistant to it) that we only use it for one thing– killing Streptococcus pyogenes, which is the bacteria that causes strep throat. It can kill a few other bacteria, like Streptococcus pneumoniae (a cause of pneumonia) and Fusobacteria (a cause of trench mouth and dental abscesses). However, because you don’t know if the pneumonia is caused by S. pneumonia or if the dental abscess is caused by Fisobacteria, you don’t use penicillin first.

Because penicillin selectively targets an enzyme that we humans don’t have or need, the side effects of this antibiotic are usually very mild.

Because the spectrum of penicillin has become so narrow, I do not recommend that anyone stock this antibiotic. Other antibiotics are the same price and have more than one use. Continue reading to see which antibiotics to keep on hand for strep throat.

Ampicillin (Fish-Cillin)

Ampicillin was invented by sticking an amino group onto the side of Penicillin. This increased the antibiotic’s ability to penetrate into bacteria, which broadened the spectrum of this antibiotic to include some gram negative bacteria. Like penicillin, it is a beta-lactam antibiotic. Like penicillin, it works by inhibiting cell wall repair leading to bacterial cell death.

It is classified as an intermediate-spectrum antibiotic. While broader in spectrum than penicillin, it is still pretty narrow. It kills the three bacteria penicillin kills plus Group C strep (enterococcus) and the gram-negative bacteria Haemophilus influenzae, Neisseria meningitidis, and members of the Enterobacteria family (like Shigella, Salmonella, and E. coli).

Because ampicillin selectively targets an enzyme that we humans don’t have or need, the side effects of this antibiotic are usually very mild.

Ampicillin is a good first line choice for strep throat, sinus infections, ear infections, some urinary tract infections, and other respiratory infections like pneumonia. Of the available pet beta lactams, it has the best CNS (central nervous system) penetration, and so it is a good choice for meningitis.

Amoxicillin (Fish-Mox)

Amoxicillinis the big brother of Ampicillin and another child of Penicillin. Like Ampicillin, it is made by adding side groups to penicillin. In Amoxicillin’s case, one side group broadens its spectrum (making it, like ampicillin, an intermediate-spectrum antibiotic) and another side group increases its absorption from the human gut. Like penicillin, it is a beta-lactam antibiotic. Like penicillin, it works by inhibiting cell wall repair leading to bacterial cell death.

It has the same spectrum as ampicillin, but it also kills Borellia (the causative agent of Lyme disease) and Moraxella (a cause of ear and sinus infections) and Heliobacter pylori (the cause of bleeding stomach ulcers). Amoxicillin is used for basically the same infections as ampicillin with the addition of being effective against lyme disease and stomach ulcers.

Because amoxicillin selectively targets an enzyme that we humans don’t have or need, the side effects of this antibiotic are usually very mild.

If I had to pick one of the three penicillins to stock, Amoxicillin would be the one. It has a broader spectrum than Penicillin (without being too broad) and is better absorbed from the stomach than Ampicillin.

Cephalexin (Fish-Flex)

Also known as Keflex in the retail world, Cephalexin is a first generation Cephalosporin. After Penicillin was discovered, mold scientists went looking at other molds to find other antibiotics (a process called bio-prospecting), and it was thus that the Cephalosporins were discovered.

They are closely related to the Penicillins in that they have a beta-lactam ring and act by inhibiting cell wall repair. Like the penicillin family, they are most effective against bacteria with thick cell walls (Gram positive) and are intermediate in spectrum. They are effective against streps (so this is a fine choice against strep throat) and the staphs. However, unlike the penicillins, they are more resistant to bacterial defenses and so work against more and different bacteria. This is especially important for one reason– Staphlococcus aureus.

Staph aureus (which I will just call Staph from now on, even though there are many other strains of Staph) is a common and very aggressive bacteria that is the cause of many infections. Staph is found on our skin and in our noses, and as long as it stays there it does not cause many problems. However, if you get a little cut or scratch, staph may get in and make an infection. STAPH IS THE #1 CAUSE OF WOUND INFECTIONS WORLDWIDE. It can cause small abscesses if your immune system gets it walled off fast enough, but if not you get more severe infections like cellulitis, necrotizing fasciitis, sepsis (infection traveling in the bloodstream), osteomyelitis (infection of the bone), endocarditis (infection of the heart), or meningitis (infection of the spinal cord). Obviously, many of these can lead to death. Being in the nose (part of the respiratory tract), it can also cause sinusitis and pneumonia. Staph was one of the first bacteria to develop a resistance to the penicillin family of antibiotics. Worldwide today over 80% of Staph strains are immune to penicillin, and in some areas as many as 97% of strains are resistant. However, they are not resistant to Keflex! So this is an antibiotic you really want to keep on hand.

Keflex is first line for infections by Streps and Staph, including skin abscesses, boils, folliculitis, mastitis, mild cellulitis, impetigo, erysipelas, and strep throat. It can also be used for ear infections, respiratory infections, and UTI’s, but it is not the best choice for these infections.

Three important notes: First is that Keflex treats regular Staph aureus, but it does not treat Methycillin Resistant Staph Aureus (MRSA). Keep reading to see what antibiotic you will need to treat that. Second is that it does not penetrate into the brain and spinal cord. So it is a very poor choice for meningitis. Third is it has a fairly short half life and usually needs to be taken three if not four times a day to get best effect.

Because Keflex selectively targets an enzyme that we humans don’t have or need and because it doesn’t wipe out all your gram negative gut bacteria, the side effects of this antibiotic are usually very mild.

In a TEOTWAWKI scenario, I foresee a lot of manual labor and violence. Both of these things lead to cuts, scratches, and puncture wounds, which means a lot of staph infections. This means you will need Keflex.

Ciprofloxicin (Fish-Flox)

Now for something completely different– an antibiotic that isn’t a beta-lactam! Ciprofloxicin belongs to the Fluoroquinolone family of antibiotics, which were discovered by accident in the lab by a chemist trying to make malaria medication, but they sure work.

Cipro works by inhibiting bacterial Topoisomerase enzymes, which makes the bacteria unable to reproduce by blocking DNA replication. This works in both gram positive and gram negative bacteria. Bacterial resistance to Cipro is increasing and spreading, but at this moment in time is still pretty rare.

Cipro is a broad-spectrum antibiotic that kills a wide variety of gram positive and gram negative bacteria. It kills Staph aureus and Pseudomonas– two bacteria that are resistant to many other antibiotics. Because it is so broad in spectrum, it is not generally recommended for less complex infections where a narrower spectrum antibiotic would work. You don’t want to use this for a strep throat or simple skin abscess, if you have Keflex on hand.

Cipro is considered the first line agent for complicated UTI’s and kidney infections, bone and joint infections, typhoid, prostatitis, abdominal infections, gonorrhea, plague, and anthrax. It is also frequently used for infections acquired in the hospital where resistances are more likely. It can also be used for sinus infections, community acquired pneumonia, strep throat, or ear infections, but it is generally considered a little too strong for these infections. Most MRSA bacteria will respond to Cipro, but resistance is developing, and there are better choices. Cipro also penetrates the blood brain barrier well and so is a good choice for meningitis.

Like any medication, Cipro is not without potential side effects, and in Cipro’s case there is a big one. In fact, it carries a Black Box warning because of it. Cipro is associated with tendonitis and tendon rupture. The risk is increased if you are over 60 and/or on steroids. It’s rare (0.1% chance or one in a thousand), but being on Cipro makes it three times as likely compared to the general population. Also, the tendon that ruptures most often is the Achilles tendon that connects your heel with your leg. So think long and hard about taking this drug, especially if it is for something less severe. Getting through the wasteland as a cripple will not be easy.

Having Cipro on hand is a good idea, though. It will treat some things nothing else will, but it should not be used frivolously. Other antibiotics will often do the same job with fewer side effects and won’t put your tendons at risk.