Antibiotics for the PAW, which one(s) and why?

[Crosscut]

I've been stocking antibiotics (fish/bird varieties mostly, and only those sold in capsule or tablet form) since just before Y2k.  Prices have gone up considerably over that time, use to get most of them for $8 - $20 per 100 back then, so I did some homework and decided one from each of the antibiotic classes (penicillins, tetracyclines, macrolides, etc) made sense and $100 or so every 5-7 years to replace them wasn't unreasonable.  With their cost now, and that I've disposed of literally thousands of expired pills over that time, decided to pare back the number to stock to maybe 4 types.  No specific type of PAW envisioned for planning purposes, just which would cover the most likely infections we might have to deal with in a long term post-disaster situation.

Think I have my first 3 decided:

1) Doxycycline

Penicillin allergic person in the core team, and Doxy is a common second-line choice for many infections where the 'cillins would otherwise be prescribed.  Activity against tick-borne diseases (Lyme/RMSF). A good number of the likely biowarfare agents including anthrax, plague, Q fever, typhus, tularemia, and brucellosis.  Some STDs (not a concern here, but young people will be young people).  Pneumonia.  Dental infections. Traveller's diarrhea, although I read that resistance to doxy is growing. 

2) Cephalexin

Uncomplicated cellulitis.  Upper respiratory, ear, and urinary tract infections.  We use this semi-regularly for our dogs, from occasional fights with other dogs, to injuries from running in the woods (stick stabs, etc), and following a porcupine "quill-ectomy".

3) Metronidazole

Anaerobic bacteria, and some amoebas (like dysentery) and protozoa (like giardia). Abscesses. Tetanus. Combined with Doxycycline for human or animal bite wounds.

4) Undecided.  Still think one from a different class than the 3 above makes the most sense and thinking either ciprofloxacin, azithromycin, clindamycin, or possibly Augmentin (amoxicillin+clavulanate). 

If you stock any, or are considering it, which one(s) and why?

[Raptor]

One of the issues and why I stopped stocking these is that their effectiveness seems to wane faster due to adaptation of "bugs" than their shelf life.

That said I do stock:

zeniquin but mainly for animal care. It seems to be the go to drug for animal skin abscesses like cat bites etc. My DVM has no problem providing it lawfully to me so that is a consideration.

Ciprofloxacin for use in humans mainly due to the fact it seems to be rx of choice prescribed by my MD and thus easy to obtain.

[RoneKiln]

Most of my life I've been prone to sinus infections during allergy season, and these easily evolve into lung infections for me. I have always, my entire life, responded very well to simple penicillin based drugs. When Covid looked like it might reach the US on a large scale, and I realized how much of our pharmaceuticals came from a country already in lockdown from Covid, I ordered vet grade penicillin and a common non penicillin antibiotic. I'm confident in penicillin, but I wanted an option for fighting anything resilient to penicillin or for someone that might be allergic to penicillin.

Since ordering them I have discovered I no longer struggle with seasonal allergies. So sinus and lung infections don't appear to be the same risk for me they used to be.

[Crosscut]

One of the issues and why I stopped stocking these is that their effectiveness seems to wane faster due to adaptation of "bugs" than their shelf life.

That said I do stock:

zeniquin but mainly for animal care. It seems to be the go to drug for animal skin abscesses like cat bites etc. My DVM has no problem providing it lawfully to me so that is a consideration.

Ciprofloxacin for use in humans mainly due to the fact it seems to be rx of choice prescribed by my MD and thus easy to obtain.

Ciprofloxicin is high on my list (along with clindamycin) as the fourth choice, it's good for bone and joint infections and for intra abdominal infections if combined with the metronidazole.  It's also the first-line choice for many of the biowarfare diseases where Doxy is the alternate choice, and it seems likely that a nation-state level biowarfare program would develop/engineer bacteria resistant to at least one of antibiotics normally used to treat it (if not both). 

Most of my life I've been prone to sinus infections during allergy season, and these easily evolve into lung infections for me. I have always, my entire life, responded very well to simple penicillin based drugs. When Covid looked like it might reach the US on a large scale, and I realized how much of our pharmaceuticals came from a country already in lockdown from Covid, I ordered vet grade penicillin and a common non penicillin antibiotic. I'm confident in penicillin, but I wanted an option for fighting anything resilient to penicillin or for someone that might be allergic to penicillin.

Since ordering them I have discovered I no longer struggle with seasonal allergies. So sinus and lung infections don't appear to be the same risk for me they used to be.

But that's a good plan IMO, double up on different antibiotics used for treating something you know you're at higher risk for.  It also highlights part of my dilemma, focus on multiple options to treat the most likely or common infections or expand the breadth of what it might be possible to treat?  Make doubly sure that pneumonia and dental infections are covered, or chose one that might give you a fighting chance for a compound fracture or penetrating abdominal trauma (as examples)?

[TACAIR]

I would very strongly suggest that if you decide to stock what would normally be a prescription drug  (of any kind) that you purchase a paper copy of the Physician's Desk Reference Guide .  Used volumes can be had in fine condition for under $50.  Check on line, buy from reputable sellers.

These have dose guidelines and lists of possible side effects. 



the life you save may be your own - prescription drugs are controlled for a reason.

[Crosscut]

I would very strongly suggest that if you decide to stock what would normally be a prescription drug  (of any kind) that you purchase a paper copy of the Physician's Desk Reference Guide .  Used volumes can be had in fine condition for under $50.  Check on line, buy from reputable sellers.

These have dose guidelines and lists of possible side effects. 



the life you save may be your own - prescription drugs are controlled for a reason.

Agreed.  Merck manual, Sanford Guide to Antimicrobial Therapy, and The Harriet Lane Handbook if there's kids in the group might be good ideas too.  And a medical dictionary!  Some teaching hospitals have their empiric antibiotic guides online and those can be good references too.  I store most of it electronically, mostly due to cost rather than by choice, but I do try to get hardcopies of the most important ones but they get dated (although not necessarily useless) pretty quickly.  My hardcopy PDR is a 1990 version.

[RoneKiln]

Amoxicillin saved me again last spring.

Last spring I was 1000 miles from home before I realized I had been fighting off a lung infection again and that it had dragged me down enough that I wasn't likely to fight it off without help. And my antibiotics were back home.

A quick video conference with an awesome doctor that believed me (rare experience for me) and I had a prescription for amoxicillin sent to a local pharmacy. She made me promise to call back in for a "more modern" antibiotic if I didn't see improvement in three days.

Two days later my lungs were clear. 

I know penicillin resistance is a serious issue, but I also suspect basic penicillin based drugs would still be quite effective in a PAW scenario for most needs. And they are still incredibly affordable. 

[Brekar]

I'm always needing some kind of antibiotic around my house, what with a bunch of large clumsy kids around. Has anyone ever tried these guys? I've heard good things about getting one of these kits just to have some decent antibiotics around.

Jase Emergency Antibiotic Kit

[RoneKiln]

I'm always needing some kind of antibiotic around my house, what with a bunch of large clumsy kids around. Has anyone ever tried these guys? I've heard good things about getting one of these kits just to have some decent antibiotics around.

Jase Emergency Antibiotic Kit

Thanks for pointing this out. I am real tempted to try them out and would also like to hear if anyone else has used them. All the reviews I found online for them were in return for free product, and could only review the ease of delivery and how nice the case and book are. I didn't see any reviews from anyone actually using the medications.

[Crosscut]

I'm always needing some kind of antibiotic around my house, what with a bunch of large clumsy kids around. Has anyone ever tried these guys? I've heard good things about getting one of these kits just to have some decent antibiotics around.

Jase Emergency Antibiotic Kit

Thanks for pointing this out. I am real tempted to try them out and would also like to hear if anyone else has used them. All the reviews I found online for them were in return for free product, and could only review the ease of delivery and how nice the case and book are. I didn't see any reviews from anyone actually using the medications.

Haven't tried them, but that's a good assortment, quantity, and price. 

[Crosscut]

Just found this morning, a 2017 empiric antibiotic selection reference doc which might be good to have:  Antibiotic Policy for Adult Patients  There are many of these available online, and often the recommended antibiotic(s) will vary for the same condition (especially for the alternative choices) so it might be a good idea to have more than one of these references in your library.

And one from the WHO that is still in draft form, the review period is closed so there will hopefully be a final version posted soon:  The WHO Essential Medicines List Antibiotic Book (DRAFT)

[majorhavoc]

I just had my second knee replacement surgery yesterday. The first one was done in May and in between I had a couple of complications. The first seemed minor (a loose dental crown) that turned out to be serious (the tooth was fractured below the gum line and infected, requiring emergency extraction - hello gap-toothed smile). The other started out serious (apparent bacterial infection of the artificial knee) that turned to be pretty minor (skin infection at the incision site). I ended up getting multiple scripts for antibiotics, with refills as needed.

Both issues were resolved but every time my pharmacy calls asking if I need a refill I say, Yes please, [*cough, cough*), for gods sake, yes!

I now have one spare 10 day course of Cephalexin (apparently all I'm going to get) and four courses (and counting) of amoxicillin.

I know all this sounds sort of like a gloat but multiple joint replacements are no picnic, those complications were sucky and especially the suspected joint infection was pretty scary.

So scoring a modest supply of post-apocalyptic antibiotics seems like a small reward for enduring all that.

[NapalmMan67]

I just had my second knee replacement surgery yesterday. The first one was done in May and in between I had a couple of complications. The first seemed minor (a loose dental crown) that turned out to be serious (the tooth was fractured below the gum line and infected, requiring emergency extraction - hello gap-toothed smile). The other started out serious (apparent bacterial infection of the artificial knee) that turned to be pretty minor (skin infection at the incision site). I ended up getting multiple scripts for antibiotics, with refills as needed.

Both issues were resolved but every time my pharmacy calls asking if I need a refill I say, Yes please, [*cough, cough*), for gods sake, yes!

I now have one spare 10 day course of Cephalexin (apparently all I'm going to get) and four courses (and counting) of amoxicillin.

I know all this sounds sort of like a gloat but multiple joint replacements are no picnic, those complications were sucky and especially the suspected joint infection was pretty scary.

So scoring a modest supply of post-apocalyptic antibiotics seems like a small reward for enduring all that.

Haven't studied in to them as much as I should.  So what is the (effective) shelf life of antibiotics?
.

[Crosscut]

From A systematic review of the stability of finished pharmaceutical products and drug substances beyond their labeled expiry dates that I saved, can't find the full pdf available online any longer though. 



But some of the data, including a table with the mean extension time in months, is in this article too.

But both amoxicillin and cephalexin fell into the category of having no failures in all lots tested, still having 95-105% of their original API (active pharmaceutical ingredient).

Drug products belonging to the group without any failure in the stability screening of more than ten lots were, among others, amoxicillin sodium tablets, ciprofloxacin tablets, doxycycline capsules, naloxone HCl injection solutions, halothane liquids, diphenhydramine syringe-needles, morphine syringe-needles, and various saline injection solutions.

The drugs were stored according to the manufacturer's recommendations, and suspect for capsule/tablet forms that probably means in the airtight pharmacy sized bottles of 500 or more.  For loose capsules/tablets dispensed by a pharmacy in a typical pill bottle then repackaging them in an airtight container with a desiccant pack for long term storage in a cool, dark, and dry place would generally be best I'd think. 

I've saved a number of studies on drug shelf lives that I've found over the years, if there's a different drug you're interested in let me know and I'll try to find info on it.

[majorhavoc]

Thats super helpful, Crosscut.  I remember doing some research on the safety of using expired antibiotics a while back. The only thing I remember clearly is that with amoxicillin at least, it won't turn toxic over time. But it will (very slowly, if stored properly) lose potency.

As far as storage goes, I recall moisture is a greater concern than temperature.  As long as it's stored in a dry environment at temps no greater than room temperature, amoxicillin will remain fairly potent for at least 5 years past expiration.

The medicine cabinet in your bathroom is pretty much the worst place to store drugs.

[NapalmMan67]

No, nothing specific, was just a general question.  Guess I hadn't thought about if they'd turn toxic over time, but figured they would degrade in effectiveness at least.

I know not the same, but I've been using aspirin that's 3 1/2 years past the "expiration" date and it seems to work ok.
.

[majorhavoc]

Yeah, the big potential problem with expired drugs is knowing which ones can turn toxic over time. Less potency can be corrected by upping the dosage as needed. But doing more harm than good with a toxic expired drug is obviously bad.

Aspirin has to be about the most benign drug known to man. I buy mine in huge bottles and use it sparingly.. I wouldn't be surprised if mine are at least as old as yours.

[Crosscut]

Just on the degradation and toxicity of solid, oral dosage form antibiotics when stored beyond their expiration, the only antibiotic class that I've ever seen any concern about is the tetracyclines (tetracycline, doxycycline, and oxytetracycline basically).  Of those the only one I have ever stored is doxycycline, and I used to replace that at one year past expiration just to be cautious.  Recently I've been replacing it less frequently as I've found more references and research that it can be safely stored and used long beyond that.

https://www.fda.gov/files/drugs/published/Extending-Expiration-Dates-of-Doxycycline-Tablets-and-Capsules-in-Strategic-Stockpiles.pdf

Doxycycline tablets and capsules are compendial drug products that are manufactured to meet the recommended tests and criteria of the United States Pharmacopeia (USP)/National Formulary (NF) monographs and FDA-approved specifications. Specification attributes include assay, dissolution, and degradant limits, which may be stability-indicating and relevant for stability studies. Stability studies reviewed by FDA over many years have confirmed that none of the components of approved doxycycline tablets and capsules, including the active ingredient, has significant potential for chemical degradation or interaction with other components in the formulation or with components of the container closure system when stored according to labeled directions.

And this, the oldest lot of doxycycline being extended almost 7.5 years beyond its original expiration date, or almost 10 years from purchase.

Of the others I have or have previously stored over the years (azithromycin, amoxicillin, amoxicillin/clavulante, cephalexin, ciprofloxacin, clindamycin, erythromycin, and metronidazole), I've never found anything reliable suggesting any of those turn toxic from degradation in storage.

And I'm still undecided on the fourth type to stock, and starting to think maybe I'll make it five types instead.