According to the WHO, antimicrobial resistance (AMR) is one of the top global public health and development threats facing humankind. The prolonged misuse and overuse of antimicrobial medications in humans, animals and plants has resulted in the emergence and spread of drug-resistant pathogens which threatens our ability to treat common infections and perform life-saving procedures.
Antimicrobial medicines are described by the WHO as the cornerstone of modern medicine, and anyone working in healthcare will be familiar with these issues; indeed the reciprocal idea of "antimicrobial stewardship" has been born out of this concern and is designed to help combat this public health emergency.
Regardless of where they work, clinicians will be used to consulting local antibiotic prescribing guidelines, and many may have noticed changes as their hospitals or communities adjust to changing resistance patterns.
Whilst I now work out of hospital, I remember frequently calling the microbiology team during my medical jobs to request authorisation for the use of certain antibiotics. Often the suggestion was to perform multiple cultures and wait for the results, much to the frustration of my seniors.
How is this topic relevant to wilderness medicine?
Surprise surprise, we are not suddenly immune to AMR when we leave our usual healthcare settings; indeed many of the areas we travel to have high levels of resistance, often due to the relative ease in obtaining antibiotics.
Limited Resources
Expeditions, by their very nature, operate in remote and often challenging environments. Unlike hospitals, which have the capacity to store a wide array of medications and equipment, expedition medics have to be extremely selective in what they carry due to space, weight, logistical and financial constraints.
It is obviously much easier to carry more kit if you are part of a well funded vehicle based expedition compared to a trekking expedition where you are expected to carry the med-kit alongside your own gear.
This balancing act often results in a reduced variety of antibiotics compared to what we are used to, and therefore we will often use broad-spectrum antibiotics, which are more likely to cover various pathogens, even when a narrower-spectrum option might be more appropriate.
Difficult Diagnoses in the Field
Diagnosing infections in remote environments is inherently challenging. The lack of advanced diagnostic tools and laboratory support means that healthcare providers must rely on clinical judgment, which can be prone to error.
This is a particular issue for expedition medics that are used to working in hospital settings where multiple investigations are common. In contrast, GPs and those working in pre-hospital settings may be more comfortable with managing uncertainty and trusting their clinical acumen.
One particular trap here is mistaking a viral infection for a bacterial infection. Just as most patients seeing their GP will have viral upper respiratory tract infections, so will most clients on an expedition.
Common things are common and not everyone will have lobar pneumonia or sepsis just because they are in a remote austere location.
The flip-side to this is that some patients will be brewing more serious infections and expeditions often operate in high-stress environments where rapid decisions are essential. This pressure to act quickly, accompanied by the fact that medics are essentially providing a private standard of medical care, can make appropriate antimicrobial stewardship more challenging.
Depending on your destination, your expedition participants may be at risk of vector borne diseases such as malaria or dengue. These obviously require different treatment, however understandably in the pre-hospital austere setting, in someone who is unwell, many of us would feel justified in giving something like IV ceftriaxone to cover "big sick" sepsis.
Importantly, I'm not saying don't do this- it is important to differentiate between little sick and big sick patients.
Clearly your paradigm and prescribing attitudes, as well as your overall management plans, will vary depending on which category your patient falls into, however taking some time to consider these themes when managing participants on expeditions can be hugely valuable.
This is where having "top cover" can sometimes be useful, so that you can discuss cases with another healthcare professional or even an infectious disease specialist depending on the context. It is important however to appreciate that this needs to be arranged prior to your trip and that you will need a rigid communications plan to ensure this is a viable option.