Question about rational antibiotic combination.

Re: Question about rational antibiotic combination.

Evelyn Barbour-Hill — Tue, 07 May 2013 13:44:23 GMT

[quote user="Toby Birch"]Animals with wounds shouldn't be out and about to roll in fox poop![/quote]

Why not?

(Only partly )

Re: Question about rational antibiotic combination.

Utlendigur — Tue, 07 May 2013 11:24:06 GMT

[quote user="Mark Hedberg"]

[quote user="Toby Birch"] Animals with wounds shouldn't be out and about to roll in fox poop!

[/quote]

True! Very true! Here's to hoping more owners take your point of view! :)

[/quote]

Ahh - but have either of you ever lived with a bored Jack Russell?

Another vote for deriding, lavage, wet-to-dry dressings or intrasite etc - but given the OP said the wound was underrun, so more difficult to manage that way, I'd probably give amox/clav. I thought antirobe and amox/clav had very similar spectrums anyway (gram +ve, some anaerobes, and a few gram -ve for amox/clav) so not sure why you would want to combine them anyway? I also though antirobe was bactericidal at the high end of the dose ie 11mg/kg bid - may be wrong.

As an aside (mini-rant) - one bugbear I have is the tendency to give antibiotics whenever a wound has a discharge - even if it's from a clean healthy granulation bed and just due to the fact that there is no epidermis to keep the fluid in. I've lost track of the number of times a case has had a wound, that is healing nicely and rapidly, redressed by a colleague and it's then been sent home with antibiotics because it's "discharging" - and the client told that means it's infected

Re: Question about rational antibiotic combination.

Bob Russell — Tue, 07 May 2013 09:34:15 GMT

I would generally stick to a single antibiotic (probably co-amox in this sort of case). If there was good drainage perhaps none but if it required a drain I would probably use antibiotics.

Open, grazes or anything granulating happily I would not use antibiotics because they don't seem necessary. For years I felt the need to routinely use post-op antibiotics but stopped (nerve racking!) years ago. Lo and behold the patients did just as well without!

I suspect that wound management and degree of bruising/trauma are more important than antibiotic choice.

Re: Question about rational antibiotic combination.

Mark Hedberg — Mon, 06 May 2013 16:46:45 GMT

[quote user="Toby Birch"] Animals with wounds shouldn't be out and about to roll in fox poop!

[/quote]

True! Very true! Here's to hoping more owners take your point of view! :)

Re: Question about rational antibiotic combination.

Toby Birch — Mon, 06 May 2013 15:06:04 GMT

Not really answering the question but were antibiotics required at all? Wound managemnt and how well they do depends very much on how well they are first dealt with. Did this wound have to be closed straight away? Flush, debride any obviously dead tissue, flush again and again and consider appropriate dressings (likely wet-to-dry in the first instance) before ongoing dressings and close when appropriate and have healthy tissue. Antibiotics probably won't be required and wound breakdown in this case probably won't be due to incorrect antibiotic but trying to do too much too soon and not working with the tissues but rather economic pressure. Animals with wounds shouldn't be out and about to roll in fox poop!

Re: Question about rational antibiotic combination.

Mark Hedberg — Mon, 06 May 2013 08:32:52 GMT

[quote user="CatherineThomas"]

Last year my dad fell off a roof onto his head, and had a very dirty wound on the back of his head. Fortunately there were no more serious injuries. Once he had been assessed the doctor flushed the wound to remove the dirt and then sutured it without clipping the hair around it. I was amazed that she didn't give him any antibiotics. But the wound healed without any problems. It made me think about the amount of antibiotics we give for wounds like that.

[/quote]I expect it was because your father was better at keeping his wound clean and reasonably disinclined to roll in fox poop. ;)

Re: Question about rational antibiotic combination.

CatherineThomas — Sun, 05 May 2013 22:44:01 GMT

Re: Question about rational antibiotic combination.

Evelyn Barbour-Hill — Sun, 05 May 2013 22:24:46 GMT

Has the original question been answered? Can we extend this discussion now?

In my opinion (of course! ) :

Firstly, proper treatment of wounds rests very much upon the initial physical measures: debridement, cleansing, irrigation, debridement, exploration, flushing, debridement, suturing, refraining from suturing, debridement and so on. The choice of antibiotic to use, if any, is of small importance.

Secondly, I'm amazed at the readiness of some (not only on this thread but others) to plunge into combinations of antibiotic drugs for no particular reason except guesswork that you might not have covered every conceivable part of the spectrum. (I'm referring to first-line treatment here; of course, if you have a non-healing wound, and culture and sensitivity indicate that a combination is really necessary, that's a different matter.) Is this what is taught in veterinary schools now? Can it be justified?

Re: Question about rational antibiotic combination.

karen jones — Sun, 05 May 2013 22:20:01 GMT

I often start with synulox and if on check up not happy with wound will add in antirobe. I keep fluroquinolones for cases that don't respond.

Re: Question about rational antibiotic combination.

Tassadar — Sun, 05 May 2013 21:48:01 GMT

Thanks for your answer, I will take that into consideration :)

Re: Question about rational antibiotic combination.

Rob Reid — Sun, 05 May 2013 21:41:56 GMT

I personally don't combine B-lactams with clindamycin etc - as previously mentioned due to the bacteriostat/bacteriocide confliction.

A B-lactam flouroquinolone combo does give you a good range of cover particulary if combined with metronidazole as well. I will tend to reserve flouroquinolones however for when I have good evidence that I need them so they don't tend to be a first line ab, probably not necessary in this case, though to be fair I've not seen the wound and don't know anything about length of time it's been there etc. so that does put you in a far better condition to judge! If in doubt take a swab for C&S before you do anything....

Personally with tmost traumatic wounds my standard protocol is to go for good initial wound management (aggressive flush with saline/debridement if necessary); i/v augmentin if I feel there is a high level of contamination followed by course of B-lactam afterwards. Manuka honey can also work wonders in these.

Re: Question about rational antibiotic combination.

Michael Woodhouse — Sun, 05 May 2013 21:05:41 GMT

I will sometimes give a single IV dose of metronidazole and even a final flush of metranidazole in dirty wounds.

Re: Question about rational antibiotic combination.

Tassadar — Sun, 05 May 2013 20:50:41 GMT

Ok, will continue just on Antirobe (as only single inj. of Synulox was given that day).Thank you for your answers :)

Re: Question about rational antibiotic combination.

Evelyn Barbour-Hill — Sun, 05 May 2013 20:38:40 GMT

[quote user="Tassadar"]Felt like a bit of additional anaerobic support combined with Synulox would be a better options (because I have seen other surgeons doing this in RTA cases).[/quote]

To be honest I don't think this is very rational. Stick with Synulox alone – or clindamycin alone if you prefer – or Stomorgyl. If there is unexpectedly poor healing, or anything else suggesting uncontrolled infection, in several days' time, do culture and sensitivity (also review whether the debridement and drainage were adequate )

Re: Question about rational antibiotic combination.

Tassadar — Sun, 05 May 2013 20:08:47 GMT

The wound was clipped/cleaned/flushed/closed and drain was placed. Wound looked a bit grotty and undermined due to big 4v4 wheel running over poor dogs leg. Felt like a bit of additional anaerobic support combined with Synulox would be a better options (because I have seen other surgeons doing this in RTA cases).

Re: Question about rational antibiotic combination.

Evelyn Barbour-Hill — Sun, 05 May 2013 19:59:56 GMT

Arlo, feel free to delete this if you feel it is against the rules.

Tassadar, I'm no expert on the finer points of antibiotic pharmacology, and I know I'm not answering your specific questions, but I'm not criticising you.

I expect you can combine beta-lactams with lincosamides. (I think fluoroquinolones should be reserved for cases where nothing else will do.) My question, though, is why you would wish to do so in the case you describe.

Assuming that you have given the wound all the attention and treatment that it should receive – I'm sure you have – if you feel antibiotic is indicated then amoxycillin/clavulanate should be adequate as a first-line choice. Or Stomorgyl (metronidazole and spiramycin).

Re: Question about rational antibiotic combination.

CatherineThomas — Sun, 05 May 2013 19:41:47 GMT

I remember being taught not to combine synulox and antirobe. I think it was something to do with combining bacteriostatic with bacteriocidal, but not sure. Recently I've heard people say that the recommendations have changed and it is now thought to be ok to combine the two. I feel I should know more about this!