Introduction

The Duration Health medication formulary is based on the World Health Organization (WHO) Model List of Essential Medicines and was created to contain the most commonly prescribed medications for non-emergency but acute conditions. A person with medications available in a Duration Health Med Kit would be able to effectively treat a large number of common acute conditions in a resource-limited setting, which would include international travel in countries or areas where medical facilities are not readily accessible, or domestically, such as in rural areas in the US where a healthcare facility may be far away, or in wilderness areas where travel is occurring on a backpacking or mountain climbing trip, for example.

While Duration Health Med Kits are built-to-order for each patient, we use the list of medications below and accompanying rationale as a starting point for each kit. We choose from a short list of medications known for their versatility and safety — they treat a variety of different conditions, and are known to be generally well-tolerated.

Infections

Antibiotics

An important category of drugs on the Duration Health formulary is antibiotics. Antibiotics treat infections caused by bacteria, but they do not work against viruses, fungi, or certain parasites. The decision of which antibiotics to include on the Duration Health formulary was made by identifying those medications that cover the most common bacteria causing infections in major organ systems, but using the fewest number of drugs. Major organ systems or sites of the body that can develop infections include: skin, ear, sinus, throat, respiratory system (lungs), intra-abdominal, and urinary tract.

While serious infections can develop in any organ system, many infections in the organ systems listed above can be treated safely with oral medication. Conversely, infections in other systems such as the brain (e.g. meningitis) are more likely to be very serious, and generally cannot be treated with oral medication outside of the hospital.

The choice of an antibiotic can be based on the results of a diagnostic test of the tissue or fluid where the infection is occurring, such skin swab culture, a rapid strep test for a throat infection, or a urine culture for a urinary tract infection. But infections may also be treated empirically, that is, based on symptoms and knowledge of the bacteria that usually cause the infection. The antibiotics in the Med Kit are meant to be used empirically in conjunction with a consultation with the Duration Health physician. Most of the medications are given orally for ease of use; they are available in a tablet or capsule formulation, or liquid for pediatrics. Some are used topically in the ear or eye, or on the skin.

DISCLAIMERS: Medication uses listed below are not intended to represent indications for treatment. A condition or disease listed below does not mean a particular medication is FDA-approved for this use. The information provided in this post and on this website is intended for your general knowledge only and is not a substitute for professional medical advice or treatment for specific medical conditions. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Our providers use their own independent judgment when deciding whether a medication is appropriate for a particular patient. Discussion below about each medication is incomplete, and does not include all information needed to use a given item safely and effectively.

Main oral antibiotics

Let's go through the exercise of constructing a Duration Health Med Kit together.

Unless contraindicated (for example, if someone is allergic), most Duration Health Med Kits contain one or more of the following 3 antibiotics. We always aim to include medications that cover the largest number of conditions with the fewest number of medications, and we have found that these 3 medications are often effective to do so.

"Rx" designates a medication that requires a prescription. "OTC" (over-the-counter) designates a medication that is available without a prescription.

• Rx Amoxicillin-clavulanate (brand name Augmentin®) – in the penicillin class; it is excellent for dental, ear and sinus infections, and skin infections. It can be used for other types of infections, but another antibiotic may be more appropriate.
• Rx Azithromycin (brand name Zithromax®) – in the macrolide class; it is excellent for community-acquired (mild) pneumonia, and traveler’s diarrhea. It can also be used for other types of infections such as skin, ear, and sinus infections.
• Rx Trimethoprim-sulfamethoxazole (also known as TMP-SMX or SMZ-TMP, brand name Bactrim® or Septra®) – in the sulfa class; it is excellent for methicillin-resistant Staph aureus (MRSA) skin infections, urinary tract infections, and for certain types of traveler’s diarrhea. It can be used for other types of infections, but another antibiotic may be more appropriate.

Q: What is special about the inclusion of amoxicillin-clavulanate (brand name Augmentin®), azithromycin (brand name Zithromax®), and trimethoprim-sulfamethoxazole (brand name Bactrim®)? What conditions do these antibiotics treat? Couldn't you treat the same number of conditions with fewer antibiotics?

A: These three antibiotics were chosen because they cover a wide spectrum of bacteria causing uncomplicated or community-acquired infections of the respiratory tract, urinary tract, intra-abdominal system, skin, ear, and sinus and throat. Specifically, amoxicillin-clavulanate offers better coverage for skin, sinus, dental and ear infections than the others, azithromycin is a better drug for respiratory infections, and trimethoprim-sulfamethoxazole offers coverage of UTIs and community-acquired MRSA that the others do not.

As well, for penicillin allergic patients, instead of amoxicillin (which is in the penicillin family of antibiotics), we may substitute ciprofloxacin, azithromycin, and doxycycline - or ciprofloxacin, azithromycin and trimethoprim-sulfamethoxazole - in the kit for similar antibacterial coverage. These medications are discussed in further detail below. For sulfa-allergic patients, instead of trimethoprim-sulfamethoxazole, we may substitute a combination of amoxicillin-clavulanate, azithromycin, PLUS ciprofloxacin and/or doxycycline in the kit for similar coverage.

Alternate oral antibiotics, and other anti-infective medications

For patients traveling to particularly extreme environments or who will be far from medical care for an extended period, we will sometimes consider adding:

• Rx Ciprofloxacin (brand name Cipro®) – in the fluoroquinolone class
• Rx Metronidazole (brand name Flagyl®) – unique class of antibiotic

For people traveling abroad, ciprofloxacin and metronidazole taken in combination provide additional coverage for some intraabdominal infections and diarrhea including those caused by some parasites. Ciprofloxacin used to be prescribed more often for traveler’s diarrhea, but increasing bacterial resistance to the drug and safety concerns with the fluoroquinolone class of antibiotics make the choice of other antibiotics more appropriate in most cases (see further discussion below).

• Rx Doxycyline (many brand names) – in the tetracycline class. This antibiotic covers many pathogens, some of them unusual. It is especially useful for the treatment of Lyme disease (for those living or traveling in Lyme endemic areas), and for malaria treatment or prophylaxis in certain countries. For those participating in water activities, doxycycline is useful in the treatment of some marine infections contracted in seawater, and for some contracted in freshwater. It is also useful in the treatment of some other tickborne diseases, sexually transmitted diseases, and anthrax.

• Rx Fluconazole (brand name Diflucan®) – this oral antifungal can be added to the Med Kit to treat fungal infections. For example, for women with a history of recurrent vaginal yeast infections, or for travelers who want maximum anti-infective coverage because of their particular circumstances (e.g. living or traveling in a very remote area)

• Rx Oseltamivir (brand name Tamiflu®) – this oral antiviral can be added to the Med Kit for the treatment of flu symptoms (after consultation with the physician) which include: new fever (100.4 degrees F or higher) and at least one of the following - cough, headache/body aches, sore throat, difficulty breathing or shortness of breath, fatigue, runny or stuffy nose. It’s most effective in decreasing flu symptoms if started within 48 hours of symptom onset.

Q: I have taken ciprofloxacin (Cipro) with me on international trips for traveler’s diarrhea. Why isn’t Cipro one of the most often prescribed medications, since the kit is intended for travelers?

A: Ciprofloxacin used to be recommended widely for the prophylaxis and treatment of traveler’s diarrhea. But increasing resistance patterns around the world and the FDA black box warning (alert about serious side effects) for fluoroquinolones mean that an alternate antibiotic is usually a better choice. It depends on the circumstance, and which medication is best requires the judgment of a qualified healthcare provider.

Q: What are some shortcomings of the oral antibiotic choices listed above?
A: Trimethoprim-sulfamethoxazole (TMP-SMX) and doxycycline are unique in that they can treat MRSA infection. TMP-SMX is unique in that it treats both urinary tract infections and MRSA, and no other antibiotic on our formulary treats both. For these reasons, we often include one or both in our Med Kits. However, both TMP-SMX and doxycycline carry unique risks. For example, TMP-SMX has a rare but serious side effect of severe rash (Stevens-Johnson syndrome) that in its most severe form can be life-threatening, and doxycycline causes sun sensitivity. We emphasize these and other associated risks in our physician consultations and written communication with patients. Ultimately, every medication has potential risks and benefits, and which is most appropriate for a given situation requires the judgment of a qualified healthcare provider.

Topical anti-infective medications

Beyond oral antibiotics, we often include topical preparations of antibiotics and other anti-infective medications in our Med Kits.

• Rx Ofloxacin (several brand names)– in the fluoroquinolone class; it is available in oral form, but can be added to the Med Kit as a solution for topical use of mild bacterial eye (bacterial conjunctivitis) and external ear infections (otitis externa) to minimize the possibility of adverse reactions with the administration of an oral drug.

• OTC Clotrimazole Cream (most common brand name Lotrimin®) – is a topical antifungal used for the treatment of mild fungal infections such as vaginal yeast infections, oral thrush, diaper rash, athlete's foot, and jock itch.

• OTC Triple Antibiotic Ointment (most common brand name Neosporin®) – a combination of the antibiotics neomycin, polymyxin B, and bacitracin; it is used for minor wound infections (cuts, scrapes, or burns). It should not be used in people with an allergy to any of the antibiotics, especially neomycin.

Other medications

Of course, infection is only one category of common acute condition that the Med Kit is equipped to treat. Below we discuss other common conditions and the relevant medications for each.

Allergic Reactions/Inflammatory Conditions

• Rx Epinephrine (brand name Epi-Pen®) – can be added to the Med Kit. Epinephrine is a drug used to treat anaphylaxis, a life-threatening allergic reaction. It must be given by injection and requires training on its use. See this blog post for useful information: https://blog.durationhealth.com/when-a-needle-can-save-a-life-epinephrine-for-anaphylaxis/

• Rx Prednisone – is an oral corticosteroid that works as a generalized anti-inflammatory agent in the body. It has many indications, but is especially useful for allergic and steroid-responsive conditions, including the very common skin condition dermatitis.

• Rx Triamcinolone (common brand names Aristocort®, Kenalog®) – is a moderate potency topical corticosteroid available as a 0.1% cream for inflammatory conditions such as dermatitis. We often include a prescription-strength topical steroid in our Med Kits (versus a lower potency, OTC topical steroid such as hydrocortisone 1%) to manage a wider range of topical steroid-responsive conditions.

• OTC Diphenhydramine (brand name Benadryl®) – is the commonly used antihistamine for allergic reactions. It is also available in some sleep aids for use in insomnia. It is available in capsules, tablets, and liquid (the latter for pediatrics and those who have trouble swallowing pills).

• OTC Hydrocortisone (various brand names) - is a mild potency corticosteroid for minor skin irritations, such as minor allergic reactions, eczema, insect bites, poison ivy, poison oak, poison sumac, irritation due to soaps, detergents, cosmetics, or jewelry. This can be added to the Med Kits.

• OTC Ketotifen (brand name Zaditor®) – is a topical antihistamine used to relieve itchy eyes due to pollen, ragweed, grass, animal hair and dander that can be added to the Med Kits.

Travel and Tropical Medicine

Altitude Sickness

• Rx Acetazolamide (brand name Diamox®) – this drug can be added to the Med Kit for those to plan to travel or recreate in high altitude areas. It is a diuretic originally used for glaucoma but found to be effective in preventing or treating the symptoms of high altitude illness.

Malaria prevention

• Rx Atovaquone-Proguanil (brand name Malarone®) – this drug can be added to the Med Kit for travelers to countries where the drug is active against endemic malaria strains. It is well tolerated, widely used, and reasonably priced compared to some other antimalarial drugs.

Jet lag/insomnia

• OTC Melatonin (many brands) – this drug can be added to the Med Kit for travelers crossing multiple time zones by air travel. As well, it is useful for insomnia not necessarily due to jet lag.

Nausea and Vomiting/Other Gastrointestinal Issues

• Rx Ondansetron (brand name Zofran®) – this drug is available on the formulary because nausea and vomiting is a common condition due to a variety of causes, and the drug is generally well tolerated. It works in the gastrointestinal tract and the brain to decrease nausea and vomiting. It is a staple of the acute treatment of nausea and vomiting in the acute care setting, e.g. the emergency department. It is administered as an orally disintegrating tablet (dissolves on tongue) as swallowing may be difficult with serious nausea and vomiting.

• OTC Famotidine (brand name Pepcid®) – is a commonly used acid reducer for heartburn that can be added to the Med Kits. It is also sometimes used with other medications to treat allergic reactions.

Over-the-Counter (OTC) Medications – Colds, Pain, Diarrhea

These OTC medications take care of many of the most common minor medical complaints and are very useful to have on hand at all times.

• OTC Oxymetazoline (brand name Afrin®) – this topical vasoconstrictor is used to treat nasal congestion and sinus pressure that occurs with the common cold and upper respiratory allergies. It may also be useful to stop bleeding from a nosebleed or can be sprayed on a minor bleeding cut.

• OTC Acetaminophen (brand name Tylenol®) – is one of the most common fever and pain reducers available. Because of the risk of liver toxicity, the maximum recommended dose per day is 3 grams. It is available in tablets and suspension (the latter for pediatrics and people who have trouble swallowing pills).

• OTC Ibuprofen (brand name Motrin®, others) – is a nonsteroidal anti-inflammatory agent (NSAID). It is one of the most common fever and pain reducers available. It does not carry the same risk of liver toxicity as acetaminophen, but is associated with bleeding issues and kidney problems. For those on blood thinners or at risk of bleeding, acetaminophen should be used instead. It is available in tablets and suspension (for pediatrics and people who have trouble swallowing pills).

• OTC Loperamide (brand name Imodium®) – is an antimotility agent that is used for acute diarrhea.

• OTC Aspirin – aspirin is used for pain, and maybe more importantly, by preventing clots, can help to prevent heart attack and strokes. If used for an acute heart attack, 325mg should be chewed immediately at the first sign of heart attack symptoms.

Where to learn more

Visit durationhealth.com to purchase a Med Kit and learn more about each of the medications above.

We welcome your questions and feedback. Please contact us at hello@durationhealth.com

By Nancy Pietroski, PharmD, WEMT, FAWM, CTH and Benjamin Jack, MD