Sunday, May 22, 2011

Cephalosporins: The Next Generation

Cephalosporins, the next generation. That sounds like I'm starting a trailer for Star Trek. Now, all I need is some guy with a deep voice saying, "Cephalosporins will go where no one has gone before."

Man, that's creepy. Especially if you think about Captain Cephalosporin Kirk that goes after every bug princess in the galaxy. "Hey bacteria babe, how you doing?"

Contrary to popular belief, I'm not a huge Star Trek fan. If a pointy eared guy comes up to me, with a psycho split-fingered sign, saying, "Live long and prosper," I'd mace him and run screaming. Then I'd feel bad and give him the card of a plastic surgeon friend of mine. Because somebody has to do something about those ears.

Anyway, back to the message at hand: Second-generation Cephalosporins.

These are the moderators. They have no mnemonic device for their names, because their names are all over the place. As antibiotics, they have more Haemophilus influenzae coverage than their predecssors and have added coverage of anaerobes, Enterobacter species, Providencia, and Morganella. On the other hand, they have less gram positive cocci coverage. What does that mean for us? They don't cover staph and strep infections like the old timers, but they do cover more gram negative bacilli, such as Bacteriodes.

Cefuroxime: Also called Ceftin and Zinacef, Cefuroxime has more coverage of H. influenzae, Enterobacter and Proteus than Cefazolin.

Cefuroxime is administered largely via IV and has a stable shelf-life. It is approved for H. influenzae meningitis which is unresponsive to other medications. It is preferred in ampicillin-resitant strains of H. infleunzae. In addition to that it is highly active against Moraxella catarrhalis, which is a common cause of otitis media, sinusitis, cholecystitis, gonorrhea, lyme disease, tonsilitis, bronchitis, and pneumonia in patients with underlying chronic lung conditions.

Normal Adult Dosage: 500 to 750 mg by IV per every 8 hours. Treatment is usually finished up with oral dosing of 250 to 500 mg every 12 hours.

Child Dosage: It can be used in children older than 3 months. Orally 30 mg per kg per day with a maximum of 1 gram per day. IV dosing is 75 to 150 mg per kg per day with a max dose of 6 grams per day.

Cefoxitin and Cefotetan: The Cephamycin twins. These Cephalosporin twins are known for their activity against Bacteroides, E. coli, P. mirabilis, and Klebsiella. The twins are emotionally stable and take on seriously mutated beasts together.

Yet, Cefotetan lives longer than it's twin. Cefotetan has a longer half-life than Cefoxitin, making its dosing less frequent. It is also more active than Cefoxitin, because the foxy one is spending too much time at clubs.

These two drugs treat infections of the womb (amnionitis and endomyometritis), aspiration pneumonia (pneumonia caused by vomit entering the trachea), human bites (now this is a good one when the Zombies come ;) ), eye cellulitis, community-acquired pneumonia, liver abscess, pelvic inflammatory disease, and surgery prophylaxis.

Normal Adult Dosage:

Both drugs are only administered by IV or IM. 1 to 2 grams every 6 hours. If given by IM, a Cefoxitin injection is painful, but the dosing is the same as IV. Can be given up to 12 grams per day.

Child Dosage:

The twins can be given to children older than 3 months of age. 80 to 100 mg per kg per day divided into 8 doses to be given every 4 hours. Cefotetan has a maximum of 6 gram per day.

Cefaclor: Brand name Raniclor, this antibiotic is great for otitis media and pharyngitis. There isn't a lot to say about this drug. It likes to keep to itself.

Normal Adult Dosage: 250 to 500 mg by mouth per every 8 hours. If renal impairment then give 50% of the usual dosage, unless the kidney problems are severe in which case you would administer approximately 25% of the usual dose.

Child Dosage: 20 to 40 mg per kg weight of child per day divided into 3 doses, to be given every eight hours. For a maximum of 2 grams per day.

WARNING: This drug can cause a severe condition called Sick Serum Syndrome which can lead to death. Another reason why it likes to keep to itself: it's trapped in self-loathing.

Well, that's it for the second generation.


Friday, May 20, 2011

Cephalosporins: The First Generation

Cephalosporins are another group of antibiotics that have cross-allergies with Carbapenems and Penicillins. But these are my favorite group. They cover pretty much everything at a relatively low cost... kind of like thugs. You pay a small price and they'll beat up anyone you want: It's beautiful.

Cephalosporins are a great mix of guidos. Some are the brute squad that tackle the dumb masses of bugs. Others are expert snipers that pick off the hardest bacteria one by one.

So if you have a patient suffering from a mutated little nasty, you can send in Specialist Cephalosporin with his little gun and that sucker is gone in no time. It's so pretty. It brings a tear to my eye.

Basically, there are so many Cephalosporins out on the market looking for work that they formed their own class system which is grouped into generations based on age. ;)

The old timers are the first generation. They love a good bingo game and can knit a sweater like you wouldn't believe. The moderate mild mannered adults are the second generation. These guys buy minivans and live in suburbia. The third generation are the gamers, they spend their days playing video games until they reek. The fourth generation are the secret ninjas that only come out to go all Bruce Lee on some big bacteria than disappear back into the darkness of the pharmaceutical shelves.

In other words, each generation covers a different group of bacteria. For the purposes of this post, I will only discuss the first generation. In next few posts, we will discuss the other generations.

The first generation covers the gram-positive bugs such as Staph and Strep. I know what you're thinking: everything covers Staph and Strep these days. Well, that's because of two things:

One: There are more species of Staph and Strep than there are Friday the 13th movies.

Two: Staph and Strep love to mutate.

Yep, these bugs mutate more than the Teenage Mutant Ninja Turtles. More than the X-men. More than New York City sewage gators. And scarily enough, more than that glowing pizza under your kid brother's bed that he tried a dirty underwear and foot fungus experiment on.

So there you have it: that's why we have a billion antibiotics out on the market that kill Staph and Strep.

Back to the subject at hand, the first-generation Cephalosporins treat more than just Staph and Strep, they attack Escherichia coli, Proteus mirabilis, Salmonella, Shigella, and Klebsiella species as well. But they do not cover Listeria or Enterococcus.

An easy mnemonic device by which to distinguish first generation Cephalosporins is by finding an "L" in their generic name. Granted, not every first generation has an "L" in its name, there are some rule breakers such as Cephapirin and Cephradine, but the most commonly used first generations do, so it is a helpful device.

So, let's use Cephalexin as an example. Notice the characteristic "l" in the middle of the generic name. I know that the trade name also has an "l" in it, but most others don't, so we will refer the mnemonic device to the generic names.

Cephalexin: This is probably the most prescribed first generation Cephalosporin there is with the most common use for it being respiratory tract infections. These are Streptococcus pneumoniae and Streptococcus pyogenes respiratory infections.

Even though penicillin is considered the first drug of choice in treating Strep infections, there has been a lot of resistance to penicillin. Cephalexin is markedly more effective at eradicating strep found in the nose and throat.

Other indications for use include Otitis media (Strep, Staph, Haemophilus influenzae [not to be confused with the influenza virus], and Moraxella catarrhalis), skin infections, and genitourinary tract infections, including acute prostatitis (Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis)

Normal adult dosage: 250 milligrams by mouth one pill every 6 hours. Strep infections may require 500 mg every 6 hours. Bladder infections require the 500 mg every 6 hours for 14 days.

Child dosage: 25 to 50 mg per every kilogram in weight of the patient. If the child is younger than one year old then give the dose every 12 hours.

Side effects: Rash, fever, colitis, aplastic anemia, and gastritis with or without nausea.

Drug interactions: Doesn't get along well with Probenecid. I'm beginning to think that Probenicid is the problem drug since it doesn't enjoy the company of any Carbapenems, Penicillins, and Cephalosporins.

Increases the serum levels of the diabetic drug Metformin. It really likes to hang out with it, and causes decreased blood sugar levels in patients taking Metformin.

Cefazolin: Hey, what do you know, it also has the characteristic "l" in its name. This is the artist otherwise known as Ancef that is administered only by injection. I call it the prissy chick of the bunch. It needs to be diluted. It needs refrigeration. It needs you to pick out the green M&Ms out of the bowl and to bring it chocolate dipped strawberries on pink plates. Because how dare you bring it normal strawberries on white plates!

It has the same coverage as Cefalexin, but is a much more aggressive antibiotic. Hey, it's a diva. You pamper it, pay a fortune for it, and it seriously kicks tail when it does its job.

In addition to the infections that Cefalexin treats, the IV-infused Cefazolin treats gram-positive septicemia, biliary tree infections, endocarditis, epididymitis (infection of a part of the testes; men appreciate this drug), and surgical prophylaxis.

Normal adult dosage: uncomplicated conditions require 250 mg to 500 mg by IV or by intramuscular injection every 8 hours.
Severe or life-threatening conditions require 1 gram to 1.5 grams given by IV every 6 hours.

If given IM then dilute with sterile water. Inject it into the patient's butt. Yep, have them bend over. The shot is a total pain in the A.

IV for an adult can be diluted in 50 to 100 mL of any of the following: Normal Saline solution, Lactate Ringer's solution, Dextrose W, and 5% Sodium Bicarbonate. The most commonly used are D5W and Normal Saline.

Child dosage: A total of 25mg per every kg weight of child per day, to be given IV over 6 hour increments, with a dilution volume at 125 mg per mL fluid.

Side effects: Similar to Cefalexin, but needs dosing adjustments in patients with kidney failure. (Cut the dose strength by half)

Same Drug interactions as all first generation Cephalosporins.

Cefadroxil: Also called Duricef, this antibiotic has the similar coverage to Cephlexin. Cefadroxil's edge is that it is especially effective for pharyngitis or throat infections, such as Strep throat.

Skin infections and urinary tract infections are also covered by this particular Cephalosporin. And like the rest of the first generation of Cephalosporins, Cefadroxil is a pregnancy category B drug, so it is relatively safe for pregnant women to take.

Normal adult dosage: 100 mg by mouth twice a day

Child dosage: 30mg per kg weight of the child per day. This can be divided into two doses.

Other First generation Cephalosporins: Cephalothin, Cephaloridine, Cephapirin and Cephradine.

The four compadres pretty much like kicking bacteria butt as any Cephalosporin does, but these shouldn't be used in patients with severe kidney problems.

Other than that, they're great drugs. Besides, they look great in bunny ears.

Hope you enjoyed the first generation. Next time, it's the second generation, known as the moderators. ;)


Saturday, May 14, 2011

Carbapenems: Who Comes Up With These Names?

There's always a scientific reason why drugs are given certain names: It's called a bored scientist with too much time on his hands is trying to win a game of Scrabble.

"Carbapenem is not a word."
"Yes, it is."
"No, it isn't. It's not even in the dictionary.""
"It's the name of a... a... um, drug that I'm creating. Yeah, that's right. It's the drug I'm working on."

Just for you, I will unravel the mystery of how names of pharmacological agents came about. The influence of the alphabet song makes its mark on the anti-platelet medication abciximab. The owners of the alphabet song are suing for copyright violations.

One scientist was up late one night watching the movie Maverick and the antiviral drug Maraviroc drug was born.

A Trekkie fan created the drug Android (an androgen receptor antagonist) after Data and his rival the Star Wars fan named the arthritis drug Anakinra after the infamous Jedi. May the force be with your anti-arthritic medication.

And if that's not fun enough, scientists get even more creative by stringing together words to form a name, just because we aren't confused enough by the goofy ones already out there.

So there are the ones named after a phrase such as bend-over-must-sting like the alkyating agent that can only be administered by shot named Bendamustine (the company even goes as far as giving it a trendy brand name of Treanda).

I'm just waiting for a scientist whom after eating a couple moldly sandwiches, gives up on a game of Scrabble to do a marathon of Lord of the Rings and youtube. Here could be the name of the newest antipsychotic medication: "Mypreciousmypreciousstarwarskidmeetswizisin."

Then there are the pharmacological agent names that are just plain cruel. These are the ones created by evil mad scientists that prefer torturing people with oxymorons.

My favorite of this category is the colonoscopy preparation called "GoLYTELY." Nothing is more of a rude awakening than this name. If it's not bad enough that you have to go in for a camera the size of Florida up your rear end, the mad scientist in his great evilness decided to psyche you out with the name "Go Lightly." Now, it's a bold-faced dirty lie; there is no "lightly" about about it. In fact, historians believe that Go LYTELY used to be an explosive device created by secret agents to turn vegetarians into salad shooters.

But at any rate, some socially-poor-but-economically-rich schmuck coined the term Carbapenems from the phrase "carve a pretty penny out of them" and we have a really cool class of antibiotic drugs; some of which are quite expensive.

Like, I mentioned in the last post: Carbapenems have cross-allergies with penicillins. So if a penicillin puts a rash spawned by Hitler on your butt then carbapenems try to match it with a rosy rash of their own.

The Carbapenems are a class of antibiotics that attack the cell wall of susceptible bacteria.

They cover a wide spectrum of bacteria. Carbapenems are kind of like Scarface with his big-A machine gun, shooting up everything. "Say Hello to my little Carbapenem!"

Seriously, Carbapenems are the big guns, saved for the life-threatening cases. And following the grand tradition of all hard hitters, they are administered IV. So, you have to get your butt shot before you feel their effects.

Carbapenems handle meningitis (Meropenem), sepsis, endocarditis, ventilator-associated pneumonia, urinary tract infections, bone infections, and complicated intra-abdominal and pelvic infections.

In a few words, they cover the gram-positives like Strep and Staph, similar to the penicillin group, but in addition to that, they also cover some seriously nasty gram-negatives and a few strains of Pseudomonas. But they don't kill Legionella or MRSA. Too bad. Oh darn, the elderly are going to have to avoid sitting near old air conditioners and MRSA sufferers are going to have to find some other drug. Yet they kill anaerobes! So, they are good for bullet wounds and some scary stuff that that incubates in the gut. Woohoo!

The one major flaw with the Carbapenem class is that they can cause dangerous seizures in patients with kidney problems. Have bad kidneys? No Carbapenems for you!

Ertapenem: Does not cover Pseudomonas. It's the only Pseudomonas-lazy Carbapenem out there. It's so lazy that it doesn't even have the gram-positive bug coverage that the other drugs in this class have. So if you're a burn patient with Pseudomonas or have a serious gram-positive bacterial infection, then don't bother with this drug. It will just disappoint you. You'll end up hating each other and heaven knows if it will try to sue for your house. But it is a pretty cheap date, if you're not into spending a lot of money and don't care about Pseudomonas.

And you might as well know that cheap dates like Ertapenem are often antisocial losers: it hates to work with the bipolar medication valproic acid (Depkote) and the drug Probenicid. They fight a lot.

Ertapenem does have its good points: it is a category B drug and is relatively safe to take during pregnancy and while breast feeding. Also, it loves kids older than 3 months old. So it's kid friendly.

Trade name Invanz, Ertapenem is only administered by injection. And just like a cheap Coyote-Ugly needs a shot of Vodka, Ertapenem needs a shot of lidocaine prior to administration just so you can handle dealing with it.

Not at all good for meningitis, but is awwwwwesome for intra-abdominal infections, urinary tract infections (use as last resort), community-acquired pneumonia (if Azithromycin doesn't work), and wound infections.

Normal Adult dose: 1 gram of Ertapenem by IV once a day over a course of 5 to 14 days depending on the severity of the condition.

Side effects include increased platelet count, vaginitis, altered mental status, chest pain, and liver enzyme elevations.

Imipenem: Trade name Primaxin, this Carbapenem includes Cilastatin. Not to be used with antivirals or cyclosporine. Also, not good for our pregnant friends, but loves children. Takes walks on beaches in the moonlight and is not so antisocial as its cheap-A brother.

Imipenem is used for endocarditis. Okay before I continue I have to state some of the ground rules of catching endocarditis. If you are a needle-drug user, you will get endocarditis. Generally this kind of endocarditis is caused by Staphyloccocus. No ifs-ands-or-buts, IV drug users will get endocarditis at some in their drug-using career. Night sweats, chills, unexplained sickness that lasts for weeks with a racing heart rate sometime after heroine injection equals bad case of endocarditis.

People that have heart valve problems may get Streptococcus mutans/viridans endocarditis from visiting the dentist. So dentists generally give prophylactic antibiotics to prevent it. Imipenem is used to cover these difficult cases of endocarditis and it is administered intravenously.

Other conditions that it covers include serious gynecological infections, intra-abdominal infections, sepsis, lung infections, bone/joint infections, Pseudomonas, and multi-bacterial infections.

Normal adult dose: 500 milligrams by IV given every 6 hours over the course of 10 days.

Side effects include confusion, drug fever, psychic disturbances, and in patients with kidney failure, seizures. So don't give it to Psychics with renal failure that want to drive buses.

Meropenem: Also called Merrem IV because it is given only by IV, this Carbapenem has some serious side effects like Stevens-Johnson Syndrome and Angioedema. Yeah, I hit you up front with those. I didn't wait to get you all excited about this drug, make you fall in love with it, and then smack you down with the "this drug can kill you if not used properly" statement. See, I care about your feelings.

One phrase for this drug: Kicks the crap out of meningitis. Yep, this one takes the Louisville Slugger and beats the holy snot out of any gram-positive bug that even dares to venture into your meninges. This is the drug that you would want to marry if you suddenly get "the headache that kills" and trust me, it won't disappoint you. It also can be used for complicated pelvic/abdominal infections such as appendicitis and peritonitis as well as serious skin infections.

Normal adult dose: 1 gram by IV per every 8 hours over a 10 day course.

But as you know, with any classy date, there comes a hefty price tag. This is one expensive drug. Sell your car and your house... and maybe a few of your children and you can pay for this Carbapenem, because it will "carve a pretty penny out" of you.

So that ends my discussion of Carbapenems. There are no more in the class. I think Ertapenem's antisocial behavior has ruined the chances of any other antibiotics joining them. Well, technically there is Dorkipenem (Doripenem) but he's the really really really expensive brother.

The following is a good site concerning wound infections, bacteria, viruses, etc. that is totally worth reviewing:

World Wide Wounds


For all those Star Wars Scientist fans out there when Scrabble isn't good enough:

Sunday, May 8, 2011

Bugs and Penicillin Drugs

Before you go to the black market to buy antibiotics and a kidney for Uncle Earl, there are somethings that you should know.

One: Kidneys are hard to get past the TWA. They like to collect them. It's a hobby.

Two: Not all antibiotics are created equal. Even the Founding Fathers, Martin Luther King, and Bugs Bunny would agree.

Some antibiotics cover bacteria that cause upper respiratory infections, while others treat bladder infections and entercolitis. Some treat sore throats and some treat STDs. But none of them treat viruses. You see there is some old school thought that antibiotics are superheroes that fight crime, leap tall buildings in a single bound, and cure the common cold. Not going to happen. Penicillin won't stop H1N1. The Z-pack won't stop a bullet. And Ciprofloxacin won't bring your ex back. Not going to happen.

Antibiotics have their limitations. So for the next few posts, I'm going to talk in depth about the different classes of antibiotics and what they are best used for.

The first class of drugs are called the penicillin family. Penicillin was discovered when a scientist left his moldy sandwich close to a petri dish filled with nasty bacteria. Seriously, who does that? Who leaves their sandwich next to a growing pile of killer bacteria? What was he trying to do? Save it for later? Yum.

Anyway, the mold on the sandwich annihilated the bad bacteria because it was the freakishly powerful penicillin. Bwahahaha!

Thereafter, penicillins have saved millions of lives over the years, especially during the World Wars. So kudos to that perky mold sandwich, it saved the day.

Personally, I have a love-hate relationship with these antibiotics. Penicillins love to give me a rash the size of Kansas. And I hate the swollen tongue and gasping for breath that comes afterwards.

Every class of antibiotics has a chance of causing an allergic reaction: we can't necessarily play favorities. But I do want to mention here the cross-reactions between penicillin allergies and those to certain other classes of antibiotics.

As much fun as it is to watch a patient balloon up after administering a drug, we doctors don't like doing it. So we try to avoid giving penicillins to people whom have already demonstrated allergic reactions to cephalosporins and carbapenems. And vice versa due to cross-reactivity between these classes. Cephalosporins and carbapenems will be discussed in later posts.

Penicillins are beta-lactams. What does that mean for us? Diddly squat. That's a scientific term that I would rather put a red-hot poker through my eye than explain. But what we can take away from this is that the penicillin class of beta-lactams has some serious weaknesses.

Let's put it this way. Bugs are smart. The mutated little beastards have figured out a way to kick the living snot out of penicillin beta-lactams, rendering them less effective against certain super chains of bugs. Freakish beastards.

So what are penicillins good for? That's a good question. They treat infections caused by gram positive bacteria, such as Streptococcus and Staphylococcus... and okay, anthrax as well (yes, anthrax. Penicillin can kick anthrax butt). Some listeria coverage and there is also syphillis and gonorrhea coverage. See STDs had to sneak in there somewhere. (Image taken from

And you're thinking, darn I left my microscope in my other camping jacket... so can you just tell me what conditions I can use the blasted drugs for.

Oh, sure. Why not? It's not like I have a 7:00 am surgical case that I have to get to tomorrow morning. ;-)

(Before I continue, I must again stress that penicillins are only to be used in patients that do not have penicillin, cephalosporin, or carbapenum allergies.)

Here are a few examples of what antibiotics in this class are used for:

Amoxicillin is the pediatrician's favorite drug for otitis media or ear infections. It is also the first line choice for Strep throat and prevention of bacterial endocarditis in patients with heart valves undergoing dental work. It can be used in anthrax treatment and prophylaxis. This drug has all but replaced penicillin in a lot of conditions.

Ampicillin: I love this drug. It's the only penicillin that won't kill me. I appreciate that. Technically, this drug belongs to a subclass of penicillins called the aminopenicillins, which were created to handle more resistant strains of bacteria. Others within this class are Augmentin (Amoxillin + clavulanate, which has more gram negative bacterial coverage than other penicillins), Unasyn (Ampicillin + sulbactam)

This drug has beautiful gram positive coverage and some gram negative coverage. This is your urinary tract infection drug, because it goes all WWF smackdown on Escheria coli. It also is the drug of choice for listeria meningitis. Ampicillin is one of the few penicillins that can cross the blood brain barrier. If you have a resistant case of meningitis in an immunocompromised patient, especially if he/she is an infant less than one month of age, give them ampicillin.

Unasyn is a more aggressive form of Ampicillin with more coverage of bugs such as Serratia, Enterobacter, Pseudomonas (swimmers ear and wound infections in burn victims), and Legionella (air conditioner related pneumonia in elderly). It's general indications are for gynecological, intestinal, and skin infections.

Oxacillin: This one's fun, because it's named after a bull and can seriously kick bacteria bum. Oxacillin treats recurrent Group B Strep (GBS) infections and is great for pregnant women when ampicillin doesn't work and for neonates suffering from GBS infections. GBS is transmitted through the vaginal canal during delivery to the infant. If there is a vaginal delivery at home, the chances are that the baby is going to acquire a GBS infection and could die. GBS infection signs of fever, lethargy, grunting, nasal flaring, pale or blue appearance, and difficulty feeding occur mostly within the first 24 hours but can occur up to 6 days of life.

Note: Oxacillin can only be administered via intramuscular injection or intravenously. Neonate doses are approximately 50mg/kg/day every 12 hours.

Timentin: A combination drug (Ticarcillin + clavulanate), Timentin is similar to Augmentin but doesn't cover Legionella. Yet, it covers Clostridium difficile, which is the most foul-smelling diarrhea you will ever smell. It makes Giardiasis smell like roses. Consider it a kind of Post-traumatic Stress Disorder for your nose, because if you smell C. diff once, then you will never mistake it again.

C. diff is the diarrhea most common in hospitalized patients which are already on enough antibiotics to kill an elephant. The most common antibiotic associated with acquiring C. diff is Clindamycin. So if you have a patient that was given Clindamycin and afterwards, suddenly gets the Great Stink of all diarrhea then you pretty much can guess it is C. diff. Treat them with Timentin or oral vancomycin and be done with the juicy squirts.

Zosyn: The brand name for piperacillin + tazobactam, Zosyn has the same coverage of the aforementioned penicillins, but with increased ability against Pseudomonas. This drug should be used in conjunction with an aminoglycoside to cover severe pseudomonas infections in burn victims. You can tell a pseudomonas infection by its characteristic blue-green color it causes in wound tissue and the sweet grape-like scent.

Okay, who was the guy that said, "Mmm! I so want to sniff that wound. I bet it smells like grapes."

Well, I hope you enjoyed my ode to penicillins.


Saturday, May 7, 2011

Code Brown

Do you ever wonder what would cause doctors to run screaming in terror? The answer is a Code Brown. (Image taken from

In the hospital setting lots of codes are used to notify personnel of important and dangerous events. For instance, Code Blue means cardiac arrest. Code White generally means stroke. Code Pink means an infant has been kidnapped. Code Black can mean act of terrorism or bomb is on the premises depending on the hospital. Code Red or Orange generally means fire. Code Brown is much much more dangerous... it's patient diarrhea.

I was rounding with the usual herd of doctors and medical students, when we came into the room of an inebriated patient. He was a frequent-flyer for his alcohol and was on a withdrawl protocol which included him wearing nothing but a hospital gown. When asked who he was he stood up proud and tall and said, "Abraham Lincoln."

Just then a tsunami of liquid brown Montezuma's revenge shot out of him all over the floor and on the shoes of a couple residents. After a few girly screams from the men, someone shouted, "Code Brown!"

You should have seen the stampede of doctors rush out the room. I think my attending physician knocked over a couple nurses and a beefy orderly to get out. People were flying. Doctors were gagging. One managed a "Diaper change stat!" between his dry heaving.

Only the third year medical student remained in the room like a deer caught in headlights. The poor guy froze in terror as the Great Stink filled the air around him in tufts of gas that smelt worse than-a-skunk-taking-a-bath-in-a-garbage-can-after-eaten-a-rotten-corpse. Fortunately, the nurses rushed in to save the day. Nurses are heroes.

In the wilderness and disaster setting, diarrhea is not so comical. It actually can be life-threatening. Cholera-- which is a glorified name for explosive watery diarrhea-- killed thousands in the past and still kills many in developing countries today.

The mechanism by which diarrhea becomes dangerous is through the profuse excretion of vital electrolytes in the constant bowel movements. It is through an osmotic effect in your bowel. Yep, that's definitely what you want to read about. You've set down with a big beefy burger about to take a bite and I'm talking to you about explosive bowel movements. Yummy.

Anyway, back to what I was saying before: this massive electrolyte loss results in heart arrhythmias which develop into heart attacks. So the Centers for Disease Control and the World Health Organization have developed inexpensive means to counterbalance this.

Now just so we are on the same page: I'm only talking about diarrhea here and am not including dysentery (bloody diarrhea), pandemic flu (unless it is a strictly diarrheal flu), and zombie attacks (which cause you to crap your pants).

The first part of the treatment: Measure the diarrhea/liquid lost from the body and give the patient the exact same amount in clean or sterile fluids.

As for replenishing electrolytes, I've gathered together some options that you can do at home or in the wilderness:

First option: Mix one Liter of clean (sterilized, boiled, or filtered ) water with Two Tablespoons sugar and one-half tablespoon of salt. Mmm yummy.

Second option: Pedialyte, Infalyte or equivalent medical electrolyte drink. Moderately expensive.

Third option: 1/2 strength Gatorade. I like this one personally. Gatorade is always on sale. And the mixture is one part water and one part Gatorade. Simple. Quick and it replenishes fluids and electrolytes at the same time.

Fourth option: Hikers electrolyte packs. One pack per liter of water.

Fifth option: I call this the kid friendly option is fruit pops, popsicles, or Jello. Man, I love Jello's versatile nature.

Naturally Disastrous Diarrhea:

In disaster settings, profound cases of diarrhea appear when sanitation gets ignored in the face of calamity. I know. I know. The last thing on your mind when an earthquake or tsunami hits your house is "darn, now where am I going to go the bathroom?"

As you all know, contamination of drinking water is imminent. Diarrheal cases increase, some of which can be infections similar to those found in developing countries, such as typhoid, E.Coli strains, Clostridium difficile and cholera. The key to managing these conditions is lots of clean water and electrolytes as mentioned above.

Most common overall regardless of disaster or not, viral gastroenteritis or the "stomach bug" is a watery diarrhea with aches, cold symptoms, chills, and nausea and vomiting. These are also treated with rehydration and electrolytes but are not nearly as severe as the above mentioned conditions.

I do want to mention one more form of diarrhea, which technically classifies as a dysentery condition, but in light of the earthquake, tsunami, and nuclear power plant disaster in Japan, this condition is worth mentioning.

Radiation enteritis is an inflammatory condition characterized by bleeding and painful straining during bowel movements. The diarrhea results from malabsorption due to inflammation of the mucosal lining of the intestines. This condition can persist for 2 to 3 months even after treatment, which is surgery. Yet, avoiding dairy and fats can help alleviate symptoms and promote nutrient absorption. Also, this is the one condition which I will suggest taking loperamide to prevent diarrhea.

Wild Bowels in the Wilderness:

The diarrheal infections in the wilderness setting are much more manageable than those found post-disaster. Giardiasis and Staph aureus are the most common types found in backpackers. In fact, giardiasis is so common that it is called backpacker's diarrhea.

Staph aureus diarrhea is the Mario Andretti of diarrheas. It acts up fast, it moves fast, and it goes away fast (unless you are immunocompromised). Staph diarrhea usually occurs from improper washing of camping dishes in non-sterilized water. Within 4 hours after ingestion, a profuse watery diarrhea and stomach cramping begin. Doesn't generally require treatment due to the fact that it lasts up to 24 hours in non-immunocompromised people.

As for Giardiasis, it's as slow as your grandpa Harold. It takes anywhere from 1 to 2 weeks after exposure for symptoms to start. So if you go camping, don't hold any board meetings or go to classy place 1 to 2 weeks afterwards. Trust me, it won't be pretty.

Giardia comes from drinking river or lake water in mountainous regions.

Symptoms include putrid smelling flatus (sorry bean burritos didn't do it to you), egg-smelling halitosis, watery diarrhea or greasy stools, abrupt onset of abdominal cramps, fever, bloating, nausea and vomiting. These symptoms are cyclic and occur over months with short periods of relief then the cycle begins again. Giardiasis can last for years if not treated. The first line treatment is metronidazole (Flagyl). (See for more information on Flagyl.)

I hope you enjoyed this explosively squishy post.