I am a Specialist Emergency Physician, and have been practising Emergency Medicine for over 15 years. On March 8th -10th 2019, I was acting in a voluntary role as a event doctor on the New Zealand Enduro, a backcountry mountain bike race in Marlborough, New Zealand.
On the afternoon of March 8th 2019, I was reviewing and treating a number of riders who had been injured in the day’s racing. Mark Maurissen approached me, and asked me to review Martin Maes, who had sustained a significant laceration to his right pretibial area (lower leg) during the day’s racing. Martin had sustained an approximately 5 centimeter long vertically orientated burst type laceration to his lower leg. There was significant soft tissue damage, and the wound was grossly contaminated (conditions were particularly muddy that day) I irrigated and debrided the wound extensively, applied a topical antiseptic solution, and sutured the skin using 4 x interrupted sutures. I was concered about a significant risk of infection given the wound location, tissue damage, and initial contamination. At that point I dispensed a course of flucloxacillin (an antibiotic) in a standard dose (500 milligrams 4 times a day for 3 days with a goal of preventing infection). I gave Martin standard wound care advice, and planned to follow him up in 2 days
On March 10th 2019 at around 10 am, I reviewed Martin’s wound. At that point, he had a clearly established serious infection surrounding the wound, despite the prophylactic antibiotics. This infection had developed over the last 24 hours. I removed 2 of the sutures, draining a small amount of pus, and irrigated and further debrided the wound. A higher dose of antibiotic was clearly indicated, as the infection was significant enough be life or limb threating if left unchecked. My standard practice in a case like this is to give a higher dose of flucloxacillin in combination with a medicine called probenicid. In this case, probenicid acts to reduce the excretion of penicillin type antibiotics from the kidneys, thus boosting the blood levels of antibiotic. These higher levels of antibiotic are particularly important for treating serious infection, and I do not believe Martins infection would have resolved without them. The only other option would have been hospitalisation for intravenous antibiotics, which carries its own set of risks and costs, and would not necessarily be more effective than adding probenicid.
I provided Martin with a prescription for 2 grams of flucloxacillin 3 times a day for the next 2 days (dropping to 1 gram 3 times a day for a further 5 days), and probenicid 500 milligrams 3 times a day for 7 days. I discussed all of this with Dr Julian Balance, an Orthopaedic Surgeon also volunteering as a race doctor. He agreed with the management plan as above.
Both Martin and Mark asked if the medications I were permissible for racing. I informed them that probenicid has no performance enhancing effects, and as far as I was aware was not a prohibited substance for racing. I checked this with Dr Balance, as well as Dr Sam Grummitt (another of the race doctors), neither of whom were aware that probenicid was a prohibited substance. There was no cellular data coverage at the event to enable us to check this. Martin began vomiting that afternoon, likely as a result of the higher doses of flucloxacillin, which often cause significant gastrointestinal upset. At that point we discussed referring him to hospital, and elected to give him a trial of an anti-vomiting drug prior to this. I dispensed 4 milligrans of ondansetron, which settled his vomiting, and enabled him to take the prescribed antibiotics.
I understand Martin made a good recovery, and was able to race 2 weeks later. I also understand that Martin returned a positive urine drug test for probenicid at that event. I have subsequently learned that probenicid is on the UCI prohibited substances list, and has previously been used as a masking agent, although it has no performance enhancing effects.
The probenicid I prescribed Martin was clearly medically indicated and I would do so again given the same clinical scenario. I believe he would have experienced a significant impairment to health had I not prescribed it, with the potantial for life threatening spread of infection. Had I known it was a prohibited substance, I would have been happy to fill in a therapeutic exemption form. I am confident that there was no performance enhancing benefit from the prescription, and in fact the severity of the infection was likely to have been detrimental to his performance in the next few weeks—Dr Tom Jerram
fonte Pinkbike