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Antibiotic Use in Orofacial

Dental Infection

Speaker Moderator


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INTRODUCTION

This presentation will review the

evaluation and management of orofacial

infections with emphasis on:

Assessment of the Patient

Diagnosis and Treatment of infection Antibiotic Therapy Indications for Prophylaxis Antifungal Agent


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ASSESSMENT

Requires a complete medical history and exam of thehead and neck region with awareness to systemicfactors as part of a comprehensive dentalexamination

Identify local and/or systemic signs andsymptoms to support the diagnosis of infection:

< malaise, fever ( >38 c), chills >

Loss of function

< dysphagia, trismus, dyspnea >


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ASSESSMENT (CONT)

Systemic signs of infection

< BP

< WBC

< CRP < urine output


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DIAGNOSIS: Infection

Determine etiology

> odontogenic

> trauma wound, animal bite

> TB, fungi, actinomycoses


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DIAGNOSIS (CONT)

Determine cellulitis versus abscess


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TREATMENT of INFECTION

Remove the cause of infection is the mostimportant of all, by either spontaneously orsurgically drain the pus.

Antibiotics are merely an adjunctive therapy.

Host defense

Drainage

Antibiotics


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INDICATION for ANTIBIOTICS

1. Severity of the infection

Acute onset

Diffuse swelling involves fascial spaces

2. Adequacy of removing the source of infection When drainage cant be established immediately

3. The state of patients host defense

When the patient is febrile

Compromised host defenses For prophylaxis


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Most oral infections are mixed in originconsisting of aerobic and anaerobic grampositive and gram negative organisms

Anaerobes predominant (75%)

MICROBIOLOGY


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COMMONLY USED A/B

Mechanism of the antibiotics


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COMMONLY USED A/B

1. Groups ofPenicillin

First choice for odontogenic infection

G(+) cocci and rod, spirochetes, anaerobes

0.7~10% hypersensitivity => PST Nature: penicillin G (IV), penicillin V (PO)

Penicillinase-resistant: oxacillin, dicloxacillin

Extended spectrum: ampicillin, amoxicillin

Combine -lactamase inhibitor: augmentin


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2. Cephalosporin

More resistance to penicillinase

G(+) cocci, many G(-) rods

Third generation: Pseudomonas aeruginosa Second choice (less effect for anaerobes)

First generation Second generation Third generation Forth generation

Cefazolin

U-SAVE-A

Tydine

Keflor

Ucefaxim

Claforan Cefepime


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3. Clindamycin

G(+) cocci

Bacteriostatic -> bactericidal

Second-line drug: should be held in reserve totreat those infections caused by anaerobesresistant to other antibiotics


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4. Aminoglycoside

G(-) aerobes, some G(+) aerobes eg S. aureus

Poorly absorbed from GI tract

Adjustment of dosage in renal dysfunction Drugs: Gentamicin, Amikacin, Amikin

Combined with penicillin or cephalosporin


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5. Metronidazole*

Only for obligate anaerobes

Can cross blood-brain barrier

To treat serious infections caused by anaerobicbacteria, combined with -lactam A/B

Effective against Bacteroides species, esp. inperiodontal infections

Drugs: Anegyn, Flagyne Avoid pregnant women


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6. Vancomycin

G(+), most anaerobes, some G(-) cocci (Neisseria)

Given intravenously, BP should be monitored

Adjustment of dosage in renal dysfunction Use as a substitute for penicillin in the

prophylaxisof the heart valve pt


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7. Chloramphenicol

Wide spectrum, highly active against anaerobes

Limited to severe odontogenic infection

threatening to the eye or brain Severe toxicity


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8. Erythromycin

G(+) cocci, oral anaerobes

Bacteriostatic

Second choice for odontogenic infections Indication for out-patients with mild infection

Drug resistence: 50% of S. aureus, Strep. viridans,


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9. Tetracycline*

Only against anaerobes

Contraindications: pregnant women, children


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SELECTION of A/B

Use Empiric therapy routinely

Use the narrowest spectrum antibiotics

Use the antibiotics with the lowest toxicity and

side effects Use bactericidal antibiotics if possible

Be aware of the cost of antibiotics


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Empiric Antibiotics in OMF Infection

First-line

Penicillin 3MU IVA q6h -> Cefazolin 1000mg q6h

Gentamycin 60-80mg IVA q8h-q12hSecond line(3A)

Augmentin 1200mg q8h + Amikin 375mg q12h + Anegyn

Mild infection

Amoxicillin 250mg #2 PO q8h

Clindamycin 300mg PO q6h


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Side Effect of Commonly Used Antibiotics

1. Penicillin hypersensitivity

2. Cephalosporin hypersensitivity

3. Clindamycin diarrhea, pseudomembrane colitis

4. Aminoglycoside damage to kidney, 8th neurotoxicity

5. Metronidazole* GI disturbance, seizures

6. Vancomycin 8th neurotoxicity, thrombophlebitis

7. Chloramphenicol bone marrow suppression

8. Erythromycin mild GI disturbance

9. Tetracyclin* tooth discoloration, photosensitivity


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PROPHYLAXIS

Indications

Updated JADA 2004


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PROPHYLAXIS (CONT)

Dental procedures recommended for prophylaxis

Updated JADA 2004


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PROPHYLAXIS (CONT)

Regimen

Updated JADA 2004


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ANTIFUNGAL AGENT

Most of fungal infection are from candida

Commonly used drugs:

(1) Nystatin (Mycostatin)= PO 4-600,000 U qid

(2) Amphotericin B= IV for severe systemic infec.

(3) Fluconazole, Ketoconazole


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G

Parmason Gargle

0.2% Chlorhexidine gluconate

Against G(+), G(-), fungus

Reduce pain and inflammation, enhance healing

Indication: immunocompromised patient, C/T R/T(prophylaxis mouthrinse reduce oral mucositis)

Use: 2-3 times daily,10-20cc/ time, 20-30sec.

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