Antibiotic Use in Orofacial Dental Infection

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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
  the head and neck region with awareness to
  systemic factors as part of a comprehensive
  dental examination
• Identify local and/or systemic signs and symptoms
  to support the diagnosis of infection
• lt erythema, warmth, swelling, and pain gt
• lt malaise, fever ( gt38 c), chills gt
• Loss of function
• lt dysphagia, trismus, dyspnea gt

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ASSESSMENT (CONT)

• Systemic signs of infection
• lt BP ?
• lt WBC ?
• lt CRP ?
• lt urine output ?

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DIAGNOSIS Infection

• Determine etiology
• gt odontogenic
• gt trauma wound, animal bite
• gt 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 most
  important of all, by either spontaneously or
  surgically drain the pus.
• Antibiotics are merely an adjunctive therapy.

Drainage
Host defense
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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MICROBIOLOGY

• Most oral infections are mixed in origin
  consisting of aerobic and anaerobic gram positive
  and gram negative organisms
• Anaerobes predominant (75)

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COMMONLY USED A/B

• Mechanism of the antibiotics

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COMMONLY USED A/B

• 1. Groups of Penicillin
• First choice for odontogenic infection
• G() cocci and rod, spirochetes, anaerobes
• 0.710 hypersensitivity gt PST
• Nature penicillin G (IV), penicillin V (PO)
• Penicillinase-resistant oxacillin, dicloxacillin
• Extended spectrum ampicillin, amoxicillin
• Combine ß-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 -gt bactericidal
• Second-line drug should be held in reserve to
  treat those infections caused by anaerobes
  resistant 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 anaerobic
  bacteria, combined with ß-lactam A/B
• Effective against Bacteroides species, esp. in
  periodontal 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
  prophylaxis of 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 lt12
• Limited usefulness in orofacial infection
• Use as adjunctive therapy for refractory
  periodontitis
• Most likely to cause superinfection

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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 -gt Cefazolin 1000mg
  q6h
• Gentamycin 60-80mg IVA q8h-q12h
• Second 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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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.