Antibiotic Use In Dentistry

Writing Prescriptions
Rx: Drug Name (can be generic) Unit Dose (ex: Pen V-K 500 mg, Elixer, Soln) VDisp: # of pills, milliliters (ml) Sig: Directions for use. q24h (daily), q12h, q8h, q6h, q4h, prn pain, till gone Refills__ Signature DEA #

General Rules
 Write Legibly!!  Remember your audience (Generally non-docs) nonthis will improve compliance.  Preferable to order specific hourly dosage time (q12h vs. bid, q8h vs. tid, etc.)  Sig: Specify # of pills to take each dose  Prescribe an endpoint. (prn pain, till gone)

Barry Brainfart Dental Clinic 666 Bite Me Ln Crossbyte Falls, MN Ph: 555-YOU-HURT
Pt. Name: Address: DOB: Date:

  

Rx: Di Si : :

Refill

Barry Brainfart, DDS

DEA:______________________

Antibiotic Strategies
 Cardinal Rules: 1) Use the right drug. 2) Use the right dose. 3) Use the correct dosing schedule. 4) Correct duration.  Hard and FastEspecially early. Why? Fast  Use a loading dose to rapidly achieve therapeutic blood levels.  Avoid combinations of bacteriostatic and bacteriocidal drugs.

Considerations
   
Gram Positive? Gram Negative? Mixed Infection? Anaerobes?

Discussion: Antibiotic Choice

   
Narrow Spectrum? Extended/Broad Spectrum? Designer Antibiotics? Anaerobes? Consider if the infection is present > 3days or if no improvement.

Narrow Spectrum Antibiotics

 Specific for the pathogen.  Fewer disturbances of non-pathogenic nonbacteria.  Fewer side effects.  Rapid response for sensitive organisms.  Ex: Pen VK, Pen G, Erythromycin

Broad Spectrum Antibiotics

 Affects both Gram + and Gram bacteria, better for mixed infections.  May give up some effectiveness for Gram + to gain effectiveness for Gram -.  Examples: Amoxicillin, Ampicillin

Common Pathogens
Necrotic pulp and apical abscesses
Obligate anaerobic bacteria
Gram negative rods
Prevotella & porphyomonas spp. Fusobacterium spp. Campylobacter rectus

Gram positive rods

Eubacterium spp. Actinomycetes spp.

Gram positive cocci

Peptostreptococcus spp.

Facultative anaerobic bacteria

Gram positive cocci
Strep and Entercoccus spp.

Common Pathogens
 Periodontal Diseases Gingivitis Fuso, strep, & actinomycetes Adult peritonitis
Bacteroides, porphyomonas, peptostreptococcus & prevotella Acute necrotizing ulcerative gingivitis Spirochetes, prevotella, fuso Localized juvenile periodontitis Actinobacillus

Common Pathogens
 Fungal Infections Candida spp. Mucorales spp.

Lets Talk About Resistance

 Three main types
Chromosome mediated
 Spontaneous mutations  Non-major form of drug resistance  Rarely lead to complete resistance

Plasmid mediated (conjugation)

    VERY important from clinical standpoint Mostly gram negs Mediate resistance to multiple drugs High transfer rate from cell to cell

Transposon (transduction and transformation)

 Phage mediated  Clinically important for Gram +

Antibiotic Choices

-Lactams
 Natural penicillins
Pen VK and Pen G
 MOA: Inhibit cell wall synthesis  Dose: 250-500 mg qid x 7-10 days  Contraindications:
Allergies Poor renal fxn

 Adverse events: GI upset  Drug interactions: oral contraceptives  Pregnancy category B

-Lactams
 Natural penicillins
Pen VK and Pen G
 Bactericidal  Allergic reaction: rare (4 per 100,000)  Spectrum:
Strep, staph, enterococcus, neiseria, treponema, listeria

 Resistance:
Mostly staph (>80%)

-Lactams
 Amino-penicillins
Amoxicillin, ampicillin
 MOA: Inhibit cell wall synthesis  Dose: 250-500 mg q 8 h x 7-10 days  Contraindications:
Allergies Poor renal fxn

 Adverse events: GI upset  Drug interactions: oral contraceptives  Amoxicillin and clavulanic acid (Augmentin)

-Lactams
 Amino-penicillins
Amoxicillin, ampicillin
 Bactericidal  ampicillin rash (4-10%)  Spectrum:
Strep, staph, enterococcus, neiseria, treponema, listeria, E. coli, proteus, H. Flu, shigella, salmonella

 Resistance:
Entero, citro, serratia, proteus vulagris, provedincia, morganella, pseudomonas aeriginosa, acinetobacter

Cephalosporins
 Cephalexin (Keflex)
MOA: Inhibit cell wall synthesis Dose: 250-1000mg q 6 h x 7-10 days Contraindications:
 Allergies  Poor renal fxn

Adverse events: mild GI Drug interactions: probenecid Pregnancy category B

Cephalosporins
 Cephalexin (Keflex)
Bactericidal Spectrum:
 Gram +

Resistance:
 Methicillin resistant gram +

Low cross sensitivity with PCN

Lincosamides
 Clindamycin (Cleocin)
MOA: binds to the 50S ribosomal subunit and inhibits protein synthesis Dose: 100-450mg q 6 h x 7-10 days Precautions:
 Poor hepatic fxn

Adverse events: GI upset, pseudomembraneous colitis Drug interactions: neuromuscular blocking agents Pregnancy category B

Lincosamides
 Clindamycin
Bactericidal or static depending on concentration Spectrum:
 Gram +, anaerobes, parasites

Resistance
 Enteroccocus

*Clostridium diff. pseudomembranous colitis!!

Macrolides
 Azithromycin (Zithromax), clarithromycin (Biaxin)
MOA: bind to the 23S rRNA in the 50S subunit ribosome Dose: 250-500 mg/day x 5-10 days Precautions :
 Poor hepatic fxn

Adverse effects: GI Drug interactions: Cytochrome P-450 (Remember Seldane?) Pregnancy category B

Macrolides
 Azithromycin, clarithromycin
Bactericidal Spectrum:
 Gram +, gram -, anaerobes

Resistance:
 B. fragilis, and strep pneumo

Tetracyclines
 Doxycycline (Vibramycin)
MOA: inhibit protein synthesis by preventing aminoacyl transfer RNA from entering the acceptor sites on the ribosome Dose: 100mg qd-bid x 7-14 days Contraindications:
 Food  pregnancy

Adverse events: GI Drug interactions: anti-epileptics Pregnancy category D

Tetracyclines
 Doxycycline
Bacteriostatic Spectrum:
 Broad, Gram +, -, anaerobes, aerobes, and spirochetes

Resistance:
 Widespread, cross resistance

PHOTO SENSITIVITY!!!

Nitroimidazoles
 Metronidazole (Flagyl)
MOA: reduced intermediate interacts and breaks the bacterial or parasitic DNA Dose: 250-1000 mg q 6-8 h x 7-10 days Precautions : poor hepatic fxn Adverse events: HA, N/V/D Drug interactions: EtOH, warfarin, Li+ Pregnancy category D

Nitroimidazoles
 Metronidazole
Bactericidal Spectrum:
 Gram - anaerobes

Resistance:
 Rare, H. Pylori?

Unpleasant metallic taste

Fluoroquinolones
 Ciprofloxacin (Cipro)
MOA: Inhibition of DNA gyrase, and Topo II Dose: 250-500 mg qd x 7-10 days Contraindications: <18 yrs old, pregnancy Adverse events: spontaneous tendon rupture Drug interactions: probenacid, warfarin Pregnancy category C

Fluoroquinolones
 Ciprofloxacin
Bactericidal Spectrum:
 Very broad except B. frag

Resistance:
 MRSA, MRSE

Antifungals
 Nystatin
MOA: inhibit cell wall synthesis Dose: 5 ml swish and swallow q 4 h x 10-14 d GI upset Drug interactions: minor Pregnancy category C

Antifungals
 Clotrimazole (Mycelex), ketoconazole (Nizoral), fluconazole (Diflucan)
MOA: inhibit cell wall synthesis Dose: 200-800 mg qd x up to 12 months GI upset Drug interactions: major p-450 enzyme inhibitor, interactions with many drugs Pregnancy category C

ADA/AAOS Advisory Statement

July 1997

AAOS Statement
Antibiotic prophylaxis is NOT recommended for dental patients with plates, pins, or screws, nor is it routinely recommended for MOST dental patients with TOTAL JOINT REPLACEMENTS.

AAOS recommendations
 Prophylaxis recommended
Total joint replacement within the last two years AND:
   

Compromised immune system OR Type 1 DM OR Previous prosthetic joint infections OR Malnourishment OR

 Hemophilia

AAOS recommendations
 Prophylaxis antibiotic recommendations
Same as AHA OR No specific regimen recommended Keflex is often the first drug of choice

Legal Considerations
 The dentist may not be aware of the patients medical condition.  Physician may not be aware of the advisory statements or of the dental procedure to be performed.  Vicarious Liability: The devil made me do it  I forgot to take my antibiotic.  Documentation.

Legal Considerations
 I forgot my antibiotics!  Animal studies have shown antibiotics are effective up to 2 hours after the procedure.  Differentiate between prophylaxis vs. treatment of an early infection.  Take into consideration patients risk factors.  Legal twists.

In Summary.

Principles of Antibiotic Therapy

 Therapeutic effectiveness
Clinical indications
 Pharmcodynamics, pharmacokinetics

Age and extent of infection

Patient factors
 Age, allergies, compliance, pregnancy risk  Patient function
Renal, hepatic, immunosuppresion, route applicability

 Cost
Brand name, length of course, alternatives?

Cost
Drug Name Pen VK Amoxicillin Ampicillin Cephalexin Clindamycin Azithromycin Clarithromycin Augmentin Doxycycline Metronidazole Ciprofloxacin Nystatin Clotrimazole Ketoconazole Fluconazole Cost of Therapy $ (~10 Days) Generic if Available 6.81 8.41 12.45 15.65 38.45 41.52 74.45 76.82 5.15 9.65 76.65 9.86 97.05 30.69 116.25

Dental Infection

AcuteRapid growth < 3 days

Chronic > 3 days

Pen VK 500mg q6h or Amox 500mg q8h or Cephalosporin

Think Anaerobes Add Metronidazole 250-500mg To PCN, Amox, or Ceph

Allergic to PCN

Clindamycin 300mg q8h

Clindamycin 300mg q8h or Cephalosporin (check allergic Rxn) or Azith or Clarithromycin