Antibiotic Use in Orofacial Dental Infection

Speaker Moderator

VGH-TPE

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

VGH-TPE

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: < erythema, warmth, swelling, and pain > < malaise, fever ( >38 c), chills >
Loss of function

< dysphagia, trismus, dyspnea >

VGH-TPE

ASSESSMENT (CONT)
Systemic signs of infection

< BP < WBC < CRP < urine output

VGH-TPE

DIAGNOSIS: Infection
Determine etiology

> odontogenic > trauma wound, animal bite > TB, fungi, actinomycoses

VGH-TPE

DIAGNOSIS (CONT)
Determine cellulitis versus abscess

VGH-TPE

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

VGH-TPE

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

VGH-TPE

MICROBIOLOGY
Most oral infections are mixed in origin

consisting of aerobic and anaerobic gram positive and gram negative organisms Anaerobes predominant (75%)

VGH-TPE

COMMONLY USED A/B

Mechanism of the antibiotics

VGH-TPE

COMMONLY USED A/B

1. Groups of Penicillin 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

VGH-TPE

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

VGH-TPE

3. Clindamycin G(+) cocci Bacteriostatic -> bactericidal Second-line drug: should be held in reserve to treat those infections caused by anaerobes resistant to other antibiotics

VGH-TPE

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

VGH-TPE

5. Metronidazole* Only for obligate anaerobes Can cross blood-brain barrier To treat serious infections caused by anaerobic bacteria, combined with -lactam A/B Effective against Bacteroides species, esp. in periodontal infections Drugs: Anegyn, Flagyne Avoid pregnant women

VGH-TPE

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

VGH-TPE

7. Chloramphenicol Wide spectrum, highly active against anaerobes Limited to severe odontogenic infection threatening to the eye or brain Severe toxicity

VGH-TPE

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,

VGH-TPE

9. Tetracycline* Only against anaerobes Contraindications: pregnant women, children <12 Limited usefulness in orofacial infection Use as adjunctive therapy for refractory periodontitis Most likely to cause superinfection

VGH-TPE

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

VGH-TPE

 Empiric Antibiotics in OMF Infection

First-line
Penicillin 3MU IVA q6h -> 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
VGH-TPE

 Side Effect of Commonly Used Antibiotics

1. Penicillin 2. Cephalosporin 3. Clindamycin 4. Aminoglycoside 5. Metronidazole*

hypersensitivity hypersensitivity diarrhea, pseudomembrane colitis damage to kidney, 8th neurotoxicity GI disturbance, seizures

6. Vancomycin
8. Erythromycin 9. Tetracyclin*

8th neurotoxicity, thrombophlebitis

mild GI disturbance tooth discoloration, photosensitivity
VGH-TPE

7. Chloramphenicol bone marrow suppression

PROPHYLAXIS
Indications

Updated JADA 2004

VGH-TPE

PROPHYLAXIS (CONT)
Dental procedures recommended for prophylaxis

Updated JADA 2004

VGH-TPE

PROPHYLAXIS (CONT)
Regimen

Updated JADA 2004

VGH-TPE

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

VGH-TPE

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.

VGH-TPE