Antibiotic Use in Orofacial Dental Infection

1. Antibiotic Use in Orofacial Dental Infection 台北榮民總醫院 牙科部 Speaker 陳雅薇 Moderator 羅文良 大夫 VGH-TPE

2. 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

3. 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

4. ASSESSMENT (CON’T) • Systemic signs of infection < BP ↓ < WBC ↑ < CRP ↑ < urine output ↓ VGH-TPE

5. DIAGNOSIS: Infection • Determine etiology > odontogenic > trauma wound, animal bite > TB, fungi, actinomycoses VGH-TPE

6. DIAGNOSIS (CON’T) • Determine cellulitis versus abscess VGH-TPE

7. 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

8. 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 can’t be established immediately 3. The state of patients’ host defense • When the patient is febrile • Compromised host defenses • For prophylaxis VGH-TPE

9. MICROBIOLOGY • Most oral infections are mixed in origin consisting of aerobic and anaerobic gram positive and gram negative organisms • Anaerobes predominant (75%) VGH-TPE

10. COMMONLY USED A/B • Mechanism of the antibiotics VGH-TPE

11. 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 β-lactamase inhibitor: augmentin VGH-TPE

12. 2. Cephalosporin • More resistance to penicillinase • G(+) cocci, many G(-) rods • Third generation: Pseudomonas aeruginosa • Second choice (less effect for anaerobes) VGH-TPE

13. 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

14. 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

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

16. 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 p’t VGH-TPE

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

18. 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

19. 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

20. 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

21. 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

22. Side Effect of Commonly Used Antibiotics VGH-TPE

23. PROPHYLAXIS • Indications Updated JADA 2004 VGH-TPE

24. PROPHYLAXIS (CON’T) • Dental procedures recommended for prophylaxis Updated JADA 2004 VGH-TPE

25. PROPHYLAXIS (CON’T) • Regimen Updated JADA 2004 VGH-TPE

26. 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

27. 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