ANTIBIOTIC PROPHYLAXIS

Antimicrobial drugs have been described as the greatest life saving technologic development in the history of medicine. The introduction of sulphonamides in 1935 was followed by other chemotherapeutic agents such as metranidazole, trimetroprim, daprone and ionized. ince the introduction of penicillin in 19!", research has produced a wide range of antibiotics. The widespread benefits of these antimicrobial agents have however been achieved at a price. Antibiotics have potentially serious adverse effects and are often very e#pensive. $n addition e#cessive enthusiasm has led to e#tensive misuse of these drugs with conse%uent emergence of resistant stains of bacteria. &ence the ma'or emphasis today is on 'udicious use of antimicrobial agents based on the (nowledge of the li(ely pathogen and its probably susceptibility. )ut many a times it ta(e time to get this information and hence go inferantibiotic prophyla#is. Antibiotic Prophylaxis: This refers to the use of antimicrobial agents for preventing the setting in of an infection or suppressing contacted infection before it can clinically manifest. Antibiotics are fre%uently given

prophylactically, however in a number of circumstances this is at best wasteful if not harmful. The basis of effective, true, chemoprophyla#is is the use of drug to prevent infection by one organism of virtually uniform susceptibility. *# )enzyl penicillin against a group. A streptococcus. )ut the term chemoprophyla#is is commonly e#tended to include suppression of disease as well as prevention of infection. The main categories of chemoprophyla#is may be summarized as+ i, ii, True prevention of infection. *#+ rheumatic fever, -T$. .revention of apportunistic infection. *#+ $* / after dental procedures, .eritonitis / after bowel surgery, $mmunicompromized patients. iii, uppression of e#isting infection before it causes overt disease. *#+ T), 0alaria, animal bites. iv, .revention of e#acerbation of chronic infection. *#+ bronchitis in cystic fibrosis. v, .revention of spread amongst contacts 1$n epidemics or sporadic cases,.

*#+ pread and influenza A / partially prevented by Amantadine. *pidemic of meningitis in community or family / 3ifampicin. .ertussin / )y erythromycin. .rophyla#is of bacterial infection can be achieved often by doses that are inade%uate for therapy. $nfection occurs where there is significant %uantitative and %ualitative bacterial insult, it occurs more readily if the patients host defense mechanisms are reduced, rendering the patient more susceptible for infection. History: .rinciples of prevention of bacterial invasion of wound began formulation 1"" years before advent of antibiotics. emmelweis 145" 5 .revented periapical fever during child birth by introduction of through handwashing and the use of chlorine disinfectants. 6isterine 147" 5 .eoples of antisepsis in operating room by use of carbolic acid sprays had dramatic reduction of post5operative infections. 144" 5 team autoclave introduced by 8och and 9ap and )own.

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terile gloves by &alstead

Thus by turn and century peoples of antisepsis and asepsis had been firmly established, infection rates after surgery dropped from 9": to 15:. *ven when good techni%ue is followed, infection rates following some types of surgeries are unacceptably high. $n contemporary surgical practice prophylactic antibiotics are used to reduce the high rate. 19!" / Antibiotics introduced. )ut a ma'or controversy developed regarding actual efficacy of antibiotics to prevent infection. 9arefully controlled studies in animals and humans by )ur(e, .ol( and tone initially defined the principles of antibiotic prophyla#is. These principles are well established. i, The antimicrobial agent is chosen on the basis of the most li(ely microorganism to cause the infection. ii, iii, An antibiotic loading dose should be employed. The antibiotic should be present at sufficient concentration in the blood and target tissues prior to dissemination of offending organisms. iv, Antibiotic should be continued only as long as microbial contamination from the operative site persists.
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The benefit from the prophyla#is must outweigh the ris( of antibiotic induced allergy, to#icity, superinfectious acid emergence of antibiotic resistant microorganisms. .rophyla#is is considered only if normal aseptic techni%ues cannot

prevent access of organisms to the sites at ris(. Complications o antibiotic prophylaxis: hort term duration of antibiotic prophyla#is does not provide ade%uate time for complications to arise. ;ccasional report of pseudomembranous colitis associated with prophylactic use of ampicillin, cephalosporins acid clindamycin, but this is relatively rare complication. 0ain concern is the in the issue of encouraging the growth of resistant bacteria. ANTIBIOTIC PROPHYLAXIS IN !"NTISTRY The empiric use of antibiotic prophyla#is for dental procedures, especially those that cause bleeding in the mouth, has become reasonably well established practice among dental professionals.

 0any dentists are confused for indications for antibiotic prophyla#is and rely on the recommendation from practitioners. 6ewis and <rant hypothesized that surgical procedures provided microorganisms with access to the systemic circulation that would result in endocardins. 9linicians and researchers are increasingly concerned about the overuse of antibiotics and resulting development of resistant strains of microorganisms. The current situation clearly re%uires, 'udicious and prudent consideration before antibiotic therapy is administered. CLINICAL SIT#ATIONS CONSI!"R"! $OR PROPHYLAXIS / *arlier many situations were considered. Table 1 + .arasch article. =ow not all are considered, but only a few are considered, namely+ Table .age 3>95 0ar 2""" ?A@A. In %cti&% %n'ocar'itins: I"( Also called acute or subacute bacterial endocartins

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 @efined as an e#udative and proliferative inflammatory alteration of endocardium, characterized by vegetations on the surface or within the endocardium that are caused by an infection with microorganisms. &eart valve commonly involved, but affects inner lining of cardiac chambers. $t is well recognized that $* arises from a pree#isting lesion, usually composed of fibrin and platelets, that develops from the disruption of endothelial lining via abnormal development disease or presence of foreign bodies and turbulent blood flow. =e#t / ?A@A 0ar 2""", ..3>7 6ast para Bri% Historical R%&i%): $t first formally described by 0orgagni in mid 17""s. &order / first to discuss scientifically possible connection between $* and oral bacterial agents. 6ewis and <rant / proposed relationship between surgical procedures bacteremias and $*. A&A formally issued in first statement on $* prophyla#is in 1955.

 A&A recommended parentral regimen of penicillin as first choice for prophyla#is and oral penicillin as a less desirable second choice. ince then A&A and A@A have modified recommendations several times 11977, 194!, 199", gradually shortening and simplifying the protocol. Although there has been much historical controversy about prophylactic use of antibiotics, there is little doubt that patients with cardiac vascular defects have greater incidence of $* and that oral bacteria are fre%uent culprits. Antibiotic prophylactic r%*im%ns: A&A5@ec5199". 0edical letter / @ec. 1949. ) A9 / ?an 199". Tables in pra(ash article .. no. 229. 6atest A&A table / ?A@A 0ar 2""", p. 37". =otable changes include+ 1. 3educing the oral dose from 3 gms to 2gms. 2. Aollow up dose of antibiotic is continued.

3. 3eplacing erythromycin with other antibiotics as alternatives to the penicillins. !. @a'aci and colleagues reported that 2gms of amo#icillin provides several hopes of antibiotic coverage. .atients with cardiac conditions considered for prophyla#is Table from ?A@A 0ar 2""" ..3>9 A&A recommends that patients diagnosed with mB. with regurgitation receive prophyla#is before undergoing dental procedures, but patients with alone and no regurgitation, no antibiotic prophyla#is re%uired. $t is prudent for dentist to as( for medical evaluation before dental care, rather than giving prophylactic antibiotics. .atient with prosthetic 'oints+ 5 $nfection no prosthetic 'oint may be classified as early and late onset. 5 *arly prosthetic 'oint infection5 due to microbial contamination of surgical site during placement of prosthesis. 5 6ate prosthetic 'oint infection 16.?$, occurs 3 or more months after surgery and may involve delayed infection from

microorganisms introduced at the time of surgery via hematogenous spread from distant site, such as mouth. 5 5 5 0ortality rate in 6.?$ / 14:. $ncidence associated with dental procedures is low 1"."!:,. &ence / A@A recommends prophylactic antibiotics only for patients with total 'oint replacement and not for patients with pins, screws or plates and patients with compressed immune systems. Type $ @0 3ecent 'oint replacement 1within 2 years,. .revious 'oint infection. 0alnourishment. &emophilia. $ndwelling catheters, neurological shona and other implants. 5 5 $ndwelling catheters. =o antibiotic prophyla#is. $f catheter in near right side of hearna / antibiotic prophyla#is re%uired. 5 9ardiac patients with newly placed steve 1initial 2 wee(s, before epithelization / A.).3e%uired.

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9atheters in patients receiving systemic mediators 1antiviral or chemotherapy, for e#tended periods antibiotic prophyla#is re%uired. )ecause decreased immunity.

.atients with renal disease undergoing hemodialysis antibiotic coverage re%uired because of AB shunts.

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.eritonial dialysis / A). not re%uired. .atient with hydrocephaly5 2 types of shunts. BA 1venticuloapical, shunt / Antibiotic prophyla#is re%uired. B. 1venticulo peritoneal, shunt / =o A. re%uired

Aor other implants / .enile implants. $mplanted dicfibrillars. 9ardiac pacema(ers

!"NTAL PROC"!#R"S CONSI!"R"! $OR PROPHYLAXIS Table from .age 371 ?A@A 2""" 0A3 5 5 3rd molar surgery, infection rate 1:. 6ocalized ?. and early onset periodontists may need prophylactic antibiotic.

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$n implants / preoperative antibiotics decrease the rate of implant failure.

Antibiotic prophylaxis in imm+nocompromis%' pati%nts 1. .atients undergoing chemotherapy 5 5 3outine procedures / =o A. re%uired. $nvasive procedure / A. re%uired.

2. .atients with &$B infection / $n absence of bacterial infection / =o A. re%uired. Antibiotics to be used because of higher ris( of systemic infection. 3. .atients with diabetes / $@@0 / increased rate of systemic disease / hence A. re%uired. 5 .oorly controlled diabetics / A. re%uired for invasive procedures. 5 Cell controlled diabetics who are not dependent an insulin therapy / A. not re%uired. !. $B drug users. 5. .atient who has undergone splenectomy ee te#t page 372 / Table 2 page 372. 0ar 2""" ?A@A.
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