Antibiotics In Oral Surgery Antibiotics In Oral Surgery

onsiderations In Antibiotic Therapy onsiderations In Antibiotic Therapy

Immune status oI the patients (Host deIense) Immune status oI the patients (Host deIense)
Microbiology oI oral inIections. Microbiology oI oral inIections.
Patient assessment Patient assessment
Antibiotic therapy Antibiotic therapy Therapeutic / Prophylactic Therapeutic / Prophylactic
Immune Status oI the patients Immune Status oI the patients
Immune Status oI the patients Immune Status oI the patients
(Host DeIense) (Host DeIense)
Immunity against intraoral Immunity against intraoral
inIection is dependant on inIection is dependant on
Humoral immune response Humoral immune response
ell Mediated immune response ell Mediated immune response
Local Iactors in immune response Local Iactors in immune response
Problems with one oI the above Problems with one oI the above
mechanisms would increase mechanisms would increase the the
potential Ior inIection. potential Ior inIection.
Microbiology O Microbiology OI Oral InIections I Oral InIections
Most oral inIections are mixed in origin consisting oI Most oral inIections are mixed in origin consisting oI
aerobic and anaerobic gram positive and gram negative aerobic and anaerobic gram positive and gram negative
organisms organisms
Anaerobes predominant (75) Anaerobes predominant (75)
Microbiology OI Oral InIections Microbiology OI Oral InIections
The types oI bacteria in dental The types oI bacteria in dental
inIections inIections
Patient Assessment Patient Assessment
omplete medical history omplete medical history
Examination oI the head and neck region. Examination oI the head and neck region.
Determine the patient`s health status. Determine the patient`s health status.
Systemic considerations Systemic considerations
Heart disease, neutropenia, splenectomy, diabetes mellitus, end Heart disease, neutropenia, splenectomy, diabetes mellitus, end- -
stage renal disease, organ transplant, HIV inIection, total joint stage renal disease, organ transplant, HIV inIection, total joint
replacement and other implanted devices, hepatic dysIunction, replacement and other implanted devices, hepatic dysIunction,
pregnancy pregnancy
History oI adverse drug reactions History oI adverse drug reactions
Potential drug Potential drug- -drug interactions drug interactions
Patient assessment Ior antibiotic treatment Patient assessment Ior antibiotic treatment
IdentiIy local and/or systemic signs and symptoms to IdentiIy local and/or systemic signs and symptoms to
support the diagnosis oI inIection: support the diagnosis oI inIection:
Local signs oI inIection Local signs oI inIection
Erythema, warmth, swelling, pain Erythema, warmth, swelling, pain
Malaise, Iever , chills Malaise, Iever , chills
Loss oI Iunction Loss oI Iunction-- -- dysphagia, trismus, dyspnea dysphagia, trismus, dyspnea
Systemic signs oI inIection Systemic signs oI inIection
BP BP
WB WB
#P #P
Urine output Urine output
Diagnosis oI Oral inIections Diagnosis oI Oral inIections
Bacterial InIection oI the oral cavity Bacterial InIection oI the oral cavity
Periapical, Periodontal, Pericoronal, Postsurgical Periapical, Periodontal, Pericoronal, Postsurgical
May begin as well May begin as well- -delineated, selI delineated, selI- -limiting condition limiting condition
Potential to spread and result in a major Iascial space inIection Potential to spread and result in a major Iascial space inIection
LiIe LiIe- -threatening sequelae can ensue threatening sequelae can ensue
Septicemia Septicemia
Ludwigs angina Ludwigs angina
avernous sinus thrombosis avernous sinus thrombosis
Airway obstruction Airway obstruction
Mediastinitis Mediastinitis
Treatment oI Oral InIections Treatment oI Oral InIections
#emove the cause oI inIection #emove the cause oI inIection
Spontaneously Spontaneously
Surgically drain the pus. Surgically drain the pus.
Facial space inIections Facial space inIections
Send the pus sample Ior culture and sensitivity exam (microbiology) Send the pus sample Ior culture and sensitivity exam (microbiology)
Antibiotics are merely an adjunctive therapy. Antibiotics are merely an adjunctive therapy.
Host defense
Drainage
Antibiotics
Antibiotic therapy in Oral Surgery Antibiotic therapy in Oral Surgery
Antibiotics Antibiotics
Organic substances produced by micro Organic substances produced by micro- -organisms organisms
Ability to destroy or inhibit growth oI bacteria and Ability to destroy or inhibit growth oI bacteria and
other micro other micro- -organisms organisms
Synthetic or semi Synthetic or semi- -synthetic synthetic
Indication For Antibiotics Indication For Antibiotics
Severity oI the inIection Severity oI the inIection
Acute Acute
DiIIuse swelling involves Iascial spaces DiIIuse swelling involves Iascial spaces
hronic hronic
Adequacy oI removing the source oI inIection Adequacy oI removing the source oI inIection
When drainage can`t be established immediately When drainage can`t be established immediately
The state oI patients` host deIense. The state oI patients` host deIense.
Febrile Febrile
ompromised host deIenses ompromised host deIenses
Prophylaxis Prophylaxis
Selection oI Antibiotics Selection oI Antibiotics
1. Determine Need 1. Determine Need
- - Therapeutic or Prophylactic use Therapeutic or Prophylactic use
2. Type oI InIection 2. Type oI InIection
- - Acute /hronic ( Acute /hronic (Susceptibility oI microorganism) Susceptibility oI microorganism)
3. Determine Immune status oI the patient 3. Determine Immune status oI the patient
4. hoose the Narrowest spectrum and lowest toxicity 4. hoose the Narrowest spectrum and lowest toxicity
5. Be aware oI the Side eIIects and development oI resistance 5. Be aware oI the Side eIIects and development oI resistance
Selection oI Antibiotics Selection oI Antibiotics
6. Use Empiric therapy routinely 6. Use Empiric therapy routinely
- - orrelate to most likely organisms orrelate to most likely organisms
7. Antibiotic 7. Antibiotic- - Bacteriocidal/Bacteriostatic Bacteriocidal/Bacteriostatic
- - Use bactericidal antibiotics iI possible Use bactericidal antibiotics iI possible
8. Previous adverse reactions 8. Previous adverse reactions
8. Focused therapy 8. Focused therapy
- - orrelate to culture and susceptibility test orrelate to culture and susceptibility test
9. ost oI therapy 9. ost oI therapy
- - Be aware oI the cost oI antibiotics Be aware oI the cost oI antibiotics
ommonly used Antibiotics in Oral Surgery ommonly used Antibiotics in Oral Surgery
Penicillin Penicillin
Penicillin Penicillin
Beta lactam antibiotic Beta lactam antibiotic
Most commonly used in oral surgery Most commonly used in oral surgery
First choice Ior odontogenic inIection First choice Ior odontogenic inIection
Bactericidal (interIeres with cell wall synthesis) Bactericidal (interIeres with cell wall synthesis)
G() cocci and rod, spirochetes, anaerobes G() cocci and rod, spirochetes, anaerobes
55- -10 adverse reaction (less common orally) 10 adverse reaction (less common orally)
0.7~10 hypersensitivity 0.7~10 hypersensitivity
Penicillin Penicillin
Precaution / ontraindications Precaution / ontraindications
Known Allergies(Anaphylactic Shock) Known Allergies(Anaphylactic Shock)
Other adverse events: GI upset, Diarrhea Other adverse events: GI upset, Diarrhea
Drug interactions: EIIect on oral contraceptives. Drug interactions: EIIect on oral contraceptives.
( (Hypothetically speaking, penicillin could impair the eIIectiveness oI birth Hypothetically speaking, penicillin could impair the eIIectiveness oI birth
control pills in a small percentage oI women. #esearchers can't rule out this control pills in a small percentage oI women. #esearchers can't rule out this
possibility, but no large studies have proved such an eIIect) possibility, but no large studies have proved such an eIIect)
Patients with poor renal Iunction Patients with poor renal Iunction
Groups oI Penicillin Groups oI Penicillin
Natural: Natural: Penicillin G (I.V), Penicillin V (PO) Penicillin G (I.V), Penicillin V (PO)
Extended spectrum Extended spectrum: : Ampicillin, Amoxicillin Ampicillin, Amoxicillin
ombine ombine - -lactamase inhibitor: lactamase inhibitor: Augmentin Augmentin
Penicillinase Penicillinase- -resistant: resistant: loxacillin, Dicloxacillin loxacillin, Dicloxacillin
Natural P Natural Penicillins enicillins
Natural P Natural Penicillins enicillins
Penicillin G used parenterally. Penicillin G used parenterally.
Phenoxymethyl penicillin (Pen V) used orally Phenoxymethyl penicillin (Pen V) used orally
Natural P Natural Penicillins enicillins
Mechanism oI Action: Inhibit cell wall synthesis Mechanism oI Action: Inhibit cell wall synthesis
Spectrum oI action : Narrow spectrum Spectrum oI action : Narrow spectrum
Mainly active against gram Mainly active against gram- -positive bacteria positive bacteria
(Staphylococci, Streptococci) (Staphylococci, Streptococci)
#esistance (beta #esistance (beta- -lactamase) increases with repeated lactamase) increases with repeated
use use
Natural Penicillin Natural Penicillin Oral Form Oral Form
W W Penicillin V K Penicillin V K is the potassium salt oI PenicillinV. is the potassium salt oI PenicillinV.
W W This chemically improved Iorm combines acid This chemically improved Iorm combines acid
stability with immediate solubility and rapid stability with immediate solubility and rapid
absorption. absorption.
Adult Dose Adult Dose
Pen VK 500 mg #28 p.o. q6h until gone Pen VK 500 mg #28 p.o. q6h until gone
Extended Spectrum Penicillins Extended Spectrum Penicillins
Amoxicillin Amoxicillin
Ampicillin Ampicillin
Extended Spectrum Penicillins Extended Spectrum Penicillins
Extended Extended- -spectrum spectrum
ModiIied to include Gram negative aerobic rods. ModiIied to include Gram negative aerobic rods.
Lack resistance to beta Lack resistance to beta- -lactamase lactamase
Active against gram Active against gram- -positive bacteria but also some positive bacteria but also some
gram gram - -negative bacteria (e.g. negative bacteria (e.g. E Coli). E Coli).
Extended Spectrum Penicillins Extended Spectrum Penicillins
Better absorbed Better absorbed
Longer halI Longer halI- -liIe liIe
Amoxicillin Amoxicillin
Adult Dose Adult Dose - - 500 mg p.o. q8h , Disp #21 500 mg p.o. q8h , Disp #21
ombine ombine - -lactamase inhibitor: lactamase inhibitor: Augmentin Augmentin
Augmentin contains a combination oI amoxicillin and Augmentin contains a combination oI amoxicillin and
clavulanate potassium. clavulanate potassium.
lavulanate potassium is a Iorm oI clavulanic acid, that lavulanate potassium is a Iorm oI clavulanic acid, that
Iights bacteria that is oIten resistant to penicillins. Iights bacteria that is oIten resistant to penicillins.
Beta Beta- -lactamase resistance and Staph. overage lactamase resistance and Staph. overage
Adult Dose Adult Dose
250 250- -500 mg amoxicillin with 125mg clavulinic acid, p.o. 500 mg amoxicillin with 125mg clavulinic acid, p.o.
q8h Disp q8h Disp #21 #21
Penicillinase #esistant Penicillin Penicillinase #esistant Penicillin - - loxacillin and loxacillin and
Dicloxacillin Dicloxacillin
These are penicillinase These are penicillinase- -resistant penicillins that have a resistant penicillins that have a
more narrow spectrum oI activity than the natural more narrow spectrum oI activity than the natural
penicillins. penicillins.
Their antimicrobial eIIicacy is aimed directly against Their antimicrobial eIIicacy is aimed directly against
penicillinase penicillinase- -producing strains oI gram positive cocci, producing strains oI gram positive cocci,
particularly particularly Staphylococcal Staphylococcal species. species.
Used in Salivary gland inIections. Used in Salivary gland inIections.
lindamycin lindamycin
lindamycin lindamycin
It is a type oI Lincosamide antibiotic It is a type oI Lincosamide antibiotic
Active against most Gram positive, and anaerobic Active against most Gram positive, and anaerobic
organisms and Staph. organisms and Staph.
Good bone penetration Good bone penetration
UseIul in severe odontogenic inIections UseIul in severe odontogenic inIections
lindamycin inhibits protein synthesis lindamycin inhibits protein synthesis
lindamycin lindamycin
Side eIIects include psuedomembranous colitis, mild Side eIIects include psuedomembranous colitis, mild
nausea and diarrhea, leukopenia, and hepatotoxicity. nausea and diarrhea, leukopenia, and hepatotoxicity.
Expensive Expensive
Adult Dose Adult Dose
300 mg p.o. q6h 300 mg p.o. q6h Disp Disp #28 #28
Metronidazole Metronidazole
Metronidazole Metronidazole
Good Ior Gram Negative anaerobic organisms Good Ior Gram Negative anaerobic organisms
Well absorbed into abscesses Well absorbed into abscesses
W W Bactericidal Bactericidal
To treat serious inIections caused by anaerobic bacteria, To treat serious inIections caused by anaerobic bacteria,
combined with combined with - -lactam A/B lactam A/B
EIIective against Bacteroides species, esp. in periodontal EIIective against Bacteroides species, esp. in periodontal
inIections inIections
Metronidazole Metronidazole
Precautions: In patients with poor hepatic Iunction, a Precautions: In patients with poor hepatic Iunction, avoid in void in
pregnant women pregnant women
W W Drug interactions: DisulIiram action with alcohol, warIarin, Drug interactions: DisulIiram action with alcohol, warIarin,
Unpleasant metallic taste Unpleasant metallic taste
ommonly used Metronidazole ommonly used Metronidazole - - Flagyl Flagyl
Adult Dose: Adult Dose:
500mg q 8 h p.o x 7 500mg q 8 h p.o x 7- -10 days 10 days
ephalosporin ephalosporin
ephalosporin ephalosporin
More resistance to penicillinase More resistance to penicillinase
G() cocci, many G( G() cocci, many G(- -) rods ) rods
Third generation: Pseudomonas Third generation: Pseudomonas aeruginosa aeruginosa
Second choice (less eIIect Ior anaerobes) Second choice (less eIIect Ior anaerobes)
First generation First generation Second generation Second generation Third generation Third generation Forth generation Forth generation
eIazolin eIazolin
U U- -SAVE SAVE- -A A
Tydine Tydine
KeIlor KeIlor
UceIaxim UceIaxim
laIoran laIoran eIepime eIepime
Macrolide Macrolide Antibiotics Antibiotics
Macrolide antibiotic Macrolide antibiotic
Erythromycin, Azithromycin and larithromycin Erythromycin, Azithromycin and larithromycin
Mainly bacteriostatic Mainly bacteriostatic
Spectrum similar to Pen V Spectrum similar to Pen V
Less eIIective against oral anaerobes Less eIIective against oral anaerobes
G () cocci, oral anaerobes G () cocci, oral anaerobes
Erythromycin Erythromycin
Erythromycin Erythromycin
Inhibits protein synthesis Inhibits protein synthesis
Side eIIects include nausea, vomiting, diarrhea, and Side eIIects include nausea, vomiting, diarrhea, and
hepatitis. hepatitis.
Adult Dose Adult Dose
Base, stearate, estolate Base, stearate, estolate
250 250- -500 mg p.o. q6h X 7 500 mg p.o. q6h X 7 - - 10 days 10 days
Antibiotics Antibiotics - - Points To Remember Points To Remember
Use the right drug. Use the right drug.
Use the right dose. Use the right dose.
Use the correct dosing schedule. Use the correct dosing schedule.
orrect duration. orrect duration.
Use a loading dose to rapidly achieve therapeutic blood levels. Use a loading dose to rapidly achieve therapeutic blood levels.
Avoid combinations oI bacteriostatic and bacteriocidal drugs. Avoid combinations oI bacteriostatic and bacteriocidal drugs.
onsider iI the inIection is present ~ 3days or iI no improvement. onsider iI the inIection is present ~ 3days or iI no improvement.
Antibiotic Prophylaxis in Oral Surgery Antibiotic Prophylaxis in Oral Surgery
Antibiotic Prophylaxis to prevent bacterial endocarditis Antibiotic Prophylaxis to prevent bacterial endocarditis
- - Indications Indications
The 2007 AHA(American Heart Association) guidelines are aimed at patients who would have the greatest The 2007 AHA(American Heart Association) guidelines are aimed at patients who would have the greatest
danger oI a bad outcome iI they developed a heart inIection. danger oI a bad outcome iI they developed a heart inIection.
Artificial heart valves Artificial heart valves
A history of infective endocarditis A history of infective endocarditis
ertain specific, serious congenital heart conditions, including ertain specific, serious congenital heart conditions, including
unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative
shunts and conduits shunts and conduits
a completely repaired congenital heart deIect with prosthetic material or device, whether placed by a completely repaired congenital heart deIect with prosthetic material or device, whether placed by
surgery or by catheter intervention, during the Iirst six months aIter the procedure surgery or by catheter intervention, during the Iirst six months aIter the procedure
any repaired congenital heart deIect with residual deIect at the site or adjacent to the site oI a any repaired congenital heart deIect with residual deIect at the site or adjacent to the site oI a
prosthetic patch or a prosthetic device prosthetic patch or a prosthetic device
A cardiac transplant that develops a problem in a heart valve. A cardiac transplant that develops a problem in a heart valve.
&pdated ADA April
Antibiotic Prophylaxis Antibiotic Prophylaxis
The 2007 AHA guidelines indicate that the Iollowing group oI The 2007 AHA guidelines indicate that the Iollowing group oI
patients no longer need any prophylactic antibiotics to prevent patients no longer need any prophylactic antibiotics to prevent
bacterial endocarditis. bacterial endocarditis.
itral valve prolapse itral valve prolapse
Rheumatic heart disease Rheumatic heart disease
Bicuspid valve disease Bicuspid valve disease
alcified aortic stenosis alcified aortic stenosis
ongenital heart conditions such as ventricular septal ongenital heart conditions such as ventricular septal
defect(VSD), atrial septal defect(ASD) and hypertrophic defect(VSD), atrial septal defect(ASD) and hypertrophic
cardiomyopathy. cardiomyopathy.
&pdated ADA April
Antibiotic Prophylaxis Antibiotic Prophylaxis For patients with joint For patients with joint
replacement replacement
The 2009 AAOS( American Academy oI Orthopedic Surgeons) The 2009 AAOS( American Academy oI Orthopedic Surgeons)
statement recommends antibiotic prophylaxis Ior patients who statement recommends antibiotic prophylaxis Ior patients who
have undergone total joint replacement beIore any invasive have undergone total joint replacement beIore any invasive
procedure that may produce bacteremia, regardless oI the length procedure that may produce bacteremia, regardless oI the length
oI time aIter the joint replacement surgery. oI time aIter the joint replacement surgery.
Antibiotic prophylaxis is Antibiotic prophylaxis is NOT NOT recommended Ior dental patients recommended Ior dental patients
with plates, pins, or screws. with plates, pins, or screws.
AAOS February 2009
Antibiotic prophylaxis Antibiotic prophylaxis - - Other onditions Other onditions
Extractions or bony surgery planned in previous radiation Extractions or bony surgery planned in previous radiation
Iield. Iield.
ancer chemotherapy ancer chemotherapy
Uncontrolled or poorly controlled diabetes. Uncontrolled or poorly controlled diabetes.
Immuno Immuno- -compromised patients where the WB is 3500 compromised patients where the WB is 3500
cells/mm3 (3.5K/mm3) or less, or the AN(Absolute cells/mm3 (3.5K/mm3) or less, or the AN(Absolute
Neutrophil ount) is 500 cells/mm3 (0.5 K/mm3) or less Neutrophil ount) is 500 cells/mm3 (0.5 K/mm3) or less
Antibiotic prophylaxis Antibiotic prophylaxis - - Other onditions Other onditions
Indwelling vascular catheter (such as Port Indwelling vascular catheter (such as Port- -aa- -caths) caths)
#enal Iailure with hemodialysis and arteriovenous shunt appliance. #enal Iailure with hemodialysis and arteriovenous shunt appliance.
AIDS AIDS
Blood dyscrasias Blood dyscrasias
Systemic lupus erythematosus Systemic lupus erythematosus
Transplant recipients (including organ transplants, bone marrow Transplant recipients (including organ transplants, bone marrow
transplants and stem cell transplants) transplants and stem cell transplants)
Antibiotic Prophylaxis - Regimen
ommon #easons Ior Antibiotic Failure ommon #easons Ior Antibiotic Failure
In Decreasing Order of Probable Importance In Decreasing Order of Probable Importance
1) Failure to surgically eradicate the source oI the inIection 1) Failure to surgically eradicate the source oI the inIection
2) Too low a blood antibiotic concentration 2) Too low a blood antibiotic concentration
3) 3) Inability oI the antibiotic to penetrate to the site oI Inability oI the antibiotic to penetrate to the site oI
inIection inIection
4) Impaired/inadequate host deIenses 4) Impaired/inadequate host deIenses
5) Patient Iailure to take the antibiotic 5) Patient Iailure to take the antibiotic
6) Inappropriate choice oI antibiotic 6) Inappropriate choice oI antibiotic
7) Limited vascularity or blood Ilow 7) Limited vascularity or blood Ilow
8) Emergence oI antibiotic resistance 8) Emergence oI antibiotic resistance
9) Delay in diagnosis 9) Delay in diagnosis
10) Incorrect diagnosis 10) Incorrect diagnosis
Antibiotics in oral surgery Antibiotics in oral surgery - - Summary Summary
Decision oI whether to give antibiotics is based on the Decision oI whether to give antibiotics is based on the
individual case. individual case.
It is important to consider the immune status oI the patient, It is important to consider the immune status oI the patient,
health status, state oI inIection (Acute/hronic), extent oI health status, state oI inIection (Acute/hronic), extent oI
surgery, side eIIects, development oI resistance and cost surgery, side eIIects, development oI resistance and cost
beIore prescribing an antibiotic. beIore prescribing an antibiotic.