1. VGH-TPE 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 Moderator 羅文良 大夫

2. 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

3. 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: 38 c), chills > Loss of function

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

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

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

7. 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. Host defense Drainage Antibiotics

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

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

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

11. 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 β-lactamase inhibitor: augmentin

12. VGH-TPE 2. Cephalosporin More resistance to penicillinase G(+) cocci, many G(-) rods Third generation: Pseudomonas aeruginosa Second choice (less effect for anaerobes) First generationSecond generationThird generationForth generation Cefazolin U-SAVE-A Tydine Keflor Ucefaxim ClaforanCefepime

13. 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

14. 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

15. VGH-TPE 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

16. 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 p’t

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

18. 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,

19. 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

20. 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

21. 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

22. VGH-TPE Side Effect of Commonly Used Antibiotics 1. Penicillinhypersensitivity 2. Cephalosporinhypersensitivity 3. Clindamycindiarrhea, pseudomembrane colitis 4. Aminoglycosidedamage to kidney, 8th neurotoxicity 5. Metronidazole*GI disturbance, seizures 6. Vancomycin8th neurotoxicity, thrombophlebitis 7. Chloramphenicolbone marrow suppression 8. Erythromycinmild GI disturbance 9. Tetracyclin*tooth discoloration, photosensitivity

23. VGH-TPE PROPHYLAXIS Indications Updated JADA 2004

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

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

26. 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

27. 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.