ANTIBIOTICS IN MAXILLOFACIAL INFECTION Resource faculty: Dr.Jyotsna Rimal Head of department Department of Oral Medicine and Radiology Dr.Iccha Kumar Maharjan Associate Professor Department of Oral Medicine and Radiology Presented by: Alka Singh BDS 2011
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ANTIBIOTICS IN MAXILLOFACIAL INFECTION
Resource faculty:
Dr.Jyotsna Rimal
Head of department
Department of Oral Medicine and Radiology
Dr.Iccha Kumar Maharjan
Associate Professor
Department of Oral Medicine and Radiology
Presented by:Alka SinghBDS 2011
CONTENTS
• INTRODUCTION
• HISTORY AND CLASSIFICATION
• PRINCIPLES FOR CHOOSING THE APPROPRIATE ANTIBIOTICS
• PRINCIPLES OF ANTIBIOTIC ADMINISTRATION
• COMBINATION ANTIBIOTIC THERAPY
• ANTIBIOTIC PROPHYLAXIS AND ITS PRINCIPLES
• MOST COMMONLY USED ANTIBIOTICS IN MAXILLOFACIAL INFECTION
INTRODUCTION
• An antibiotic is a word derived from the
Ancient Greek meaning:
(anti, i.e., "against", and bios, i.e., "life")
• DEFINITION:
SUBSTANCES PRODUCED BY MICROORGANISMS, WHICH SUPPRESS THE GROWTH OF OR KILL OTHER MICROORGANISMS AT VERY LOW CONCENTRATIONS
HISTORY
Louis Pasteur was one of the first physician who observed that bacteria kill other bacteria.
Penicillin, the first natural antibiotic discovered by Alexander Fleming in 1928.
Chain and Florey followed up this observation in 1939 which culminated the use of Penicillin in clinical use in 1941.
On the basis of spectrum of activity: - Narrow: Penicillin, Streptomycin - Broad: Ampicillin,Tetracycline,Chloramphenicol
On the basis of effect: - Bacteriostatic: Erythromycin , Tetracycline, Sulfonamides - Bactericidal: Penicillin, Cephalosporin
On the basis of antibiotics obtained from: - Fungi: Penicillin , Cephalosporin - Bacteria : Bacitracin, Polymixin B - Actinomycetes : Aminoglycoside, Chloramphenicol, tetracycline
INDICATIONS• Treatment of established infections;
• infections that persists inspite of local measures• where there is signs of systemic involvement eg.submandibular
lymphadenopathy and fever• when surgical access is difficult e.g severe trismus• when there is a diffuse , spreading infection eg.facial cellulitis
• Prophylaxis against infections:• Immunocompromised patient• Surgical procedures with a high likelihood of infections
» Maxillofacial trauma » Major or difficult surgery » When the consequences of infections are serious » Infective endocarditis» Orthopaedic joint prosthesis
Before antibiotic prescription one should know,
1. Bacterial flora causing most odontogenic infections
2 .The basic mechanism of host defenses
3. The variety of contemporary antibiotics and principles to choose
Once the decision has been made to use antibiotics as an adjunct to treating infection the antibiotics should be properly selected following a set of principles…
PRINCIPLES FOR CHOOSING ANTIBIOTIC
1) IDENTIFICATION OF THE CAUSATIVE ORGANISM
2) DETERMINATION OF ANTIBIOTIC SENSITIVITY
3) USE OF A SPECIFIC, NARROW-SPECTRUM ANTIBIOTIC
4) USE OF THE LEAST TOXIC ANTIBIOTIC
5) PATIENT DRUG HISTORY
6) USE OF A BACTERICIDAL RATHER THAN A BACTERIOSTATIC DRUG
7) USE OF THE ANTIBIOTIC WITH A PROVEN HISTORY OF SUCCESS
8) COST OF THE ANTIBIOTIC
9) ENCOURAGE PATIENT COMPLIANCE
Principles of antibiotic administration
•Proper dose (3-4×MIC)
•Proper time interval(4×t1/2)
•Proper route of administration•Consistency in route of administration •Combination in antibiotic therapy
Duration of action of antibioticsDepends on t1/2Uaual dose interval =4×t1/2As at 5t1/2 95%of drugs has been excretedEg. t1/2 for cephazolin 2 hours ,dose interval =8 hrs
Half life of some antibioticsPenicillin=30 minMetronidzole=8 hrsTetracycline=6-10 hrs(given qid)Doxycycline=18- 24 hrs(given od)
RATIONALE• To have an additive synergistic effect.
• In mixed infections when bacteria are sensitive to different drugs.
• To achieve delay in development of resistance.
• To decrease the incidence of adverse reactions to an individual drug , another drug is added so that the doses of individual drug can be reduced and possible toxic effects can be avoided
• To reduce the cost of therapy
COMBINATION ANTIBIOTIC THERAPY
Indications: when its necessary to increase the spectrum ,e.g. life
threatening sepsis of unknown cause
when increased bactericidal effect against a specific organism is desired e.g.. infection caused by group d streptococcus –penicillin and aminoglycosides is given
prevention of rapid emergence of resistance
rapidly progressive odontogenic infection e.g.. Severe cellulitis rapidly progressing posteriorly around retro pharyngeal space, bactericidal activity against Streptococcus and oral anaerobes is important ;
rational approach to treatment would be penicillin G AND metronidazole
Disadvantage of combination therapy
- Increased incidence and variety of adverse effects.
- Increased chances of super infections.
- Emergence of resistance.
- Increased cost of therapy
ANTIBIOTIC AS PROPHYLAXIS
• Use of AMA(Antimirobial) for preventing the setting in
of an infection or suppressing contacted infection
before it becomes clinically manifest.
1. Prophylaxis against specific microorganisms• Rheumatic fever- group. A Streptococci-long acting
Penicillin G• HIV infection- zidovudine+lamivudine+indinavir
(needle stick injury)2. Prevention of infection in high risk situations3. Prevention of infection in general
Ampicillin or 2 g IM or IV* 50 mg/kg IMor IVCefazolin or
Ceftriaxone1 g IM or IV
50 mg/kg IMor IV
Allergic toPenicillin orAmpicillin—Oral regimen
Cephalexin or 2g 50mg/kg
Clindamycin or 600mg 20mg/kgAzithromycin orClarithromycin
500mg 15mg/kg
Allergic toPenicillin orAmpicillin andunable to takeoral medication
Cefazolin orCeftriaxone
1 g IM or IV 50 mg/kg IMor IV
ORClindamycin
600 mg IMor IV
20 mg/kg IMor IV
*Adapted from Prevention of Infective Endocarditis: Guidelines From the American Heart Association, by the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease. Circulation, 2007
Case Report
A 22 year old boy reported to dental OPD with massive swelling of the cheek to the level of the eyelid.before the onset of swelling ,he had a toothache in molar region .his temperature was 101F ,and the skin of his cheek was warm tender and erythematous.
Diagnisis:buccal space infection
Treatment: percutaneous incision and drainage penicillin(500mg×qid× 10 days) followed by endodontic filling of offending tooth
ideal antibiotic for treating dental infections-bactericidal against gram positive cocci and the major pathogens of mixed anaerobic infections.
with minimal adverse effects and allergic reactions and relatively low in cost.
Microorganisms: S. pneumoniae, H. influenza, Bacteroides spp., Fusobacterium spp., StreptococcusDrugs used:Amoxicillin- 1st line antibiotic given for a minimum of 10 daysSecond generation cephalosporins, azithromycin and amoxicillin- clavulanate: resistant cases
7)OsteomyelitisMicrobiology: Staphylococcus aureus, S. epidermidis
Drugs:• Empirical antibiotic of choice: Penicillin• Penicillin+Metronidazole( enhances killing of anaerobes)• Penicillin resistant: Clindamycin• Azithromycin• First and second generation cephalosporins• Minocycline and doxycycline(low grade dentoalveolar infections)
ANTIBIOTICS FOR IMMUNOCOPROMISED PATIENT
suppressed immunity ↑ risk for dentoalveolar infection
Immunosuppression determined by ANC(Absolute neutrophil count)
ANC<500ml indicates severe neutropenia
gingival disease in immunosuppressed:chlorhexidine
Use of broad spectrum antibiotic is appropriate
penicillin vk,amoxicillin,clindamycin,azithromycin commonly used
Prior consultation form oncologist is recommended
SOME ANTIBIOTICS COMMONLY USED IN MAXILLOFACIAL INFECTION
Penicillin
Semisynthetic derivative of Penicillin
Cephalosporins
βlactam antibiotics
MECHANISM OF ACTION
B-lactam antibiotics Mechanism of action :Acts by inhibiting the synthesis of bacterial cell walls. It inhibits cross-linkage between the linear peptidoglycan polymer chains that make up a major component of the cell walls of both Gram-positive and Gram-negative bacteria
• Dosage: Oral suspension (100,000U/ml): 400,000-600,000 units 4-5 times/d(swish
and swallow)
• 100,000U/g cream and oinment: Apply to affected area 4-5 times/d
• Powder (50 million U): Sprinkle on tissue contact area of denture
• Common side effects: Nausea, vomiting, diarrhoea, stomach pain
SYSTEMIC ANTIFUNGAL
Use
Administration
Dosage
Side effects
Monitoring
Ketoconazole
Oral and oesophageal Candidiasis
Tablets
200mg on 1st day100mg daily for 7-10
Headache,nausea,vomiting,rash,diarrhea
Liver function test,potasium
Itraconazole
Oral and oesophagealCandidiasis
Suspension
100-200mg/10ml od 1- 2 wk
Nausea,pruritus,diarrhea,Incresed liver enzyme
Liver function test
Fluconazole
Oral and oesophageal Candidiasis
Tablets
200-400mg/d as single doseFor 7-14 days
Pruritus,vomitimg,abdominal pain
Liver function test
RESEARCH ON EFFICACY OF COMBINATION THERAPY
Title Comparison of clinical efficacy between 3-day combined clavulanate/ amoxicillin preparation treatment and 10-day amoxicillin treatment in children with pharyngolaryngitis or tonsillitis. Links Export Central Citation
Author(s) Kuroki H, Ishiwada N, Inoue N, Ishikawa N, Suzuki H, Himi K, Kurosaki T
Source Journal of infection and chemotherapy
Date of Publication 2013
Volume 19
Issue 1
Pages 12-9
Publisher Name Springer Japan (1-11-11 Kudan-kita, Chiyoda-ku, No. 2 Funato Bldg., Tokyo 102-0073, Japan)
City of Publication Japan
Abstract The efficacy of 3-day treatment with a combined clavulanate/amoxicillin preparation (Clavamox combination dry syrup for pediatric cases) and 10-day treatment with amoxicillin against pediatric pharyngolaryngitis and tonsillitis caused by Group A beta-hemolytic Streptococcus was compared. Among the patients included in the efficacy evaluation (54 from the clavulanate/ amoxicillin group and 43 from the amoxicillin group), the clinical response rate on completion of treatment was 98.1 % in the clavulanate/amoxicillin group and 92.9 % in the amoxicillin group, thus supporting the equivalent efficacy of these two therapies. The Group A beta-hemolytic Streptococcus eradication rate at approximately 1-2 weeks after completion/discontinuation of treatment was 65.4 % in the clavulanate/amoxicillin group and 85.4 % in the amoxicillin group. Even in cases from which the pathogen continued to be isolated, relapse/recurrence of clinical symptoms was seldom seen. Urinalysis, conducted to assess the presence or absence of acute glomerulonephritis, revealed no abnormality in any patient. These results suggest that 3-day treatment with this clavulanate/amoxicillin preparation is expected to provide a valid means of treating pediatric pharyngolaryngitis and tonsillitis caused by Group A beta-hemolytic Streptococcus. 2012 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.
EMBASE keywords adolescent // antibiotic sensitivity // article // body temperature // child // controlled study // diarrhea/si [Side Effect] // drug efficacy // drug eruption/si [Side Effect] // drug safety // drug withdrawal // eradication therapy // female // Haemophilus influenzae // human // *laryngitis/dt [Drug Therapy] // major clinical study // male // minimum inhibitory concentration // Moraxella catarrhalis // multicenter study // Neisseria // nonhuman // open study // patient compliance // *pharyngitis/dt [Drug Therapy] // preschool child // randomized controlled trial // respiratory tract inflammation/si [Side Effect] // school child // Streptococcus group A // Streptococcus pneumoniae // *tonsillitis/dt [Drug Therapy] // urinalysis // urticaria/si [Side Effect] // *amoxicillin/ae [Adverse Drug Reaction] // *amoxicillin/ct [Clinical Trial] // *amoxicillin/cm [Drug Comparison] // *amoxicillin/dt [Drug Therapy] // *amoxicillin plus clavulanic acid/ae [Adverse Drug Reaction] // *amoxicillin plus clavulanic acid/ct [Clinical Trial] // *amoxicillin plus clavulanic acid/cm [Drug Comparison] // *amoxicillin plus clavulanic acid/dt [Drug Therapy] // cefcapene pivoxil
Title Comparison of clinical efficacy between 3-day combined clavulanate/ amoxicillin preparation treatment and 10-day amoxicillin treatment in children with pharyngolaryngitis or tonsillitis. Links Export Central Citation
Author(s) Kuroki H, Ishiwada N, Inoue N, Ishikawa N, Suzuki H, Himi K, Kurosaki T
Source Journal of infection and chemotherapy
Date of Publication
2013
Volume 19
Issue 1
Pages 12-9
Publisher Name
Springer Japan (1-11-11 Kudan-kita, Chiyoda-ku, No. 2 Funato Bldg., Tokyo 102-0073, Japan)
City of Publication
Japan
Abstract The efficacy of 3-day treatment with a combined clavulanate/amoxicillin preparation (Clavamox combination dry syrup for pediatric cases) and 10-day treatment with amoxicillin against pediatric pharyngolaryngitis and tonsillitis caused by Group A beta-hemolytic Streptococcus was compared. Among the patients included in the efficacy evaluation (54 from the clavulanate/ amoxicillin group and 43 from the amoxicillin group), the clinical response rate on completion of treatment was 98.1 % in the clavulanate/amoxicillin group and 92.9 % in the amoxicillin group, thus supporting the equivalent efficacy of these two therapies. The Group A beta-hemolytic Streptococcus eradication rate at approximately 1-2 weeks after completion/discontinuation of treatment was 65.4 % in the clavulanate/amoxicillin group and 85.4 % in the amoxicillin group. Even in cases from which the pathogen continued to be isolated, relapse/recurrence of clinical symptoms was seldom seen. Urinalysis, conducted to assess the presence or absence of acute glomerulonephritis, revealed no abnormality in any patient. These results suggest that 3-day treatment with this clavulanate/amoxicillin preparation is expected to provide a valid means of treating pediatric pharyngolaryngitis and tonsillitis caused by Group A beta -hemolytic Streptococcus. 2012 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.