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ANTIBIOTICS IN ORAL &

MAXILLOFACIAL SURGERY
ANTIBIOTIC TERMINOLOGY

DEFINITION SUBSTANCES DERIVED FROM


MICROORGANISMS WHICH SUPPRESS THE GROWTH / KILL
THE MICROORGANISMS AT A VERY LOW CONCENTRATION
OR
A CHEMICAL SUBSTANCE PRODUCED BY
MICROORGANISMS HAVING THE PROPERTY OF INHIBITING
THE GROWTH OF OR DESTROYING OTHER
MICROORGANISMS IN HIGH DILUTION

CHEMOTHERAPY :TREATMENT OF SYSTEMIC INFECTIONS


WITH SPECIFIC DRUGS THAT SELECTIVELY SUPPRESS THE
INFECTING MICROORGANISM WITHOUT SIGNIFICANTLY
AFFECTING THE HOST.
CLASSIFICATION
BASED ON TYPE OF ORGANISM THEY ACT
UPON:
1. Antibacterial - penicillin
amino glycosides
erythromycin
2. Antifungal - griseofulvin
amphotericin
ketoconazole
3. Antiviral- acyclovir
amantidine
zidovudine
4. Antiprotozoal- metronidazole
chloroquine
CHEMICAL STRUCTURE
Sulfonamides and related drugs :
○ Sulfones - Dapsone (DDS)
○ Para amino salicylic acid (PAS)
Diaminopyrimidines
○ Trimethoprim, pyrithamine
Quinolones
○ Nalidixic acid, Norfloxacin, Ciprofloxacin etc
β - lactam antibiotics
○ Penicillins, cephalosporins, monobactams, carbapenems
Tetracyclines
○ Oxytetracycline, Doxycycline etc
Nitrobenenzene Derivative
○ Chloramphenicol
Aminoglycosides
○ Streptomycin Gentamycin, Neomycin etc
- Macrolide antibiotics
○ Erythromycin, Roxithromycin, Azithromycin etc
Polypeptide antibiotics
○ Polymyxin - B, colistin, Bacitracin, Tyrothricin etc

Glycopeptides
○ Vancomycin, Teicoplamin

Oxazolidinase
○ Linezolid

Nitrofuran derivatives
○ Nitrofurantoin, Furazolidine

Nitroimidazoles
○ Metronidazole, Tinidazole

Polyene antibiotics
○ Nystatin, Amphotericin - B, Hamycin

Azole derivatives
○ Miconazole, clotrimazole, ketoconazole, fluconazole
SPECTRUM OF ACTIVITY

Narrow spectrum
Penicillin G, streptomycin and
erythromycin.
Broad spectrum
Tetracyclines, chloramphenicol.
Extended spectrum
Semi synthetic Penicillins, new
cephalosporins, aminoglycoside.
CLASSIFICATION
(v) TYPE OF ACTION:
Primarily Bacteriostatic Primarily
Bactericidal
Sulfonamides Penicillins , Cephalosporins,
Tetracyclines Aminoglycosides,
Chloramphenicol Vancomycin,
Erythromycin Ciprofloxacin, Isoniazid ,
Ethambutol Rifampin, Cotrimoxazole,

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SOURCE
Fungi
Penicillin, Cephalosporin, Griseofulvin.
Bacteria
Polymyxin B, Colistin, Bacitracin, Tyrothricin
Aztreonam.
Actinomycetes
Aminoglycosides, Tetracyclines, Chloramphenicol,
Macrolides, Polyenes.
PRINCIPLES OF ANTIBIOTIC THERAPY
PRINCIPLE 1: DETERMINE THE SEVERITY OF
INFECTION

PRINCIPLE 2: EVALUATE STATE OF


PATIENT’S HOST DEFENSE MECHANISMS

PRINCIPLE 3: DETERMINE WHETHER


PATIENT SHOULD BE TREATED BY GENERAL
DENTIST OR SPECIALIST

PRINCIPLE 4: TREAT INFECTION SURGICALLY


PRINCIPLE 5 : SUPPORT THE PATIENT MEDICALLY

PRINCIPLE 6 : CHOOSE AND PRESCRIBE


APPROPRIATE ANTIBIOTIC

PRINCIPLE 7 : PROPER ANTIBIOTIC


ADMINISTRATION

PRINCIPLE 8 : MONITORING THE PATIENT


DETERMINATION OF THE SEVERITY OF
INFECTION

Complete history-Time of onset


-Duration of infection
-Rapidity of progress

Eliciting patient’s symptom

Physical examination
2)EVALUATE STATE OF
PATIENT’S HOST DEFENSE
MECHANISMS
Uncontrolled metabolic diseases
e.g. - uremia, alcoholism, malnutrition, severe diabetes
(decreased function of leucocytes, decreased
chemotaxis, decreased phagocytosis, decreased
bacterial killing)

2- Immuno Suppressing diseases


Interfere with host defense mechanism
e.g.- leukemias, lymphomas, malignant tumours

3- Immuno Supressing drugs


e.g.- cancer chemotherapeutic drugs
Immunosuppressive agents
3)DETERMINE WHETHER PATIENT
SHOULD BE TREATED BY GENERAL
DENTIST OR SPECIALIST

Criteria for referral to a specialist :


1.Rapid progressive infection
2.Difficulty in breathing
3.Difficulty in swallowing
4.Fascial space involvement
5.Elevated temperature(>101 degree F)
6.Severe jaw trismus(<10mm)
7.Toxic appearance
4)TREAT INFECTION SURGICALLY
GOALS :
1.To remove the cause of infection
2.To provide drainage of accumulated
pus and necrotic debris
MODES :
1.Endodontic treatment
2.Extraction
3.Incision and drainage
+extraction\ endodontic treatment

Drainage of pus
Reduction in tissue tension
Improved local blood supply and increased
delivery of host defenses
5)SUPPORT THE PATIENT
MEDICALLY
Odontogenic infection

Pain and swelling

No adequate fluid and nutritional


intake

Depressed host defenses

Adequate analgesics and fluid intake


PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

(I) IDENTIFICATION OF THE CAUSATIVE


ORGANISM:-

Scientifically – culture in lab


Empirically - knowledge of
the pathogenesis & clinical
presentation.
Initial empirical therapy
instituted with a fair degree of reliability.

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

Typical odontogenic infection is caused by a mixture of aerobic


& anaerobic bacteria (70%)
Aerobic bacteria - 5% (gm positive cocci)
Pure anaerobic bacteria - 25% (gm positive cocci - 30% & gm
negative rods - 50%)
All are sensitive to penicillin & penicillin like drugs, but
Fusobacterium frequently resistant to erythromycin (apprx. 50%)

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PRINCIPLES FOR CHOOSING
APPROPRIATE ANTIBIOTIC

CULTURES SHOULD BE PERFORMED:-

1. Pt. with an infection has compromised host defenses


2. Received appropriate treatment for 3 days without
improvement
3. Postoperative wound infection
4. Recurrent infection
5. Actinomycosis is suspected, or
6. Osteomyelitis is present

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PRINCIPLES FOR CHOOSING
APPROPRIATE ANTIBIOTIC

(II) DETERMINATION OF ANTIBIOTIC


SENSITIVITY:-
Not responded to initial antibiotic therapy or a postoperative
wound infection - causative agent identified & the antibiotic
sensitivity determined.

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

The result of these studies provide the information needed to


prescribe the most appropriate antibiotic.

Penicillin is excellent for treatment of streptococcus infection & is


good to excellent for the major anaerobes of odontogenic
infections.
Erythromycin - Streptococcus, Peptostreptococcus & Prevotella

but is ineffective against Fusobacterium.

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

Clindamycin - streptococcus & major anaerobic groups.


Cephalexin - moderately active against streptococcus & is good to
excellent against anaerobes.

Metronidazole - no activity against streptococcus but has


excellent activity against anaerobes.

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

(III) USE OF A SPECIFIC, NARROW SPECTRUM


ANTIBIOTIC:-

Advantages -
less chances of developing resistant organisms.
E.g. streptococcus sensitive to penicillin , cephalosporin and
tetracycline.
Minimizes the risk of super infections.
E.g. moniliasis and gram negative pneumonias

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

(IV) USE OF THE LEAST TOXIC ANTIBIOTIC:-


Equally effective but less toxic drugs have to be used.

E.g. bacteria causing odontogenic infection susceptible to both

penicillin and chloramphenicol.

More toxicity present with the latter drug.

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

(V) PATIENT DRUG HISTORY:-


Previous allergic reactions
Previous toxic reactions
Allergy rate to penicillin - 5 %
Cross sensitivity Penicillins and cephalosporins.
Toxic reactions - identify the drug and precise reaction
Likely to happen again.

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

(Pharmacologic factors in antibiotic selection)


(VI) USE OF A BACTERICIDAL RATHER THAN A
BACTERIOSTATIC DRUG:-
Advantages:
1. Less reliance on the host resistance

2. killing of the bacteria by the antibiotic itself

3. Faster results

4. Greater flexibility with dosage intervals.

Used especially when the host defenses are low.

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

(VII) USE OF THE ANTIBIOTIC WITH A


PROVEN H/O SUCCESS:-
Critical observation of the clinical effectiveness over a prolonged
period -----assessment of
Frequency of treatment success and failures
Frequency of adverse reactions
Frequency of side effects
Standards for use

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

(VIII) COST OF THE ANTIBIOTIC:-

Difficult to place a price tag on health.


In some situations, more expensive antibiotic is the drug of
choice.
In other situations, there may be a substantial difference in price
for drugs of equal efficacy.
Surgeon should consider the cost of the antibiotic prescribed.

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PRINCIPLES FOR CHOOSING APPROPRIATE
ANTIBIOTIC

(IX) ENCOURAGE PATIENT COMPLIANCE:-


Dosage interval that encourages compliance
OD 80%
BID 69%
TID 59%
QID 35%
Non-compliant start feeling better
3-5 days 50%
>7 days 20%
Antibiotic that would have the highest compliance would be the
drug given OD for 4 or 5 days.

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Indications for use of
antibiotics
Rapidly progressive swelling
Diffuse swelling
Compromised host defenses
Involvement of facial spaces
Severe pericoronitis
Osteomyelitis
Use of antibiotics is not
necessary
Chronic well localized abscess

Minor vestibular abscess

Dry socket

Mild pericoronitis
INDICATIONS OF EMPIRICAL
ANTIBIOTIC THERAPY :
The site and feature of the infection have been
well defined.

The circumstances leading to the infection are


well known.

Organisms that most commonly cause such


infections.
EMPIRIC ANTIBIOTIC TREATMENT
Early infection (first 3 days of symptoms and mildly
immunocompromised)
Penicillin
Clindamycin
Cephalexin

Late infection (After 3 days of symptoms or moderately to severely


immunocompomised)
Clindamycin
Revicillin and metranidazole.
Ampicillin and sulbactam.
Cephalosporin (first or second generation).

-Mild, moderate and severe compromised based on CD4 / viral


loads, glycemic control, and the degree of alcoholic related disease.
7)PROPER ANTIBIOTIC ADMINISTRATION

Proper dose.
Proper time interval.
Proper route of administration.
Combination antibiotic therapy.
PRINCIPLES OF ANTIBIOTIC THERAPEUTIC DOSE

(I) PROPER DOSE:-


Dose - 3 to 4 times the MIC
for e.g. penicillinase producing staphylococcus -
MIC 6 µg/ ml , plasma level - 18µg /ml
Administration of doses above this level - increases the
likelihood of toxicity & is wasteful.
Sub therapeutic levels - mask the infection, recurrence.

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DRUG DOSE CALCULATION
BASED ON BODY SURFACE AREA

Individual dose = BSA[m2] x adult dose


1.7
BASED ON BODY WEIGHT

Individual dose = BW[kg] x average


70 adult dose
IN PEDIATRICS

YOUNG’S FORMULA :

CHILD DOSE = Age x adult dose


Age + 12
DILLING’S FORMULA :

CHILD DOSE = Age x adult dose


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NEONATES AND INFANTS

Greater percentage of body weight


compared with body water

Greater volume of distribution


Increased serum half lives
Reduced gastric emptying
Reduced plasma protein binding
Reduced GFR
ELDERLY

Reduced host defenses


Underlying illness
Reduced total body water
Lean body mass
Reduced cardiac output
Reduced gastric emptying time
Decreased renal function
LOADING DOSE; This is a single or few
quickly repeated doses given in the beginning to
attain target concentration capacity.

MAINTAINANCE DOSE: This is the dose


repeated at specific interval after attainment of
target cycles per second
ANTIBIOTIC LOADING DOSES

INDICATIONS :
1.The half-life of the antibiotic is longer
than 3-hours.
2. A delay of longer than 12-hours to
achieve therapeutic blood levels is unacceptable.

Because most acute orofacial infections


begin and peak rapidly
DURATION OF ANTIBIOTIC DOSING

The ideal antibiotic duration is the shortest


time that will prevent both clinical and
microbiological relapse.

Clinical improvement of the patient


Remission of infection.
MISCONCEPTIONS IN LONGER DURATION OF
ANTIBIOTICS

Prolonged antibiotic therapy destroys resistant


bacteria.
Prolonged antibiotic therapy is necessary to
prevent rebound infections.
The dosage and duration of therapy can be
extrapolated from one infection to another.
The prescriber knows how longer the infection
will last.
PRINCIPLES OF ANTIBIOTIC THERAPEUTIC DOSE

(II) Proper time interval:-


Established plasma t 1/2 - one half of the absorbed dose is
excreted.
Usual dosage interval for therapeutic use of antibiotics - Four
times the half life.
E.g. cefazolin t1/2 - 2 hours.

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PRINCIPLES OF ANTIBIOTIC THERAPEUTIC DOSE

Antibiotics once prescribed should be taken at least for a


period of 4 to 5 days. In severe infections prolonged use
may be necessary.

The antibiotic once prescribed should not be


changed until an adequate time lapse, i.e. 48 to 72 hours,
for evidence of effectiveness or otherwise.

After the infection is successfully resolved, treatment


should be continued for a period of 48 to 72 hours

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PRINCIPLES OF ANTIBIOTIC THERAPEUTIC DOSE

(III) Proper route of administration:-


In some infections, only the parenteral route produces necessary
serum level of antibiotic

For e.g. Penicillin V oral - 2 gm


Plasma level - 4 µG/ mL

Oral route - variable absorption.

Serious well established infection - parenteral route

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PRINCIPLES OF ANTIBIOTIC THERAPEUTIC DOSE

(IV)Consistency in Route of Administration:-


After initial response , immediate discontinuation of parenteral
route - Recurrence

Maintenance of peak blood levels of antibiotic for an adequate


period is important - max. tissue penetration & effective
bactericidal action.

After the 5th day of parenteral administration, the blood levels


achievable with oral administration are usually sufficient.

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PRINCIPLES OF ANTIBIOTIC THERAPEUTIC DOSE

(V) Combination Antibiotic therapy:-


Life threatening sepsis of unknown cause
Increased bactericidal effect against a specific µorg is desired.
E.g. treatment of infections caused by enterococcus
Prevention of rapid emergence of resistant bacteria
E.g. tuberculosis
Empiric treatment of certain odontogenic infections
E.g. Penicillin G & Metronidazole

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MINIMAL INHIBITORY CONCENTRATION
Is the lowest antibiotic concentration that prevents growth
of microorganism after an incubation period of 18 - 24
hours incubation period with a standard inoculum of 104
to 105 cfu/ml

MINIMAL BACTERICIDAL CONCENTRATION


Is the lowest concentration of drug that causes the
complete destruction of the organisms or permits survival
of less than 0.1% of the inoculum
RULE OF THUMB

The concentration of the antibiotic in the


blood should exceed the MIC by a factor
of 2-8 times to offset the tissue barriers
that restrict access to the infected site.