Reminder

Terms and Concepts
1. Antimicrobial or anti-infective-drugs used to prevent or treat infections caused by pathogenic (disease-producing) microorganisms. Include antibacterial, antiviral, and antifungal drugs. 2. Antibacterial or antibiotic-usually refer only to drugs used in bacterial infections. 3. Antiviral- drugs used to treat viral infections. 4. Antifungal- drugs used to treat fungal infections. 5. Antiparasitic- drugs used to treat parasite infections or infestations.

Reminder
6. Broad Spectrum- antibacterial drugs that are effective against several groups of microorganisims. 7. Narrow Spectrum- antibacterial drugs which are effective against only a few groups of microorganisms. 8. Bacteriocidal- action of an antibacterial drug in that it kills microorganisms. 9. Bacteriostatic- action of an antibacterial drug in that it inhibits growth of the microorganism. 10. Superinfection- a new or secondary infection that occurs during antimicrobial therapy of a primary infection.

Terms
11. Antibiotic combination therapy- use 2 or more drugs in combination to treat infections known or thought to be caused by multiple microorganisims, to get a synergistic effect, to prevent emergence of drug-resistance organisims, or to treat clients whose immune system is suppressed or client with bone marrow or organ transplant.

Mechanism of Action:
1. Inhibition of Cell Wall Synthesis 2. Disruption of Cell Membrane 3. Inhibition of Protein Synthesis 4. Interference with Metabolic Processes

NB: Bactericidal Bacteriostatic

Table 1 Summary of some common antibiotics
Beta-lactams (penicillins, cephalosporins) Broad-spectrum antibiotics*. Flucloxacillin and coamoxiclav are effective against some penicillinresistant organisms.

Aminoglycosides Effective against gram negative bacteria e.g. (streptomycin, Pseudomonas. Reserved for serious infections e.g. gentamicin, tobramycin) septicaemia, meningitis, hospital-acquired pneumonia. Glycopeptides (vancomycin, teicoplanin) Tetracyclines (doxycycline, minocycline) Effective against Staphylococci resistant to other drugs, including many strains of MRSA**.

Broad-spectrum antibiotics

Macrolides (erythromycin) Metronidazole Quinolones (ciprofloxacin) Antitubercular drugs (rifampicin, isoniazid, rifabutin, streptomycin) sulphonamides (cotrimoxazole, trimethoprin)

Broad-spectrum antibiotics, prescribed if patient is allergic to penicillins. Prescribed for surgical prophylaxis, bacterial vaginosis, pressure sores, leg ulcers. Effective against gram negative bacteria, gonorrhoea, gastro-intestinal infections. Reserved for treatment/ containment of tuberculosis(TB). Co-trimoxazole is reserved for serious infections associated with HIV/AIDS. Trimethoprin is prescribed for urinary tract infections.

* Broad spectrum antibiotics are used when the infectious agent is unknown. Narrow spectrum antibiotics are prescribed when the micro-organisms have been identified from tissue samples. ** Many bacteria produce an enzyme which destroys beta lactam antibiotics. In addition to this, MRSA (methicilin-resistant Staphylococcus aureus) produces an inactivating protein which confers resistance to most other antibiotics.

Indications for the use of antibacterials
(together with appropriate surgical drainage or other measures) ± Cervical fascial space infections; ± Osteomyelitis and osteoradionecrosis; ± Odontogenic infections in ill, toxic or susceptible patients (e.g. immunocompromised); ± Acute ulcerative gingivitis; ± Some instances of:
‡ pericoronitis; ‡ dental abscess; ‡ dry socket;

Prophylactic use of Antibacterials
± infective endocarditis ; ± in cerebrospinal rhinorrhoea; ± in compound facial or skull fractures; ± in major oral and maxillofacial surgery (e.g. osteotomies or tumour resection); ± In surgery in immunocompromised or debilitated patients, or following radiotherapy to the jaws.

Drainage is essential if there is pus: antibacterials will not remove pus;

Routes of administration
‡ Oral preparations of antimicrobials are preferred in most instances. ‡ Topical antibacterials, should usually be avoided, as they may produce sensitization and may cause the emergence of resistant strains.

Routes of administration
‡ Parenteral administration of antibacterials may be indicated where:
± no oral preparation is available; ± high blood levels are required rapidly (e.g. serious infections); ± the patient cannot or will not take oral medications (e.g. unconscious patient); ± the patient is to have a GA within the following 4 h.

Which Antibacterial??
‡ Anaerobes are implicated in many odontogenic infections, and these often respond to penicillins or metronidazole ‡ Odontogenic infections are typically polymicrobial. ‡ Most bacteria causing odontogenic infections are penicillin-sensitive. Oral phenoxymethyl penicillin is usually effective and is cheap.

‡ Amoxicillin is active orally (absorption better than ampicillin). ‡ Not resistant to penicillinase. ‡ Contraindicated in penicillin hypersensitivity ‡ 500 mg PO q6-8hr

‡ Augmentin is a mixture of amoxicillin and potassium clavulanate
± inhibits some penicillinases and therefore is active against most Staph. aureus; ± inhibits some lactamases and is therefore active against some Gram-negative and penicillin-resistant bacteria ‡ Contraindicated in penicillin hypersensitivity.

‡ Metronidazole may be preferred as an alternative to a penicillin if the patient is allergic, or has had penicillin with the previous month (resistant bacteria). ‡ Suppositories are effective. Contraindicated in pregnancy. ‡ 500 mg PO, q6-8hr ‡ with meals. ‡ Use only for 7 days

‡ Erythromycin is an alternative for penicillin-resistant infections where a Beta-lactamase producing organism is involved. However, many organisms are now resistant to erythromycin or rapidly develop resistance and its use should therefore be limited to short courses. ‡ 250-500 mg PO QID

‡ Clindamycin is no more effective than penicillins against anaerobes ‡ Should not be used for routine treatment of odontogenic infections. ‡ Serious side-effects, mainly antibioticassociated colitis. So limited use. ‡ Clindamycin is used for prophylaxis of endocarditis in patients allergic to penicillin ‡ 150-450 mg PO q6-8hr

‡ Tetracyclines have a broad antibacterial spectrum, but of the many preparations there is little to choose between them. ‡ Use of Tetracyclines may predispose to candidiasis. ‡ Useful in Acute ulcerative gingivitis. ‡ 100 mg PO BID ‡ Contraindicated in pregnancy and children up to at least 7 years

‡ Cephalosporins are broad-spectrum, expensive antibiotics with few absolute indications for their use in dentistry, ‡ Gentamicin is reserved for use in pregnancy and myasthenia gravis. Reduce dose in renal disease, 5 mg/kg daily.

Which Antibacterial??
‡ Pus (as much as possible) should be sent for culture and sensitivities, but antimicrobials should be started immediately following sampling, if they are indicated.

Antibacterial Teatrtment Failure
‡ patient non-compliance ‡ local factors (e.g. foreign body); ‡ unusual type of infection;.

Antibacterial Teatrtment Failure
‡ inadequacy of drainage of pus; ‡ inappropriateness of the drug or dose; ‡ antimicrobial insensitivities of microorganism (staphylococci are now frequently resistant to penicillin and some show multiple.

Antibacterial Teatrtment Failure
‡ impaired host defences (unusual and opportunistic infections are increasingly identified, particularly in the immunocompromised patient); ‡ non-infective cause for the condition! ‡ In serious or unusual cases of infection, consult the clinical microbiologist.

‡ ‡ ‡ ‡

Candida Albicans Local Factors Systemic Factors Antifungals are used to treat oral or oropharyngeal fungal infections but underlying predisposing factors should first be considered.

‡ In immunocompromised patients, antifungals are used for prophylaxis, ‡ In immunocompromised patients antifungals are increasingly administrated systemically (azoles)

‡ Antifungal resistance is now a significant problem to immunocompromised persons, especially those with a severe immune defect, who may show Candida species resistant to fluconazole and, sometimes, to other azoles.

‡ Antifungal resistance may sometimes be overcome by using higher drug doses, or changing the agent ‡ Antifungals should be continued for at least 1 week following resolution of clinical manifestations.

‡ Nystatin is not active orally, very active ative topically. ‡ Pastilles taste better than lozenge.
‡ Dose qid ± 500 000 unit loz-enge, ± 100 000 unit pastille or ± 100 000 unit per mL of suspension.

‡ Amphotericin is close to Nystatin characteristics ‡ Topically applied 10 to100 mg q6h

‡ Miconazole is active topically and orally. ‡ Also has antibacterial activity. ‡ Interacts with terfenadine cisapride, astemizole and warfarin. ‡ Avoid in pregnancy, porphyria ‡ Dose
± 250 mg tablet q6h ± 25 mg/ml gel (Daktarin®) used as 5 mL q6h for 14 days

‡ herpes viruses are associated with most oral viral infections, ‡ Also (papillomaviruses, and enteroviruses). ‡ HIV and other viruses may also cause orofacial lesions.

‡ Management of viral infections is predominantly supportive, as, at present, there are few antiviral agents of proven efficacy. ‡ Most antivirals will achieve maximum benefit if given early in the disease.

‡ Systemic aciclovir should be used with caution in pregnancy and renal disease. Aciclovir may cause liver enzymes, and urea, rashes and CNS effects. ‡ Famciclovir should also be used with caution in pregnancy and renal disease. Famciclovir may cause headache and nausea. ‡ Topical Forms (cream) are preferred in oral medicine
± 5 application by days ± 5-10 days

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