Antibiotic Use In Dentistry

Jason Sriwijaya
Clinical Pharmacology Department
Medical Faculty Hasanuddin University
 Antibiotic Strategies
 Cardinal Rules: 4’D
1) Use the right Drug.
2) Use the right Dose.
3) De escalation to pathogen directed therapy
4) Correct Duration.
 Hard and Fast—Especially early. Why?
 Use a loading dose to rapidly achieve therapeutic blood
levels.
 Avoid combinations of bacteriostatic and bacteriocidal
drugs.
 Considerations
 Gram Positive?
 Gram Negative?
 Mixed Infection?
 Anaerobes?
 Consideration for Antimicrobial
Therapy

Ramasamy A, The International Arabic Journal of Antimicrobial Agents 2014 ; 4: 1-15

 Discussion: Antibiotic Choice

 Narrow Spectrum?
 Extended/Broad Spectrum?
 Anaerobes? Consider if the infection is
present > 3days or if no improvement.
 Narrow Spectrum Antibiotics
 Specific for the pathogen.
 Fewer disturbances of non-pathogenic
bacteria.
 Fewer side effects.
 Rapid response for sensitive organisms.
 Ex: Pen VK, Pen G, Erythromycin
 Broad Spectrum Antibiotics
 Affects both Gram + and Gram – bacteria,
better for mixed infections.
 May give up some effectiveness for Gram +
to gain effectiveness for Gram -.
 Examples: Amoxicillin, Ampicillin
 Common Pathogens
Necrotic pulp and apical abscesses
Obligate anaerobic bacteria
Gram negative rods
Prevotella & porphyomonas spp.
Fusobacterium spp.
Campylobacter rectus
Gram positive rods
Eubacterium spp.
Actinomycetes spp.
Gram positive cocci
Peptostreptococcus spp.
Facultative anaerobic bacteria
Gram positive cocci
Strep and Entercoccus spp.
 Common Pathogens

 Periodontal Diseases
Gingivitis
Fuso, strep, & actinomycetes
Adult peritonitis
Bacteroides, porphyomonas,
peptostreptococcus & prevotella
Acute necrotizing ulcerative gingivitis
Spirochetes, prevotella, fuso
Localized juvenile periodontitis
Actinobacillus
 MICROBIOLOGY

 Most oral infections are mixed in origin

consisting of aerobic and anaerobic gram
positive and gram negative organisms
 Anaerobes predominant (75%)
 Let’s Talk About Resistance
 Three main types
– Chromosome mediated
 Spontaneous mutations
 Non-major form of drug resistance
 Rarely lead to complete resistance
– Plasmid mediated (conjugation)
 VERY important from clinical standpoint
 Mostly gram negs
 Mediate resistance to multiple drugs
 High transfer rate from cell to cell
– Transposon (transduction and transformation)
 Phage mediated
 Clinically important for Gram +
 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.

Drainage

Host defense Antibiotics

Antibiotic Choices
Antibiotics Useful in dental
Practice
Management of Common Dental Conditions
Classification of Antibiotics
 ß-Lactams
 Natural penicillins
– Pen VK and Pen G
 MOA: Inhibit cell wall synthesis
 Dose: 250-500 mg qid x 7-10 days
 Contraindications:
– Allergies
– Poor renal fxn
 Adverse events: GI upset
 Drug interactions: oral contraceptives
 Pregnancy category B
 ß-Lactams
 Natural penicillins
– Pen VK and Pen G
 Bactericidal
 Allergic reaction: rare (4 per 100,000)
 Spectrum:
– Strep, staph, enterococcus, neiseria, treponema, listeria
 Resistance:
– Mostly staph (>80%)
 ß-Lactams
 Amino-penicillins
– Amoxicillin, ampicillin
 MOA: Inhibit cell wall synthesis
 Dose: 250-500 mg q 8 h x 7-10 days
 Contraindications:
– Allergies
– Poor renal fxn
 Adverse events: GI upset
 Drug interactions: oral contraceptives
 Amoxicillin and clavulanic acid (Augmentin)
 ß-Lactams
 Amino-penicillins
– Amoxicillin, ampicillin
 Bactericidal
 “ampicillin” rash (4-10%)
 Spectrum:
– Strep, staph, enterococcus, neiseria, treponema, listeria,
E. coli, proteus, H. Flu, shigella, salmonella
 Resistance:
– Entero, citro, serratia, proteus vulagris, provedincia,
morganella, pseudomonas aeriginosa, acinetobacter
 Cephalosporins
 Cephalexin (Keflex)
– MOA: Inhibit cell wall synthesis
– Dose: 250-1000mg q 6 h x 7-10 days
– Contraindications:
 Allergies
 Poor renal fxn
– Adverse events: mild GI
– Drug interactions: probenecid
– Pregnancy category B
 Cephalosporins
 Cephalexin (Keflex)
– Bactericidal
– Spectrum:
 Gram +
– Resistance:
 Methicillin resistant gram +
– Low cross sensitivity with PCN
 Lincosamides
 Clindamycin
– MOA: binds to the 50S ribosomal subunit and inhibits
protein synthesis
– Dose: 100-450mg q 6 h x 7-10 days
– Precautions:
 Poor hepatic fxn
– Adverse events: GI upset, pseudomembraneous
colitis
– Drug interactions: neuromuscular blocking agents
– Pregnancy category B
 Lincosamides
 Clindamycin
– Bactericidal or static depending on
concentration
– Spectrum:
 Gram +, anaerobes, parasites
– Resistance
 Enteroccocus

*Clostridium diff. pseudomembranous colitis!!

 Macrolides
 Azithromycin
– MOA: bind to the 23S rRNA in the 50S subunit ribosome
– Dose: 250-500 mg/day x 5-10 days
– Precautions :
 Poor hepatic fxn
– Adverse effects: GI
– Drug interactions: Cytochrome P-450 (Remember
Seldane?)
– Pregnancy category B
 Macrolides
 Azithromycin, clarithromycin
– Bactericidal
– Spectrum:
 Gram +, gram -, anaerobes
– Resistance:
 B. fragilis, and strep pneumo
 Tetracyclines
 Doxycycline
– MOA: inhibit protein synthesis by preventing aminoacyl
transfer RNA from entering the acceptor sites on the
ribosome
– Dose: 100mg qd-bid x 7-14 days
– Contraindications:
 Food
 pregnancy
– Adverse events: GI
– Drug interactions: anti-epileptics
– Pregnancy category D
 Tetracyclines
 Doxycycline
– Bacteriostatic
– Spectrum:
 Broad, Gram +, -, anaerobes, aerobes, and
spirochetes
– Resistance:
 Widespread, cross resistance
– PHOTO SENSITIVITY!!!
 Nitroimidazoles
 Metronidazole
– MOA: reduced intermediate interacts and
breaks the bacterial or parasitic DNA
– Dose: 250-1000 mg q 6-8 h x 7-10 days
– Precautions : poor hepatic fxn
– Adverse events: HA, N/V/D
– Drug interactions: EtOH, warfarin, Li+
– Pregnancy category D
 Nitroimidazoles
 Metronidazole
– Bactericidal
– Spectrum:
 Gram - anaerobes
– Resistance:
 Rare, H. Pylori?
– Unpleasant metallic taste
 Fluoroquinolones
 Ciprofloxacin
– MOA: Inhibition of DNA gyrase, and Topo II
– Dose: 250-500 mg qd x 7-10 days
– Contraindications: <18 yrs old, pregnancy
– Adverse events: spontaneous tendon rupture
– Drug interactions: probenecid, warfarin
– Pregnancy category C
 Fluoroquinolones
 Ciprofloxacin
– Bactericidal
– Spectrum:
 Very broad except B. frag
– Resistance:
 MRSA, MRSE
 COMMONLY USED A/B

 Mechanism of the antibiotics

 Antibiotics commonly used in
application to odontogenic infections.
Antibiotic prophylaxis against bacterial
endocarditis in oral procedures (AHA).
 Antibiotics use in pregnancy
 The United States Food and Drug Administration (FDA) has
established four levels of drug risk during pregnancy: (A) without
demonstrated risk;
 (B) without effects in animals, though with undemonstrated
innocuousness in humans;
 (C) no studies conducted in either animals or humans, or
teratogenic effects recorded in animals without due evaluation in
humans; and
 (D) teratogenic effects upon the fetus – use of the drug being
conditioned to the obtainment of benefit that outweighs the risks.
 (X) in turn contemplates teratogenic effects that outweigh any
possible benefit derived from the drug.
 No antibiotic corresponds to group A.
 Group B (i.e., warranting caution with treatment
during pregnancy) contains the following
antibiotics: azithromycin, cephalosporins,
erythromycin, metronidazole and penicillins
with or without beta-lactamase inhibitors.
 Group C in turn includes clarithromycin, the
fluorquinolones and the sulfa drugs (including
dapsone).
 Group D contains the aminoglycosides and
tetracyclines (38).
ADA/AAOS Advisory
Statement
July 1997
 AAOS Statement
Antibiotic prophylaxis is NOT
recommended for dental patients
with plates, pins, or screws, nor is
it routinely recommended for
MOST dental patients with TOTAL
JOINT REPLACEMENTS.
 AAOS recommendations
 Prophylaxis recommended
– Total joint replacement within the last two years
AND:
 Compromised immune system OR
 Type 1 DM OR
 Previous prosthetic joint infections OR
 Malnourishment OR
 Hemophilia
 AAOS recommendations

 Prophylaxis antibiotic recommendations

– Same as AHA OR
– No specific regimen recommended
– Keflex is often the first drug of choice
 Legal Considerations
 I forgot my antibiotics!
 Animal studies have shown antibiotics are
effective up to 2 hours after the procedure.
 Differentiate between prophylaxis vs.
treatment of an early infection.
 Take into consideration patient’s risk factor
In Summary….
 Principles of Antibiotic Therapy

 Therapeutic effectiveness
– Clinical indications
 Pharmcodynamics, pharmacokinetics
– Age and extent of infection
 Patient factors
 Age, allergies, compliance, pregnancy risk
 Patient function
– Renal, hepatic, immunosuppresion, route
applicability
 Cost
– Brand name, length of course, alternatives?
 Cost

Drug Name Cost of Therapy Rp (~10 Days) Generic if Available

Amoxicillin 15000

Ampicillin 15000

Cefadroxil 22500

Clindamycin 60000

Azithromycin 200000

Lincomycin 30000

AmoxiClav 450000

Doxycycline 20000

Metronidazole 15000

Ciprofloxacin 20000