Antibiotics in O.S

ROLE OF ANTIBIOTICS IN ORAL SURGERY
DEPARTMENT OF ORAL AND MAXILLO-FACIAL SURGERY
CONTENTS
Introduction Factors determining the efficiency of antimicrobial agents Classifications of antimicrobials agents Principles of antibiotic therapy Principles of antibiotic administrations -lactam antibiotics Erythromycin Sulfonamides and Trimethoprim Cotrimoxazole Fluoroquinolones Aminoglycosides Metronidazole Antiviral antibiotics Antibiotic prophylaxis Myths 2
Introduction
Antibiotic : An antibiotic is a substance produced by a micro-organism, which selectively suppress the growth of or kill other micro-organism at very low concentrations.
Chemotherapeutic agent: drug which is manufactured entirely by chemical synthesis. Eg, sulphonamide, trimethoprim, & many anti-tubercular drugs.
Tripati K.D, Essentials of Medical Pharmacology, 6th edition, Jaypee brothers, 2008. 4
Factors determining the efficiency of antimicrobial agents:

Host defence
Source of infection
Tissues affected Margin of safety; & Bacterial susceptibility/resistance to the agent being used.
Tripati K.D, Essentials of Medical Pharmacology, 6th edition, Jaypee brothers, 2008.
Classifications of antimicrobials agents:
On the basis of preparation

Naturally occuring, eg, penicillins, cephalosporins, erythromycin, tetracycline, chloramphenicol, & aminoglycosides. Synthetic, eg, sulfonamides
On the basis of family:

Penicillins Cepholosporins Sulfonamides Tetracyclines Aminoglycosides Macrolide
On the basis of spectrum of activity:

Narrow: penicillinG, erythromycin, streptomycin Broad spectrum: tetracycline, chloramphenicol Extended spectrum: amoxcycillin, ampicillin
On the basis of effect:
Bacterostatic: erythromycin, tetracycline, sulfonamide, etc Bacterocidal: penicillins, cepholosporins, etc Acting on gram +ve bacteria: penicilline, cepholosporins, erythromycin, bactricin, tetracycline, gentamycin Acting on gram ve bacteria: penicilline acts on gonococci
On the basis of systems: Urinary tract: nalidixic acid, furadantin Skin: neomycin, bactricin, polymyxcin Orally(locally): neomycin, streptomycin.
Principles of antibiotic therapy

I Selection of antimicrobials:
i) Clinical evaluation & diagnosis for antimicrobiological aetiology
ii) Study of culture & sensitivity

iii) Age of the patient iv) Pregnancy & neonatal v) Severity of disease
10 Tripati K.D, Essentials of Medical Pharmacology, 6th edition, Jaypee brothers, 2008.
vi) Nature of the drug vii) Possibility of drug resistance
viii) History of previous allergic reactions to a microbial agent

ix) Risk of toxicity of the drug x) Cost of therapy
xi) Narrow spectrum of antibiotic
II. Antimicrobial combinations

To have an additive synergistic effect against an organism. 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 an individual drug can be reduced & possible toxic effects can be avoided.
Tripati K.D, Essentials of Medical Pharmacology, 6th edition, Jaypee brothers, 2008.12
When infection is severe & body defence is inadequate & where the diagnosis is difficult To reduce the chances of super-infections To reduce the cost of therapy
The risk involved in combination therapy are following:

Increased risk of super-infection by resistant organisms. Emergence of organisms resistant to multiple drugs used. Increased risk of adverse reactions.
Sense of false security; which may lead to incomplete evaluation & inadequate therapy for the patient.
Increase in the cost of therapy. In general, antibiotics should not be combined unless it is not documented by sensitivity testing & antagonism has been excluded.
The situations where antibiotic prophylaxis is indicated are as follows: For preventing endocarditis following minor surgical procedures or tooth extraction.
III. Antimicrobial Prophylaxis
In patients with compound musculoskeletal injury, penetrating wounds, skull injuries or rhinorrhea & otorrhoea. Deep punctured wounds that are at high risk of infections.
Routine prophylaxis in cases of minor surgical procedures is not necessary.
Oral and Maxillofacial Surgery by Neelima Malik Year 2001 15
Principles of antibiotic administrations

The principle comprise of the following: Dosage & duration of drug. Route & frequency of administration
Oral and Maxillofacial Surgery by Neelima Malik Year 2001 16
-Lactam antibiotics:
General antibiotics of this group are: Penicillins Semisynthetic derivatives of pebicillin Cephalosporins. Structure
Antibacterial activity:
inhibiting cell wall synthesis of suspectible bacteria. They are effective mainly during growth phase when cell walls are being synthesized.
Bacterial resistance
bacteria can produce enzymes known formerly, as penicillinase. These enzymes can destroy the lactam ring in the nucleus of penicillins & its derivatives thereby rendering them ineffective.
Mechanisms of antibiotic resistance

1. Production of enzymes destroying and modifying AB -lactamases AG modifying enzymes 2. Decrease of cell membrane permeability 3. Active efflux of AB from cell 4. Modification of AB target sites
Toxic effects: principle toxic effect is allergy Excretion: unchanged through kidney
Penicillins
Penicillin was first discovered in 1929 by Fleming. It is derived from a mould, penicillin notatum. It was the first antibiotic to be used & is still the best.
Classification:
Antibiotics Spectrum of activity
Natural penicillins (penicillin G, penicillin V)
All streptococci, minimal activity against staphylococci, meningococci, most G+ anaerobes

As above plus enhanced activity against staphylococci (except MRSA) G+ cocci & some G- bacilli
-lactamase resistant penicillins (nafcillin, methicillin, oxacillin, cloxacillin, dicloxacillin) Extended-spectrum penicillins (ampicillin, amoxicillin, carbenicillin, ticarcillin, mezlocillin, piperacillin) -lactam with -lactamase inhibitor (amoxicillin/clavulanic acid, ampicillin sulbactam, ticarcillin/clavulanic acid, piperacillin/tazobactam)
Improved activity against lactamase producing bacteria (staphylococci & selected G- bacilli) Not all -lactamses are inhibited
22
Administrations
Length of course
Measurement of penicillins (units & micrograms): A

standard method of expressing the potency of penicillin was adopted in 1944 using crystalline sodium penicillin G as the standard. It is expressed in 'International units'(iu). 250 mg penicillin equals approximately 4,00,000 iu.
Toxic effects
Other effects Pregnancy Lactation Oral contraceptives
Cephalosporins
Cephalosporins have similar structure to penicillin but have a different source. Compared with penicillins: More resistant to lactamase hydrolysis Wider antibacterial spectrum Improved PK-properties Mode of action: : They are bactericidal. They act by inhibiting the cell wall synthesis in growing bacteria.
Spectrum of activity
Antibiotic 1. Generation . narrow spectrum (cephalexin, cephazolin, cephalotin, cephapirin) Spectrum of activity G+ bacteria (= oxacillin) & some G(E.coli, Klebsiella, Proteus)
2. Generation . extended spectrum (cefaclor, cefuroxime, cefoxitin)
G+ bacteria (= oxacillin) & improved G- (Enetrobacteraciae, Citrobacter, Proteus)

G+ bacteria (= oxacillin) & activity against wide range G- bacteria; Pseudomonas . CTZ G+ bacteria (= oxacillin) & marginally increased activity against G- bacteria + ESBL
3. Generation . broad spectrum (cefotaxime, ceftriaxone, ceftazidime, cefixime) 4. Generation . extended spectrum (cefepime, cefpirome)
First generation Parenteral Cephalothin Cefazolin Oral Cephalexin Cephradine Cefadroxil
Second generation Parenteral Cefuroxime Cefoxitin Oral Cefaclor Cefuroxime axetil
Third generation Parenteral Cefotaxim Ceftizoxime Ceftriaxone Ceftazidime Oral Cefixime Cefpodoxime proxetil Cefdinir Ceftibuten
Fourth generation Parenteral

Cefipine Cefpirome
Cefoperazone
Ceftamet pivoxil
Adverse effects:
Pain : after im severe with cephalothin
Thrombophelebitis of injected vein
Diarrhoea alteration of gut ecology Hypersensitivity reactions similar to

pencillin
Nephrotoxicity highest with

cephaloridine
Broad sprectrum of activity -- immunosuppression (candidasis)
Monobactams Aztreonam:
Novel lactam in which other ring is missing Inhibits gm ve enteric bacilli, but does not inhibit gm+ve cocci or faeceal aneorobes Indications: UTI, GIT Dose: 0.5-2g i.m, or i.v 6 hrly Azenam, Trezam 0.5, 1.0, 2.0 g/vial inj
Carbapenems Imipenem:
Extermely potent & broad-spectrum lactam antibiotic It is resistant to lactamases, inhibit pencillinase producing staphylococci Limiting feature is rapid hydrolysis by the enzyme dehydropeptidase I located on the brush broder of renal tubular cells To overcome this clistatin is added 0.5g i.v, 6 hrly Indications: hospital acquired infections, cancer, AIDS patients
Erythromycin
Principle member of Macrolide group of antibiotics. Broad spectrum antibiotic- static at low conc, % cidal at high conc. It is effective against most Gram-positive cocci, including many penicillin resistant strains of staphylococci and Staph. aureus, and many Gram-negative bacteria encountered in dental infection.
Mode of Action: inhibition of protein synthesis. Absorption : upper small intestine, food delays. Hence, given 1
hr before food
Excretion: unchanged in bile via liver, quarter of dose through

kidney
Toxic effects
Gastrointestinal effects Cholestatic hepatitis hypersensitivity
Interactions
Antihistaminics & sympathomemitics Theophylline Carbamazepine
Warfarin
Benziodiazepines Oral contraceptives
Pregnancy & lactation: safer drug
Concomitant use of other antibiotics: Lincomycin & clindamycin appear to compete with erythromycin, hence these antibiotics should not be used along with erythromycin.
Newer macrolides
Limitations of erythromycin:
narrow spectrum, gastric intolerance, gastric acid lability, poor tissue penetration & short life
Roxithromycin, Clarithromycin & Azithromycin Uses: pharyngitis, tonsillitis, sinusitis, soft tissue infection
Sulfonamides
Sulfonamides were first introduced in 1935. These agents are bacteriostatic; and get inactivated by presence of pus. Sulfonamides act by inhibition of bacterial synthesis of folic acid from Para-AminoBenzoic Acid (PABA).
Absorption, Distribution and Excretion:
Toxic effects: Allergic reactions: skin rashes, polyartertitis nodsa,periphrea neuritis, photosensitivity Hemopoietic system: prolonged therapy lead to macrocytic anemia
Renal damage: crystallization of sulfnomides lead to renal damage Pregnancy and Lactation: increase incidence of foetal malformation
Oral Contraceptives: render ineffective of contraceptives
Sulfadiazine
It penetrates blood-brain barrier and achieves high levels in CSF. It is commonly used for prophylaxis to posttraumatic meningitis. A loading dose of 3 g is followed by 1 g, 6 hourly for 7 to 10 days.
Caution should be exercised by taking a fluid intake of atleast 2 liters/day to avoid crystalluria and renal damage. Dose: 0.5g QID, to 2g TDS
Cotrimoxazole
This agent inhibits the conversion of folic to folinic acid which is important for bacterial synthesis of DNA and RNA.
Spectrum of activity Indication: acute exacerbation in post irradiation osteomyelitis secondary to osteo-radio necrosis. It is also used in mixed Actinomycotic infections along with penicillin.
Adverse reaction:
nausea, vomiting, stomatitis, headache, rashes folate deficiency, blood dyscrasias occur rarely
Dosages: adult- 80mg trimitoprim+400mg

sulfamethoxazole,2BD children- 20 &100 mg respectively
Septran, Sepmax, Bactrim,

Fluoroquinolones
Act by inhibiting DNA gyrase enzyme
Antibacterial spectrum:
broad spectrum of activity effective against staphylococci including methicillin resistantStaph aureus (MRSA) against streptococci including Strep pneumoniae. Entero-bacteriaceae (E. coli, Klebsiella and Proteus mirabilis), including many organisms which are resistant to penicillins, cephalosporins and aminoglycosides.
Absorption, distribution and excretion: absorbed from

GIT, distributed through body fluids & excreted by kidney
Adverse reactions
G.I. tract toxicity CNS toxicity
First generation
Norfloxacin Ciprofloxacin Ofloxacin Pefloxacin
Second generation
Lomefloxacin Levofloxacin Saprofloxacin Gatifloxacin/ Moxifloxacin
Ciprofloxacin
Most potent 1st generation Most suspectible ones are aerobic gm ve bacilli Rapidly bactericidal activity & high potency
Adverse effects: GI, CNS, Tendonitis & tendon rupture

Contraindicated in pregnancy Uses: UTI, Gonnrrhoea, bone, soft tissue, wound infection, RTI Oral 250-750mg, i.v 100-200
Aminoglycosides
Used as stable salts which are highly water soluble Not absorbed orally, distribute only extra-cellularly don't penetrate brain or CSF Excreted unchanged in urine Bactericidal and more active at alkaline pH Act by interfering bacterial protein synthesis Active against aerobic gm ve bacilli not anaerobes Narrow margin of safety All exhibit ototoxicity & nephrotoxicity
Gentamycin
Spectrum of activity: Gentamicin is effective against a wide
range of Gram-positive and negative bacteria including penicillinase resistant staphylococci.
Indications: severe anerobic infections, as prophylaxis in

infective endocarditis
Dose and administration: im/iv infusion

Adult dose is 3-7 mg/kg/day in 2-3 divided doses. Child dose is 1-3 mg/kg/day in 2-3 divided doses.
Toxic effects:
Ototoxicity Nephro- toxicity
Pregnancy and lactation: not safe drug
Metronidazole
It is a prototype nitromidazole. It is effective in anaerobic infections and acute necrotizing ulcerative gingivitis (ANUG). Metronidazole is used with one of the penicillins, usually, amoxycillin to treat acute orofacial infections with an anaerobic component of causative microorganisms.
Metronidazole, can also be used in combination with cephalosporins for treating anaerobic infections where there is penicillin allergy or any other contraindication.
Administration, absorption and distribution: absorbed

from GIT, distributed through body fluids, crosses placental barrier & appears in milk
Excretion: urine, saliva, breast milk

Toxic effects and contraindications:
Blood dyscrasias are reported. CNS pathology Metronidazole is contraindicated in patients who are taking phenytoin.
Enhance the effects of warfarin and prolong coagulation time.
LINCOMYCIN AND CLINDAMYCIN

Lincomycin was first described in 1963 and later its derivatives clindamycin. Clindamycin is more active and has less side-effects. The oral preparations of clindamycin has replaced oral lincomycin.
Lincomycin is reserved for parenteral administrations.
Antibacterial activity: antibiotics are bacteriostatic; and act

by inhibiting protein synthesis.
Distribution:
well-distributed, do not penetrate CSF, appear in breast milk, cross placental barrier, distribution includes bone and because of their presence in bone it has been suggested that these antibiotics are suitable for treating bone infections.
These antibiotics form a second line of treatment in osteomyelitis.

Administration & Excretion: absorbed orally, should be

given 1 hr before meals. Excreted either through kidney or liver
Toxic effects:
related to gastrointestinal tract Hematological reactions include neutropenia, leucopenia, agranulocytosis and thrombocytopenic purpura. Pseudomembranous colitis is characterized by diarrhoea, abdominal pain, fever, and blood and mucus faeces.
Pregnancy and lactation: safe

150-300mg QID oral, 200-600mg i.v, 8hrly.
Dalcap , Clincin, Dalcin

ANTIVIRAL ANTIBIOTICS
Antiviral compounds can be classified as follows: 1.Compounds interfering with nucleic acid synthesis/ AntiHerpes virus, e.g. idoxuridine, acyclovir. 2.anti retro virus: a) nucleoside reverse transcriptase inhibitors: zidovudine, didanonsine, b) nonnucleaside reverse tanscriptase inhibitors: nevirapine, efavirenz c) protease inhibitors: ritonavir, indinavir 3. anti-influnza virus: amantadine, rimantadine 4.nonselective antiviral drugs: ribavirin, lamivudine
SUGGESTED ANTIBIOTIC THERAPY FOR MAXILLO-FACIAL TRAUMA PATIENT:

Wound Abrasions Intra op iv ---------Post op topical Post op enteral
Contusions haematoma
Punctures
Simple lacerations
Bacitracin zinc(500U/g) bd ----------Polymxin B (5000U/g)bd Neomycin sulfate (3.5mg/g) bd & --------Cephalexin ------------------Ad: 500mg 6hly Ch: 25-50mg/kg/d in 4 equal divided doses Pencillin V or ----------------------------------------Amoxicilin with clavulanic acid Ad: : 500mg 6hly Ch: 15-50mg/kg/d in equally divided dose 6hly --------------Bacitracin zinc(500U/g) bd ----------------------Polymxin B (5000U/g)bd Neomycin sulfate (3.5mg/g) bd 52 Oral and Maxillofacial infection 4TH edition by Topazian.
Complex Cefazolin lacerations Ad:0.5-1.5g/4hly-12h Ch:25-50mg/kg/d in 4 equal divided doses
Bacitracin zinc(500U/g) bd Polymxin B (5000U/g)bd Neomycin sulfate (3.5mg/g) bd
Cephalexin Ad: 500mg 6hly Ch: 25-50mg/kg/d in 4 equal divided doses
Soft tissue Cefazolin avulsions Ad:0.5-1.5g/4hly-12h Ch:25-50mg/kg/d in 4 equal divided doses
Burns
Cefazolin Ad:0.5-1.5g/4hly-12h Ch:25-50mg/kg/d in 4 equal divided doses
Oral and Maxillofacial infection 4TH edition by Topazian. 53
Maxillary/ mandibular fractures
Aqueous pencillin G 2million ---------------------------units Aqueous pencillin G 2million units for oral contaminants or cefazolin Ad:0.5-1.5g/4hly-12h Ch:25-50mg/kg/d in 4 equal divided doses, for cutaneous contaminants
Pencillin V, 500mg Pencillin V Ad: 500mg 6hly Ch:15-50mg/kg in equal divided doses 6hly
Crainofacial fractures
Cefazolin ------------------------------ Cephalexin Ad:0.5-1.5g/4hly-12h --Ad: 500mg 6hly Ch:25-50mg/kg/d in 4 equal Ch: 25-50mg/kg/d in 4 divided doses equal divided doses
Suspected Nafcillin 2-6g 6hly, gentamicin intra cranial 3-5mg/d in 3 equal divided contaminati doses (adults) on
Bacitracin zinc(500U/g) Cephalexin bd Ad: 500mg 6hly Polymxin B Ch: 25-50mg/kg/d in 4 (5000U/g)bd equal divided doses Neomycin sulfhate (3.5mg/g) bd Oral and Maxillofacial infection 4TH edition by Topazian. 54
ANTIBIOTIC REGIMEN FOR OSTEOMYELITIS OF THE JAW:

REGIMEN I: for hospitalized/medically compromised

patient or when intravenous therapy is indicated Aqueous pencillin, 2 million U iv 4hly, plus metronidazole 500mg, 6hly When improved for 48-72 hrs, switch to: Pencillin V, 500mg PO 4hly + metronidazole, 500mg PO 6hly, for an additional 4-6 weeeks OR Ampicillin/ Sulbactam 1.5-3g iv 6hly When improved for 48-72 hrs, switch to: Amoxicillin /calvulanate (augmentin), 875/125mg PO bd, for an additional 4-6 weeks
REGIMEN II: for out patient procedure

Pencillin V, 2g, plus metronidazole, 0.5 g 8hly PO for 2-4 weeks after sequestrum removed & patient without symptoms OR Clindamycin, 600 to 900 mg 6hly iv, then: Clindamycin, 300-450mg 6hly PO OR Cefoxitin(Mefoxin), 1 g 8hly iv or2g 4hly im or iv, no symptoms, then switch to: Cephalexin (Keflex), 500mg 6hly PO, for 2-4 weeks For pencillin allergic patients: Clindamycin600 to 900 mg 6hly iv, then: Clindamycin, 300-450mg 6hly PO, if allergy not of anaphylactoid type
Pencillin remains emphrical antibiotic of choice in treatment of most dentoalveolar infection in the non-compromised host Metronidazole is an effective supplement to pencillin and enhances killing of anaerobes Oral clindamycin both aerobic and anaerobic killing. If pencillin has been used for 2-3 days without resolution of infection then, use of another non- lactam or lactamase stabile antibiotic ( ie clindamycin) should be considered.
Oral and Maxillofacial infection 4TH edition by Topazian.
57
ANTIBIOTIC THERAPY FOR ODONTOGEIC INFECTIONS:
Antibiotics are indicated in combination with surgery both therapeutic and prophylactically in the following situations:
Acute cellulitis of dental origin. Acute pericoronitis with elevated temperature and trismus Deep fascial space infections Open(compound) fractures of the mandible and maxilla or other facial bones Extensive, deep or old(>6hrs) orofacial lacerations Dental infections or oral surgery in the compromised host Prophylaxis for dental surgery in the patients with valvular cardiac disease or a prosthetic valve
Oral and Maxillofacial infection 4TH edition by Topazian.
58
GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

Prophylaxis with antibiotics is indicated for:
Procedures with an elevated contamination risk
Patients who have risks related to internal illnesses (prophylaxis should be administered in cooperation with the attending physician) Patients with endocarditis risks, in whom antibiotics prophylaxis is urgently necessary.
[QI vol 38, no 8, 2007, 689-697] 59
Cardiac conditions associated with endocarditis

Prophylaxis recommended High risk Prosthetic valves Prophylaxis not recommended Moderate risk Most other congenital cardiac malformations Negligible risk Isolated secondum atrial septal defect(ASD)
Previous bacterial endocarditis

Complex cyanotic congenital heart disease (CHD) Surgically constructed systemic pulmonary shunts
Acquired valvular dysfunction

Hypertrophic cardiomyopathy Mitral valve prolapse (MVP)
Surgical repair of ASD or PDA

Previous coronary bypass graft surgery MVP without valvular regutation Previous rheumatic fever Cardiac pacemakers &implanted defibrillators Innocent heart murmurs
Dental procedures & endocarditis prophylaxis Endocarditis prophylaxis recommended for Dental extraction Periodontal procedures including surgery, scaling & root planning RCT instrumentation or surgery beyond apex. Subgingival placement of antibiotic fibers or strips Intraligmentary local anaesthetic injections Prophylatic cleaning of teeth or implants where bleeding is anticipated Endocarditis prophylaxis not recommended for Restorative dentistry with/ without retraction cord LA injections (nonintraligamentary) Postoperative suture removal Taking impresions Taking oral radiograph Shedding of primary teeth Intracanal endodontic treatment, post placement & buildup.
Prophylactic regimens for dental procedures:

Standard general prophylaxis: Amoxicillin
Adults 2.0gm, children 50mg/kg orally one
hour before procedure.
Cannot oral medications: Ampicillin

Adults 2.0gm, im/iv, children 50mg/kg im/iv within 30min before procedure.
Allergic to penicillin: Clindamycin

Or, Or, Adults 500mg, children 20mg/kg orally one hour before procedure. Cephalexin/ Cephadroxil Adults 2.0gm, childern 50mg/kg orally one hour before procedure. Azithromycin/ Clarithromycin Adults 500mg, children, 15mg/kg orally one hour before procedure.
Allergic to penicillin & unable to take oral medications:

Clindamycin adults 600mg, children 15mg/kg iv one hour before procedure Or Cephazolinadults 1.0g, children 25mg/kg im/iv within 30min before procedure.
Prophylaxis in absence of active infection

Short-term prophylaxis: begin 2-4 hrs before operation & continue to a maximum of 48 hrs after the operation (indicated in cases of unstable diabetes). Ultra short-term prophylaxis: begin 2-4 hrs before operation & continue to a maximum of 24 hrs after the operation (indicated in cases of endocarditis). One shot prophylaxis: a 1-time antibiotic parenteral administration (eg, at the beginning of the operation; indicated in trauma cases.)
[QI vol 38, no 8, 2007, 689-697]
64
CHOICE OF DRUGS
Pregnancy: safer antibiotics are
Pencillin G, Ampicillin Amox-clav Cloxacillin Pipercillin Cephalosporins Erythromycin
In breast feeding:
A. In milk is too small to be harmful to infant, safe in ordinary doses
Cephalosporins Cloxacillin Erythromycin Gentamycin Pipercilin
Tripati K.D, Essentials of Medical Pharmacology, 6th edition, Jaypee brothers, 2008.
65
B. With special precautions or drugs contraindicated

Aminoglycosides:-- risk is not known, but manufactures advise caution
Amoxycillin/ampicillin:- diarrhoea, candidasis Azithromycin:- avoid, no, risk to infant Cotrimoxazole :- folate deficiency,risk of kernicterus, haemolysis in G-6-PD deficient; safe for healthy older infants Clindamycin:- small amount in milk, risk of diarrhoea, watch for blood in stools Ciprofloxicin:- high conc in milk, theoretical risk of arthropathy Metronidazole:- significant amount in milk, avoid high doses, suspend breast feeding for 12hr after single use Penincillins:- toxicity unlikely but risk of allergy Streptomycin:- compatible with breast feeding, watch for diarrhoea & thrush in infant Sulfonamides:- rashes, small risk of kernicterus in neonate, haemolysis in G-6PD deficient, safer for older infants Tetracyclines:- growth retardation, candidasis, tooth discoluration
66
Myths
Myth# 1 : antibiotics are not harmful
Swifth J Q, Antibiotic therapy- managing odontogenic infections. The Dental Clinics of 67 North America 46(2002) 623-633.
Myth# 2: doses & duration of antibiotic treatment should be nonspecific & variable for most odontogenic infections. A rule of thumb when prescribing is that the antibiotic should last for 3 days after the patients symptoms have resolved.
Swifth J Q, Antibiotic therapy- managing odontogenic infections. The Dental Clinics of 68 North America 46(2002) 623-633.
Myth#3 antibiotics are always indicated when treating dental pain
Myth#4 Clindamycin is a first line drug for infections

Swifth J Q, Antibiotic therapy- managing odontogenic infections. The Dental Clinics of North America 46(2002) 623-633. 69
Myth#5 If a peri-apical radiolucency, sinus tract,
fistula, or localised abscess is present, antibiotics are always indicated
Myth#6 Antibiotics must be implemented several
days before commencement of surgery

Myth#7 Indurated soft tissues means drainage is not indicated
Myth#8 Over prescription of antibiotic therapy does not occur in dentistry
BIBLIOGRAPHY
Oral and Maxillofacial infection 4TH edition by Topazian. Oral and Maxillofacial Surgery by Neelima Malik Year 2001 Oral and Maxillofacial Surgery by B.Srinivisan 2nd Edition Pharmacology by K.D. Tripati 5th edition Pharmacology & pharmacotherapeutics by Sathoskar 6th edition. Swifth J Q, Antibiotic therapy- managing odontogenic infections. the dental clinics of north america 46(2002) 623-633. Seymour r & whitworth, Antibiotic prophylaxis for endocarditis, prosthetic joints & surgery. The Dental clinics of North America 46(2002) 635-651. Hersh E, Antibiotics & oral contraceptives. The Dental clinics of North America 46(2002) 653-664. Lambrecht T, Antibiotics prophylaxis and therapy in oral surgery: a review, QI, vol 38, no.8, sep 2007, 689-697. Tripati K.D, Essentials of Medical Pharmacology, 6th edition, Jaypee brothers, 2008.
72
73
Classification
First generation: effective against Gram-positive microorganisms, except enterococci. Methicillin resistant Staph. aureus and Staph. epidermidisThey are also active against E.coli, Klebsiella, Pneumonia and P mirabilis.
Fourth generation Second generation: greater activity against Third generation: less activity against Gram-
Gram- positive microorganisms to first generation cephalosporins.
includes cefotaxime
positive organisms than first generations and more activity against Entero-bacteriaceae, including beta-lactamase producing strains.
includes cephalothin and cephalexin.
Similar to 3rd gen. but highly resistant to lactamases

74

Antibiotics in O.S

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ROLE OF ANTIBIOTICS IN ORAL SURGERY

DEPARTMENT OF ORAL AND MAXILLO-FACIAL SURGERY

Factors determining the efficiency of antimicrobial agents:

Classifications of antimicrobials agents:

On the basis of preparation

On the basis of family:

On the basis of spectrum of activity:

On the basis of effect:

Principles of antibiotic therapy

ii) Study of culture & sensitivity

vi) Nature of the drug vii) Possibility of drug resistance

viii) History of previous allergic reactions to a microbial agent

xi) Narrow spectrum of antibiotic

II. Antimicrobial combinations

To achieve delay in development of resistance.

The risk involved in combination therapy are following:

III. Antimicrobial Prophylaxis

Oral and Maxillofacial Surgery by Neelima Malik Year 2001 15

Principles of antibiotic administrations

Oral and Maxillofacial Surgery by Neelima Malik Year 2001 16

Mechanisms of antibiotic resistance

Natural penicillins (penicillin G, penicillin V)

All streptococci, minimal activity against staphylococci, meningococci, most G+ anaerobes

Measurement of penicillins (units & micrograms): A

Other effects Pregnancy Lactation Oral contraceptives

2. Generation . extended spectrum (cefaclor, cefuroxime, cefoxitin)

G+ bacteria (= oxacillin) & improved G- (Enetrobacteraciae, Citrobacter, Proteus)

First generation Parenteral Cephalothin Cefazolin Oral Cephalexin Cephradine Cefadroxil

Second generation Parenteral Cefuroxime Cefoxitin Oral Cefaclor Cefuroxime axetil

Fourth generation Parenteral

Diarrhoea alteration of gut ecology Hypersensitivity reactions similar to

Nephrotoxicity highest with

Broad sprectrum of activity -- immunosuppression (candidasis)

Excretion: unchanged in bile via liver, quarter of dose through

Pregnancy & lactation: safer drug

Absorption, Distribution and Excretion:

Dosages: adult- 80mg trimitoprim+400mg

Septran, Sepmax, Bactrim,

Absorption, distribution and excretion: absorbed from

Adverse effects: GI, CNS, Tendonitis & tendon rupture

Indications: severe anerobic infections, as prophylaxis in

Dose and administration: im/iv infusion

Administration, absorption and distribution: absorbed

Excretion: urine, saliva, breast milk

LINCOMYCIN AND CLINDAMYCIN

Lincomycin is reserved for parenteral administrations.

Antibacterial activity: antibiotics are bacteriostatic; and act

These antibiotics form a second line of treatment in osteomyelitis.

Administration & Excretion: absorbed orally, should be

Pregnancy and lactation: safe

Dalcap , Clincin, Dalcin

SUGGESTED ANTIBIOTIC THERAPY FOR MAXILLO-FACIAL TRAUMA PATIENT:

Complex Cefazolin lacerations Ad:0.5-1.5g/4hly-12h Ch:25-50mg/kg/d in 4 equal divided doses

Bacitracin zinc(500U/g) bd Polymxin B (5000U/g)bd Neomycin sulfate (3.5mg/g) bd

Cephalexin Ad: 500mg 6hly Ch: 25-50mg/kg/d in 4 equal divided doses

Soft tissue Cefazolin avulsions Ad:0.5-1.5g/4hly-12h Ch:25-50mg/kg/d in 4 equal divided doses

Bacitracin zinc(500U/g) bd Polymxin B (5000U/g)bd Neomycin sulfate (3.5mg/g) bd

Cephalexin Ad: 500mg 6hly Ch: 25-50mg/kg/d in 4 equal divided doses

Cefazolin Ad:0.5-1.5g/4hly-12h Ch:25-50mg/kg/d in 4 equal divided doses

Bacitracin zinc(500U/g) bd Polymxin B (5000U/g)bd Neomycin sulfate (3.5mg/g) bd

Cephalexin Ad: 500mg 6hly Ch: 25-50mg/kg/d in 4 equal divided doses

Oral and Maxillofacial infection 4TH edition by Topazian. 53

Maxillary/ mandibular fractures