Antibiotics (93)

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  • Generation by G(-) rods against
  • Not be used as a subsitute for penicillin or other drugs that are effective against orofacial infections
  • No activity against anaerobes, so don’t use alone
  • 主要用於治療 MRSA ,口服是用來治療 pseudomembrane colitis 。注意 IV 給葯速度
  • For PST(+) patient
  • * Not use in pregnancy. Vancomycin IV too rapid-> decrease blood pressure. BP monitor is needed.
  • Antibiotics (93)

    1. 1. Antibiotic Use in Orofacial Dental Infection 台北榮民總醫院 牙科部 Speaker 陳雅薇 Moderator 羅文良 大夫
    2. 2. INTRODUCTION <ul><li>This presentation will review the evaluation and management of orofacial infections with emphasis on: </li></ul><ul><li>■ Assessment of the Patient </li></ul><ul><li>■ Diagnosis and Treatment of infection </li></ul><ul><li>■ Antibiotic Therapy </li></ul><ul><li>■ Indications for Prophylaxis </li></ul><ul><li>■ Antifungal Agent </li></ul>
    3. 3. ASSESSMENT <ul><li>Requires a complete medical history and exam of the head and neck region with awareness to systemic factors as part of a comprehensive dental examination </li></ul><ul><li>Identify local and/or systemic signs and symptoms to support the diagnosis of infection: </li></ul><ul><li>< erythema, warmth, swelling, and pain > </li></ul><ul><li>< malaise, fever ( >38 c), chills > </li></ul><ul><li>Loss of function </li></ul><ul><li>< dysphagia, trismus, dyspnea > </li></ul>
    4. 4. ASSESSMENT (CON’T) <ul><li>Systemic signs of infection </li></ul><ul><li>< BP ↓ </li></ul><ul><li>< WBC ↑ </li></ul><ul><li>< CRP ↑ </li></ul><ul><li>< urine output ↓ </li></ul>
    5. 5. DIAGNOSIS: Infection <ul><li>Determine etiology </li></ul><ul><li>> odontogenic </li></ul><ul><li>> trauma wound, animal bite </li></ul><ul><li>> TB, fungi, actinomycoses </li></ul>
    6. 6. DIAGNOSIS (CON’T) <ul><li>Determine cellulitis versus abscess </li></ul>
    7. 7. TREATMENT of INFEC TION <ul><li>Remove the cause of infection is the most important of all, by either spontaneously or surgically drain the pus. </li></ul><ul><li>Antibiotics are merely an adjunctive therapy. </li></ul>Host defense Drainage Antibiotics
    8. 8. INDICATION for ANTIBIOTICS <ul><li>1. Severity of the infection </li></ul><ul><li>Acute onset </li></ul><ul><li>Diffuse swelling involves fascial spaces </li></ul><ul><li>2. Adequacy of removing the source of infection </li></ul><ul><li>When drainage can’t be established immediately </li></ul><ul><li>3. The state of patients’ host defense </li></ul><ul><li>When the patient is febrile </li></ul><ul><li>Compromised host defenses </li></ul><ul><li>For prophylaxis </li></ul>
    9. 9. <ul><li>Most oral infections are mixed in origin consisting of aerobic and anaerobic gram positive and gram negative organisms </li></ul><ul><li>Anaerobes predominant (75%) </li></ul>MICROBIOLOGY
    10. 10. COMMONLY USED A/B <ul><li>Mechanism of the antibiotics </li></ul>
    11. 11. COMMONLY USED A/B <ul><li>1. Groups of Penicillin </li></ul><ul><li>First choice for odontogenic infection </li></ul><ul><li>G(+) cocci and rod, spirochetes, anaerobes </li></ul><ul><li>0.7~10% hypersensitivity => PST </li></ul><ul><li>Nature: penicillin G (IV), penicillin V (PO) </li></ul><ul><li>Penicillinase-resistant: oxacillin, dicloxacillin </li></ul><ul><li>Extended spectrum: ampicillin, amoxicillin </li></ul><ul><li>Combine β - lactamase inhibitor: augmentin </li></ul>
    12. 12. <ul><li>2. Cephalosporin </li></ul><ul><li>More resistance to penicillinase </li></ul><ul><li>G(+) cocci, many G(-) rods </li></ul><ul><li>Third generation: Pseudomonas aeruginosa </li></ul><ul><li>Second choice (less effect for anaerobes) </li></ul>Cefepime Claforan Keflor Ucefaxim Cefazolin U-SAVE-A Tydine Forth generation Third generation Second generation First generation
    13. 13. <ul><li>3. Clindamycin </li></ul><ul><li>G(+) cocci </li></ul><ul><li>Bacteriostatic -> bactericidal </li></ul><ul><li>Second-line drug : should be held in reserve to treat those infections caused by anaerobes resistant to other antibiotics </li></ul>
    14. 14. <ul><li>4. Aminoglycoside </li></ul><ul><li>G(-) aerobes, some G(+) aerobes eg S. aureus </li></ul><ul><li>Poorly absorbed from GI tract </li></ul><ul><li>Adjustment of dosage in renal dysfunction </li></ul><ul><li>Drugs: Gentamicin, Amikacin, Amikin </li></ul><ul><li>Combined with penicillin or cephalosporin </li></ul>
    15. 15. <ul><li>5. Metronidazole * </li></ul><ul><li>Only for obligate anaerobes </li></ul><ul><li>Can cross blood-brain barrier </li></ul><ul><li>To treat serious infections caused by anaerobic bacteria, combined with β - lactam A/B </li></ul><ul><li>Effective against Bacteroides species, esp. in periodontal infections </li></ul><ul><li>Drugs: Anegyn, Flagyne </li></ul><ul><li>Avoid pregnant women </li></ul>
    16. 16. <ul><li>6. Vancomycin </li></ul><ul><li>G(+), most anaerobes, some G(-) cocci (Neisseria) </li></ul><ul><li>Given intravenously, BP should be monitored </li></ul><ul><li>Adjustment of dosage in renal dysfunction </li></ul><ul><li>Use as a substitute for penicillin in the prophylaxis of the heart valve p’t </li></ul>
    17. 17. <ul><li>7. Chloramphenicol </li></ul><ul><li>Wide spectrum, highly active against anaerobes </li></ul><ul><li>Limited to severe odontogenic infection threatening to the eye or brain </li></ul><ul><li>Severe toxicity </li></ul>
    18. 18. <ul><li>8. Erythromycin </li></ul><ul><li>G(+) cocci, oral anaerobes </li></ul><ul><li>Bacteriostatic </li></ul><ul><li>Second choice for odontogenic infections </li></ul><ul><li>Indication for out-patients with mild infection </li></ul><ul><li>Drug resistence: 50% of S. aureus , Strep. viridans , </li></ul>
    19. 19. <ul><li>9. Tetracycline * </li></ul><ul><li>Only against anaerobes </li></ul><ul><li>Contraindications: pregnant women, children <12 </li></ul><ul><li>Limited usefulness in orofacial infection </li></ul><ul><li>Use as adjunctive therapy for refractory periodontitis </li></ul><ul><li>Most likely to cause superinfection </li></ul>
    20. 20. SELECTION of A/B <ul><li>Use Empiric therapy routinely </li></ul><ul><li>Use the narrowest spectrum antibiotics </li></ul><ul><li>Use the antibiotics with the lowest toxicity and side effects </li></ul><ul><li>Use bactericidal antibiotics if possible </li></ul><ul><li>Be aware of the cost of antibiotics </li></ul>
    21. 21. <ul><li>Empiric Antibiotics in OMF Infection </li></ul><ul><li>■ First-line </li></ul><ul><li>Penicillin 3MU IVA q6h -> Cefazolin 1000mg q6h </li></ul><ul><li>Gentamycin 60-80mg IVA q8h-q12h </li></ul><ul><li>■ Second line (3A) </li></ul><ul><li>Augmentin 1200mg q8h + Amikin 375mg q12h + Anegyn </li></ul><ul><li>■ Mild infection </li></ul><ul><li>Amoxicillin 250mg #2 PO q8h </li></ul><ul><li>Clindamycin 300mg PO q6h </li></ul>
    22. 22. <ul><li>Side Effect of Commonly Used Antibiotics </li></ul>tooth discoloration, photosensitivity 9. Tetracyclin* mild GI disturbance 8. Erythromycin bone marrow suppression 7. Chloramphenicol 8th neurotoxicity, thrombophlebitis 6. Vancomycin GI disturbance, seizures 5. Metronidazole* damage to kidney, 8th neurotoxicity 4. Aminoglycoside diarrhea, pseudomembrane colitis 3. Clindamycin hypersensitivity 2. Cephalosporin hypersensitivity 1. Penicillin
    23. 23. PROPHYLAXIS <ul><li>Indications </li></ul>Updated JADA 2004
    24. 24. PROPHYLAXIS (CON’T) <ul><li>Dental procedures recommended for prophylaxis </li></ul>Updated JADA 2004
    25. 25. PROPHYLAXIS (CON’T) <ul><li>Regimen </li></ul>Updated JADA 2004
    26. 26. ANTIFUNGAL AGENT <ul><li>Most of fungal infection are from candida </li></ul><ul><li>Commonly used drugs: </li></ul><ul><li>(1) Nystatin (Mycostatin)= PO 4-600,000 U qid </li></ul><ul><li>(2) Amphotericin B= IV for severe systemic infec. </li></ul><ul><li>(3) Fluconazole, Ketoconazole </li></ul>
    27. 27. Parmason Gargle <ul><li>0.2% Chlorhexidine gluconate </li></ul><ul><li>Against G(+), G(-), fungus </li></ul><ul><li>Reduce pain and inflammation, enhance healing </li></ul><ul><li>Indication: immunocompromised patient, C/T R/T </li></ul><ul><li>(prophylaxis mouthrinse reduce oral mucositis) </li></ul><ul><li>Use: 2-3 times daily,10-20cc/ time, 20-30sec. </li></ul>

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