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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) Presentation Transcript

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