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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.
  • 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.

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