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Antibiotic Use In DentistryAntibiotic Use In Dentistry
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Writing PrescriptionsWriting PrescriptionsRx: Drug Name (can be generic) Unit DoseRx: Drug Name (can be generic) Unit Dose
(ex: Pen V(ex: Pen V--K 500 mg, Elixer, Soln)K 500 mg, Elixer, Soln)
Disp: # of pills, milliliters (ml)Disp: # of pills, milliliters (ml)
Sig: Directions for use. q24h (daily), q12h, q8h, q6h, q4h,Sig: Directions for use. q24h (daily), q12h, q8h, q6h, q4h,
prn pain, till goneprn pain, till gone
Refills__Refills__ SignatureSignature
DEA #DEA #
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General RulesGeneral Rules
Write Legibly!!Write Legibly!!
Remember your audience (Generally nonRemember your audience (Generally non--docs)docs)
this will improve compliance.this will improve compliance. Preferable to order specific hourly dosage timePreferable to order specific hourly dosage time
(q12h vs. bid, q8h vs. tid, etc.)(q12h vs. bid, q8h vs. tid, etc.)
Sig: Specify # of pills to take each doseSig: Specify # of pills to take each dose Prescribe an endpoint. (prn pain, till gone)Prescribe an endpoint. (prn pain, till gone)
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Barry Brainfart Dental Clinic 666 Bite Me Ln
Crossbyte Falls, MN Ph: 555-YOU-HURTPt. Name: Address: DOB:
Rx: Date:
Di :
Si :
Refill Barry Brainfart, DDS
DEA:______________________
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Antibiotic StrategiesAntibiotic Strategies
Cardinal Rules: 1) Use the right drug.Cardinal Rules: 1) Use the right drug.
2) Use the right dose. 3) Use the correct2) Use the right dose. 3) Use the correct
dosing schedule. 4) Correct duration.dosing schedule. 4) Correct duration. Hard and FastHard and FastEspecially early. Why?Especially early. Why?
Use a loading dose to rapidly achieveUse a loading dose to rapidly achieve
therapeutic blood levels.therapeutic blood levels. Avoid combinations of bacteriostatic andAvoid combinations of bacteriostatic and
bacteriocidal drugs.bacteriocidal drugs.
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ConsiderationsConsiderations
Gram Positive?Gram Positive?
Gram Negative?Gram Negative?
Mixed Infection?Mixed Infection?
Anaerobes?Anaerobes?
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Discussion: Antibiotic ChoiceDiscussion: Antibiotic Choice
Narrow Spectrum?Narrow Spectrum? Extended/Broad Spectrum?Extended/Broad Spectrum?
Designer Antibiotics?Designer Antibiotics?
Anaerobes? Consider if the infection isAnaerobes? Consider if the infection ispresent > 3days or if no improvement.present > 3days or if no improvement.
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Narrow Spectrum AntibioticsNarrow Spectrum Antibiotics
Specific for the pathogen.Specific for the pathogen.
Fewer disturbances of nonFewer disturbances of non--pathogenicpathogenic
bacteria.bacteria. Fewer side effects.Fewer side effects.
Rapid response for sensitive organisms.Rapid response for sensitive organisms.
Ex: Pen VK, Pen G, ErythromycinEx: Pen VK, Pen G, Erythromycin
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Broad Spectrum AntibioticsBroad Spectrum Antibiotics
Affects both Gram + and GramAffects both Gram + and Gram bacteria,bacteria,
better for mixed infections.better for mixed infections.
May give up some effectiveness for Gram +May give up some effectiveness for Gram +to gain effectiveness for Gramto gain effectiveness for Gram --..
Examples: Amoxicillin, AmpicillinExamples: Amoxicillin, Ampicillin
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Common PathogensNecrotic pulp and apical abscesses
Obligate anaerobic bacteriaGram negative rods
Prevotella & porphyomonas spp.Fusobacterium spp.
Campylobacter rectus
Gram positive rodsEubacterium spp.
Actinomycetes spp.
Gram positive cocciPeptostreptococcus spp.
Facultative anaerobic bacteriaGram positive cocci
Strep and Entercoccus spp.
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Common PathogensCommon Pathogens
Periodontal DiseasesPeriodontal DiseasesGingivitisGingivitis
Fuso, strep, & actinomycetesFuso, strep, & actinomycetesAdult peritonitisAdult peritonitis
Bacteroides, porphyomonas,Bacteroides, porphyomonas,peptostreptococcus & prevotellapeptostreptococcus & prevotella
Acute necrotizing ulcerative gingivitisAcute necrotizing ulcerative gingivitisSpirochetes, prevotella, fusoSpirochetes, prevotella, fuso
Localized juvenile periodontitisLocalized juvenile periodontitisActinobacillusActinobacillus
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Common PathogensCommon Pathogens
Fungal InfectionsFungal InfectionsCandida spp.Candida spp.
Mucorales spp.Mucorales spp.
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Lets 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 +
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Antibiotic ChoicesAntibiotic Choices
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-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
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-Lactams
Natural penicillins
Pen VK and Pen G
BactericidalAllergic reaction: rare (4 per 100,000)
Spectrum:
Strep, staph, enterococcus, neiseria, treponema, listeria
Resistance: Mostly staph (>80%)
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-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)
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-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
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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
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Cephalosporins
Cephalexin (Keflex)
Bactericidal
Spectrum: Gram +
Resistance:
Methicillin resistant gram +
Low cross sensitivity with PCN
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LincosamidesLincosamides
Clindamycin (Cleocin)
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
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Lincosamides
Clindamycin
Bactericidal or static depending on
concentration Spectrum:
Gram +, anaerobes, parasites
Resistance
Enteroccocus
*Clostridium diff. pseudomembranous colitis!!*Clostridium diff. pseudomembranous colitis!!
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Macrolides
Azithromycin (Zithromax), clarithromycin (Biaxin)
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
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Macrolides
Azithromycin, clarithromycin
Bactericidal
Spectrum: Gram +, gram -, anaerobes
Resistance:
B. fragilis, and strep pneumo
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Tetracyclines
Doxycycline (Vibramycin) 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
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Tetracyclines
Doxycycline
Bacteriostatic
Spectrum: Broad, Gram +, -, anaerobes, aerobes, and
spirochetes
Resistance:
Widespread, cross resistance
PHOTO SENSITIVITY!!!
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Nitroimidazoles
Metronidazole (Flagyl)
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
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Nitroimidazoles
Metronidazole
Bactericidal
Spectrum: Gram - anaerobes
Resistance:
Rare, H. Pylori?
Unpleasant metallic taste
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Fluoroquinolones
Ciprofloxacin (Cipro)
MOA: Inhibition of DNA gyrase, and Topo II
Dose: 250-500 mg qd x 7-10 days Contraindications:
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Fluoroquinolones
Ciprofloxacin
Bactericidal
Spectrum: Very broad except B. frag
Resistance:
MRSA, MRSE
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Antifungals
Nystatin
MOA: inhibit cell wall synthesis
Dose: 5 ml swish and swallow q 4 h x 10-14 d GI upset
Drug interactions: minor
Pregnancy category C
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Antifungals
Clotrimazole (Mycelex), ketoconazole
(Nizoral), fluconazole (Diflucan)
MOA: inhibit cell wall synthesis Dose: 200-800 mg qd x up to 12 months
GI upset
Drug interactions: major p-450 enzyme inhibitor,
interactions with many drugs
Pregnancy category C
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ADA/AAOS AdvisoryADA/AAOS Advisory
StatementStatement
July 1997July 1997
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AAOS StatementAAOS Statement
Antibiotic prophylaxis isAntibiotic prophylaxis is NOTNOT
recommended for dental patientsrecommended for dental patientswithwith plates, pins, or screws,plates, pins, or screws, nor isnor is
it routinely recommended forit routinely recommended for
MOSTMOST dental patients withdental patients with TOTALTOTAL
JOINT REPLACEMENTS.JOINT REPLACEMENTS.
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AAOS recommendationsAAOS 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
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AAOS recommendations
Prophylaxis antibiotic recommendations Same as AHA OR
No specific regimen recommended
Keflex is often the first drug of choice
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Legal ConsiderationsLegal Considerations
The dentist may not be aware of theThe dentist may not be aware of the
patients medical condition.patients medical condition.
Physician may not be aware of the advisoryPhysician may not be aware of the advisorystatements or of the dental procedure to bestatements or of the dental procedure to be
performed.performed.
Vicarious Liability: The devil made me do itVicarious Liability: The devil made me do it
I forgot to take my antibiotic.I forgot to take my antibiotic.
Documentation.Documentation.
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Legal ConsiderationsLegal Considerations
I forgot my antibiotics!I forgot my antibiotics!
Animal studies have shown antibiotics areAnimal studies have shown antibiotics are
effective up to 2 hours after the procedure.effective up to 2 hours after the procedure. Differentiate between prophylaxis vs.Differentiate between prophylaxis vs.
treatment of an early infection.treatment of an early infection.
Take into consideration patients risk factors.T
ake into consideration patients risk factors. Legal twists.Legal twists.
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In Summary.In Summary.
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Principles of Antibiotic Therapy
Therapeutic effectiveness
Clinical indications Pharmcodynamics, pharmacokinetics
Age and extent of infection
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Patient factors
Age, allergies, compliance, pregnancy risk
Patient function
Renal, hepatic, immunosuppresion, routeapplicability
Cost
Brand name, length of course, alternatives?
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Cost
Drug Name Cost of Therapy $ (~10 Days) Generic if Available
Pen VK 6.81
Amoxicillin 8.41
Ampicillin 12.45
Cephalexin 15.65
Clindamycin 38.45
Azithromycin 41.52
Clarithromycin 74.45
Augmentin 76.82
Doxycycline 5.15
Metronidazole 9.65
Ciprofloxacin 76.65
Nystatin 9.86
Clotrimazole 97.05
Ketoconazole 30.69
Fluconazole 116.25
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Dental Infection
AcuteRapid growth
< 3 daysChronic > 3 days
Pen VK 500mg q6h or
Amox 500mg q8h or
Cephalosporin
Allergic to PCN
Clindamycin 300mg q8h or
Cephalosporin (check allergic Rxn) or
Azith or Clarithromycin
Think Anaerobes
Add Metronidazole 250-500mg
To PCN, Amox, or Ceph
Clindamycin 300mg q8h