ANTIBIOTICS IN ORAL ANTIBIOTICS IN ORAL SURGERYSURGERY

DR. SUGANYADR. SUGANYA

LECTURER IN OMFSLECTURER IN OMFS

WHAT IS AN ANTIBIOTIC ?WHAT IS AN ANTIBIOTIC ? Substances produced naturally by a Substances produced naturally by a

living micro organism which prevents living micro organism which prevents or inhibits the growth and survival of or inhibits the growth and survival of another micro organismanother micro organism. .

CHEMOTHERAPEUTIC AGENTS

Substances are either partially / wholly produced by

synthetic agents

TYPESTYPES

Bacteriostatic – stops the bacteria Bacteriostatic – stops the bacteria from dividing. Ex : Erythromycin, from dividing. Ex : Erythromycin, sulfa drugs, Tetracyclinesulfa drugs, Tetracycline

Bactericidal – kills the bacteria. Ex: Bactericidal – kills the bacteria. Ex: Penicillin, Cephalosporin, Penicillin, Cephalosporin, MetronidazoleMetronidazole

General PrinciplesGeneral Principles

Empirical Antibiotic therapy -limited role in the Empirical Antibiotic therapy -limited role in the prevention of the management of infectionsprevention of the management of infections

proper dose at proper interval, through appropriate proper dose at proper interval, through appropriate route, blood concentration should be maintained at route, blood concentration should be maintained at desired leveldesired level

Least toxic, Most economical, most effectiveLeast toxic, Most economical, most effective Drug with least spectrum must be chosenDrug with least spectrum must be chosen Patient should be warned about side effects and Patient should be warned about side effects and

complicationscomplications Preference must be given to use known drug with Preference must be given to use known drug with

proven effectivenessproven effectiveness Culture and Antibiotic sensitivity test require in Culture and Antibiotic sensitivity test require in

Diabetes, Immuno suppressed pt, SABE, On dialysis.Diabetes, Immuno suppressed pt, SABE, On dialysis.

INDICATIONSINDICATIONSCURATIVE : CURATIVE :

Infection which cannot be treated by Infection which cannot be treated by surgery alonesurgery alone

Space infection involving inaccessible areasSpace infection involving inaccessible areas

Deep seated infections – osteomyelitis, Deep seated infections – osteomyelitis, cervico facial actino mycosiscervico facial actino mycosis

Infection which respond to antibiotic Infection which respond to antibiotic therapy alonetherapy alone

PROPHYLACTIC :PROPHYLACTIC :

To prevent onset of infection following any To prevent onset of infection following any invasive procedureinvasive procedure

PRINCIPLES : PRINCIPLES : Risk of infection must be significantRisk of infection must be significantChoose correct antibioticChoose correct antibioticAntibiotic level must be highAntibiotic level must be highTime the antibiotic correctlyTime the antibiotic correctlyUse shortest effective antibiotic Use shortest effective antibiotic

exposureexposure

ADVANTAGES:ADVANTAGES:Decreases incidence of infectionDecreases incidence of infectionDecreases health care costDecreases health care costDecreases total antibiotic usageDecreases total antibiotic usageAllows fewer resistant bacteriaAllows fewer resistant bacteria

DISADVANTAGES:DISADVANTAGES:

Alters host flora Alters host flora

May be of no benefitMay be of no benefit

May encourage lax surgery May encourage lax surgery

CostCost

ToxicityToxicity

INDICATIONS FOR INDICATIONS FOR PROPHYLAXISPROPHYLAXIS

DiabeticDiabetic Immuno compromisedImmuno compromised RadiotherapyRadiotherapy Prior to surgical closure of OAF Prior to surgical closure of OAF TransplantationsTransplantations Extraction in SABE, Valvular disease/ Extraction in SABE, Valvular disease/

replacement, renal problem, cancer replacement, renal problem, cancer chemotherapy, cirrohosis of liverchemotherapy, cirrohosis of liver

Complicated jaw fractureComplicated jaw fracture Surgical intervention causing large bony cavitySurgical intervention causing large bony cavity Prior to Dental implants,Extensive soft tissue Prior to Dental implants,Extensive soft tissue

lesionlesion

SPECTRUM OF ANTIBACTERIAL SPECTRUM OF ANTIBACTERIAL ACTIVITYACTIVITY

NARROWNARROW EXTENDEDEXTENDED

Bacitracin Bacitracin AminoglycosideAminoglycoside

ClindamycinClindamycin CephalosporinCephalosporin

MacrolideMacrolide Extended-Spectrum Extended-Spectrum

MetronidazoleMetronidazole pencillin pencillin

Penicillin G,VPenicillin G,V FluoroquinoloneFluoroquinolone

PolymyxinPolymyxin ImipenemImipenem

VancomycinVancomycin MonobactamMonobactam

BROADBROAD BACTERICIDALBACTERICIDAL

Chloramphenicol Chloramphenicol Aminoglycoside Aminoglycoside

SulphanamideSulphanamide BacitracinBacitracin

TetracyclineTetracycline CarbacephaemCarbacephaem

TrimethoprimTrimethoprim CephalosporinCephalosporin

MetronidazoleMetronidazole

PenicillinPenicillin

BACTERIOSTATICBACTERIOSTATIC

ChloramphenicolChloramphenicol

ClindamycinClindamycin

MacrolideMacrolide

SulfonamideSulfonamide

TetracyclineTetracycline

TrimethoprimTrimethoprim

BASED ON CHEMICAL STRUCTURE & BASED ON CHEMICAL STRUCTURE & PROPOSED MECHANISM OF ACTIONPROPOSED MECHANISM OF ACTION

1.Inhibit the bactierial cell wall 1.Inhibit the bactierial cell wall synthesissynthesis

Ex : Penicillin, Cephalosporin, Vancomycin, Ex : Penicillin, Cephalosporin, Vancomycin, Bacitracin, Miconazole, ketoconazoleBacitracin, Miconazole, ketoconazole

2. Agents act directly on cell membrane of 2. Agents act directly on cell membrane of micro organism affectingmicro organism affecting permeability permeability leading to leakage of intracellular leading to leakage of intracellular components. Ex: Polymyxin, Nystatincomponents. Ex: Polymyxin, Nystatin

3. Agents that affect the function of 3. Agents that affect the function of ribosomal subunits to cause a ribosomal subunits to cause a reversible inhibition ofreversible inhibition of protein protein synthesissynthesis

Ex: ChloramphenicolEx: Chloramphenicol

4. Agents that 4. Agents that bind to ribosomal bind to ribosomal subunitssubunits altering protein synthesis altering protein synthesis leading to cell deathleading to cell death

Ex: AminoglycosideEx: Aminoglycoside

5. Agents that 5. Agents that affect nucleic acid affect nucleic acid metabolismmetabolism

Ex : RifampicinEx : Rifampicin

6. Agents 6. Agents block specific metabolic block specific metabolic stepssteps essential to mic.org essential to mic.org

Ex : Trimethoprim Ex : Trimethoprim

7. Nucleic acid analogs 7. Nucleic acid analogs inhibit viral inhibit viral enzymeenzyme essential for DNA synthesis essential for DNA synthesis

Ex: Zidovudine, AcyclovirEx: Zidovudine, Acyclovir

II. II. ACCORDING TO MICRO ORGANISMACCORDING TO MICRO ORGANISM

1.1. Against Against Gram + veGram + veSystemic – Pencillin, ErythromycinSystemic – Pencillin, ErythromycinTopical -- Lincomycin, BacitracinTopical -- Lincomycin, Bacitracin

2. Against 2. Against Gram – veGram – ve Systemic – streptomycin, AminoglycideSystemic – streptomycin, Aminoglycide

3. Against 3. Against Gram + ve & Gram – veGram + ve & Gram – ve Systemic – Ampicillin, AmoxicillinSystemic – Ampicillin, AmoxicillinTopical - NeomycinTopical - Neomycin

4. Against Gram + ve, - ve, Ricketssiae, 4. Against Gram + ve, - ve, Ricketssiae, ChlamydiaeChlamydiae

Ex: Tetracycline, ChloramphenicolEx: Tetracycline, Chloramphenicol

5. Against Acid fast Bacilli 5. Against Acid fast Bacilli

Ex: Rifampicin, KanamycinEx: Rifampicin, Kanamycin

6. Against Protozoa6. Against Protozoa

Ex: Metronidazole,TinidazoleEx: Metronidazole,Tinidazole

7. Against Fungi7. Against Fungi

Ex: Nystatin, Amphotericin B, Ex: Nystatin, Amphotericin B, Griseoflavin, FluconazoleGriseoflavin, Fluconazole

8. Antimalignancy Antibiotics 8. Antimalignancy Antibiotics

Ex: Actinomycin DEx: Actinomycin D

PENICILLINPENICILLIN The most important of the antibiotics The most important of the antibiotics

was first extracted from penicillum was first extracted from penicillum notatum.notatum.

CLASSIFICATIONCLASSIFICATION

1. NATURAL PENICILLIN1. NATURAL PENICILLIN

a. Penicillin G (Benzyl Penicillin)a. Penicillin G (Benzyl Penicillin)

b. Procaine Penicillin Gb. Procaine Penicillin G

c. Benzathine penicillinc. Benzathine penicillin

II. II. ACID RESISTANT PENICILLINACID RESISTANT PENICILLIN

a. Phenoxy methyl penicillin ( Penicllin V)a. Phenoxy methyl penicillin ( Penicllin V)

b. Phenoxy ethyl penicillinb. Phenoxy ethyl penicillin

EE

III. III. PENICILLINASE RESISTANT PENICILLINPENICILLINASE RESISTANT PENICILLIN

Ex. Methicillin, Oxacillin, Cloxacillin, Ex. Methicillin, Oxacillin, Cloxacillin, DicloxacillinDicloxacillin

IV. IV. PENICILLIN EFFECTIVE AGAINSTPENICILLIN EFFECTIVE AGAINST

GRAM + VE AND (-) VEGRAM + VE AND (-) VE

Ex. Ampicillin, AmoxycillinEx. Ampicillin, Amoxycillin

V. V. EXTENDED SPECTRUM PENICILLINEXTENDED SPECTRUM PENICILLIN

a.a. Carboxy Penicillin – Carbenicillin, Carboxy Penicillin – Carbenicillin, TiconacillinTiconacillin

b.b. Anti Pseudomonal Penicllin – PiperacillinAnti Pseudomonal Penicllin – Piperacillin

VII. VII. PENICILLIN WITH beta PENICILLIN WITH beta LACTAMASELACTAMASE INHIBITIORINHIBITIOR

Amoxycillin + Clavulanic Acid (Augumentin)Amoxycillin + Clavulanic Acid (Augumentin)

Ticarcillin + Clavulanic acid (Timentin)Ticarcillin + Clavulanic acid (Timentin)

M.O.AM.O.A

Bactericidal, act by interfering with bacterial Bactericidal, act by interfering with bacterial cell wall synthesiscell wall synthesis

PREPARATION & DOSAGEPREPARATION & DOSAGE

a.a. Benzyl penicillin:Benzyl penicillin:ORALORAL:- 2 lakhs – 8 lakhs units every 6 -12hrs.:- 2 lakhs – 8 lakhs units every 6 -12hrs.

TAB:-TAB:- 2 lac,2.5lac, 4 lac,5lac, 8 lac M.units 2 lac,2.5lac, 4 lac,5lac, 8 lac M.units

INJINJ:-1-24 MU/day,i.m or i.v in divided doses ; 1,2,3,5,10,20 MU vials:-1-24 MU/day,i.m or i.v in divided doses ; 1,2,3,5,10,20 MU vials

B:PENICILLIN G PROCAINEB:PENICILLIN G PROCAINE:-:- 6 – 12 lac units daily I.M 8 -12hr6 – 12 lac units daily I.M 8 -12hr

C:FORTIFIED BP INJ:-C:FORTIFIED BP INJ:-

3 lac – PBP3 lac – PBP

1 lac – benzyl penicillin / ml1 lac – benzyl penicillin / ml

D: PENIDURE (BENZATHINE PENICILLIN):-D: PENIDURE (BENZATHINE PENICILLIN):-

6 – 24 lac IM every 3 weeks6 – 24 lac IM every 3 weeks

E: PROBENICID:-E: PROBENICID:-

2 gm / day in divided doses 2 gm / day in divided doses

Increases plasma penicillin level 2 -4 times.Increases plasma penicillin level 2 -4 times.

Anaphylaxis / Allergy/ Ser.sick like syn/ Renal Anaphylaxis / Allergy/ Ser.sick like syn/ Renal disturbances/ disturbances/ Hemopoietic disturbances.Hemopoietic disturbances.

Test for Allergy – Skin test.Test for Allergy – Skin test.

PENICILLIN REGIMEN:PENICILLIN REGIMEN:

1.Oral1.Oral:: PENICILLIN .V – 250 mg-500mg 6 hrly. PENICILLIN .V – 250 mg-500mg 6 hrly.

2.Fortified benzyl penicillin:2.Fortified benzyl penicillin: P.P 6 lacP.P 6 lac

B.P 2 lac once daily.B.P 2 lac once daily.

3.Inj.Benzyl penicillin :3.Inj.Benzyl penicillin : i.m moderate dosei.m moderate dose – 5 lac units 6 hrly. – 5 lac units 6 hrly.

i.m large dose i.m large dose – 1 – 2 M.u 4 -6 hrs.– 1 – 2 M.u 4 -6 hrs.

i.v large dose i.v large dose –2 M.u 2 hrs. –2 M.u 2 hrs.

AMOXYCILLIN:AMOXYCILLIN:SSemi- synthetic penicillin.emi- synthetic penicillin.

Extended spectrum penicillinsExtended spectrum penicillins – – AMINOPENICILLINSAMINOPENICILLINSM.O.A:M.O.A:All B lactum antibiotics interfere with synthesis of bacterial All B lactum antibiotics interfere with synthesis of bacterial

cellwall cellwall

• Inhibits transpeptidases so that cross-linking of Inhibits transpeptidases so that cross-linking of peptidoglycan polymers does not take place.peptidoglycan polymers does not take place.

• Enhanced activity is due to ability to penetrate lipid barriers Enhanced activity is due to ability to penetrate lipid barriers & more complex cell wall.& more complex cell wall.

ABSORPTION, FATE & EXCRETION:ABSORPTION, FATE & EXCRETION:• 250250mg oral dose yields peak plasma concentration in 1-2 mg oral dose yields peak plasma concentration in 1-2

hrs of 3.5- 5mg/mlhrs of 3.5- 5mg/ml• Half life – 1 hr.Half life – 1 hr.• Partially renal, partially biliary excretion.Partially renal, partially biliary excretion.

Adverse effectsAdverse effects::• diarrhoea,rashesdiarrhoea,rashesUsesUses::Orodental infectionsOrodental infectionsEarly periodontitisEarly periodontitisTyphoidTyphoidBronchitisBronchitisUrinary tract infectionsUrinary tract infectionsSubacute bacterial endocarditisSubacute bacterial endocarditisGonorrheaGonorrheaPreparations:Preparations:Amoxylin,novamox,synamox– 250mg,500mg Amoxylin,novamox,synamox– 250mg,500mg

capcapMox – 125,250,500 mg capMox – 125,250,500 mg cap 125mg/5ml dry.syr125mg/5ml dry.syr

blood levels increases 2 times as ampicillin.blood levels increases 2 times as ampicillin. 250- 500 mg 8 hrly.250- 500 mg 8 hrly.

in severe case : 3 gm 12hrly i.m/i.vin severe case : 3 gm 12hrly i.m/i.v AMOXYCILLIN+CLOXACILLIN:AMOXYCILLIN+CLOXACILLIN:USES:USES: post-operative infection,bacterial endocarditis post-operative infection,bacterial endocarditisPREPPREP: novaclox, amyclox – 250,500mg.: novaclox, amyclox – 250,500mg.

AMOXYCILLIN+CLAVUL.ACID:AMOXYCILLIN+CLAVUL.ACID: M.O.A: Clav.acid protects amoxy from degradation by B- M.O.A: Clav.acid protects amoxy from degradation by B-

lactamase enzyme.lactamase enzyme. extends antibiotic spectrum.extends antibiotic spectrum.

AMPHI.+SULBACTUM:AMPHI.+SULBACTUM:Sulbactum – inactivates B lactamase Sulbactum – inactivates B lactamase preventing destruction of preventing destruction of

B lactam antibiotics.B lactam antibiotics.

CEPHALOSPORINS & B CEPHALOSPORINS & B LACTUMS:LACTUMS:

Broad spectrum ,bactericidal antibiotic Broad spectrum ,bactericidal antibiotic for treatment of septicemia, pneumonia,for treatment of septicemia, pneumonia,

meningitis, biliary meningitis, biliary tuberculosis, ,peritonitis, urinary tuberculosis, ,peritonitis, urinary tract infection.tract infection.

against gram+ve organism.against gram+ve organism.

M.O.A:M.O.A:

Inhibits cell wall synthesis. Inhibits cell wall synthesis.

I GenerationI Generation: : II II GenerationGeneration::

1.Cephalexin 1.Cefuroxime1.Cephalexin 1.Cefuroxime2.Cephaloridin 2.Cefaclor2.Cephaloridin 2.Cefaclor3.Cephazolin 3.Cephazolin 4.Cephadroxil(have anti Staph.4.Cephadroxil(have anti Staph.Activity).Activity).

III GenerationIII Generation: : IV IV GenerationGeneration::

1.Cefotaxime 1.Cefepime Hcl1.Cefotaxime 1.Cefepime Hcl2.Ceftazidime 2.Carbapenem2.Ceftazidime 2.Carbapenem3.Ceftriaxone3.Ceftriaxone(less effective than I(less effective than IGeneration .against gram +ve cocci)Generation .against gram +ve cocci)

CEPHALEXIN:CEPHALEXIN:M.O.A:M.O.A:Inihibition of cell wall synthesisInihibition of cell wall synthesis..Absorption,fate&excretion:Absorption,fate&excretion: half life:60 minshalf life:60 minsExcreted unchanged in urine.Excreted unchanged in urine.ADR:ADR:allergic reaction,GI distrubancesallergic reaction,GI distrubancesUSES:USES:In odontogenic infections by KlebsiellaIn odontogenic infections by KlebsiellaANUGANUGAgainst staphylococci,streptococciAgainst staphylococci,streptococciPREP:PREP:Sporidex, cephaxin – 250,500mgSporidex, cephaxin – 250,500mg

Cefotaxime:Cefotaxime:Half life – 1 hr.Half life – 1 hr.

Uses:Uses:

*Meningitis*Meningitis

*Life- threatening resistant *Life- threatening resistant hospital hospital

acquired infectionsacquired infections

*Septicemia.*Septicemia.

Preparations:Preparations:

Omnatax, oritakim --0.25,0.5.1g injOmnatax, oritakim --0.25,0.5.1g inj

QUINOLONE & QUINOLONE & FLUOROQUINOLONE:-FLUOROQUINOLONE:-

Nalidixic acidNalidixic acid CiprofloxacinCiprofloxacin NorfloxacinNorfloxacin well tolerated bactericidial drugs with well tolerated bactericidial drugs with

broad spectrum of antimicrobial activity & broad spectrum of antimicrobial activity & excellent bioavailability.excellent bioavailability.

Ciprofloxacin:Ciprofloxacin:M.O.A:M.O.A: By inhibiting bacterial DNA gryase enzyme which is By inhibiting bacterial DNA gryase enzyme which is

required for DNA replication required for DNA replication bacterial lysis bacterial lysis

ABSORPTION,FATE,&EXCRETION:ABSORPTION,FATE,&EXCRETION:• Rapidly absorbed from GIT.Rapidly absorbed from GIT.• High tissue penetrabilityHigh tissue penetrability• Half life Half life 3-4hrs 3-4hrs• Primarily excreted in urinePrimarily excreted in urineADVERSE EFFECTS:ADVERSE EFFECTS: GI disturbances, dizziness, headache, hypersentivity GI disturbances, dizziness, headache, hypersentivity

reaction, tendonitisreaction, tendonitisUSES:USES:• Urinary tract infection,Urinary tract infection,• Typhoid,Typhoid,• GonorrhoeaGonorrhoea• Respiratory infectionsRespiratory infections• G-ve septicemiaG-ve septicemia• Orodental pseudomonas infection.Orodental pseudomonas infection.PREPARATIONS:PREPARATIONS: Cipro 500, 750, 250 mg tab.Cipro 500, 750, 250 mg tab. Avoid in pregnancy/ young patients.Avoid in pregnancy/ young patients.

AMINOGLYCOSIDES:-AMINOGLYCOSIDES:-Gentamycin, Amikacin, Tobramycin, Gentamycin, Amikacin, Tobramycin,

Kanamycin,Stretptomycin.Kanamycin,Stretptomycin.

MACROLIDESMACROLIDES::Erythromycin, Rozithromycin, Erythromycin, Rozithromycin,

Azithromycin, Clindamycin, Vancomycin.Azithromycin, Clindamycin, Vancomycin.

M.O.A:M.O.A:Act by binding to 50s ribosomal sub unit of Act by binding to 50s ribosomal sub unit of

bacteria & inhibit protein synthesis.bacteria & inhibit protein synthesis.

AgainstClostridia,C.diphtheriae,Listeria,StreptoAgainstClostridia,C.diphtheriae,Listeria,Strepto.pyogens,Strepto.viridans,H.influenzae.pyogens,Strepto.viridans,H.influenzae

destroyed by gastric acid juice so,enteric destroyed by gastric acid juice so,enteric coated.coated.

DosageDosage::6 hrly dosage:6 hrly dosage:

i)i) 1-2 gm/day – adults1-2 gm/day – adults

ii)ii) 5mg/kg – less than 1 yr5mg/kg – less than 1 yr

iii)iii) 10 mg/kg – upto 8 yrs10 mg/kg – upto 8 yrs

iv)iv) 15mg/kg - 8-12yrs15mg/kg - 8-12yrs

USES:USES:1.In penicillin allergic pts1.In penicillin allergic pts

2.In SABE (S.viridans) 1gm- 4-6hrly – 4-6 weeks2.In SABE (S.viridans) 1gm- 4-6hrly – 4-6 weeks

++

gentamycin 1mg/kg 8 hrly.gentamycin 1mg/kg 8 hrly.

Rozithromycin:Rozithromycin:More resistant to acid More resistant to acid Hydrolysis Hydrolysis better absorptionbetter absorptionAzithromycin:Azithromycin:Acts against atypical microorganisms, gm +ve & gm-ve Acts against atypical microorganisms, gm +ve & gm-ve For RTI, urethritisFor RTI, urethritisClindamycin:Clindamycin: Lincosamide,acts by binding to 50s ribosomal units Lincosamide,acts by binding to 50s ribosomal units

suppresses protein syn.suppresses protein syn.DOSAGE:DOSAGE:150-450 mg 4 times a day150-450 mg 4 times a day4 – 8 gms iv / day4 – 8 gms iv / dayChildren: 10 -20 mg /kg daily 3-4 divided dose orallyChildren: 10 -20 mg /kg daily 3-4 divided dose orally 600 mg iv 8-12 hrly.600 mg iv 8-12 hrly.Adv. Reaction:Adv. Reaction: Pain at inj. site, stomatitis, Pain at inj. site, stomatitis,

glossitis,A.N.edema,hypotension,cardiac arrestglossitis,A.N.edema,hypotension,cardiac arrest

Metronidazole: nitroimidazole , active Metronidazole: nitroimidazole , active amoebicide:amoebicide:

M.O.A:M.O.A: bactericidal bactericidal inhibition of DNA replication, inhibition of DNA replication, fragmentation of DNA, mutation of bacterial genome.fragmentation of DNA, mutation of bacterial genome.

Absorption, fate,&excretion:Absorption, fate,&excretion: well absorbed after oral administration.well absorbed after oral administration. half life – 8 hrs.half life – 8 hrs. excreted in urine.excreted in urine.

ADR:ADR: Metallic taste *peripheral neuropathyMetallic taste *peripheral neuropathy abdominal cramps *glossitisabdominal cramps *glossitis head ache *stomatitis head ache *stomatitis dryness of mouth *vertigodryness of mouth *vertigo dizziness *ataxiadizziness *ataxia

USES:USES:

1.Anaerobic infections, brain abscess, ANUG, ulcerative 1.Anaerobic infections, brain abscess, ANUG, ulcerative gingivitis, helicobacter pyroli gastritis, amoebiasisgingivitis, helicobacter pyroli gastritis, amoebiasis

2.In periodontitis2.In periodontitis

3. eradication of B.fragilis infection.3. eradication of B.fragilis infection.

PREPARATIONSPREPARATIONS::

flagyl, metrogyl -- 400 mg tabflagyl, metrogyl -- 400 mg tab

INTERACTIONS:INTERACTIONS:

1.1. Warfarin/ coumarin : potentiates the anticoagulant effect – Warfarin/ coumarin : potentiates the anticoagulant effect – increased prothrombin time.increased prothrombin time.

2.2. AlcoholAlcohol

3.3. Disulfuram – confusional state.Disulfuram – confusional state.

Tetracycline:Tetracycline:Broad spectrum antibacterial drugsBroad spectrum antibacterial drugsAgainst Chlamydial, Rickettsial, Mycoplasma,Brucella,SpirochaeteAgainst Chlamydial, Rickettsial, Mycoplasma,Brucella,SpirochaeteM.O.A:M.O.A: Bacteriostatic --act by binding to 30s ribosomes, inhibiting the Bacteriostatic --act by binding to 30s ribosomes, inhibiting the

protein synthesis protein synthesis Onset of action : 2 – 4 hrs.Onset of action : 2 – 4 hrs.Duration of action: upto 12 hrs.Duration of action: upto 12 hrs.

Adverse effectsAdverse effects: anorexia, nausea, vomiting,epigastric distress, : anorexia, nausea, vomiting,epigastric distress, esophageal ulcer, super infection, tooth discoloration, neutropenia.esophageal ulcer, super infection, tooth discoloration, neutropenia.

Contraindicated :Contraindicated : pregnancy & lactation. pregnancy & lactation.InteractionsInteractions::AntacidAntacidAnticoagulant -- increases hypothrombineic effectAnticoagulant -- increases hypothrombineic effectCimetidine – decreases GI absorptionCimetidine – decreases GI absorptionDairy products – decreases efficacy of tetracycline.Dairy products – decreases efficacy of tetracycline.DOSAGEDOSAGE::Adults 1g daily in 2-4 divided dose.Adults 1g daily in 2-4 divided dose.Chidren – 25- 50 mg/kg body wt , 3 divided doses.Chidren – 25- 50 mg/kg body wt , 3 divided doses.

Sulphonamide & Trimethoprim:Sulphonamide & Trimethoprim:BacteriostaticBacteriostatic

Acts by inhibiting bacterialActs by inhibiting bacterial synthesis of folic acid from PABA.synthesis of folic acid from PABA.

AbsorptionAbsorption: by oral , : by oral , crosses placental barrierscrosses placental barriersexcreted through kidneys by glomerular filtration excreted through kidneys by glomerular filtration renal renal

damage.damage.

Toxic effectsToxic effects::Skin rashes, exfoliative dermatitisSkin rashes, exfoliative dermatitisProlonged therapy Prolonged therapy macrocytic anemia macrocytic anemiaCrystallization Crystallization hematuria, renal pain – decreased urinary flow. hematuria, renal pain – decreased urinary flow.Displaces bilirubin from plasma albumin in babies in I trimester Displaces bilirubin from plasma albumin in babies in I trimester

fetal malformation.fetal malformation.Contraindicated:Contraindicated:Pregnancy & lactation. Pregnancy & lactation.

INFECTIVE ENDOCARDITISINFECTIVE ENDOCARDITIS

Bacteria attaches to sterile vegetation which exist Bacteria attaches to sterile vegetation which exist on abnormal valve.on abnormal valve.

Vegetation arise because of turbulent flow around Vegetation arise because of turbulent flow around an incompetent valve.an incompetent valve.

Turbulent flow Turbulent flow loss of surface endocardium loss of surface endocardium exposes underlying collagen exposes underlying collagen platelet & fibrin platelet & fibrin aggregates with collagen aggregates with collagen sterile fibrin sterile fibrin platelet thrombus platelet thrombus VEGETATION VEGETATION no no problem to pt until it becomes infected with problem to pt until it becomes infected with bacteria.bacteria.

DENTAL PROCEDURES IN WHICH DENTAL PROCEDURES IN WHICH PROPHYLAXIS RECOMMENDEDPROPHYLAXIS RECOMMENDED

Dental extractionDental extraction Periodontal procedurePeriodontal procedure Dental implant placementDental implant placement Periapical endodontic procedurePeriapical endodontic procedure Initial placement of Orthodontic bandInitial placement of Orthodontic band Intraligment L.A injectionIntraligment L.A injection D.Prophylaxis which bleeding is D.Prophylaxis which bleeding is

expectedexpected

Dental prophylaxis NOT Dental prophylaxis NOT RECOMMENDEDRECOMMENDED

Restorative procedureRestorative procedure Routine L.A injectionRoutine L.A injection Intra canal endodontic therapyIntra canal endodontic therapy Suture removalSuture removal Placement of removable appliancesPlacement of removable appliances Making impressionMaking impression

ANTIBIOTIC REGIMEN:ANTIBIOTIC REGIMEN:I.Standard prophylaxis:I.Standard prophylaxis:Amoxcillin – adult 2gm orally 1 hr pre-op.Amoxcillin – adult 2gm orally 1 hr pre-op. children 50mg orally 1 hr pre-op.children 50mg orally 1 hr pre-op.

II.Penicillin allergicII.Penicillin allergic::Clindamycin – adult - 600 mg orally 1hr pre-opClindamycin – adult - 600 mg orally 1hr pre-op children 20mg/kg orally 1 hr pre-op.children 20mg/kg orally 1 hr pre-op.(or)(or)Cephalexin/cefadroxil – adult – 2g orally 1hr pre-opCephalexin/cefadroxil – adult – 2g orally 1hr pre-op children 50 mg/kg orally 1hr pre-op.children 50 mg/kg orally 1hr pre-op.(or)(or)Azithromycin/ clarithromycin – adult 500mg orally 1hr pre-opAzithromycin/ clarithromycin – adult 500mg orally 1hr pre-op children 15mg/kg orally 1hr pre-children 15mg/kg orally 1hr pre-

op.op.

III.Unable to take oral medication:III.Unable to take oral medication:Amipicillin – adult – 2gm i.m/i.v within 30 mins pre-op.Amipicillin – adult – 2gm i.m/i.v within 30 mins pre-op. children – 50mg/kg i.m/i.v within 30 mins pre-op.children – 50mg/kg i.m/i.v within 30 mins pre-op.

IV.IV. Unable to take oral medication & Unable to take oral medication & penicillin allergic:penicillin allergic:

Clindamycin :Clindamycin :

adult – 600mg i.v 30 mins before adult – 600mg i.v 30 mins before procedure.procedure.

children – 20mg/kg i.v 30 mins before children – 20mg/kg i.v 30 mins before procedureprocedure

(or)(or)

Cefazolin:Cefazolin:

adult – 1g i.m/i.v 30 mins before adult – 1g i.m/i.v 30 mins before procedure.procedure.

children 25mg/kg i.m/i.v 30 mins before children 25mg/kg i.m/i.v 30 mins before procedureprocedure