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ANTIBIOTICS IN ORAL AND

MAXILLOFACIAL SURGERY

INDIAN DENTAL ACADEMY

Leader in continuing dental education
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AIM
INTRODUCTION
DEFINITION
HISTORY
CLASSIFICATION
PRINCIPLES FOR CHOOSING ANTIBIOTICS
PRINCIPLES OF ANTIBIOTIC ADMINISTRATION
THERAPEUTIC USES OF ANTIBIOTICS IN ORAL AND MAXILLOFACIAL SURGERY
SPECIAL CONDITIONS
ANTIBIOTIC PROPHYLAXIS IN HEAD AND NECK SURGERY
ANTIBIOTIC MISUSE
ANTIBIOTIC RESISTANCE
CONCLUSION


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AIM
INTRODUCTION
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DEFINITION








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HISTORY OF ANTIBIOTICS

1877 Louis Pasteur
Inhibition of some
microbes by others
1908 Gelmo
Synthesized
sulfanilamide.

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1928 Fleming
Penicillin notatum inhibits growth
PENICILLINS
1941 Chain n Florey
Discovered properties of penicillin
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1932 Domagk Prontosil
Therapeutic value sulfonamides
1943, Selman Waksman isolated,
Streptomyces griseus Streptomycin
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Mechanism of action
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CLASSIFICATION
Antibiotics are broadly classified in to

Bactericidal antibiotics- they kill bacteria
eg:Cotrimoxazole, fluoroquinolones, penicillins,
cephalosporins, aminoglycosides, vancomycin, teicoplanin

Bacteriostatic antibiotics- they inhibit bacterial
proliferation.
Eg:Sulfonamides, tetracyclines, chloramphenicol

Erythromycin is bacteriostatic in low doses and bactericidal
in higher doses


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Based on their mechanism of action
antibiotics are classified as


I. Inhibit cell wall synthesis: penicillins, cephalosporins, vancomycin,
bacitracin, cycloserine.

II. Damage of cell membrane causing leakage of cell contents: polymixins,
amphoterecin B, nystatin.

III. Bind to ribosomes and inhibit protein synthesis: chloramphenicol,
tetracyclines, erythromycin, clindamycin, aminoglycosides.

IV. Inhibit DNA gyrase: fluoroquinolones

V . Inhibit DNA function: rifampicin.

VI. Inhibit DNA synthesis: acyclovir, zidovudine.

VII. Interfere with metabolism: sulfonamides, trimethoprim

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PRINCIPLES FOR CHOOSING ANTIBIOTICS
State of host defences
use of least toxic antibiotics
patient drug history
use of bactericidal rather than bacteriostatic
drugs
use of antibiotics with a proven history of
success
cost of antibiotic:



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State of host defences
When a patients defences are impaired
,antibiotics, play a more important role in
control of infections.
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Determination of Antibiotic
sensitivity

Pencillin Excellent for treatment of
streptococcus infection

Erythromycin effective againsstreptococcus,pepto
streptococcus, prevotella
Clindamycin good for streptococcus.
Cephalexin Moderate active against
streptococcus,
Metronidazole No action against Streptococcus.
Excellent activity against anaerobes

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Use of narrow spectrum Antibiotic
If streptococcus is sensitive to pencillin,
cephalosporin and tetracycline , Penicillin
should be used because it has narrowest
spectrum.
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Use of least toxic antibiotics
Though chloramphenicol is more effective
than penicilin, it is not preferred because of its
potential to cause severe bone marrow
depression.

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Patient drug history
Two aspects should be reviewed in drug
history
Previous allergic reactions
Previous toxic reactions
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Antibiotic Interacting drug Mechanism Effect
Metronidazole Alcohol Inhibition of aldehyde
dehydrogenase
Disulfiram reaction
Gentamicin Furosemide Additive Ototoxicity
Metranidazole Warfarin Inhibition of
metabolism
Potentiation of
anticoagulant
Rifampicin Oestrogens Induction of
metabolism
Reduced effects of
contraceptive
Rifampicin Warfarin Induction of
metabolism
Reduced effects of
Warfarin
Tetracyclines Antacids Chelation Reduced effects of
Tetracyclinesq
Tetracyclines Warfarin Altered clotting factor
activity
Potentiation of
anticoagulation
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Use of bactericidal rather than
bacteriostatic drugs
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Use of antibiotics with a proven
history of success
The best evaluation of the efficacy of a drug in
a particular situation is the critical observation
of its clinical effectiveness over a prolonged
period
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COST OF ANTIBIOTIC
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PREVIOUS ANTIBIOTIC THERAPY










omfs clinics of N.A vol 15 feb 2003
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TISSUE DISTRIBUTION OF THE ANTIBIOTIC

Although abscess cavities are not vascular, some penetration of
antibiotic dose occur.
Clindamycin best penetrates in to an abscess and attains abscess
concentration of 33% of serum levels. So it may be best in odontogenic
infections.
Bone penetration of the antibiotics is an important ,especially in
osteomyelitis.
tetracyclins, fluroquinolones, clindamycin best penetrates in to the
bone.
(omfs clinics of N.A vol 15 feb 2003)

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Cerebrospinal fluid penetration, or ability of an
antibiotic to cross blood-brain barrier, is paramount
in the treatment of infections that threaten the
CNS, as in actual or impending cavernous sinus
thrombosis
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PENETRATE B.B.B


1. Penicillins
2. Ampicillins
3. Ciprofloxacin
4. Fluroquinalones
5. Metronidazole
6. Trimethoprin
7. Fluconazole
8. acyclovir

DOES NOT PENETRATE B.B.B

1. Cephalosporins
2. Clindamycin
3. Macrolides
4. Aminoglycosides
5. Amphotericin
6. Ethambutol



(omfs clinics of N.A vol 15 feb
2003)
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PRINCIPLES OF ANTIBIOTIC
ADMINISTRATION
Proper dose
Proper time interval
Route of administration
consistency in route of administration

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Proper dose
. Gentamicin is effective in concentrations up
to 4-6 microgram/ml but the incidence of
nephrotoxicity increases dramatically at 10
microgram/dl plasma level
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Proper time interval
. T1/2 of cefazolin is 2hrs . so interval between
doses should be 8hrs
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Route of administration
If given orally, should be given 30mins before
or 2 hrs after meals for maximum absorption.
When long term parenteral administration is
necessary IV is preferred over IM as IM is
poorly accepted by patient
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consistency in route of administration
Maintenance of peak blood levels of
antibiotics for adequate period is important to
achieve maximum tissue penetration and
effective bacterial killing
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combination antibiotic therapy

Indications of combination therapy

If patients condition does not improve
after initial therapy????

If initial therapy failed ????



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DEVELOPMENT OF ADVERSE REACTIONS
Antibiotic associated collitis:
treatment: discontinue antibiotic
vancomycin and metranidazole.

Super infection and recurrent infection:



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THERAPEUTIC USES OF ANTIBIOTICS IN ORAL
AND MAXILLOFACIAL SURGERY
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MOENING(1989)
It would seem presumptuous to state that
penicillin is currently not effective against
most odontogenic infections and premature to
consider substituting another antibiotic as the
drug of choice for mild to moderate
odontogenic infection especially when low
cost and lack of toxicity is considered.
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ABSCESS

Penicillin is the drug of choice
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PERICORONITIS
Penicillin is the drug of choice
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ODONTOGENIC INFECTIONS AND DEEP FASCIAL SPACE
INFECTIONS OF DENTAL ORIGIN:
Penicillin+Metranidazole
Azithromycin is better than Erythromycin
Amoxicillin + Clavulanic acid severe
infections
Minocycline or Doxycycline low grade
infections
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For immunocompromised or hospitalized
patients:
CLINDAMYCIN alone
(or)
CLINDAMYCIN+METRONIDAZOLE
(or)
GENTAMICIN
(or)
PARENTERAL AMPICILLIN+SULBACTUM
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SALIVARY GLAND INFECTIONS:

Out patient- amoxicillin+clavulanic acid
In patient- ampicillin+sulbactum(parenteral)
In case of penicillin allergy clindamycin is used
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causative organisms are staphylococcus
epidermis, hemolytic streptococci, prevotella,
porphyromonas
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Regimen 1: for hospitalized /medically
compromised patient or when IV therapy is
indicated
Aq penicillin 2 million units IV 4 hrly , metronidazole 500mg 6 hrly

When improved for 48-72hrs, switch to penicillin V 500mg per oral
4 hrly plus metronidazole 500mg per oral 6 hrly for an additional 4-
6 weeks.

Ampicillin/sulbactum 1.5 -3 gms IV 6hrly, when improved for 48-72
hrs switch to amoxicillin/clavunate 875/125 mg per oral bid for an
additional 4-6 weeks.

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Regimen 2: for out patient treatment

PenicillinV 2gm plus metronidazole 0.5 gm 8hrly per oral
for 2-4 weeks after last sequestrum removed and patient
without symptoms.
Clindamycin 600-900mg 6hrly IV then clindamycin 300-
450mg 6hrly per oral.
Cefoxitin 1.0 gm 8hrly IV or 2gm 4hrly IM or IV until no
symptoms, then switch to cephalexin 500mg 6hrly per oral
for 2-4 days.

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Penicillin allergy-clindamycin and cefoxitin
Macrolides are not recommended

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CHRONIC SUPPURATIVE
OSTEOMYELITIS
Treatment should begin with IV therapy and continue
even after discharge using home IV therapy usually with
ampicillin/salbactum sodium because it is stable for
24hrs after mixing with IV fluids.
IV therapy for 2 weeks or until the patient has shown
improvement for 48-72 hrs. Oral therapy should be
continued for 4-6 weeks after patient has no symptoms
or from the date of last debridement


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If ampicillin/sulbactum sodium is ineffective
clindamycin therapy is indicated
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Antibiotic impregnated beads :


eg: tobramycin or gentamicin in acrylic resin
bone cement beads. They are removed after
10-14 days

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SPECIAL CONDITIONS
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SAFE RELATIVELY SAFE AVOID
PENICILLIN METRANIDAZOLE TETRACYCLINES
CEPHALOSPORINS CHLORAMPHENICOL
AZITHROMYCIN SULPHANAMIDES
CLINDAMYCIN AMINOGLYCOSIDES
CLOTRIMOXAZOLE
PREGNANCY
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CHILDREN
Tetracyclines
permmenant intrinsic dental staining
Fluoroquinolones-
chondrotoxicity in growing cortilage
Carbapenems, imipenem-
risk of seizures

(omfs clinics of N.A vol 15 feb 2003)

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LIVER DISEASES
To be avoided
1. Tetracyclines
2. Erythromycin
3. talampicilin

preferable
1. amoxicillin
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Safe fairly safe less safe avoid
Cloxacillin
erythromycin
Ketoconazole
rifampicin

Ampicillin
Amoxicillin
Clindamycin
metronidazole
Aminoglycoside
Cphalosporins
Fluconazole
vancomycin
Sulphonamide
s
Cephaloridine
Cephalothin
tetracycline
Safe - no dosage change usually needed
Fairly safe - dosage change only in sever renal failure.
Less safe - dosage reduction is needed
Avoid - in all the patents
CHRONIC RENAL FAILURE
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ANTIBIOTIC PROPHYLAXIS IN HEAD
AND NECK SURGERY
ADVANTAGES


DIS ADVANTAGES









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PRINCIPLES

1.RISK OF INFECTION MUST BE SIGNIFICANT

2.CHOOSE CORRECT ANTIBIOTIC

3.ANTIBIOTIC PLASMA LEVELS MUST BE HIGH

4.ANTIBIOTIC MUST BE TIMED CORRECTLY

5.USE SHORTEST ANTIBIOTIC EXPOSURE THAT IS
EFECTIVE




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RISK OF INFECTION MUST BE
SIGNIFICANT
a) Bacterial inoculums should be sufficient
size to cause infection.
b) Prolonged and extensive surgery.
c)Presence of foreign body

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.CHOOSE CORRECT ANTIBIOTIC:
a) Antibiotic must be effective against
causative organism.
b) Choose narrow spectrum antibiotic
c) It should be least toxic
d) Select bactericidal antibiotic

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ANTIBIOTIC PLASMA LEVELS MUST BE HIGH:
a) Prophylactic doses should be higher
than therapeutic doses
b) Antibiotic should diffuse into all fluids
and tissue spaces where surgery is going on.
c) Doses should be at least two times the
therapeutic dose.

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penicillin-1gm
Cephalosporins-1gm
Clindamycin-300m
Clarithromycin-500mg

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ANTIBIOTIC MUST BE TIMED
CORRECTLY
penicillin should be given every 2 hrs.
Cephalexin should be given every 2 hrs
Clindamycin should be given every 3 hrs

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USE SHORTEST ANTIBIOTIC EXPOSURE
THAT IS EFECTIVE
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ANTIBIOTIC PROPHYLAXIS OF WOUND
INFECTION:

1.PARENTERAL REGIMEN:
1. Penicillin:
Preoperative 1 million units IV
Intraoperative 1 million units IV q2hrs
Post operative 1 million units IV in recovery room

2.Cephazolin(penicillin allergic patients)
Preoperatively 1gm IV
Intraoperatively 1gm Ivq 4h
Postoperatively 1gm IV in recovery room.


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3.Clindamycin
Preoperatively 600mg IV
Intraoperatively 600mg IV 4h
Post operatively 600mg IV in recovery room

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2.ORAL REGIMEN:
1.Penicillin
Preoperative 2mg po 30min before
Intraoperative 1mg per oral 2hrly
Post operative 1mg per oral 2hrly
2. Erythromycin
Preoperative 1gm 1hr before
Intraoperative 500mg per oral 2hrs
Post operative 500mg peroral 2hrs

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ORTHOGNATHIC SURGERY
rapid I.V administration of penicillin G 600,00 U achieves a
peak of 7micro.gm/ml, which is greater than 3 to 4 times
more than the MIC for susceptible organisms.
penicillin should be given parenterally in dose of 1 or 2
million U preoperatively and an additional dose every 11/2
to 2 hrs. least A.B dose should be given in recovery room.
it can prevent prolonged use of antibiotics
joms vol 49 1991
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ANTIBIOTIC MISUSE
PREVENTION

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ANTIBIOTIC RESISTANCE:

MULTIPLE DRUG RESISTANT ORGANISMS
VRE- Vancomycin resistant enterococci

MRSA- methicillin/oxacillin resistant staphylococcus aureus

ESBLs-extended spectrum beta lactamases(which are
resistant to cephalosporins and monobactams)

PRSP-Penicillin resistant streptococcus pneumoniae

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PREVENTION:

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CONCLUSION:

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REFERENCES

Oral and maxillofacial infections-topazian
Contemporary oral and maxillofacial surgery-peerson
Pharmacology and pharmacotherepeutics-satoskar
Davidsons principles and practice of medicine
Oral and maxillo facial surgery-daniel.m.laskin
OMFS clinics of n.a vol 15 feb 2003
Peterson L. Antibiotic prophylaxis against wound infections in oral and
maxillofacial surgery. J Oral Maxillofac Surg 1990;48:617-20.
Antibiotic prophylaxis in Oral and Maxillofacial Surgery. Med Oral Patol Oral
Cir Bucal 2006;11:E292-6.



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