trends of usage of antimicrobial agents in dental practice on

Trends of usage of antimicrobial agents in dental practice on the basis of prescription analysis

Oral cavity organisms

400 more than species

Aerobic as well as anaerobic

10 – 100 Anerobic times more

, , Spirochetes Candida viral

To deal with - Dental Caries , , Dentoalveolar abscess pulp infection

periapical abscess Gingivitis – , Periodontitis pericoronitis

, , periodontal abscess osteomyelitis-peri implantitis

Deep fascial infection

Indications for Chemotherapeutic Agents

Orodental Infections To prevent other infections – bacterial

endocarditis To prevent postoperative infection Improve healing

Aims of study To get general idea of prescribing trends Comparing the trends in institutional

practice and private practice To analyze the prescriptions in order to

determine - The rationale - indications, adequacy of dosage, and duration of treatment

The adequacy for prophylaxis The attention given to - contraindications and precautions

Period of study: 01/01/05–06/30/05: 6 months

Material: OPD antimicrobial Prescriptions Data collected from –

TEACHING INSTITUTES: 03 PRIVATE CLINICS: 30

¤ SPECIALISTS: 10

¤ GDP: 20 (General Dental Practitioners)

7593TOTAL

3975Total

2740GDP

1235Spec ialis ts

PRIVATECLINICS

3618 Total

903, GMC Miraj

910, TKDC Kolhapur

1805, VPDC Sangli

Total Pres criptions INSTITUTES

TEACHING INSTITUTES

39 (1.07%)

62 (1.71%)

136 (3.7%)

226 (6.24%)

1390 (38.4%)

495 (13.68%)

105 (2.9%)

404 (11.16%)

761 (21%)

Total ( %)

20

5

22

45

95

123

37

137

419

3

109Clindamycin

2037Tetra

1995Sulfa/cotrimoxazole

63118Macrolide

475820Quino + metro/T

135237Quinolone

1652Cephalosporin

52215Pen + clavulanate

120222 Penicillins

21 DRUG

PRIVATE CLINICS

33 (0.83%)528Clindamycin 52 (1.3%)448Tetra 78 (1.96%)6216Sulfa/cotrim264 (6.64%)23034Macrolide2466 (62.3%)1661805Quino + metro/T261 (6.56%)16497Quinolone162 (4.07%)6795Cephalosporin337 (8.47%)26077Pen+ clavulanate322 (8.10%)24775 PenicillinsTOTAL (%)GDPSPE DRUG

TRENDS – Institutes Vs Private

72 (0.95%)3339Clindamycin 114 (1.51%)5262Tetra 214 (2.84%)78136Sulfa/cotrim490 (6.5%)264226Macrolide3856 (51.2%)24661390Quino+metro/T756 (10%)261495Quinolone267 (3.54%)162105Cephalosporin741 (9.83%)337404Pen+clavulanate1083 (14.4%)322761 PenicillinsTOTAL (%)PRIINSTI DRUG

Trends

6 .5%6.64%6.24% Macrolides

9 .8 3%8.47%11.16% + Penicillinclavulanate

1 0 .0 3%6.56%13.68% Quinolone alone

1 4 .3 7%8.10%21% Penicillins

5 1 .1 8%62.3%38.41% + Quinolone/metronidazole T

TOTALPRIVATEINSTITUTES

Other remarkable observations

CIPRO IN CHILDREN Ciprofloxacin ( up to 5 years): 1.3% Ciprofloxacin ( 5-10 years): 2.7% Ciprofloxacin ( > 10 years): 3%

Inadequate frequency of admn Amoxicillin: 250 mg bid: 16.7% Ampicillin: 250 mg bid: 15%

Timing of treatment/prophylaxis

Inadequate duration: 19.4%Ciprofloxacin single dose,

Amoxicillin 2 days, Ampicillin 2 days

Antibiotic started after the procedure: 61.3%

ORO DENTAL INFECTIONS

Periapical/Periodontal Abscess Acute Suppurative pulpitis/Toxic

cellulitis. Salivary Gland Sepsis/Sinusitis Post Surgical/Post Traumatic. Oro-antral/Oro-nasal Fistula. Ludwig’s angina/Purulent osteitis Pericoronitis/Mucositis/Pemphigus

SPECTRUM

MACROLIDE

CLINDA CEPHA

AMPI/AMOXY

PEN G/PEN V

ORODENTALINFECTIONS

Prophylaxis (Prevention)

1. Bacterial Endocarditis.

2. Prosthetic Joint Infections.

3. Immuno-Compromised Hosts.

4. Procedures and others.

SBE PROPHYLAXIS RECOMMENDED Extractions, Periodontal procedures Prophylactic cleaning Implant placement, Re-implantation Endodontic

Instrumentation/Surgery beyond root apex, Placement or removal of orthodontic bands

Intraligamentary LA

SBE PROPHYLAXIS - 1 (1 hr before procedure) STANDARD REGIMEN Amoxicillin 2 g

PENICILLIN ALLERGY Clindamycin 600 mg Cephalexin/Cefadroxil 2 gm Clarithromycin/Azithromycin 500

mg

SBE PROPHYLAXIS - 2 30 mins before

procedure) Failure to take P/O Ampicillin 2 gm IM/IV Penicillin allergy & Failure to

take P/O Clindamycin 600 mg IV Cefazolin 1 gm IM/IV

PREFER CIDAL AGENT, SUSCEPTIBILITY

NARROWEST SPECTRUM

CORRECT DOSING AND ADEQUATE DURATION OF TREATMENT

Inferences Most commonly prescribed antimicrobials

were quinolones in combination with (51% ).metronidazole and tinidazole

Amongst , the quinolones c iprofloxacin andofloxacin were the quinolones chosen by95% .of the prescribers

Quinolones – , ciprofloxacin ofloxacin were prescribed 10%alone by .prescribers

4. Inadequacy of the frequency of administration was found in 15-17%

.prescriptions 5. Inadequate duration of treatment was

observed in 19.4% .prescriptions 6. First generation quinolones were

prescribed to the children in the range of1-3% of the prescriptions given for

.quinolones 7. The antimicrobial agent was started

AFTER THEPROCEDURE in about 61% .cases

BIBLIOGRAPHY

1. Sudha P et al: Journal of Indian society of Pedodontics and preventive dentistry 23-2 (2005) 74-792. Studervant et al: JIDA 64 (1993) 389-3923. Damle et al: Community dental oral epidemiol:22(1994) 62-634. Dajani et al: Prevention of bact endocarditis recommendations by AHA: JAMA: 277-1997-1794-18015. Oral health and morbidity - implications of oral infections on the elderly - Jukka H. Meurman, Piia Hämäläinen GerodontologyVol. 23 Issue 1 Page 3 March 2006

5. Lin LJ, Chiu GK, Corbet EF. Are periodontal diseases risk factors for certain systemic disorders-what matters to medical practitioners? Hong Kong Med J. 2003;9:31-37.

6. Loesche WJ. Association of the oral flora with important medical diseases. Curr Opin Periodontol. 1997;4:21-28.

7. 1989 World Workshop in Clinical Periodontics. Ann Periodontol. 1999;4:1-112.

1999 International Workshop for a Classification of Periodontal Diseases and Conditions. Papers. Ann Periodontol. 1999;4:1-112.

8. Evaldson G, Heimdahl A, Kager L, Nord CE. The normal human anaerobic microflora. Scand J Infect Dis Suppl. 1982;35:9-15.

9. Heimdahl A, von Konow L, Satoh T, Nord CE. Clinical appearance of orofacial infections of odontogenic origin in relation to microbiological findings. J Clin Microbiol. 1985;22:299-302.

10. Brook I, Frazier EH, Gher ME. Aerobic and anaerobic microbiology of periapical abscess. Oral Microbiol Immunol. 1991;6:123-125.

11. Brook I, Hunter V, Walker RI. Synergistic effect of Bacteroides, Clostridium, Fusobacterium, anaerobic cocci, and aerobic bacteria on mortality and induction of subcutaneous abscesses in mice. J Infect Dis. 1984;149:924-928.

12. Namavar F, Verweij-van Vught AMJJ, Vel WAC, Bal M, MacLaren DM. Polymorphonuclear leukocyte chemotaxis by mixed anaerobic and aerobic bacteria. J Med Microbiol. 1984;18:167?172.

13. Namavar F, Verweij AMJJ, Bal M, Martijn van Steenbergen TJ, de Graaf J, MacLaren DM. Effect of anaerobic bacteria on killing of Proteus mirabilis by human polymorphonuclear leukocytes. Infect Immun. 1983;40:930-935.

14. Gibbons RJ, MacDonald JB. Hemin and vitamin K compounds as required factors for the cultivation of certain strains of Bacteroides melaninogenicus. J Bacteriol.1960;80:164-170.

15. Mouton, C., Hammond PG, Slots J, Genco RJ. Serum antibodies to oral Bacteroides asaccharolyticus (Bacteroides gingivalis): relationship to age and periodontal disease. Infect Immun. 1981;31:182-192.

16. Slots J. Microbial analysis in supportive periodontal treatment. Periodontol. 2000;12:56-59.

17. Gronbaek Frandsen EV. Bacterial degradation of immunoglobulin A1 in relation to periodontal diseases. APMIS Suppl. 1999.87:1-54.

18. Duerden BI. Virulence factors in anaerobes. Clin Infect Dis. 1994;Suppl 4:S253-S259.

19. Brook I. The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection. Rev Infect Dis. 1984;6:601-607.

20. Roos K, Grahn E, Holn SE. Evaluation of beta-lactamase activity and microbial interference in treatment failures of acute streptococcal tonsillitis. Scand J Infect Dis. 1986;18:313-319.

21. Brook I, Gober AE. Emergence of beta-lactamase-producing aerobic and anaerobic bacteria in the oropharynx of children following penicillin chemotherapy. Clin Pediatr. 1984:23:338-341.

22. Tuner K, Nord, CE. Emergence of beta-lactamase producing microorganisms in the tonsils during penicillin treatment. Eur J Clin Microbiol. 1986;5:399-404.

23. Brook I, Gober A. Prophylaxis with amoxicillin or sulfisoxazole for otitis media: effect on the recovery of penicillin-resistant bacteria from children. Clin Infect Dis. 1996;22:143-145.

24. Brook I, Gober AE. Monthly changes in the rate of recovery of penicillin-resistant organisms from children. Pediatr Infect Dis J. 1997;16:255-257.

25. Brook I, Douma M. Antimicrobial Therapy Guide for the Dentist. Newtown, Pa: Handbooks in Health Care Co.; 2003.

26. Stanford Guide to Antimicrobial Therapy. 33rd ed. Vermont: Antimicrobial Therapy, Inc; 2002.

27. Ehrenfeld M. Clindamycin in the treatment of dental infections. In: Zumbrano D, ed. Clindamycin in the Treatment of Human Infections. 2nd ed. Kalamazoo, Mich: Pharmacia and Upjohn; 1997.

28. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med. 2002;346:334-339.

29. Conrads G. DNA probes and primers in dental practice. Clin Infect Dis. 2002;1(Suppl 1):S72-S77.

30. Craig WA. Pharmacokinetic/pharmacodynamic parameters: rationale for antibacterial dosing of mice and men. Clin Infect Dis. 1998;26:1-12.

31. Longman LP, Preston AJ, Martin MV, Wilson NH. Endodontics in the adult patient: the role of antibiotics. J Dent. 2000;28:539-548.

32. Isla A, Canut A, Gascon AR, et al. Pharmacokinetic/pharmacodynamic (PK/PD) analysis of antimicrobial treatment of orofacial odontogenic infections. Clin Pharm. 2003.