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Role of Antibiotics In Exodontics
Dr.V.RAMKUMAR
CONSULTANT DENTAL &FACIOMAXILLARY SURGEON
REG NO:4118 -TAMILNADU –INDIA( ASIA)
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History
• Pasteur & joubert ( 1877)
• Modern era (1936) sulfanilamide
• Golden year (1941) penicillin.
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Definition
• Antibiotics are substances produced by microorganisms, which suppress the growth of or kill other microorganisms at very low concentrations.
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Classification
1. On the basis of preparation :i. Naturally occurring, e.g. from fungi, e.g. penicillins, cephalosporins,
erythromycin, tetracycline, chloramphenicol, and aminoglycosides, etc.
ii. Synthetic, e.g. sulfonamides.
2. On the basis of family:i. Penicillinsii. Cephalosporinsiii. Sulfonamidesiv. Tetracyclinesv. Aminoglycosidesvi. Macrolide
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3. On the basis of spectrum of activity:i. Narrow: penicillins
ii. Broad: ampicillins, tetracyclines.
4. On the basis of effect:i. Bacteriostatic: erythromycine, tetracycline, sulfonamide,
etc.
ii. Bactericidal: penicillins, cephalosporins, etc.
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5. On the basis of their effect on Gram-positive or Gram-negative bacteria:
i. Antibiotics acting on Gram-positive bacteria: penicillins, cephalosporins, erythromycine, bacterim, tetracycline,
gentamicin, etc.
ii. Antibiotics acting on Gram-negative bacteria: penicillin acts on gonococci.
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6. On the basis of systems:
i. Urinary tract:
– Nalidixic acid: acts on kidney and urinary bladder
– Furadantin: acts on bladder
ii. Skin : Neomycin, bacitracin, polymyxin.
iii. Orally (locally): neomycin, streptomycin.
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Antimicrobial vs Antibiotic
Confusion regarding antimicrobialand antibiotic !!
Mechanisms by which antibiotics may inhibit growth and multiplication :Alteration of cell membrane permeabilityAlteration in synthesis of cellular componentInhibition of Cellular metabolism
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Sites of action
Inhibiting formation of the bacterial cell wall
Inhibiting bacterial protein synthesis
Inhibiting nucleic acid synthesis
Altering the permeability of cytoplasmic membranes
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Factors influencing the efficacy:
Drug bindingProtection of pathogensTotal bacterial loadEffectiveness of host defensesPathogens in the periodontal tissues, root canals and other oral sites not affected by the therapy
Systemic and Topical antibiotics
What to use and Where ??
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Rationale of antibiotic usage
Microbial etiology Concept based on the premise….Patients who do not respond to mechanical therapy
Thus the concept of antibiotic therapy centers upon the pathogenic microbiota, the patient and the drug
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3 ways : Empirical therapy
Definitive therapy Prophylactic-against specific organisms-high risk-In general
Uses in dentistry and their side effects
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Choice of an antibiotic :
Patient factors :1.Age
2. Dose modification :
3. Local factors : Pus Hematomas Ph Anaerobic environment4. Drug allergy
5. Impaired host defence
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Organism related considerations:
• Clinical diagnosis itself directs…• Choice
Combination therapySynergismTo reduce severity or incidence of adverse effectsPrevent resistanceTo broaden the spectrum of antibiotic action
“Good decisions improve the chances of successful outcomes”
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Various antibiotics
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QUINOLONES
• Synthetic
• Having a quinolone structure
• Primarily active against Gm–ve bacteria
• Newer fluorinated compounds also inhibit Gm+ve ones
• 1st member nalidixic acid in mid 1960s
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Fouoroquinolones
• Quinolones antimicrobials having one or more fluorine substitution.
• First generation Fouoroquinolones –
• Second generation Fouoroquinolones -
Norofloxacin Ofloxacin
Ciprofloxacin Pefloxacin
Lomefloxacin Levofloxacin
Sparfloxacin Gatifloxacin
Moxifloxacin
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Beta Lactam Antibiotics
These are antibiotics having a β-lactam ring. The two major groups are pinicillins and cephalosporons.
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PENICILLINS
• Penicillin was the first antibiotic to be used clinically in 1941. it is a miracle that the least toxic drug of its kind was the first to be discovered. It was originally obtained from the fungus Penicillium notatum, but the present source is a high yielding mutant of P.chrysogenum.
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Semisynthetic Penicillin
Classification –1. Acid resistant alternative to penicillin G phenoxymethyl
penicillin (Penicillin V).2. Penicillinase resistant penicillins Methicillin, Oxacillin,
Cloxacillin.3. Extended spectrum penicillins
a) Aminopenicillins: Ampicillin, Bacampicillin, Amoxicillin.b) Carboxypenicillins: Carbenicillin, Carbenicillin indanyl,
Carbenicillin phenyl (Carfecillin), Ticarcillin.c) Ureidopenicillins: Piperacillin, Mezlocillin.d) Micillinam (Amdinocillin).
β-lactamase inhibitors Clavulanic acid Sulbactam.
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Cephalosporins
• These are a group of semisynthetic antibiotics derived form ‘cephalosporin-C’ obtained from a fungus Cephalosporium. They are chemically related to penicillins; the nucleus consists of a β-lactam ring fused to a dihydrothiazine ring.
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First generation
Second generation
Parenteral
Cephalothin
Cefazolin
Oral
Cephalexin
Cephradine
Cefadroxil
Parenteral
Cefuroxime
Cefoxitin
Oral
Cefaclor
Cefuroxime axetil
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Third generation
Fourth generation
Parenteral
Cefotaxime
Ceftizoxime
Ceftriaxone
Ceftazidime
Cefoperazone
Oral
Cefixime
Cefpodoxime procetil
Cefdinir
Ceftibuten
Parenteral
Cefpime
Cefpirome
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• All cephalosporins are bactericidal and have the same mechanism of action as penicillin, i.e. inhibition of bacterial cell wall synthesis.
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Tetracyclines and Chloramphinicol(Broad Spectrum Antibiotics)
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Aminoglycoside Antibiotics
These are a group of natural and semisynthetic antibiotics having polybasic amino groups linked glycosidically to two or more aminosugar (streptidine,2-deoxy streptamine, garosamine residues).
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Macrolide and Other Antibacterial Antibiotics
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MACROLIDE ANTIBIOTICS
• These are antibiotics having a macrocyclic lactone ring with attached sugar. Erythromycin has been in use from the 1950s, Roxithromycin, Clarithromycin and Azithromycin are the recent additions.
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Erythromycin
Mechanism of action
• Erythromycin is bacteriostatic at low but cidal at high concentrations.
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Adverse effects
1. Gastrointestinal
2. Very high doses of erythromycin have caused reversible hearing impairment.
3. Hypersensitivity
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MISCELLANEOUS ANTIBIOTICS
• Clindamycin
• Vancomycin
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Principles for choosing ANTIBIOTICS!!!!!
• IDENTIFICATION OF THE CAUSATIVE ORGANISM• DETERMINATION OF ANTIBIOTIC SENSITIVITY• SPECIFIC, NARROW SPECTRUM – Ab • LEAST TOXIC Ab• Pt’s DRUG HISTORY• BACTERICIDAL RATHER THAN
BACTERIOSTATIC• Ab WITH PROVEN HISTORY OF SUCCESS• COST OF Ab
+
+
+
+
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ANTIBIOTIC ADMINISTRATION
• Proper dose
• proper time interval
• Proper route of administration
• Combination antibiotic therapy
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Causes of failure
• Inadequate surgical treatment• Depressed host defence• Prence of foreign body• Antibiotic problems
– drug not reaching infection– Dose not adequate– Wrong bacterial diagnosis– Wrong antibiotics
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Classification of wounds ( CCSC )
Class I (Clean) – Non-Traumatic or surgical
Class II (Clean contaminated) – Fresh
Class III ( Contaminated )
Class IV ( Dirty )
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Class I – No Antibiotics
Class II – Rarely / depressed host, prosthetic device infection prolonged surgery and reduced blood supply.
Class III & IV - Antibiotics
When to
use?????
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Prophylactic antibiotics
• J F Burke – 1961
• MIC 15 To 30 mints(Iv)s
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Indications of prophylactic Ab
• Endocarditis• Valvular heart diseases• Total joint replacement• ESR• Prosthetic valves• DM• Leukemia • COL • Immunosuppressed patients
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Prophylactic regimens for dental procedures
Situation Antibiotic Regimen
• Standard general prophylaxis
Amoxicillin Adults, 2.0 g; children, 50 mg/kg orally one hour before procedure
• Can not use oral medications
Ampicillin Adults, 2.0 g IM/IV; children, 50 mg/kg IM/IV within 30 minutes before procedure
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Contd..
• Allergic to penicillin
Clindamycin
or
Cephalexin
Cephadroxil
or
Azithromycin or Clarithromycin
Adults, 500 mg; children, 20 mg/kg
orally one hour before procedure
Adults, 2.0 g; children, 50 mg/kg
orally one hour before procedure
Adults, 500 mg; children, 15 mg/kg orally one hour before procedure
• Allergic to penicillin and unable to take oral medications
Clindamycin
or
Cephazolin
Adults, 600 mg; children, 15 mg/kg IV
one hour before procedure
Adults, 1.0 g; children 25 mg/kg IM/IV within 30 minutes before procedure
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Antibiotics-The Miracle drugs
Use, Misuse and Abuse
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Misuse of antibiotics :
Inappropriate antibiotic
Failure to take the entire prescribed course
Saving antibiotics for a future illness
Sharing or using someone else’s medicine
Era of antibiotic on demand
False sense of security
Over the counter availability (self medication)
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Is antibiotic misuse a serious problem ?
Antibiotic misuse can lead to the development of antibiotic-resistant bacteria.
Misusing antibiotics means they may not be effective when needed to treat an infection in the future.
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Abuses :
Humans have ignored a clear warning that excessive or abuse of antibiotics would lead to a world filled with human carriers of bacteria resistant to known antibiotics
Broad spectrum and long courses of therapyProphylactic use for simple surgical procedures
“When in doubt cover”Well defined limited infectionsPain
“Selective pressure phenomenon”
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Emerging Antimicrobial Resistant Organisms: The Global Problem of Antibiotic Misuse
Adaptations (product of selection)Acquisition and transmission of antibiotic
resistance (horizontal gene transfer)
Mechanisms:1. Mutation2. Destruction or inactivation3. Efflux
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Development of resistance
• Mutation
• Transduction
• Transformation
• conjugation
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How to prevent abuse ??
Sufficient risk of infection morbidityBactericidal antibiotics are preferred …
Narrow spectrum antibiotic effective
Dosages should not be reduced.
Aggressive antibiotic protocol in immuno- compromised patients
Close up follow up of patients with infection
Difficult chronic and sub acute infections
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How to prevent antibiotic abuse
Most appropriate
Maintain high enough levels of the drug
No “Just in case”
2 or more drugs to be administered
Restrict use of drugs
Strictly regulate the amplification of drug resistance
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Policy for antibiotic use
Surveillance systems
Educational and Compliance programs
Solutions for bacterial resistance :
Research
Quality control in pharmaceutical production
Other modalities : “Decoy molecules”
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Summary and Conclusion
Can we instead be facing the end of golden era of antibiotics ??
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Thank YouHave a Nice Day…..