handout of antibiotics in dentistry
TRANSCRIPT
8/4/2019 Handout of Antibiotics in Dentistry
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Antibiotic Use In Dentistry
Kevin Nakagaki, D.D.S.
Director, Hospital Dental ClinicUniversity of Minnesota
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Writing Prescriptions
Rx: Drug Name (can be generic) Unit Dose
(ex: Pen V-K 500 mg, Elixer, Sol’n)
Disp: # of pills, milliliters (ml)
Sig: Directions for use. q24h (daily), q12h, q8h, q6h, q4h,
prn pain, till gone
Refills__ Signature
DEA #
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General Rules
Write Legibly!!
Remember your audience (Generally non-docs)
this will improve compliance. Preferable to order specific hourly dosage time
(q12h vs. bid, q8h vs. tid, etc.)
Sig: Specify # of pills to take each dose 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-HURT
Pt. Name: Address: DOB:
Rx: Date:
Disp:
Sig:
Refill____ Barry Brainfart, DDS
DEA:______________________
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Antibiotic Strategies
Cardinal Rules: 1) Use the right drug.2) Use the right dose. 3) Use the correctdosing schedule. 4) Correct duration.
Hard and Fast—Especially early. Why?
Use a loading dose to rapidly achieve
therapeutic blood levels. Avoid combinations of bacteriostatic and
bacteriocidal drugs.
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Considerations
Gram Positive?
Gram Negative?
Mixed Infection? Anaerobes?
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Discussion: Antibiotic Choice
Narrow Spectrum?
Extended/Broad Spectrum?
Designer Antibiotics?
Anaerobes? Consider if the infection ispresent > 3days or if no improvement.
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Narrow Spectrum Antibiotics
Specific for the pathogen.
Fewer disturbances of non-pathogenic
bacteria. Fewer side effects.
Rapid response for sensitive organisms.
Ex: Pen VK, Pen G, Erythromycin
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Broad Spectrum Antibiotics
Affects both Gram + and Gram – bacteria,better for mixed infections.
May give up some effectiveness for Gram +to gain effectiveness for Gram -.
Examples: Amoxicillin, Ampicillin
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Common Pathogens
Necrotic pulp and apical abscessesObligate anaerobic bacteria
Gram negative rodsPrevotella & 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 Pathogens
Periodontal DiseasesGingivitis
Fuso, strep, & actinomycetes
Adult peritonitisBacteroides, porphyomonas,peptostreptococcus & prevotellaAcute necrotizing ulcerative gingivitis
Spirochetes, prevotella, fusoLocalized juvenile periodontitis
Actinobacillus
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Common Pathogens
Fungal InfectionsCandida spp.Mucorales spp.
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Let’s 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 Choices
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ß-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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ß-Lactams
Natural penicillins
– Pen VK and Pen G
Bactericidal
Allergic reaction: rare (4 per 100,000)
Spectrum:
– Strep, staph, enterococcus, neiseria, treponema, listeria
Resistance:
– Mostly staph (>80%)
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ß-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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ß-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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Lincosamides
Clindamycin (Cleocin)
– MOA: binds to the 50S ribosomal subunit and inhibitsprotein 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 onconcentration
– Spectrum:
Gram +, anaerobes, parasites
– Resistance
Enteroccocus
*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 theribosome
– 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, andspirochetes
– Resistance:
Widespread, cross resistance – PHOTO SENSITIVITY!!!
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Nitroimidazoles
Metronidazole (Flagyl)
– MOA: reduced intermediate interacts andbreaks 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: <18 yrs old, pregnancy
– Adverse events: spontaneous tendon rupture
– Drug interactions: probenacid, warfarin
– Pregnancy category C
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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 Advisory
Statement
July 1997
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AAOS Statement
Antibiotic prophylaxis is NOT
recommended for dental patientswith plates, pins, or screws, nor is
it routinely recommended forMOST dental patients with TOTAL
JOINT REPLACEMENTS.
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AAOS recommendations
Prophylaxis recommended
– Total joint replacement within the last two yearsAND:
Compromised immune system OR
Type 1 DM OR
Previous prosthetic joint infections OR
MalnourishmentOR
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 Considerations
The dentist may not be aware of thepatient’s medical condition.
Physician may not be aware of the advisorystatements or of the dental procedure to beperformed.
Vicarious Liability: ―The devil made me do it‖
―I forgot to take my antibiotic.‖
Documentation.
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Legal Considerations
I forgot my antibiotics!
Animal studies have shown antibiotics areeffective up to 2 hours after the procedure.
Differentiate between prophylaxis vs.treatment of an early infection.
Take into consideration patient’s risk factors. Legal twists.
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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
Acute — Rapid growth
< 3 daysChronic > 3 days
Pen VK 500mg q6h or
Amox 500mg q8h orCephalosporin
Allergic to PCN
Clindamycin 300mg q8h or
Cephalosporin (check allergic Rxn) or
Azith or Clarithromycin
Think Anaerobes
Add Metronidazole 250-500mgTo PCN, Amox, or Ceph
Clindamycin 300mg q8h