antibiotic use in dentistry kevin nakagaki, d.d.s. director, hospital dental clinic university of...
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Antibiotic Use In DentistryAntibiotic Use In Dentistry
Kevin Nakagaki, D.D.S.Kevin Nakagaki, D.D.S.
Director, Hospital Dental ClinicDirector, Hospital Dental Clinic
University of MinnesotaUniversity of Minnesota
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Writing PrescriptionsWriting Prescriptions
Rx: Drug Name (can be generic) Unit DoseRx: Drug Name (can be generic) Unit Dose(ex: Pen V-K 500 mg, Elixer, Sol’n)(ex: Pen V-K 500 mg, Elixer, Sol’n)
Disp: # of pills, milliliters (ml)Disp: # of pills, milliliters (ml)
Sig: Directions for use. q24h (daily), q12h, q8h, q6h, q4h, Sig: Directions for use. q24h (daily), q12h, q8h, q6h, q4h, prn pain, till goneprn pain, till gone
Refills__Refills__ SignatureSignature DEA #DEA #
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General RulesGeneral Rules
Write Legibly!!Write Legibly!! Remember your audience (Generally non-docs) Remember your audience (Generally non-docs)
this will improve compliance.this will improve compliance. Preferable to order specific hourly dosage time Preferable to order specific hourly dosage time
(q12h vs. bid, q8h vs. tid, etc.)(q12h vs. bid, q8h vs. tid, etc.) Sig: Specify # of pills to take each doseSig: Specify # of pills to take each dose Prescribe an endpoint. (prn pain, till gone)Prescribe an endpoint. (prn pain, till gone)
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Barry Brainfart Dental Clinic 666 Bite Me LnCrossbyte Falls, MN Ph: 555-Y OU-HURTPt. Name: Address: DOB:
Rx: Date:
Disp:
Sig:
Refill____ Barry Brainfart, DDS
DEA:______________________
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Antibiotic StrategiesAntibiotic Strategies
Cardinal Rules: 1) Use the right drug. Cardinal Rules: 1) Use the right drug. 2) Use the right dose. 3) Use the correct 2) Use the right dose. 3) Use the correct dosing schedule. 4) Correct duration.dosing schedule. 4) Correct duration.
Hard and Fast—Especially early. Why?Hard and Fast—Especially early. Why? Use a loading dose to rapidly achieve Use a loading dose to rapidly achieve
therapeutic blood levels.therapeutic blood levels. Avoid combinations of bacteriostatic and Avoid combinations of bacteriostatic and
bacteriocidal drugs.bacteriocidal drugs.
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ConsiderationsConsiderations
Gram Positive?Gram Positive? Gram Negative?Gram Negative? Mixed Infection?Mixed Infection? Anaerobes?Anaerobes?
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Discussion: Antibiotic ChoiceDiscussion: Antibiotic Choice
Narrow Spectrum?Narrow Spectrum? Extended/Broad Spectrum?Extended/Broad Spectrum? Designer Antibiotics?Designer Antibiotics? Anaerobes? Consider if the infection is Anaerobes? Consider if the infection is
present > 3days or if no improvement.present > 3days or if no improvement.
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Narrow Spectrum AntibioticsNarrow Spectrum Antibiotics
Specific for the pathogen.Specific for the pathogen. Fewer disturbances of non-pathogenic Fewer disturbances of non-pathogenic
bacteria.bacteria. Fewer side effects.Fewer side effects. Rapid response for sensitive organisms.Rapid response for sensitive organisms. Ex: Pen VK, Pen G, ErythromycinEx: Pen VK, Pen G, Erythromycin
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Broad Spectrum AntibioticsBroad Spectrum Antibiotics
Affects both Gram + and Gram – bacteria, Affects both Gram + and Gram – bacteria, better for mixed infections.better for mixed infections.
May give up some effectiveness for Gram + May give up some effectiveness for Gram + to gain effectiveness for Gram -. to gain effectiveness for Gram -.
Examples: Amoxicillin, AmpicillinExamples: Amoxicillin, Ampicillin
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Common PathogensNecrotic pulp and apical abscesses
Obligate anaerobic bacteriaGram negative rods
Prevotella & 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 PathogensCommon Pathogens
Periodontal Diseases Periodontal Diseases GingivitisGingivitis
Fuso, strep, & actinomycetesFuso, strep, & actinomycetesAdult peritonitisAdult peritonitis
Bacteroides, porphyomonas, Bacteroides, porphyomonas, peptostreptococcus & prevotellapeptostreptococcus & prevotellaAcute necrotizing ulcerative gingivitisAcute necrotizing ulcerative gingivitisSpirochetes, prevotella, fusoSpirochetes, prevotella, fuso
Localized juvenile periodontitisLocalized juvenile periodontitisActinobacillusActinobacillus
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Common PathogensCommon Pathogens
Fungal InfectionsFungal InfectionsCandida spp.Candida spp.Mucorales 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 ChoicesAntibiotic 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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LincosamidesLincosamides
Clindamycin (Cleocin)– MOA: binds to the 50S ribosomal subunit and inhibits
protein 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 on
concentration– Spectrum:
Gram +, anaerobes, parasites
– Resistance Enteroccocus
*Clostridium diff. pseudomembranous colitis!!*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 the ribosome
– 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, and spirochetes
– Resistance: Widespread, cross resistance
– PHOTO SENSITIVITY!!!
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Nitroimidazoles
Metronidazole (Flagyl)– MOA: reduced intermediate interacts and
breaks 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 ADA/AAOS Advisory StatementStatement
July 1997July 1997
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AAOS StatementAAOS Statement
Antibiotic prophylaxis is Antibiotic prophylaxis is NOTNOT recommended for dental patients recommended for dental patients with with plates, pins, or screws,plates, pins, or screws, nor is nor is
it routinely recommended for it routinely recommended for MOSTMOST dental patients with dental patients with TOTAL TOTAL
JOINT REPLACEMENTS.JOINT REPLACEMENTS.
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AAOS recommendationsAAOS recommendations
Prophylaxis recommended – Total joint replacement within the last two years
AND: Compromised immune system OR Type 1 DM OR Previous prosthetic joint infections OR Malnourishment OR
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 ConsiderationsLegal Considerations
The dentist may not be aware of the The dentist may not be aware of the patient’s medical condition.patient’s medical condition.
Physician may not be aware of the advisory Physician may not be aware of the advisory statements or of the dental procedure to be statements or of the dental procedure to be performed.performed.
Vicarious Liability: “The devil made me do it”Vicarious Liability: “The devil made me do it” ““I forgot to take my antibiotic.”I forgot to take my antibiotic.” Documentation.Documentation.
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Legal ConsiderationsLegal Considerations
I forgot my antibiotics!I forgot my antibiotics! Animal studies have shown antibiotics are Animal studies have shown antibiotics are
effective up to 2 hours after the procedure.effective up to 2 hours after the procedure. Differentiate between prophylaxis vs. Differentiate between prophylaxis vs.
treatment of an early infection.treatment of an early infection. Take into consideration patient’s risk factors.Take into consideration patient’s risk factors. Legal twists.Legal twists.
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In Summary….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, route applicability
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 days
Chronic > 3 days
Pen VK 500mg q6h orAmox 500mg q8h or
Cephalosporin
Allergic to PCN
Clindamycin 300mg q8h orCephalosporin (check allergic Rxn) or
Azith or Clarithromycin
Think AnaerobesAdd Metronidazole 250-500mg
To PCN, Amox, or Ceph
Clindamycin 300mg q8h