This seminar will provide information about antibiotic principle administration.

1. Presented by:
Diwakar vasudev

2.  LOCAL
 Pain
 Swelling
 Surface erythema
 Pus formation
 Limitation of movement

3.  Systemic
 Fever
 Lymphadenopathy
 Malaise
 Toxic appearance
 Elevated white blood cell count

4.  Non infectious condition mimics infection
 During 2nd and 3rd day after surgery swelling
and pain are commonly significant.
 Surgical insult cause pain, swelling ,and
elevation in neutrophills.
 Clinical judgement is important while making
the diagnosis of infection.
 Common eg: patient 2 days after 3rd molar
surgery shows pain and swelling but has not
elevated temperature , foul mouth odor, or
malaise.

5.  With the inflammation migration of WBCs and
production of antibodies provides most of the
protection.
 If the host defenses are impaired infection
may results from minor bacterial invasion.

6.  Causes of depressed defences can be divided
into 4 categories.
 Physiologic
 Disease related
 Defective immune system
 Drug suppression-related

7.  Physiolgical depression
 It is because of the patient inabilty to deliver the
defending agents such as white blood cells ,
antibodies and compliment to the site of bacterial
invasion.
 Shock
 Disturbances in the circulation
 Caused by
 Advanced age or obesity and fluid imbalances are the
examples

8.  Disease related
 Malnutrition syndrome, often as a result of
alcoholism.
 Patients with cancer and leukemia
 Diabetes is a predisposing factor to infection
in the extremitis,
 orofacial region is not much so affected but
in poorly controlled diabetes.

9.  Defective immune system
 Agammaglobulinemia
 Multiple myleoma
 Total body radiation therapy
 Childern who have had spleenectomy are
more suspeptible to pneumonia caused by
Sterptococcus pneumoniae

10.  Therapeutic drugs
 2 groups of drugs
 Cytotoxic drugs
 Immunosuppressive drugs
 Cytotoxic drugs
 Patients may have increased susceptibility to
infections for upto 1 year after a course of
cancericidal therapy.

11.  Immunosuppressive drugs
 Glucocotricoids, azathioprine and
cyclosporine are used in variety of clinical
stituation such as organ transplation
 Therapy of these drugs depresses the T and B
cell lymphocytes.
 Aggressive antibiotic therapy must be
considered in treating established infections
in patients in any of these categories.

12.  Identification of the pathogen may be
determined scientifically either in laboratory
where the organism can be isolated from pus,
blood, or tissue or empirically based on the
previous knowledge.
 The typical odontogenic infection is caused
by mixture of aerobic and anaerobic bacteria
 70% infections – mixed flora
 5% infections – pure aerobic bacteria
 25% infections – pure anarobic bacteria

13. Situations in which culture should be performed
 If no improvement is seen clinically even after 3
days of appropriate treatment.
 If the infection is the postoperative wound
infection.
 If the infection is recurrent.
 If actinomycosis is supected.
 If osteomyelitis is present.
 In these situations deviations from the normal
bacterial flora is more likley to occur.

14.  Most odontogenic infections are caused by
organisms such as streptococci that do not
vary much in their antibiotic senitivity
patterns .
 Viridans streptococci that have been exposed
to B lactams may become quite resistant in
short time (2-3 days.) and they can cause
serious infection in some patients
 Penicillinase-resistant penicillin should be
used.

15.  Penicillin – Excellent for treatment of
streptococus infection and good to excellent for
the major anaerobes of odontogenic infection.
 Erythromycin- effective against sterptococcus,
peptostreptococcus and prevotella but is
ineffective against Fusobacterium.
 Clindamycin- Good for streptococcus
 Cephalexin – only moderate active against
streptococcus
 Metronidazole- It has no activity against
streptococcus but is effective against anaerobic
group.

16.  Antibiotic of a narrowest spectrum should be
choosen.
 Opportunity for development of resistant
strains is presented each time when bacteria
is exposed to antibiotics.
 In case of Narrow spectrum antibiotics fewer
organisms have the opportunity to become
resistant.
 The use of narrow- spectrum antibiotics also
minimize the risk of development of
suprainfection.

17.  Antibiotics are used to kill bacteria, but some
antibiotics may also kill normal human cells
thus they can be highly toxic.
 For eg: Bacteria that cause odontogenic
infections are sensitive to both penicillin and
chloramphenicol but cloramaphenicol is
more toxic than penicillin.

18.  Two items must be reviewed
 Previous allergic reaction
 Previous toxic reaction
 Allergy rate to penicillin is approx 5%
 It is well documented that there is actual
cross – sensitivity between penicillins and
cephalosporins do exist.

19.  Advantages
 1) Less reliance on the host reistance
 2) Killing of bacteria by the antibiotic itself
 3) Faster result
 4) Greater flexibilty with doasge interval

20. Bactericidal Antibiotics Bacteriostatic Antibiotics
Penicillins Tetracylines
Cephalosporins Erythromycin
Aminoglycosides Calrithromycin
Vancomycin Arithromycin
Metronidazole Clindamycin
Imipenem Sulfa
Fluroqunilones

21.  It is difficult to place a price tag on the health,
but surgeon should consider the cost of the
antibiotic to prescribe.
 In some situation more expensive antibiotic is
the drug of choice.
 In other situation, there may be a substantial
difference in the price for drug of equal
efficacy. Eg :penicillin V differs dramatically
from the price of cephalexin and clindamycin.
 When expensive drugs are to be pescribed
patient should be told regarding that to
prevent the angery feeling when he/she
purchasing the drug.

22.  Once daily administration- Approx 80%
 Twice daily administration – Approx 69%
 Four times a day- Approx 35%
 Patient stops to take antibiotics when after
acute symptoms subsides
 Highest compliance is on drug that could be
given once daily and for 4-5 days

23.  PROPER DOSE
 For therapeutic purposes the peak concentration
of the plasma antibiotic shoud be 3-4 times the
that of MIC.
 Dosage beyond this is wasteful and may be toxic
.
 Increased dose is justified in which infected area
is away from blood supply and in non vital tissue.
 Actinomycosis and Osteomyelitis are example
where such problems can occur.

24.  Each antibiotic has a established plasma half life
time(t½).
 The usual dose interval for therapeutic use of
antibiotics is 4 times to that ½.
 For eg:t ½ for cephazoline is almost 2 hrs thus
the time interval dose should be 8 hours.
 In patients with preexisting renal disease and
subsequent decreased clearance rate may require
longer dose interval excessive plasma level and
resultant toxicity may occur.
 An alternative drug that is excreted by liver such
as erythromycin may be used

25.  IN some infections only the parenteral route
can provide the necessary serum level of
antibiotics.
 For eg: the maximum plasma peak level of
penicillin v that can be reached by using oral
the oral route is 2g ( this gives a dose level of
almost 4ug/ml)
 Oral route also results in the most variable
absorption
 Most antibiotic should be taken in fasting
state.

26.  While treating the serious infection consistency
in the route should be maintained.
 Immediate shifting of the parenteral route to the
oral route may results in the reinfection
 Maintainence of the peak blood level of antibiotic
for an adequate period is important to maximum
tissue penetration.
 Bacteria usually takes 5-6 days fro complete
irradication.
 In mild infections blood levels achieved by the
oral route is suffcient.

27.  In adition to treating infections with most specific
antibiotics possible and avoiding broad spectrum
antibiotics, combination drug therapy should also be
avoided when not specifically indicated.
 It leads to depession of normal host flora and
increased opportunity for resistant bacteria to
emerge.
 But clear indication
 Patient of life threatening sepsis of unknown cause.
 Increased bactericidal effect against specific
organism is desired
 For prevention of rapid emergence of resistant
bacteria
 In empiric treatment of certain odontogenic infection.

28.  RESPONSE TO TREATMENT
 Most commonly the response begins by the second
day and initially is a subjective sense of feeling
better.
 5-7 day course of antibiotics is necessary.
 If no improvement is noted by the end of 2nd or 3rd
day patient must be carefully revaluated.
 Special attention should be given to determine the
need for additional surgical intervention.
 Other possible site of infection also should be
examined, and for the hospitalized patient, portals of
entry such as IV and foley catheters should be
examined as possible sites of infection.

29. CAUSES OF FAILURE IN TREATMENT OF INFECTION
Inadequate surgical treatment
Depressed host defences
Presence of foreign body
Antibiotics problems
Drugs not reaching the infection
Dose not adequate
Wrong bacterial diagnosis
Wrong antibiotic
Table Adapted from Peterson LJ

30.  Hypersenstivity reactions can occur with all
antibiotics
 Penicillins and cephalosporins have the
highest incidence of reaction
 These reaction may include accelerated
anaphylactic (type 1) reactions or less svere
reactions associated with edema, urticaria,
and itching , or may be delayed reactions,
presenting only as a low grade fever.

31.  Toxic reaction are seen often with an antibiotics.
 Penicillin is a drug which has extremely low toxicity
potential.
 Most of these are dose related.
 One toxic reaction is antibiotic associated colitis
(AAC).
 It was originally associated with clindamycin therapy
but now has been recognized to be caused by almost
every antibiotic, the exception of the aminoglyoside
 Three most common drugs leads to AAC are
clindamycin, ampicillin/amoxicillin and
cephalosporinns.
 Patients receiving antibiotics that alter colonic flora
may have overgrowth of C.difficile which leads to
AAC

32.  When the indigenous flora is altered or eliminated by
the antibiotic, the pathogenic bacteria resistant to the
antibiotic may cause a secondary infection or
superinfection.
 Common example is candidiasis it occurs most
commonly after long term penicillin therapy for eg :
long term therapy for osteomyelitis or actinomycosis.
 Facial surgeons occasionally face recurrent infection
when treating patients with odontogenic infections.
 An occasional infectious situation may be masked or
put into remissive state by antibiotic therapy, only to
recur when antibiotic therapy is stopped.

33. Abscess:
 Acute dentoalveolar cellulitis and abcess
usually require antibiotic therapy.
 Penicillin is usually the drug of choice.
 Adjunctive treatment can also be done
 Conversely many chronic dentoalveolar
abscesses need no antibiotic therapy
 Treatment may be entirely surgical

34.  Acute pericoronitis, if severe may require
antibiotic therapy.
 Bacteria responsible for pericoronitis is all
anaerobic bacteria including gram positive cocci
(peptostreptococcus) and gram negative rods
(prevotella)
 Many patients can be treated without antibiotic
therapy.
 However when there is clear established infection
with temperature elevationand sufficient trismus
in these cases patients require antibiotic therapy
before the surgery can performed.
 Penicillin is the drug of choice.

35.  Infection of the jaws usually require surgical
treatment.
 Antibiotic therapy is also essential for the
success of the treatment
 Osteomyelitis must be treated with antibiotics
for much longer period than soft tissue
infections.
 Intravenous B lactams are treatment of choice
for methicillin susceptible S. aureus.
 Vancomycin is the drug of choice methicillin
resistant s. aureus.

36.  Several newer agents for treatment of
methicillin resistant s. aureus inculde
linezolid and daptomycin.
 Rifampin combined with other
staphylococcus agents may increase cure
rates.
 Oral fluroquninolones and parentral B lactum
agents can be used for treatment of gram
negative osetomyelitis.
 Increasing resistance has complicated the
management of thses infection.

37.  All compound fractures may be assumed to
be contaminated, if not frankly infected .
 All fractures through root- bearing alveolar
bone should be consider compound because
they communicate with the oral cavity
through socket.
 Antibiotics must be given in the therapeutic
dose as soon as possible and continued until
the active fractures treatment is completed.

38.  Early antibiotic therapy should be given as
possible after the diagnosis has been made to
diminish the chance of infection.
 Penicillin is the drug of choice for facial
fractures.
 IF CSF leaks are present other antibiotics may
be choosen after consulting with
neurosurgeon.
 Patients who has sustained a facial fracture
must be given antibiotics according to the
therapeutic principles and not according to
the prophylactic guidelines.

39.  Antibiotics are of no benefit if a facial wound can
be cleaned, Debrided of non vital tissue and
other debris and closed adequately in the
reasonable time.
 Even through and through wounds of lips and
cheeks may be treated without antibiotic support
if adequate soft tissue debridement is performed.
 If the wound has been opened for 6 hours or
more, it should be considered infected a delayed
primary closure is the method of choice

40.  Wounds caused by animal and human bite
should be consider as special situation.
 Principle management of these wounds is
thorough debridement and excision of all non
vital tissue.
 As a general rule wounds should be closed
primarily after thorough debridement.
 Exception for bite wound is that they should
be closed with delayed primary closure.

41.  Recent controlled studies have indicated that
primary closure without the use of antibiotics
after thorough debridement of devitalized
compromised tissue , copious irrigations with
saline solution results in infection rate that
are as low as if antibiotics were used.
 When antibiotics are indicated, the drug of
choice is amoxicillin with clavulanic acid.

42. Severity of infection Antibiotic of choice
Outpatient Penicillin
Clindamycin
Cephalexin (only if the penicillin allergy was not the anaphylactoid
type; use caution
Penicillin allergy:
Clindamycin
Moxifloxacin
Metronidazole alone
Inpatient Clindamycin
Ampicillin + metronidazole
Ampicillin+Sulbactum
Penicillin allergy
Clindamycin
Third gen cephalosporin IV (only if the penicillin allergy was not the
anaphylactoid type ;
Moxifloxacin ( especially for Eikenella Corrodens)
Metronidazole alone (if neither clindamycin nor cephalosporin can be
tolerted
Empiric antibiotics of choice for odontogenic infections

43. Characterstics Inocculation
Duration 0-3 days
Pain Mild- Moderate
Size small
Localization Diffuse
Palpation Soft, doughy, mild
tender
Appearance Normal colouration
Skin quality Normal
Surface temperature Slightly heated
Loss of function Minimal or none
Tissue fluid Edema
Level of malaise Mild
Degree of seriousness Mild
Predominant bacteria Aerobic
STAGES OF INFECTION

44. Characterstics Cellulitis
Duration 3-7 days
Pain Severe and generalized
Size large
Localization Diffuse
Palpation Hard, exquisitely,tender
Appearance Reddened
Skin quality Thickened
Surface temperature Hot
Loss of function severe
Tissue fluid Serosanguineous,
flecks of pus
Level of malaise severe
Degree of seriousness severe
Predominant bacteria Mixed

45. Characterstics Abscess
Duration Over 5 days
Pain Moderate-severe and
loalized
Size Small
Localization Circumscribed
Palpation Fluctuant, tender
Appearance Peripherally reddened
Skin quality Centrally
Surface temperature Moderately heated
Loss of function Moderately severe
Tissue fluid Pus
Level of malaise Moderate-severe
Degree of seriousness Moderate-severe
Predominant bacteria Anaerobic bacteria

46.  Severity score =1
 Low risk to airway
 Low risk to vital structure
 Vestibular infection
 Subperiosteal infection
 Space of body of mandible
 Infraorbital space infection
 Buccal space infecion

47.  Severity score =2
 Moderate risk to airway
 Moderate risk to vital structure
 Submandibular space infection
 Submental space infection
 Sublingual space infection
 Pterygomadibular space infection
 Submassetric space infection
 Superfical temporal space infection
 Deep temporal ( or infratemporal)

48.  Severity score =3
 High risk to airway
 High risk to vital structure
 Lateral pharyngeal space
 Retropharyngeal space infection
 Pretracheal space infection

49.  Severity score =4
 Exterme risk to airway
 Exterme risk to vital structure
 Danger space (space 4)
 Mediastinum space infection
 Intracranial infection

50.  References
 Peterson text book of principle of
maxillofacial surgery.
 Topazian text book of odontogenic infection
 Oral and maxillofacial surgery clinics of north
america feb 2003