Antibiotic indications for OS

Tara Renton

Antibiotic indications for OSPeri-operative Elective

• Pre operative (A,C,D +E)– Amoxycillin Oral 2g– OR– Erythromycin Oral 1g

• + Post operative (A,B, D and E)– 3 days Pen V or Amoxycillin 250mg

TDS– Or 3 days Metronidazole 200mg TDS

• Additional if recent Abs included above– Clindimycin 600 mg TDS for 7 days

warn pt pseudo membraneous collitis

Patients at risk Patients at risk post op infection due to immuno-compromise (A)

Immature immunity infantsMalnutrition older populationDiseaseDiabetes Mellitis (type 1 and 2)AlcoholismCirrhosisRenal failureSplenectomyMalignant tumoursLeukaemia Lymphoma MyelomaCollagen diseaseHIV AIDSPagets MedicationSteroidsImmunosuppressants/ chemotherapy organ

transplantBisphosphonatesRadiation therapy

• Remember • Kids may be prone to

rapid spreading infections due to elevated metabolic rate

• Dry sockets do not occur in kids

• Multiple dry sockets may be a sign of pathology OR osteomyelitis

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Situations when the use ofAntibiotics is NOT necessary

o For the prevention of infective endocarditis BSAC/NICE 2010

o When identification and removal of source with local infection is possible Ellis et al BDJ 2011

o Chronic well-localized abscess Ellis et al BDJ 2011

o Minor vestibular abscess Ellis et al BDJ 2011

o Dry socket RCS Eng Guidelines 1996

o Mild pericoronitis RCS Eng Guidelines 1996

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Antibiotics in OS are indicated for infections when;

– For acute local infection where you are unable to remove the cause immediately

– For rapidly spreading infection with systemic signs

– For persistent, recurrent on responsive infection

Principles of infection managementPrinciples of infection managemento Identify patients at risk and prevent post op infections

where possibleo Removal of source (extirpation of pulp / extraction)o Incision and drainage (I+D) if not all pus drained @ extn or cellulitic spread with no obvious pus

o Medical support if indicated

o Antibioticso Analgesics

Culture + sensitivity (C+S) if indicatedRecurrent / Non responsive infectionCompromised host defensesRapidly spreading local infectionEvidence systemic infectionSuspected Actinomycosis

o Re-evaluation identify patient in trouble EARLY on for referral

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Patient in troubleSystemic signs•Fever > 36.8c•Lymphadenopathy•Trismus•Rash •Raised WBC/ CrP

Systemic symptoms•Malaise•Dehydration•Difficulty swallowing,speaking or breathing

Indications for Culture andAntibiotics Sensitivity

Recurrent / Non responsive infection

Compromised host defenses

Rapidly spreading local infection

Evidence systemic infectionSuspected Actinomycosis

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Specific AB regimens

• Prevention BONJ/ORN• Secondary care

– Management BONJ– Management ORN– Management OM

Suggested protocol for PREVENTION of BONJ/ORN

Pre administration of BPSComplete invasive procedures prior to IV bisphosphonates /radiation(? Short arch therapy, OHI, Fluoride RS, Corsodyl gel)AVOID extractions use RCT/extrusion where possibleRemove denturesRegular dental check up

If routine extn required after BPs takenCorsodyl 10 mls QDS pre and post operatively for all casesLow risk Oral BPs < 3 years no added risk factors (medical probs/steroids)

Primary care extn with minimal trauma. Preop 2g AmoxycillinMod risk BP /ORN Pt > 3 yrs Oral BPs in patients on steroids /smoker / concomittent

immuno compromise. Preop 2g Oral Amoxycillin / post op Oral Amoxycilin or metronidazole 7 days

High risk IV BPs previously 2 week preop Pentoxyfiline 400mg BD Vitamin E 1000IU / 4 weeks post op plus clindamycin

RefsMarks et al 2007 www.ada.org/prof/resources/topics/osteonecrosis.aspNHS Evidence - oral healthformerly a Specialist Library of the National Library for HealthMHRA: Bisphosphonates and osteonecrosis of the jaw (2007) [view]Osteonecrosis of the jaw with bisphosphonates (2006) [view]FDA: Osteonecrosis of the jaw: important drug precaution (2005) [view]Bandolier: Bisphosphonates and jaw necrosis (2006)

Suggested protocol for Management of BONJ/ORN

ReferIf more complex surgical treatment is requiredORThe patient presents with painful separated bone sequestrumStage 2 case Attain CBCT of region

MxCorsodyl 10 mls QDS pre and post operatively for all casesIV BPs previously 2 week preop Pentoxyfiline 400mg BD

Vitamin E 1000IU / 4 weeks post op plus ClindamycinLA surgery should be undertaken with minimal trauma lifting

sequestrum away with irrigation with corsodyl and minimal debridement and loose sutures.

Review

– Multiple dry socket???– CBCT of area (usually mandibular region)– Bone sequestrae not present

• 6 weeks Clindamycin

– Bone sequestrae present• LA removal and debridement of sequestrae• Preoperative Abs and Post op Abs• Review

Suggested protocol for Management of OM

Refs Schwartz AB, Larson EL Antibiotic prophylaxis and postoperative complications after tooth extraction and implant

placement: a review of the literature. J Dent. 2007 Dec;35(12):881-8. Epub 2007 Sep 29.Ellison BDJ 2011.Kunkel M, Kleis W, Morbach T, Wagner W Severe third molar complications including death-lessons from 100 cases

requiring hospitalization. J Oral Maxillofac Surg. 2007 Sep;65(9):1700-6.Halpern LR, Feldman S. Perioperative risk assessment in the surgical care of geriatric patients. Oral MaxillofacSurgClin

North Am 2006;18:19-34, v-vi.Pynn BR, Sands T, Pharoah MJ. Odontogenic infections: Part one. Anatomy and radiology. Oral Health 1995;85: 7-10, 13-

4, 17-8.Holmstrup P, Poulsen AH, Andersen L, Skuldbol T, Fiehn NE. Oral infections and systemic diseases. Dent Clin North

Am 2003;47:575-98. Daramola OO, Flanagan CE, Maisel RH, Odland RM. Diagnosis and treatment of deep neck space abscesses. Otolaryngol

Head Neck Surg 2009;141:123-30. Gift HC, Drury TF, Nowjack-Raymer RE, Selwitz RH.

The state of the nation's oral health: mid-decade assessment of Healthy People 2000.J Public Health Dent 1996;56:84-91.

Kunkel M, Kleis W, Morbach T, Wagner W. Severe third molar complications including death - lessons from 100 cases requiring hospitalization. J Oral MaxillofacSurg 2007; 65: 1700-6.

Marioni G, Rinaldi R, Staffieri C, Marchese-Ragona R, Saia G, Stramare R, Bertolin A, Dal Borgo R, Ragno F, Staffieri A. Deep neck infection with dental origin: analysis of 85 consecutive cases (2000-2006). ActaOtolaryngol 2008;128: 201-6;1-6.

Sands T, Pynn BR, Katsikeris N. Odontogenic infections: Part two. Microbiology, antibiotics and management. Oral Health1995;85:11-4, 17-21, 23.

Dirschl DR, AlmekindersLC. Osteomyelitis. Common causes and treatment recommendations. Drugs 1993;45:29-43.

Refs

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• Eur J Clin Microbiol Infect Dis. 2009 Apr;28(4):317-23. Epub 2008 Sep 17.• Osteomyelitis of the jaw: resistance to clindamycin in patients with prior antibiotics exposure.• Pigrau C, Almirante B, Rodriguez D, Larrosa N, Bescos S, Raspall G, Pahissa A.• Source• Hospital Universitari Vall D'Hebron, Universitat Autonoma, Barcelona, Spain. cpigrau@vhebron.net• Abstract• The purpose of this paper was to review our clinical experience in patients with osteomyelitis (OM)

of the jaw, focusing on aspects of antimicrobial resistance. A retrospective review of the medical records of adult patients with jaw OM was carried out. Among 46 cases of jaw OM, the cause was odontogenic in 32 (seven had recent dental implants and four bisphosphonate osteonecrosis), postoperative/post-traumatic in eight, and secondary to osteoradionecrosis in six. Clinical features were chronic in 91.3%. The infection was polymicrobial in 24/41 (65.9%). Viridans streptococci were the most commonly isolated agents. Among 26 viridans streptococci tested, 81% were susceptible to penicillin and 96% to fluorquinolones, but only 11.5% to clindamycin. Overall, 35/38 (92.1%) had at least one clindamycin-resistant isolate. Appropriate antibiotics were administered for a mean of 5.8 +/- 3.2 months. Beta-lactams were used in 19 cases and fluorquinolones in 14. Among 39 cases with long-term follow-up, only two relapsed. Currently, jaw OM is commonly related to osteoradionecrosis, dental implants, and bisphosphonates. In patients with prior antibiotics exposure, a high percentage of infections were caused by clindamycin-resistant microorganisms, thus, beta-lactams should be the antibiotic of choice. In penicillin-allergic cases, the new fluorquinolones, probably in combination with rifampin and/or clindamycin, could be a promising alternative

• reported good activity for clindamycin at 300 mg against staphylococcal osteomyelitis in humans when given orally at 8- hour intervals or IV at 6-hour intervals.

• Xue IB, Davey PG, Philips G: Variation in postantibiotic effect of clindamycin against clinical isolates of Staphylococcus aureus and implications for dosing of patients with osteomyelitis. Antimicrob Agents Chemother 40(6):1403–1407, 1996.

• clindamycin for the treatment of osteomyelitis because it shows a good penetration into the bone tissue

• Oropharyngeal anaerobic infections may not respond to penicillin and thus require a drug effective against penicillin-resistant anaerobes (see below). Oropharyngeal infections and lung abscesses should be treated with clindamycin or a β-lactam/β-lactamase combination such as amoxicillin/clavulanate In patients allergic to penicillin, clindamycin or metronidazole (plus a drug active against aerobes) is useful.

• Taori KB, Solanke R, Mahajan SM, Rangankar V, Saini T. CT evaluation of mandibular osteomyelitis. Indian J Radiol Imaging. 2005;15:447-451

• Eyrich G, Baltensperger M, Bruder E, Graetz K. Primary chronic osteomyelitis in childhood and adolescence. A retrospective analysis of 11 cases and review of the literature. J Oral Maxillofac Surg. 2003;61:561-573.

• Schultz C, Holterhus P, Seidel A, Jonas S, Barthel M, Kruse K.Chronic recurrent multifocal osteomyelitis in children.Pediatr Infect Dis J. 1999;18:1008-1013.

• Job-Deslandre C, Krebs S, Kahan A. Chronic recurrent multifocal osteomyelitis: Five-years outcomes in 14 patients cases. J Bone Spin. 2001;64:245-251.

• Lavis JF, Gigon S, Gueit I, Michot C, Tardif A, Mallet E. Chronic recurrent multifocal osteomyelitis of the mandible. A case report. Arch Pediatr. 2002;9;1252-1255.

• Reinert S, Widlitzek H, Venderink DJ. The value of magnetic resonance imaging in the diagnosis of mandibular osteomyelitis. Br J Oral Maxillofac Surg. 1999;37:459-463.

• Pozza DH, Neto NR, Sobrinho JB, Santos JN, Weber JB, de Oliveira MG. Combined treatment by antibiotic therapy and surgery of chronic mandibular osteomyelitis: a case report. R Ci méd boil. 2006:5;75-79.

Analgesic regime for TMS (adult pts)

• Ibuprofen 400-600mg QDS per oral• Paracetamol 500mg -1g QDS per oral• Prescribe above together as synergistic effect with

combination• Advise to start when Local anesthetic is wearing off

– If allergic to NSAIDS or pregnant Paracetamol alone– Codeine rarely indicated OR beneficial– Rescue mediation = Tramadol