Transcript Antibiotic indications for OS Peri

Antibiotic indications for OS
Tara Renton
Peri-operative
for elective
surgery
• Prevention of post operative infections
• in a compromised host
• before placement of foreign body
Infection
diagnosis
• 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
Specific
regimes
• for prevention BONJ and ORN
• For Mx osteomyelitis, OM, ORN, Sialdenitis, ANUG,
sinusitis.
Antibiotic indications for OS
Peri-operative Elective
Surgical
extraction
Foreign body
placement
• A Compromised host with
immuno compromise (see list)
• B Patient presenting with
abscess or local infection
• C Implants
• D bone graft
• 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
• E Patients at low risk above
Routine ext
of BONJ or ORN
– Clindimycin 600 mg TDS for 7 days
warn pt pseudo membraneous
collitis
Patients at risk
post op infection due to immuno-compromise (A)
Immature immunity infants
Malnutrition older population
Disease
Diabetes Mellitis (type 1 and 2)
Alcoholism
Cirrhosis
Renal failure
Splenectomy
Malignant tumours
Leukaemia Lymphoma Myeloma
Collagen disease
HIV AIDS
Pagets
Medication
Steroids
Immunosuppressants/ chemotherapy organ
transplant
Bisphosphonates
Radiation 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 of
Antibiotics 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 management
o Identify patients at risk and prevent post op infections
where possible
o 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 Antibiotics
o Analgesics
Culture + sensitivity (C+S) if indicated
Recurrent / Non responsive infection
Compromised host defenses
Rapidly spreading local infection
Evidence systemic infection
Suspected Actinomycosis
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o Re-evaluation identify patient in trouble EARLY on for
referral
Patient in trouble
Systemic signs
• Fever > 36.8c
• Lymphadenopathy
• Trismus
• Rash
• Raised WBC/ CrP
Systemic symptoms
• Malaise
• Dehydration
• Difficulty swallowing,speaking or breathing
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Indications for Culture and
Antibiotics Sensitivity
Recurrent / Non responsive infection
Compromised host defenses
Rapidly spreading local infection
Evidence systemic infection
Suspected 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 BPS
Complete invasive procedures prior to IV bisphosphonates /radiation
(? Short arch therapy, OHI, Fluoride RS, Corsodyl gel)
AVOID extractions use RCT/extrusion where possible
Remove dentures
Regular dental check up
If routine extn required after BPs taken
Corsodyl 10 mls QDS pre and post operatively for all cases
Low risk Oral BPs < 3 years no added risk factors (medical probs/steroids)
Primary care extn with minimal trauma. Preop 2g Amoxycillin
Mod 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
Refs
Marks et al 2007 www.ada.org/prof/resources/topics/osteonecrosis.asp
NHS Evidence - oral health
formerly a Specialist Library of the National Library for Health
MHRA: 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
Refer
If more complex surgical treatment is required
OR
The patient presents with painful separated bone sequestrum
Stage 2 case Attain CBCT of region
Mx
Corsodyl 10 mls QDS pre and post operatively for all cases
IV BPs previously 2 week preop Pentoxyfiline 400mg BD
Vitamin E 1000IU / 4 weeks post op plus Clindamycin
LA surgery should be undertaken with minimal trauma lifting
sequestrum away with irrigation with corsodyl and minimal
debridement and loose sutures.
Review
Suggested protocol for Management of OM
– 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
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, 134, 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. [email protected]
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.
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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/βlactamase combination such as amoxicillin/clavulanate In patients
allergic to penicillin, clindamycin or metronidazole (plus a drug
active against aerobes) is useful.
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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;37:459463.
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