235

Antibiotics in oral surgery

The antibiotics have been developed in past 50 years has significant impact on the
health of human race. The antibiotics in oral surgery are mainly used for two
purposes.
1) Antibiotic prophylaxis to prevent infections.
2) Antibiotics in treatment of infections.

Antibiotic prophylaxis to prevent infections (204,206,207)

Antibiotic prophylaxis defined as the preoperative use of antibiotics to prevent

infection.
The prevention of wound infection is one of the major goals of every surgeon.
Despite the use of the best surgical techniques, some surgeries still carry a high
risk of wound infections (206). The risk of infection is more when patient’s
immune system is compromised. When infections do occur, results in increased
patient morbidity and suffering. This leads to additional expense to patient and
increased antibiotic usage and delayed recovery. The clinical studies have shown
that the risk of infection reduced by administration of prophylactic antibiotics.
There are certain inherent risks associated with the use of these agents, such as
toxic and allergic reactions, emergence of resistance bacteria, drug interactions
and supra infections. Moreover, prophylactic antibiotic do not prevent all
(206)
postoperative infections . For these reasons their use should be based on an
understanding of certain basic principles. The purpose of this chapter is to review
these principles and discuss their application in specific clinical situations.
 236

The principle of prophylactic antibiotics

The principle of proper antibiotic prophylaxis has been established in general
surgery and they are applicable to the field of oral surgery (204,212).
The principles are
1. The intended procedure must carry a significant risk of postoperative
infections.
2. The correct antibiotic must be selected.
3. The antibiotic must be administered in a proper manner so that antibiotic
level should be high and use of the shortest effective antibiotic exposure is
preferred
4. Not to rely solely on prophylactic antibiotics to prevent postoperative
infections. There for prevention of infection can be achieved by achieving
two goals a) Reducing the number of bacteria in the surgical wound b)
Enhancing the host defenses so as to prevent the bacteria that inevitably
enter the wound from causing clinically evident infection.(207)
The risk of infection (206)
The most important factor, which increases the risk of postoperative infection,
is wound contamination. The age of the patient, nature of underlying disease,
presence of necrotic tissue and a decreased blood supply can increase the
potential for wound infection. General surgical wounds have been classified
according to the expected degree of contamination and the expected incidence
of postoperative infections in each class is unknown (204). This classification
based on contamination from respiratory, gastrointestinal/genitourinary tracts.
Because of the difference in host response to such contamination and oral
contamination, this classification cannot be used for intraoral wounds.
However it is modified to establish the indications for prophylactic antibiotics
in oral and maxillofacial surgery.
CLASS 1- clean surgical wounds, low infection rates, no significant tissue
trauma/ inflammation, the incision closed primarily, the wound is not drained
 237

and there is no communication with oral cavity. Clean surgery has got
infection rate of approximately 2%.
CLASS 2- clean contaminated surgical wounds similar to clean wounds but
communication with oral cavity occurs without significant bacterial
contamination. The expected infection rate is 10 % to15 %
CLASS 3- contaminated surgical wounds; fresh traumatic injuries involving
the oral cavity, the wounds were surgeon placed drain. Infection rate is 20 % to
30%.
CLASS 4-Dirty wounds of traumatic origin with delayed treatment that
communicate with the oral cavity and contain devitalized tissue OR foreign
bodies.

 Clean wounds do not require antibiotic prophylaxis, however it should

be used in clean contaminated wounds.
 Contaminated wounds usually can be managed with preoperative
antibiotics if there are no other significant risk factors. Postoperative
antibiotics are considered if the patient’s immune system compromised.
 Patients with dirty wounds, which are already infected, require
preoperative and postoperative therapeutic antibiotics.
 Surgical factors other than degree of contamination may also influence
infection rates. Operative procedures that last longer than 3 hours and
procedures for insertion of major foreign bodies (implants), both have
increased infection rates.
 Issue of host defense also important in considering prophylactic
antibiotics.
 238

In general following group of patients have increased tendency for susceptibility

for infection.
 Group of patients who have poorly controlled diabetes, end stage renal
disease, severe alcoholic cirrhosis and malnutrition syndromes.
 Group of patients, who have diseases that interfere with host defenses
including the myeloproliferative diseases, neutropenic and
agammaglobulinemia.
 Group of patients taking immunosuppressive drugs that interfere with host
defenses, such as cyclosporine and steroids and cancer chemotherapeutic
drugs.
Considering above factors decision should be made to use prophylactic antibiotics
and to use postoperative antibiotics also to prevent recontamination during
postoperative period.

Selection of antibiotic
The appropriate antibiotic selection should be made for prophylactic purposes
in particular patient. This selection is made based on certain requirements.
 The antibiotics chosen by the surgeon must be effective against the bacteria
that are most likely to cause infection following surgical procedure. It need not
to be able to eliminate every pathogenic bacteria encountered. Streptococci,
Aerobic gram+ve cocci and aerobic gram –ve rods are commonly
(213)
contaminating organisms of wounds in oral and maxillofacial surgery . The
infections by anaerobic bacteria are also considered. When the skin is involved,
the presence of staphylococcus aureus and epidermidis also considered.
 Use of least toxic agent available.
 The selected antibiotic should be bactericidal, nonallergic, and capable of
achieving therapeutic tissue concentrations and have a long half-life so that
redosing generally not required during the procedure.
 239

The antibiotic that currently fulfils above requirement is Penicillin’s. For

transcutaneous procedures a first generation cephalosporins such as cefazolin,
can be used since it is effective against most staphylococci. Patient if has non-
anaphylactic reactions to penicillin, a first generation cephalosporin
indicated. For those patients who had an anaphylactoid reaction to penicillin,
clindamycin is often recomonded as the third choice (206).

Proper administration of antibiotics

The selected antibiotic should be used in right dose, right route, and right time
and for right duration. The above approach is known as Rational antibiotic
(5)
therapy . It makes antibiotic maximally effective and reduces the
development of bacterial resistance.
 For an antibiotic to maximally effective, the plasma concentration must
be high so as to allow diffusion into the tissue contaminated by the
bacteria. To achieve this preoperative prophylactic antibiotic should be
given twice the usual therapeutic dose (214).
 Correct time of administration of antibiotics is considered. To be
maximally effective antibiotic should be in the tissue at the time of
contamination occurs. As a general guideline antibiotics should not be
given on the previous day nor in the patient’s room before arrival in the
(206)
operating room . The antibiotic should be administered
intravenously/ intramuscularly 30 minute before the placement of
(214)
incision at twice the therapeutic dose . For penicillin the dose is 2
million units and for cefazolin it is 1g. This dose adequately provides
coverage for up to 4 hours (As a general rule prophylactic antibiotic
dosage interval should be one half of the usual therapeutic interval). So
if the procedure is prolonged, however it is advisable to administer
additional doses every 4 hours until the surgery is completed.
 240

 In patients who are medically compromised it may be advisable to

continue prophylactic oral antibiotics until biologic sealing of the
wound has occurred.
(208)
 Use the shortest effective antibiotic exposure . Continuing
antibiotic administration after surgery does not decrease the incidence of
(215)
wound infection . For short procedure a single dose of antibiotic
preoperatively is sufficient to prevent wound contamination. For longer
procedures intraoperative doses are given as necessary, and a final dose
in the recovery room is sufficient to control infection. The new
approach will reduce the toxicity, allergy, and supra infection and
overall decrease in the use of antibiotic and expense. Equally important
is this type of short-term antibiotic use has been associated with
essentially few side effects and complications (206,207). Usually antibiotics
that have little OR no toxicity like Penicillin, and cephalosporins are
used. There has been occasional report of pseudomembraneous colitis
associated with prophylactic use of ampicillin, the cephalosporins and
clindamycin. More over short term prophylactic antibiotic has no
influence on the growth of resistant bacteria.

Adjunctive procedures to prevent infections

Along with the prophylactic antibiotic if we follow proper surgical technique, the
postoperative infection can be reduced. Proper technique involves (207)
 Adequate cleansing of surgical site
 Strict adherence to sterile technique.
 Avoiding tissue trauma
 Minimizing operating time
In general risk of infection has been shown to increase with each hour of
surgery. Shaving of the surgical site should be done just before preparation of the
 241

surgical site. Shaving the skin evening before surgery shown to increase infection
(216)
rate . The use of surgical drain also may contribute for postoperative infection.
They should be removed as soon as possible.
The above measures greatly improve the effectiveness of antibiotic prophylaxis.

Specific application of antibiotic use,

in
Oral and Maxillofacial surgery

Dentoalveolar surgery:
Although the oral microbiological flora contaminates intraoral extractions
(207,208)
wounds and surgical wounds, the infection rate is very low . This is due
to excellent blood supply to oral tissue. It is unnecessary to use prophylactic
antibiotics to prevent infection in healthy individual.
Prophylactic antibiotics are indicated in following scenario (6):
 If the procedure involves the maxillary sinus OR nasal cavity, can result in
cross contamination with new organisms.
 If the patient host defense mechanism is compromised e.g.; Poor nutritional
states, complicating medical problems, presence of necrotic tissue / foreign
body and decreased blood supply to the region.
 Patients who have received organ transplants may be on long-term
immunosuppressive therapy and patients who are receiving chemotherapy
for cancer should have their surgery done under preventive antibiotic
coverage.
 Patients who have diagnosed metabolic disease (diabetes mellitus) that is
well controlled do not require antibiotic therapy. However patients with
 242

uncontrolled metabolic disease (fluctuation in glucose level, under insulin

therapy) prophylactic antibiotic cover indicated.
 Patient undergoing chemotherapy antibiotic prophylaxis is considered if
invasive dental procedure is carried out.
 Patient with AIDS, in the absence of bacterial infection does not generally
(206)
require antibiotic prophylaxis . Antibiotics considered in case where
more chances of bacteraemia may occur (In case of extraction of teeth with
abscess).
 AHA/ADA reconsiders use of antibiotic coverage for chronic intravenous
drug abusers and for patients who have undergone splenectomy (6,206,207).

Impacted third molar surgery:

Many practitioners routinely use antibiotics during impacted teeth removals are
(217,218)
generally postoperatively . When antibiotics are used in this manner studies
show that there is no significant reduction in postoperative infection after third
(219)
molar removal . The infections after third molar removal are relatively
(220,221)
uncommon . The postoperative infections include alveolar osteitis and facial
space infections. In these conditions however, antibiotics are given
postoperatively/ preoperatively does not cause significant reduction in problems.
Isolated cases of severe facial space infection after third molar removal has been
(220)
reported , but incidence is too low to justify the routine use of prophylactic
antibiotic. Such treatments should be reserved only for patients with significant
(207,222)
medical risk factors for infection . In these cases it should be given
immediately before surgery and for 3 to 5 days after surgery to provide an
adequate period of coverage.
 243

Dental Implants:
Studies conducted by Peterson l, Larsen p, on the effects of antibiotic on the
infection rate after implant placement in which no control group was used
conclude that preoperative antibiotic was effective in preventing postoperative
(225)
infections. In other better controlled studies however no difference in
postoperative infections / implant failure was found between the two groups. In a
more recent studies which was large multicentric (226) analyzed the implant failures
and found that significant reduction in failure up to stage 2 surgery seen when high
dose preoperative antibiotics were given. These findings were confirmed in a
follow up study at 36 months in the same patient population 4.6% vs. 10 % failure
(227)
. These studies showed the benefit of using prophylactic antibiotics in dental
implant patients.

Orthognathic surgery:
Orthognathic surgery performed via an extra oral approach is considered a clean
procedure and prophylactic antibiotic should not be necessary unless
(207)
communication with the mouth is anticipated . Intraoral procedures and
surgeries that involve maxillary sinus and nasal passage are clean contaminated
wounds and short-term antibiotics have been shown to reduce the postoperative
(229, 230)
infection rates . In one study in which a 5 day regimen was shown to be
(231) (228)
better than one day regimen . But Aboobaker pointed out that; the
difference was caused by the difference in the criteria used to establish wound
infection.

Maxillofacial fractures
Patients with condylar process fractures treated by either by open reduction/
closed reduction require (extra oral incision) no prophylactic antibiotic
(207,208)
coverage . Fractures in non-tooth bearing areas that are not in
communication with the mouth are considered clean wounds do not require
 244

antibiotic therapy. In patients with compound fractures of the facial skeleton

antibiotics are necessary to prevent infection at fracture sites. Approximately
50 % fractures in patients who do not receive antibiotics become infected. The
administration of antibiotic reduces this to less than 10 %(232,233). But in most of
these studies, however antibiotics were not only given preoperatively but also
(234)
for a long period postoperatively. More recent investigations shown that
short-term antibiotic prophylaxis equally effective in these situations.
Mid facial fractures compounded in the mouth, nose/ para nasal sinuses
requires antibiotic coverage (207), other studies (232,235) have shown that it may not
be necessary. One of these studies (235) was not well controlled and other studies
had relatively small number of cases used, the issue remains unresolved. So it
should be reasonable to consider such wounds as clean contaminated wounds
and preoperative prophylactic antibiotics should be used.
Patients with traumatic injuries that involve the oral mucosa, gingiva/
tongue do not require prophylactic antibiotics because such wounds, although
contaminated, generally heal without infections (207).
Simple extra oral lacerations from relatively clean objects that are closed
within 4 hours also have low infections rate and do not require prophylactic
(236)
antibiotics . Extra oral soft tissue injuries, such as those caused by blunt
injuries, gun shot wounds and bites and injuries that involve orocutaneous
communication fall into either the category of clean – contaminated/
contaminated wounds and the patients should receive pre treatment antibiotic
prophylaxis. If the wounds are extremely dirty such patients also should
receive postoperative therapeutic antibiotics.

Major head and neck surgery (207):

Several studies/ researchers support the fact that patients who undergo major
surgical procedures in the head and neck region, such as oncologic and
reconstructive surgery, should receive preoperative antibiotics. There is question
 245

regarding how long they should be used post operatively. Several studies that have
shown that there is no advantage in extending the prophylactic antibiotics beyond
one day after surgery in such cases unless there are packs / drains in the wounds/ it
is impossible to obtain primary closure and if there is prolonged leakage of saliva
into the wound (237).
Transoral preprosthetic surgery, craniofacial surgery and tumor surgery
considered to be class2/ clean contaminated (205,208) have been demonstrated that the
use of short-term perioperative antibiotics demonstrated to be effective in
preventing postoperative wound infections.

Antibiotic in head and neck infections

Oral and Maxillofacial surgeons see patients with infections as parts of their
every day practice. The infections can be odontogenic, the sinus infections,
osteomyelitis, and fungal infections. These infections not only produce pain
swelling, severe inflammation, but also it may spread to CNS and it may cause
respiratory difficulty. These events may lead to life threatening conditions.
Timely and deliberate efforts to establish debridement and drainage as well as
appropriate antibiotic therapy should be selected by clinician (238).
Odontogenic infections are the most commonly occurring infectious process.
In last four decades of managing infectious disease significant changes
occurred in the use of antibiotics and antimicrobials. The decision to use
antibiotics in managing odontogenic infections were based on several factors.
The clinician must first diagnose the cause of infection and should determine
(7)
the appropriate dental treatment to reduce /control infectious process . It is
important to understand the mechanism of antimicrobial resistance, its
potential problems, and the means of overcoming it before selecting a
appropriate antibiotic therapy.
 246

Indications for use of antibiotics

Antibiotic therapy should be used as an adjunct to dental treatments never used

alone as the first line of care. Pain alone/localized swellings do not require
antibiotic treatment. Pulpitis, Apical periodontitis, draining sinus tract or localized
(6)
swelling can usually be treated endodontically without antibiotics . The
circulation within the pulp is compromised in the presence of
inflammation/infection. Because an antibiotic is carried by vascular system, its
ability to reach bacteria in a therapeutic concentration will be limited. This
environment diminishes the efficiency of the antibiotic. Endodontic
treatment/access opening of tooth and removing the bacteria and their by products
thoroughly debriding the root canal system-effectively eliminates the infection,
curtails the inflammation and promotes healing. Swelling can be drained through
the tooth/through soft tissue incision. Drainage stimulates healing, relieves
pressure, improves circulation and eliminates bacteria. Remove the cause
whenever possible

Antibiotics are indicated when systemic signs of involvements are evident.

Fever, malaise, lymphadenopathy/ trismus are clinical signs indicating the possible
spread of infection has occurred. In above scenario antibiotics are indicated. The
choice of antibiotics should be based on knowledge of usual causative microbe.
The patients with compromised host defense mechanism may indicate
antibiotic therapy in conjunction with dental treatment.

Selection of appropriate antibiotics (5,7,238,241)

Selection of antibiotic in managing odontogenic infection is made based on
several factors.
 247

1. Host factors in antibiotic selection

 Usual pathogens
 Allergy/ intolerance
 Immune system compromise
 Previous antibiotic therapy
 Special conditions
2. Pharmacological factors
 Antimicrobial spectrum
 Tissue distribution of antibiotics
 Pharmacokinetics
 Adverse reactions
 Special conditions
 Antibiotic drug interactions
 Cost
 Mechanism of action
 Development of bacterial resistance to antibiotics

Factors affecting selection of antibiotic

1. Common pathogen (241,243)

Odontogenic infections are characterized by combination of facultative
streptococci and oral anaerobes. Approximately 3% of the strains of the species
are resistant to the penicillins. Among the anaerobic organisms peptostreptococci
and members of the genera Provetella and Porphyromones predominates.
Although the peptostreptococci remain penicillin sensitive, approximately 25% of
the strains of provetella and porphymonas are penicillin resistant (243). Studies show
that the penicillin sensitive streptococci predominate during the first 3 days of
clinical symptoms and the more resistant gm-ve and +ve obligate anaerobes
 248

(242)
appear in significant number there after. Flym et al found a clinical rate of
26% for penicillin resistance in hospitalized cases. Organisms like Eikenella
corrodens, which may be some times found in the odontogenic infections dog and
cat bites, is fairely resistant to penicillin’s and completely resistant to the
(243)
Clindamycin . The fluoroquinolones have become the antibiotic of choice for
the infections caused by above organisms.

2. Allergy/intolerance/ adverse drug reactions (241)

The history of allergy obtained from the patient/ from the patients family.
Penicillin allergy is common, macrolide intolerance and drug interactions are
frequent problems. The choice of clindamycin, metronidazole/ newer antibiotics
should be considered in such cases. Between 1% -10% of patients who initially
take penicillin develop allergic reactions and persons who do not develop
reactions have less than 1% of chance of developing an allergy on re-exposure. A
hypersensitivity reaction to clindamycin, which is a substitute to penicillin in
penicillin allergic patients, is a rare event. Approximately 10% to 15% of the
(7)
penicillin allergic patients are also sensitive to the cephalosporins . The cross
allergic group tends to include persons who have anaphylactoid reaction to the
penicillin’s. The cephalosporins should be avoided in these patients. The newer B-
lactem antibiotics, the monobactems and carbepenems, have much less frequent
cross sensitivity with the penicillin group (7).
Adverse reactions and toxic reactions of antibiotic used in head and neck
infections are relatively mild and uncommon. A history of adverse reactions/
intolerance of an antibiotic, such as photo toxicity with tetracycline’s/ GIT
intolerance of erythromycins, nephrotoxicity and ototoxicity of the amino
glycosides, and antibiotic based colitis with B-lactem, antipsudomonal penicillins,
cephalosporines and clindamycin should be considered when selecting appropriate
antibiotic.
 249

3. Immune system compromise

Whenever possible in immune compromised patients, a bactericidal rather than
bacteriostatic antibiotic should be selected (241). The HIV- infected individuals
seem to be able to handle oral bacterial infections almost as well as non-infected
persons. In head and neck infections B-lymphocytes is largely responsible for
combating extra cellular bacterial pathogen. On the other hand fungal and viral
infections, which are resisted by cell-mediated immunity (T cells) are prevalent in
poorly controlled HIV infected individuals. In terminal stages of AIDS, all types
of lymphocytes are depleted (240).

4. Previous antibiotic therapy

Patients who are taking antibiotics consistently/ previously will have a
higher incidence and proportion of organisms resistant to that antibiotic
therapy. In such scenario the clinician has the choice of changing the current
antibiotic / increasing the dose, perhaps by using the parenteral route. With
penicillin V (oral) and G (IV) peak serum blood levels are 5.6 micro gram/ml
and 20 microgram/ml respectively. If we change oral to parenteral route of
(241)
administration of antibiotic dramatic increase in efficiency is seen . The
resistance to endocarditis associated viridans streptococci (Strept. mitis, S.
sanguis, Strept. salivarius) is high upto 58%.

5. Antibacterial action
If an antibacterial agent has to display activity against likely pathogen, it
must first reach the site of infection, it then needs to penetrate the target site in
the bacteria, maintain adequate concentration at the site of infection, and
remain there for sufficiently long period of time such that the organism is
 250

inhibited from carrying out its normal life functions and should be able to kill
the pathogen. To measure the activity of particular antibiotic at the site of
infection minimum bactericidal concentration (MBC)/ minimum inhibitory
concentration (MIC) are used. The minimum inhibitory concentration (MIC)
which is the concentration of the antibiotic required to kill a given percentage
of the strains of a particular species, usually 50%/ 90%. These data are used in
selecting empirical antibiotic choice in various head and neck infections (212).

6. Tissue distribution of antibiotics

The antibiotic that best penetrates abscess cavity is clindamycin; the abscess
concentration of clindamycin reaches 33% of serum level (244). When treating
osteomyelitis bone penetration of antibiotic is important factor. The antibiotic that
best penetrates/ even accumulate in bone are the tetracyclines, clindamycin, and
the fluoroquinolones (1).
CSF penetration/ the ability of bacteria to cross blood brain barrier is important
factor in use of antibiotics against CNS infections. Clindamycin, macrolides,
cefazolin and most of cephalosporins, aminoglycosides, amphotericin, ethambutol
do not penetrate blood brain barrier (1). Penicillin G in high doses reaches 5% to
10% of the serum concentration in the CSF when meninges are inflamed. In
odontogenic infections that threaten the CNS, the addition of metronidazole (30%-
100% penetration), ampicillin (13%- 14%penetration) is more efficious than using
penicillin G alone (245).

7. Post-antibiotic effect (212)

PAE is defined as persistent suppression of bacterial growth after brief exposure
of bacteria to an antibacterial agent even in the absence of host defense
mechanisms. In PAE inhibition of bacterial growth is seen when either the
antibacterial agent is no longer present in the medium or if present its
concentration is well below the MIC. Type of antibiotic used, concentration and
 251

duration of antibiotic exposure, bacterial species and strain, affects PAE.

Quinolones and Aminoglycosides was the first to describe this phenomenon.
When gram+ve and gram –ve bacteria exposed to 4times greater than MIC of
quinolones for 1 hour PAE was about 2 hour. This effect will help the clinician to
select appropriate antibiotic as well as proper dose (241).

8. Pharmacokinetics
Concentration dependent Vs Time dependent antibiotics (212,5)
The effectiveness of some antibiotics such as fluoroquinolones and
aminoglycosides is concentration dependent, where as other antibiotic such as B-
lactems and vancomycin is time dependent. In concentration dependent antibiotics,
efficacy is determined by the ratio of the serum concentration of the antibiotic to
the minimum inhibitory concentration (MIC), which is the concentration of the
antbiotic required to kill a given percentage of the strains of a particular species,
usually 50%/ 90%. In time dependent antibiotics, it is necessary to maintain the
serum concentration above the MIC for at least 40% of the dosage interval. In time
dependent antibiotics it is necessary to know the serum elimination half life (t1/2).
For e.g. penicillin G half life is ½ hour .By 5 half lives only 3% of the peak serum
level of penicillin remains. The peak serum level after administration of Penicillin
G is 0.20 microgram/ml, after 8 half lives / 4hours serum concentration is
approximately o.15 microgram/ ml. The MIC of viridans streptococci is
0.2microgram/ml. So IV penicillin G, 2million units every 4 hors should be highly
effective against viridans group of streptococci.
Once daily dosing of the aminoglycosides as a means of reducing their
(246)
ototoxicity and nephrotoxicity recently evaluated shows modest increase in
therapeutic advantage and possible decrease in toxicity. This approach is attractive
since it is much cost saving.
 252

9. Special conditions

Tetracyclines and fluoroquinolones should be avoided in the children, because of

dental intrinsic staining and chondrotoxicity respectively. Among carbepenems,
imepenum is not recomonded in children because of the risk of seizures.
Meropenem is an acceptable alternative.
Antibiotics in pregnancy (241):
The penicillin’s, cephalosporins, erythromycin, and clindamycin cross the
placenta have therapeutic effects on the fetus as well as the mother and are not
(1)
associated with congenital defects . Among macrolides, clarythromycin are
class C drugs with uncertain safety. In penicillin group Ticaricillin should be
avoided. Amino glycosides may produce fetal toxicity and nephrotoxicity.
Tetracycline if given after 5 months of gestation may result in permanent
discoloration of fetal teeth, maternal liver toxicity, and congenital defects. It is
category D drug, should be avoided during pregnancy. Metronidazole use in
pregnancy is controversial. It is carcinogenic in rodents, but such effects in
humans yet to be proved. It may be used in 2nd and 3rd trimester. It is classified
as category B drug. Sulfonamides when administered in 3rd trimester /close to
delivery persists in blood for 2 to 3 days after birth and are associated with
jaundice, hemolytic anemia, and kernicterus in new born. This drug should be
avoided during third trimester. Vancomycin listed as FDA category C drug.
There has been controversy regarding the potential for fetal auto toxicity and
nephrotoxicity. Flouroquinolones safety during pregnancy is not established.
Blood volume and creatinine clearance increase in pregnant patient. This
can lead to a lower serum concentration of antibiotics in pregnant patient when
compared with non-pregnant patients. There fore in critical infections, serum
 253

level of antibiotics may need to be monitored and compensatory adjustments

may be necessary.

10. Cost

Although clinical effectiveness, and reduction of morbidity of infection and

treatment are paramount concern in the management of head and neck infections,
cost is a factor that should be considered when other factor do not predominate.

Principles of managing odontogenic infections (239,240,241)

1. Determine severity of infection

2. Evaluate the host defenses noting any disease states/ medications, which
could adversely affect the host.
3. Drainage
4. Prescribing antibiotics of proper dosage regimen and duration of therapy.
5. Follow up to confirm treatment expense and to look for adverse reactions
and the possibilities of opportunist infections.
6. Consider culturing and susceptibility testing in case of treatment failure.
Culturing is considered in the following situations.
 Initial antibiotic therapy has been un successful in controlling the infection
 If the infection is spreading to other facial spaces.
 The patient demonstrates signs and symptoms of septicemia.

Defer culture if (239)

 The infection is small / confined locally to soft tissue.
 Any specimen would likely to be contaminated with oral micro flora (Eg.
Plaque, pericoronitis)
 The infection has spontaneously established external drainage and has no
evidence of further spread is evident
 254

Empiric antibiotic of choice in head and neck infections

1. Odontogenic infections
Empiric antibiotics are administered before culture and sensitivity tests results
are available; specific antibiotic therapy is selected on the basis of culture and
sensitivity test results. The increase in penicillin resistance and failure of penicillin
(242)
therapy in a study recommended clindamycin as the emperic antibiotic of
choice in odontogenic infections serious enough to require hospitalization. A
loading dose of 600mg may be administered approximately 1 hour before the
surgical therapy begins, followed by 300mg every 6hours for the duration of
infection.
The penicillin resistance has not yet been problem in out patient dental infections
(241,247)
. Penicillin V remains the antibiotic of choice for out patient odontogenic
infections. A loading dose of 2000mg penicillin VK approximately 1 hour before
the beginning of surgical therapy followed by 500mg every 6 hours prescribed. If
within 48 hours the patient is not responding to penicillin, one could consider
(6)
adding metronidazole . It is prescribed in a 500mg dose every 8 hours. The
duration of antibiotic therapy in managing odontogenic infections is controversial.
Earlier concept was to continue antibiotic therapy for 2-3 days after the symptoms
of infection subside. Due to developing antibiotic resistance recent studies (248) says
that antibiotic can be stopped safely once the symptoms of the infection subsides.
At this time the host defenses have gained control of the infection. However
treatment of severe infections in immunocompromised patients may be of longer
duration. Because of their ineffectiveness against oral anaerobes, the macrolides
 255

are no longer considered among the emperic antibiotic of choice for odontogenic
infections. The second choice is first generation cephalosporines. Amoxicillin is a
broad spectrum antibiotic considered in treatment of immunocompromised
patients (6).
2. Sinus infections
Sinus problems most of the time mimics the pain of the odontogenic origin.
Some times sinus infections may be of dental origin. An oral and maxillofacial
surgeon may have to treat these conditions commonly. Antibiotic treatment should
be reserved for patients who already have been treated for 7 days with only
decongestants and analgesics and who have maxillary/ facial pain/ purulent nasal
discharge. Patients with severe pain / fever may require antibiotic therapy sooner
and hospitalization may be necessary. If antibiotics have been prescribed in
previous month / if the incidence of strept. pneumonia is more than 30%,
amoxicillin and clavulinic acid/ second-generation cephalosporin is prescribed for
(245)
2 weeks . Recent studies show that penicillin/ amoxicillin alone is as effective
as other broad spectrum and expensive antibiotics (249).
In chronic sinusitis flora becomes more anaerobic, antibiotic alone may not be
sufficient and corrective surgery, and consultation with otorhinolaryngology is
indicated.
If a patient with diabetes mellitus / immunocompromised patient, patient on
deferoximine therapy previously diagnosed with sinus infections, fungal infections
should be suspected. Amphotericin B and surgery are indicated
3. Osteomyelitis of the jaws
Odontogenic pathogens are the most frequent causative agents of osteomyelitis.
Actinomyces are another prominent pathogen in chronic osteomyelitis. Long
course of antibiotic effective against these organisms are required. Oral penicillin
plus probencid can be used for long term out patient therapy. Probencid inhibits
the renal excretion of penicillin and increases the blood level obtained by oral
route.
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4. Fungal infections
Various fungi cause a wide spectrum of infectious manifestations in the head and
neck. The major fungal infections of concern to oral and maxillofacial surgeon are
histoplasmosis and blastomycosis, which cause granulomatous lesions,
aspergillosis and mucormycosis, which cause sinusitis, and candidiasis which
cause surface lesions in non immunocompromised patients and may cause
disseminated and invasive disease in immunocompromised persons. Sampling
culturing, histological examination and use of molecular method diagnose these
infections.
In general fungal infections are treated with azole type antifungal agents for less
severe cases and amphotericin B for disseminated and severe disease. In surface
candidiasis in a healthy immune system, clotrimazole is a better- tasting yet
economical alternative to nystatin.