Sei sulla pagina 1di 90

Antibiotics in

Dentistry
Prepared and Presented By:
Niyas Ummer
1
st
Year PG
Department of Oral Medicine & Radiology
KMCT Dental College
Overview
Introduction
Terminology
History
Classification
General Considerations
Routes of administration
Choice of agent
Combined use
Problems with use
Prophylactic use
Failure
Commonly used antibiotics in
dentistry
Mechanism of action
Uses
Adverse Effects
Interactions
Contra-indications
Dosage and availability

Recent Advances
Misuse
Conclusion
References
Introduction to Antibiotics
The magic word Antibiotic inevitably springs to mind
whenever an infection has to be dealt with. Antimicrobial drugs
are the greatest contribution to 20th century of therapeutics -
Antibiotic era. Their advent changed the outlook of the
physician about the power drugs can have on diseases.

Antibiotics are essential weapon against infection; hence
wise use of antibiotics requires the clinician to take the stance
that positive indication must be present before antibiotic drugs
are prescribed. As a class, antibiotics are one of the most
frequently used as well as misused drugs.
Terminologies Used
Antibiotics:
Substances produced by microorganisms, which selectively suppress
the growth of or kill other microorganisms at very low concentrations

Chemotherapy:
Treatment of systemic infections with specific drugs that selectively
suppress the infecting microorganism without significantly affecting
the host

Antimicrobial Agent:
Synthetic as well as naturally obtained drugs that attenuate
microorganisms
Terminologies Used
Term "antibacterial" derives from Greek anti - "against and
baktria, "staff, cane"

Term "antibiotic" derived from anti and bios, "life"
History of Antibiotics
Milestones in History
Louis Pasteur observed, "if we could intervene in the antagonism observed
between some bacteria, it would offer perhaps the greatest hopes for
therapeutics

Term 'antibiosis by the French bacteriologist Jean Paul Vuillemin

Antibiosis first described in 1877 in bacteria when Louis Pasteur and Robert
Koch observed that an airborne bacillus could inhibit the growth of Bacillus
anthracis

Renamed antibiotics by Selman Waksman, an American microbiologist, in
1942

Synthetic antibiotic chemotherapy began in Germany with Paul Ehrlich in the
late 1880s
In 1928, Alexander Fleming observed antibiosis against bacteria by a fungus
of the genus Penicillium
Postulated the effect was mediated by an antibacterial compound named
penicillin, and that its antibacterial properties could be exploited
Attempted to use a crude preparation to treat some infections
But unable to pursue its further development
Period of Empirical Use
(16
th
- 17
th
Century)
Mouldy curd by Chinese on boils
Chaulmoogra oil by Hindus in leprosy
Chenopodium by Aztecs for intestinal worms
Mercury by Paracelsus for syphilis
Cinchona bark for fevers
Chaulmoogra
Chenopodium
Phase of Dyes and Organometallic
Compounds
Paul Ehrlich (1890-1935)
Coined term chemotherapy
Atoxyl for sleeping sickness
Arsphenamine for syphilis

Modern Era of Antibiotics
Domagk (1935) Prontosil in pyogenic infection - first
commercially available antibiotic
Classification of Antibiotics
Classification of Antibiotics
Based on Chemical Structure:
Sulfonamides
Sulfadiazine, Sulfones (Dapsone)
Diaminopyridines
Trimethoprim, Pyrimethamine
Quinolones
Nalidixic Acid, Norfloxacin, Ciprofloxacin
-lactam
Penicillins, Cephalosporins, Monobactams, Carbapenems
Tetracyclines
Oxytetracycline, Doxycycline
Nitrobenzene derivative
Chloramphenicol
Aminoglycosides
Streptomycin, Gentamycin, Amikacin, Neomycin
Macrolide
Erythromycin, Clanthromycin, Azithromycin
Lincosamide
Lincomycin, Clindamycin
Classification of Antibiotics
Based on Chemical Structure:
Glycopeptide
Vancomycin, Teicoplanin
Oxazolidinone
Linezolid
Polypeptide
Polymyxin-B, Colistin, Bacitracin, Tyrothricin
Nitrofuran derivatives
Nitrofurantoin, Furazolidone
Nitroimidazoles
Metronidazole, Tinidazole
Nicotinic acid derivatives
Isoniazid, Pyrazinamide, Ethionamide
Polyene
Nystatin, Amphotericin-B, Hamycin
Azote derivatives
Miconazole, Clotrimazole, Ketoconazole, Fluconazole
Others
Rifampin, Spectinomycin, Sodium fusidate, Cycloserine,
Viomycin, Ethambutol, Thiacetazone, Clofazimine, Griseofulvin
Classification of Antibiotics
Based on type of organisms against which primarily active:

Antibacterial Penicillins, Aminoglycosides, Erythromycin, etc.
Antifungal Griseofulvin, Amphotericin B, Ketoconazole, etc.
Antiviral Acyclovir, Amantadine, Zidovudine, etc.
Antiprotozoal Chloroquine, Pyrimethamine, Metronidazole, Diloxanide, etc.
Anthelmintic Mebendazole, Pyrantel, Niclosamide, Diethyl carbamazine, etc.
Classification of Antibiotics
Based on spectrum of activity:

Narrow-spectrum Penicillin G, Streptomycin, Erythromycin
Broad-spectrum Tetracyclines, Chloramphenicol
Classification of Antibiotics
Based on type of action:

Primarily bacteriostatic
Sulfonamides, Erythromycin, Tetracyclines, Ethambutol,
Chloramphenicol, Clindamycin, Linezolid
Primarily bactericidal
Penicillins, Cephalosporins, Aminoglycosides, Vancomycin,
Polypeptides, Nalidixic acid, Rifampin, Ciprofloxacin, Isoniazid,
Metronidazole, Pyrazinamide, Cotrimoxazole
Classification of Antibiotics
Based on source obtained from:

Fungi Penicillin, Cephalosporin, Griseofulvin
Bacteria Polymyxin B, Colistin, Bacitracin, Tyrothricin, Aztreonam
Actinomycetes Aminoglycosides, Tetracyclines, Chloramphenicol, Macrolides, Polyenes
Choice of an Antibiotic
Agent
Choice of an Antibiotic Agent
Depends on qualities of patient, the infecting organism and the
drug

Patient factors
Organism-related factors
Drug factors
Patient Factors
1. Age:
Affect kinetics of drugs

2. Genetic Factors:
Primaquine, nitrofurantoin, sulfonamides, chloramphenicol and
fluoroquinolones - produce haemolysis in G-6-PD deficient patient
Patient Factors
3. Renal and Hepatic Function:
Cautious use and dose modification when the organ for its disposal is
defective

Renal Failure
Dose reduction in
mild failure
Aminoglycosides, Amphotericin
B, Cephalosporins, Ethambutol,
Vancomycin, Flucytosine
Dose reduction in
moderate-severe
failure
Metronidazole, Carbenicillin,
Cotrimoxazole, Aztreonam,
Meropenem,
Fluoroquinolones,
Clarithromycin, Imipenem
Drugs to be
avoided
Cephalothin, Talampicillin,
Nalidixic acid, Tetracyclines,
Nitrofurantoin (except
doxycycline)
Liver Disease
Dose
reduction
Chloramphenicol, Isoniazid,
Metronidazole, Rifampin,
Clindamycin
Drugs to be
avoided
Erythromycin estolate,
Tetracyclines, Pyrazinamide,
Nalidixic acid, Talampicillin,
Pefloxacin
Patient Factors
4. Local Factors:
Pus and secretions decrease the efficacy (sulfonamides, aminoglycosides)
Necrotic material or foreign body makes eradication impossible
Haematomas foster bacterial growth
Lowering of pH at the site of infection reduces activity (macrolide,
aminoglycoside)
Anaerobic environment in the centre of an abscess impairs bacterial
transport processes which concentrate aminoglycosides in the cell
Penetration barriers hamper the access to the site of infection
Some attain high concentration due to ion trapping (Trimethoprim,
fluoroquinolones )
Patient Factors
5. Drug Allergy:
If a drug has caused allergic reaction - it has to be avoided in that patient
-lactams, sulfonamides, fluoroquinolones, nitrofurantoin frequently
cause allergy

6. Impaired Host Defense:
Pyogenic infections - in neutropenic
Infections by low grade pathogens and intracellular organisms - if cell-
mediated immunity is impaired

Normal host defence - a bacteriostatic AMA may achieve cure
impaired host defence - intensive therapy with cidal drugs
Patient Factors
7. Pregnancy:
All AMAs should be avoided in the pregnant because of risk to the foetus
Penicillins, many cephalosporins and erythromycin - safe
Tetracyclines - acute yellow atrophy of liver, pancreatitis and kidney
damage in the mother - teeth and bone deformities in the offspring
Aminoglycosides - foetal ear damage
Risk Category of Drugs in Pregnancy
Category Description
A
Adequate studies in pregnant women have failed to demonstrate a risk to
the foetus
B
Adequate human studies are lacking, but animal studies have failed to
demonstrate a risk to the foetus amoxicillin
or,
Adequate studies in pregnant women have failed to demonstrate a risk to
the foetus, but animal studies have shown an adverse effect on the foetus
C
No adequate studies in pregnant women and animal studies are lacking or
have shown an adverse effect on foetus, but potential benefit may warrant
use of the drug in pregnant women despite potential risk
D
There is evidence of human foetal risk, but the potential benefits from use
of the drug may be acceptable despite the potential risk
X
Studies in animals or humans have demonstrated foetal abnormalities, and
potential risk clearly outweighs possible benefit
Organism-related Factors
1. Initial Empirical Therapy:
Identification and antimicrobial sensitivity - time consuming, expensive &
impractical
Well defined site and features - organisms causing such infections reliably
deduced
Dental infections - acute nature - treatment cannot be delayed
Not possible to obtain appropriate samples of infected material
Organism-related Factors
2. Identification of Causative Organism:
Type of bacteria (aerobic/anaerobic) and their specific identification
Odontogenic infections - caused by a mixture of aerobic and anaerobic
bacteria (70%)

Well-circumscribed chronic non-advancing abscesses - mostly anaerobic
Cellulitis type - show exclusively aerobic bacteria
Infection is contained longer & controlled only anaerobic flora
Abscess anaerobic bacteria
Organism-related Factors
3. Antibiotic Sensitivity for Causative Organism:
Antibiotic therapy is initial / empirical or definitive, depending on
whether the organism is identified precisely.
Drug Factors
1. Spectrum of Activity:
For definitive therapy, a narrow-spectrum drug which selectively affects
the concerned organism is preferred
For empirical therapy, often a broad-spectrum drug has to be used to
cover all likely pathogens

2. Type of Activity:
Acute infections resolve faster with a cidal drug - reduces the number of
bacteria at the site of infection
Patients with impaired host defence, life-threatening infections,
infections at less accessible sites (SABE) or when carrier state is possible
(typhoid) bactericidal
Drug Factors
3. Sensitivity of the Organism:
on the basis of MIC values (if available) and consideration of
postantibiotic effect

4. Relative Toxicity:
less toxic antibiotic is preferred
Drug Factors
5. Pharmacokinetic Profile:
Antibiotic has to be present at the site of infection in sufficient concentration for an
adequate length of time
Aminoglycosides and fluoroquinolones produce concentration-dependent
inhibition inhibitory effect depends on the ratio of peak concentration to the MIC
-lactams, glycopeptides and macrolides produce time-dependent inhibition
antimicrobial action depends on the length of time the concentration remains above
MIC
Drug which penetrates better and attains higher concentration at the site of infection
is more effective

6. Route of Administration:
Less severe infections - oral antibiotic
Serious infections - parenteral antibiotic
Drug Factors
7. Evidence of Clinical Efficacy:
Relative value of different AMAs in treating an infection is decided on the
basis of comparative clinical trials
Optimum dosage regimens and duration of treatment are also
determined on the basis of such trials
Reliable clinical trial data, if available, is the final guide for choice of the
antibiotic

8. Cost:
Less expensive drugs are to be preferred
Principles of Antibiotic Dosing for
Orofacial Infections
Employ high doses for a short duration
Achieve blood levels of antibiotic at 2-8 times the MIC
Use frequent dosing intervals
Determine the duration of therapy by remission of disease
Proper time intervals (four times the T)
Proper route of administration
Penetration of drug
Routes of Administration
Antibiotic Combinations
More than one AMAs are frequently used concurrently
Objectives:
To achieve synergism and enhance antimicrobial action
To reduce severity or incidence of adverse effects
To prevent emergence of resistance
To broaden the spectrum of antimicrobial action for polymicrobial
infections
For empirical therapy of an infection in which the cause is unknown
Prophylactic Use
Antibiotic prophylaxis with dental procedures is reasonable only
for patients with cardiac conditions associated with the highest
risk of adverse outcomes from endocarditis
Prophylactic Use
High Risk Patients:
Prosthetic cardiac valve or prosthetic material used in valve repair
Previous endocarditis
Congenital heart disease only in the following categories:
Unrepaired cyanotic congenital heart disease, including those with palliative shunts and
conduits
Completely repaired congenital heart disease with prosthetic material or device,
whether placed by surgery or catheter intervention, during the first six months after the
procedure
Repaired congenital heart disease with residual defects at the site or adjacent to the
site of a prosthetic patch or prosthetic device
Cardiac transplantation recipients with cardiac valvular disease
Prophylactic Use
Dental procedures for which prophylaxis is reasonable:
All dental procedures that involve manipulation of gingival tissue or the
periapical region of teeth, or perforation of the oral mucosa
Prophylactic Use
Antibiotic prophylaxis is NOT recommended for:
Routine anesthetic injections through noninfected tissue
Taking dental radiographs
Placement of removable prosthodontic or orthodontic appliances
Adjustment of orthodontic appliances
Placement of orthodontic brackets
Shedding of deciduous teeth
Bleeding from trauma to the lips or oral mucosa
Problems associated with
Antibiotic use
Toxicity
Hypersensitivity
Drug resistance
Superinfection
Nutritional Deficiencies
Masking of infection
1. Toxicity
Local Irritancy:
Exerted at the site of administration
Gastric irritation, pain and abscess formation
Complication - Thrombophlebitis of the injected vein
E.g. erythromycin, tetracycline, chloramphenicol

Systemic Toxicity:
Dose related and predictable organ toxicities
High Therapeutic Index Penicillins, some Cephalosporins, Erythromycin
Low Therapeutic Index Aminoglycosides, Tetracyclines, Chloramphenicol
Very Low Therapeutic Index Polymyxin B, Vancomycin, Amphotericin B
2. Hypersensitivity
Unpredictable and unrelated to dose
Reactions range from rashes to anaphylactic shock
Practically all AMAs are capable of causing
More commonly involved - penicillins, cephalosporins,
sulfonamides, fluoroquinolones
3. Drug Resistance
Unresponsiveness of a microorganism to an AMA

Natural Resistance:
Inherently lack the metabolic process or the target site which is affected
by the particular drug
Generally a group or species characteristic

Acquired Resistance:
Development of resistance by an organism (which was sensitive before)
due to the use of an AMA over a period of time
By mutation or gene transfer
3. Drug Resistance
Cross Resistance:
Acquisition of resistance to one AMA conferring resistance to another AMA,
to which the organism has not been exposed
Complete, or partial
Two-way, or one-way

Prevention:
No indiscriminate and inadequate or unduly prolonged use prefer symptom
determined shorter courses
Prefer rapidly acting and selective (narrow spectrum) AMAs
Broad-spectrum drugs - only when a specific one cannot be determined or is
not suitable
Use combination of AMAs for prolonged therapy
Infection by organisms notorious for developing resistance treated
intensively
4. Superinfection
Appearance of a new infection as a result of antimicrobial therapy
Commonly associated with the use of broad/extended-spectrum
antibiotics
More common when the host defense is compromised
Sites involved are those that normally harbor commensals
Generally more difficult to treat

To minimize superinfections:
Use specific (narrow-spectrum) AMA
Do not use antimicrobials to treat trivial, selflimiting or untreatable (viral)
infections
Do not unnecessarily prolong antimicrobial therapy
5. Nutritional Deficiencies
Some of the B complex group of vitamins and Vitamin K are
synthesized by the intestinal flora
Prolonged use of antimicrobials which alter this flora result in
vitamin deficiencies
6. Masking of an infection
Short course of an AMA may be sufficient to treat one infection
but only briefly suppress another one contacted concurrently
Other infection will be masked initially
Manifest later in a severe form
Failure of Antibiotic Therapy
Success of therapy measured either clinically in terms of
improvement in symptoms/signs or microbiologically as
eradication of the infecting organism
Antimicrobials may fail to cure an infection/fever, or there may
be relapses
When a real or apparent failure of the antimicrobial regimen
occurs, the diagnosis and therapy should be reviewed
Failure of Antibiotic Therapy
Causes of failure:
Improper selection of drug, dose, route or duration
Treatment begun too late
Failure to take necessary adjuvant measures
Poor host defense
Infecting organism present behind barriers
Trying to treat untreatable infections or other causes of fever
Presence of dormant or altered organisms which later give rise to a
relapse
Common Antibiotics in
Dentistry
Mechanism of action
Uses
Adverse Effects
Interactions
Contra-indications
Dosage and availability
Penicillins
Classification:
Natural penicillin Penicillin G
Acid resistant penicillin Penicillin V
Penicillinase resistant penicillin Methicillin
lactamase inhibitors Clavulanic acid
Penicillin active against
pseudomonas
Carboxy and ureidopenicillins
Extended spectrum penicillins
Aminopenicillins: Ampicillin
Carboxypenicillin: Carbenicillin
Ureidopenicillin: Piperacillin
Penicillin G
Antibacterial Spectrum:
Streptococci, pneumococci, N. gonorrhoea, clostridia, M. TB,
spirochaetes, actinomyces israeli, B. anthracis

Mechanism of Action:
Interfere with the synthesis of bacterial cell wall

Adverse Effects:
Local irritancy and direct toxicity
Hypersensitivity reactions
Super infections
Jarisch-Herxhemier reactions


Penicillin G
Uses:
Dental infections: periodontal abscess, periapical abscess, pulpitis
Medicinal uses: Gonorrhoea, syphilis, tetanus

Preparations and Dose:
Sodium penicillin G inj.: Benzyl pen 0.5,1 MU inj.
Procaine penicillin G inj.: 0.5,1 MU dry powders in vial
Fortified procaine penicillin G inj.: 3+1 lac U vial
Benzathine penicillin G: Penidure LA 0.6, 1.2, 2.4 MU as
dry powder in vial

Penicillin G
Contraindications:
Allergies
Poor renal function

Drug Interactions:
Oral contraceptives

Pregnancy category: B

Trade Names: PENCIP, PENTIDS, SODICILLIN
Ampicillin
Antibacterial Spectrum:
E. coli, proteus, salmonella, shigella and many Gram positive
organisms like cocci, bacilli etc.

Mechanism of Action:
Interfere with the synthesis of bacterial cell wall

Adverse Effects:
Diarrhoea
Rashes

Drug Interactions:
Oral contraceptives
Ampicillin
Uses:
Urinary tract infection
Respiratory tract infection
Meningitis, gonorrhoea
SABE, typhoid fever
Bacillary dysentery, septicemias

Contraindications:
Allergies
Poor renal function

Dosage:
0.5-2g oral/I.M/I.V every 6 hrs for adults
25-50 mg/kg/day for children

Trade Names: AMPISYN, AMPILIN, AMPI-500, ALFACILLIN, AMPICILLIN
Amoxicillin
Similar to ampicillin in all aspects except:
Oral absorption is better
Incidence of diarrhea
It is less active against Shigella and H. influenzae

Dosage:
250-500mg TDS given for 5 days

Uses:
Choice of drug for prophylaxis of local wound infection as well as distant
infection following dental surgery

Trade Names: MOX, AMOX, AMOXIL, AMOXIPEN, AUGMENTIN
(Amoxicillin and clavulanic acid)
Methicillin
MRSA (methicillin resistant staph. aureus) are organisms
resistant to methicillin
Drug of choice: vancomycin/linezolid
Ciprofloxacin can also be used

Cephalosporins
Mechanism of Action:
Interfere with the synthesis of bacterial cell wall

Classification:
First Generation:
Effective against
gram positive cocci, including penicillinase producing staph
most anaerobes and community acquired infections caused by E.coli, Proteus and klebsiella
Examples are: Cefalexin, Cefadroxil

Second Generation:
Show increased antibacterial activity
Cefmandole has markedly increased activity. But it has less activity against strep.
Cefactor, increased activity against H.influenzae
Cephalosporins
Classification:
Third Generation:
Ceftriaxone shows high efficacy in bacterial meningitis, multi resistant typhoid fever,
complicated urinary tract infections, abdominal sepsis and septicemias
Examples are: Cefpodoxime proxetil, cefoperazone

Fourth Generation:
Examples are: Cefepime, cefpirome

Dosage: 250-1000mg q 6 h x 7-10 days

Uses:
Dental infections
General medical uses like meningitis, typhoid etc
Cephalosporins
Adverse Effects:
Pain after I.M injection
Diarrhoea
Hypersensitivity reactions
Nephrotoxicity
Bleeding
Neutropenia and thrombocytopenia

Contraindications:
Allergies
Poor renal function.

Drug Interactions: Probenecid

Pregnancy Category: B

Tetracyclines
Antibacterial Spectrum:
Cocci: N. gonorrhoea and N. menigitidis
Bacilli: Clostridia and anaerobic bacilli, H. ducreyi
Some spirochetes, mycoplasma, actinomyces

Mechanism of Action:
Inhibit protein synthesis by binding to 30S ribosomes - prevent
aminoacyl transfer RNA from entering the acceptor sites on the
ribosome

Uses:
Orodental infections
Gingivitis
Periodontal ligament related diseases
Tetracyclines
Adverse Effects:
Irritative effects
Liver damage
Kidney damage
Phototoxicity
Teeth and bones: Enamel hyperplasty, inhibition of fibula growth, dental
caries, brown discolouration, formation of calcium tetracycline crystals
Antianaboilic effects
Increased intracranial pressure
Diabetes insipidus
Vestibular toxicity
Hypersensitivity
Superinfection
Tetracyclines
Dosage: 100 mg qd-bid x 7-14 days

Contraindications:
Food
Pregnancy

Drug Interactions:
Anti-epileptics

Pregnancy category: D
Chloramphenicol
Antibacterial Spectrum:
H. influenzae, salmonella, klebsiella along with those sensitive to
tetracycline

Mechanism of Action:
Inhibit protein synthesis binding to 50S subunit

Uses:
Enteric fever
H. influenzae meningitis
Anaerobic reactions
Intraocular infections
Chloramphenicol
Adverse Effects:
Bone marrow depression
Hypersensitivity reactions
Irritative effects
Superinfections
Gray baby syndrome
Chloramphenicol
Dosage: Daily dose not to exceed 23 g; duration of therapy to be < 2
weeks, total dose in a course < 28 g

Contraindications:
Pregnancy

Drug Interactions:
Inhibits metabolism of tolbutamide, chlorpropamide, warfarin,
cyclophosphamide and phenytoin
Phenobarbitone, phenytoin, rifampin enhance metabolism
Antagonize the cidal action of -lactams/aminoglycosides on certain bacteria


Pregnancy category: D
Aminoglycosides
Antibacterial Spectrum:
Gram negative bacilli, H.ducreyi, yersinia pestis, gram positive
cocci, enterococci

Mechanism of Action:
Inhibit protein synthesis

Uses:
Tuberculosis
Plaque
Tularemia
Brucellosis
Enterococcal infections
Subacute bacterial infections
Aminoglycosides
Adverse Effects:
Ototoxicity
Nephrotoxicity
Neuromuscular blockade
Allergy
Superinfection
Aminoglycosides
Dosage: 0.5-1 gm by I.M injection

Contraindications:
Pregnancy (risk of foetal ototoxicity)
Concurrent use of other ototoxic drugs, e.g. high ceiling diuretics, minocycline.
Concurrent use of other nephrotoxic drugs, e.g. amphotericin B, vancomycin

Precautions:
Patients past middle age
Kidney damage

Drug Interactions:
Cautious use of muscle relaxants


Trade Names: GENTACIL, GENTYCIN, GENTAMICIN
Macrolides
Antibacterial Spectrum:
Streptococcus, staphylococcus, gonorrhea, clostridia

Mechanism of Action:
Act by inhibiting protein synthesis by binding to the bind to
the 23S rRNA of 50S ribosomal subunits

Uses:
Dental infections: Periodontal, periapical abscess, necrotizing ulcerative
gingivitis, gingival cellulites
General medical uses: Pharyngitis, tonsillitis, rheumatic fever

Macrolides
Adverse Effects:
Gastrointestinal problems
Hypersensitivity
Reversible hearing impairment
Macrolides
Dosage:
Erythromycin: 250-500 mg 6 hourly (max.4g/day), children 30-60-
mg/kg/day
Azithromycin: 500 mg once daily 1hr before or 2hrs after food for 3 days

Precautions:
Poor hepatic function

Drug Interactions:
Cytochrome P-450

Pregnancy category: B
Metronidazole
Antibacterial Spectrum:
Entamoeba histolytica, giardia lamblia, anaerobic bacteria, like
clostridium, spirochetes, peptococcus

Mechanism of Action:
Reduced intermediate interacts and breaks the bacterial or
parasitic DNA

Adverse Effects:
Anorexia, nausea, metallic taste, abdominal cramps
Headache, dryness of mouth, rashes, and Glossitis (rare)
Thrombophlebitis of the injected vein
Metronidazole
Uses:
Orodental infections
Drug of choice in acute necrotizing ulcerative gingivitis
Periodontitis, pericoronitis, acute apical infections, brain abscess
Drug of choice for all forms of anaerobic infections, acute dysentery, liver
abscess
Drug of choice for intestinal giardiasis and trichomonas vaginitis

Dosage: 200-400 mg TDS (15-30mg/kg/day)

Trade Names: METROGYL, FLAGYL
Metronidazole
Contraindications:
Pregnancy
Chronic alcoholism

Precautions:
Poor hepatic function

Drug Interactions:
EtOH
Warfarin
Li+

Pregnancy category: D
Fluoroquinolones
Antibacterial Spectrum:
All organisms are susceptible except some strep, anaerobic
cocci, mycobacterium

Mechanism of Action:
Bind to A subunit of DNA gyrase with high affinity and interfere
with strand cutting and resealing functions

Adverse Effects:
GIT: Nausea, vomiting, bad taste, anorexia
CNS: Dizziness, headache, restlessness, anxiety
Skin/hypersensitivity
Fluoroquinolones
Uses:
Urinary tract infections
Gonorrhea
Soft tissue, bone and joint infections especially gram negative organisms
Community acquired pneumonia

Dosage: Ciprofloxacin 250-500 mg QD x 7-10 days

Trade Names: BIOCIP, CIP, CIPLOX, CIPLO
Fluoroquinolones
Contraindications:
Children (damage of the cartilage in weight bearing joints)
Pregnancy

Drug Interactions:
Probenacid
Warfarin

Pregnancy category: C
Clotrimoxazole
Combination of trimethoprim and sulfamethoxazole (1:20)

Antibacterial Spectrum:
Same as sulfonamide but include salmonella typhi,
klebsiella, enterobacter

Mechanism of Action:
Inhibit bacterial dihydrofolate reductase

Clotrimoxazole
Uses:
Pneumocystis carnii pneumonia in AIDS patients
Tonsillitis, Pharyngitis, sinusitis
Urinary tract infections, orodental infections

Adverse Effects:
Methamoglobinemia
Blood dyscarasis
Nausea, vomiting, stomatitis, headache and rashes
Neonatal hemolysis

Contraindications:
Pregnancy
Conclusion
Newer Antibiotics
Ceftolozane/tazobactam: Antipseudomonal cephalosporin/-lactamase
inhibitor combination (cell wall synthesis inhibitor)
Ceftazidime/avibactam: Antipseudomonal cephalosporin/-lactamase
inhibitor combination (cell wall synthesis inhibitor)
Ceftaroline/avibactam: Anti-MRSA cephalosporin/ -lactamase inhibitor
combination (cell wall synthesis inhibitor)
Plazomicin: Aminoglycoside (protein synthesis inhibitor)
Eravacycline: A synthetic tetracycline derivative / protein synthesis inhibitor
targeting the ribosome
Brilacidin: Peptide defense protein mimetic (cell membrane disruption)
Misuse in Dentistry
Treatment of Nonresponsive Infections:
Diseases caused by viruses are self-limited

Therapy of Fever of Unknown Origin:
Fever persisting for 2 or more weeks only 1/4
th
are due to infections
Require treatment with agents that are not used commonly for bacterial
infections, surgical drainage or prolonged courses of pathogen-specific
therapy
May mask an underlying infection, delay the diagnosis, and prevent
identification of the infectious pathogen
Noninfectious causes

Inappropriate Reliance on Chemotherapy Alone:
Drainage, debridement, and removal of foreign body
Misuse in Dentistry
Improper Dosage:
Dosing errors (wrong frequency of administration or use of either an
excessive or a subtherapeutic dose)
Excessive amounts can result in significant toxicities
Too low a dose may result in treatment failure or resistance

Lack of Adequate Bacteriological Information:
Bacterial cultures and Gram stains of infected material
Frequent use of drug combinations or drugs with the broadest spectra
Agents are selected more likely by habit than for specific indications
Dosages employed are routine rather than individualized
Conclusion
Antibiotic therapy is an art and a science. There are so
many confounding variables (such as suspected pathogen, ability
to establish drainage, pharmacokinetic properties of the drug,
mechanism of action of the antibiotic, virulence of the infection,
the current health status of the host, and host defense
mechanisms), that it is not possible to make antibiotic therapy
into a mechanistic technologic science.

The most important decision for the dental practitioner to
make is not only which antibiotic to use but whether to use one
at all.
References
Essentials of Medical Pharmacology, 6th Edition K. D. Tripathi
Goodman & Gilmans The Pharmacological Basis of Therapeutics, 11th
Edition
Pharmacology and Pharmacotherapeutics - R. S. Satoskar

Manoj Kumar Jain, Sheetal Oswal K. Antibiotics in Dentistry An Art and
Science. Annals of Dental Specialty 2013; 1(1):20-25.
Prevention of Infective Endocarditis: Guidelines From the American Heart
Association, by the Committee on Rheumatic Fever, Endocarditis, and
Kawasaki Disease. Circulation, 2007; 116: 1736-1754.

Online sources:
http://www.medclik.com
http://en.wikipedia.org/wiki/Antibacterial
Thank You