2Peri-operative for elective surgery Prevention of post operative infectionsin a compromised hostbefore placement of foreign bodyPeri-operative for elective surgeryFor acute local infection where you are unable to remove the cause immediatelyFor rapidly spreading infection with systemic signsFor persistent, recurrent on responsive infectionInfection diagnosisfor prevention BONJ and ORNFor Mx osteomyelitis, OM, ORN, Sialdenitis, ANUG, sinusitis.Specific regimes
3Antibiotic indications for OS Peri-operative Elective SurgicalextractionA Compromised host with immuno compromise (see list)B Patient presenting with abscess or local infectionForeign body placementC ImplantsD bone graftRoutine extE Patients at low risk of BONJ or ORNPre operative (A,C,D +E)Amoxycillin Oral 2gORErythromycin Oral 1g+ Post operative (A,B, D and E)3 days Pen V or Amoxycillin 250mg TDSOr 3 days Metronidazole 200mg TDSAdditional if recent Abs included aboveClindimycin 600 mg TDS for 7 days warn pt pseudo membraneous collitis
4Patients 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 therapyRememberKids may be prone to rapid spreading infections due to elevated metabolic rateDry sockets do not occur in kidsMultiple dry sockets may be a sign of pathology OR osteomyelitis
5Situations when the use of Antibiotics is NOT necessary For the prevention of infective endocarditis BSAC/NICE 2010When identification and removal of source with local infection is possible Ellis et al BDJ 2011Chronic well-localized abscess Ellis et al BDJ 2011Minor vestibular abscess Ellis et al BDJ 2011Dry socket RCS Eng Guidelines 1996Mild pericoronitis RCS Eng Guidelines 1996
6Antibiotics in OS are indicated for infections when; For acute local infection where you are unable to remove the cause immediatelyFor rapidly spreading infection with systemic signsFor persistent, recurrent on responsive infection
7Principles of infection management Identify patients at risk and prevent post op infections where possibleRemoval of source (extirpation of pulp / extraction)Incision and drainage (I+D)if not all pus extn or cellulitic spread with no obvious pusMedical support if indicatedAntibioticsAnalgesicsCulture + sensitivity (C+S) if indicatedRecurrent / Non responsive infectionCompromised host defensesRapidly spreading local infectionEvidence systemic infectionSuspected ActinomycosisRe-evaluation identify patient in trouble EARLY on for referral
8Patient in trouble Raised WBC/ CrP Systemic signs Fever > 36.8c LymphadenopathyTrismusRashRaised WBC/ CrPSystemic symptomsMalaiseDehydrationDifficulty swallowing,speaking or breathing
9Indications for Culture and Antibiotics Sensitivity Recurrent / Non responsive infection Compromised host defenses Rapidly spreading local infection Evidence systemic infection Suspected Actinomycosis
10Specific AB regimens Prevention BONJ/ORN Secondary care Management BONJManagement ORNManagement OM
11Suggested 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 upIf 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 daysHigh risk IV BPs previously 2 week preop Pentoxyfiline 400mg BD Vitamin E 1000IU / 4 weeks post op plus clindamycinRefsMarks et al 2007NHS 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)11
12Suggested 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. Review12
13Suggested protocol for Management of OM Multiple dry socket???CBCT of area (usually mandibular region)Bone sequestrae not present6 weeks ClindamycinBone sequestrae presentLA removal and debridement of sequestraePreoperative Abs and Post op AbsReview
14RefsSchwartz AB, Larson EL Antibiotic prophylaxis and postoperative complications after tooth extraction and implant placement: a review of the literature. J Dent Dec;35(12): Epub 2007 Sep 29.Ellison BDJKunkel 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):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: Daramola OO, Flanagan CE, Maisel RH, Odland RM. Diagnosis and treatment of deep neck space abscesses. Otolaryngol Head Neck Surg 2009;141: 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: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 ( ). 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.
16Eur J Clin Microbiol Infect Dis. 2009 Apr;28(4):317-23 Eur J Clin Microbiol Infect Dis. 2009 Apr;28(4): 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.SourceHospital Universitari Vall D'Hebron, Universitat Autonoma, Barcelona, Spain.AbstractThe 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
17reported 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 tissueOropharyngeal 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.
18Taori KB, Solanke R, Mahajan SM, Rangankar V, Saini T Taori KB, Solanke R, Mahajan SM, Rangankar V, Saini T. CT evaluation of mandibular osteomyelitis. Indian J Radiol Imaging. 2005;15: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:Schultz C, Holterhus P, Seidel A, Jonas S, Barthel M, Kruse K.Chronic recurrent multifocal osteomyelitis in children.Pediatr Infect Dis J. 1999;18:Job-Deslandre C, Krebs S, Kahan A. Chronic recurrent multifocal osteomyelitis: Five-years outcomes in 14 patients cases. J Bone Spin. 2001;64: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;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: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.
19Analgesic regime for TMS (adult pts) Ibuprofen mg QDS per oralParacetamol 500mg -1g QDS per oralPrescribe above together as synergistic effect with combinationAdvise to start when Local anesthetic is wearing offIf allergic to NSAIDS or pregnant Paracetamol aloneCodeine rarely indicated OR beneficialRescue mediation = Tramadol