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Prophylactic Antibiotics for Medically Compromised Chapter 21 / Treatment of Endodontic Infections, Cysts, and Flare-ups / 695 are immunocompromised. The usual oral dosage for PROPHYLACTIC ANTIBIOTICS amoxicillin with clavulanate is 1,000-mg loading dose FOR MEDICALLY COMPROMISED followed by 500 mg every 8 hours. An alternate dosage PATIENTS is 875 mg every 12 hours. Erythromycin has traditionally been the alternative Prophylactic antibiotic coverage may be indicated choice for patients allergic to penicillin, but it is not for medically compromised patients requiring endo- effective against anaerobes associated with endodontic dontic treatment. The American Heart Association infections. Clarithromycin and azithromycin are (AHA) and the American Academy of Orthopaedic Surgeons have made guidelines for prophylactic anti- macrolides like erythromycin, with some advantages 23,24 over the latter. They have a spectrum of antimicrobial biotic coverage. The guidelines are meant to aid activity that includes facultative bacteria and some practitioners but are not intended as the standard of anaerobic bacteria associated with infections of endo- care or as a substitute for clinical judgment. The dontic origin. They also have less gastrointestinal upset incidence of endocarditis following most procedures than erythromycin. The oral dosage for clarithromycin on patients with underlying cardiac disease is low (see is a 500-mg loading dose followed by 250 mg every 12 Chapter 7 ‘‘Microbiology of Endodontic Disease’’). hours. The oral dosage for azithromycin is a 500-mg A reasonable approach for prescribing prophylactic loading dose followed by 250 mg once a day. antibiotics considers the degree to which the underlying Clindamycin is effective against both facultative disease creates a risk for endocarditis, the apparent risk and strict anaerobic bacteria associated with endo- for producing a bacteremia, adverse reactions to the prophylactic antibiotic, and the cost-benefit aspect of dontic infections. It is well distributed throughout 23 the body, especially to bone, where its concentration the regimen. Antibiotic prophylaxis is employed to approaches that of plasma. Both penicillin and clin- prevent surgical infections or their postoperative seque- lae, to prevent metastatic bacteremias, and to prevent damycin have been shown to produce good results in 25 treating odontogenic infections.4,5,20 Clindamycin is accusation that ‘‘all was not done for the patient.’’ It is suspected that antibiotic prophylaxis is often prescribed rapidly absorbed even in the presence of food in the 25 stomach.21 The oral adult dosage for serious endo- to prevent malpractice claims. dontic infections is a 600-mg loading dose followed How antibiotics quickly kill bacteria in the blood is by 300 mg every 6 hours. difficult to answer when many antibiotics are only Metronidazole is a nitroimidazole that is active effective with actively dividing bacteria. It is speculated against parasites and anaerobic bacteria. However, it that antibiotics may reduce metastatic infections by 4,5,22 preventing adhesion of bacteria to tissues or inhibiting is ineffective against facultative bacteria. It is a 26 valuable antimicrobial agent in combination with growth after attachment. The principles of antibiotic penicillin when penicillin alone has been ineffective.22 prophylaxis state that the antibiotic must be in the The usual oral dosage for metronidazole is a 1,000-mg system prior to an invasive procedure. If a patient has loading dose followed by 500 mg every 6 hours. Con- not taken the prescribed antibiotic, he or she should be sultation with, and referral to other specialists in the rescheduled or wait an hour after administration of the management of facial infections, is indicated for antibiotic for treatment. However, there is data to support the use of an antibiotic up to 2 hours after severe or persistent infections. 25 Cephalosporins are usually not indicated for the the onset of bacteremia. treatment of endodontic infections. First-generation The incidence of bacteremia has been shown to be cephalosporins do not have activity against the anae- low during root canal therapy. A transient bactere- robes usually involved in endodontic infections. mia can result from the extrusion of microorganisms from the root canal to the periapical tissues of the Second-generation cephalosporins have some efficacy 27–31 for anaerobes, however, there is a possibility of cross- tooth. In addition, positioning rubber dam allergenicity of cephalosporins with penicillin. clamps and accomplishing other dental procedures Doxycycline occasionally may be indicated when the may produce bleeding and can lead to a bacteremia. above antibiotics are contraindicated. However, many strains Medically compromised dental patients who are at of bacteria have become resistant to the tetracyclines. risk of infection should receive a regimen of antibio- Ciprofloxacin is a quinilone antibiotic that is not tics that either follows the recommendations of the AHA or an alternate regimen determined in consul- effective against anaerobic bacteria usually found in 23 endodontic infections. With a persistent infection, it tation with the patients’ physicians. Chapter 24 may be indicated if culture and sensitivity tests gives the antibiotic regimens recommended for demonstrated the presence of susceptible organisms. dental procedures. It is believed that amoxicillin, 696 / Endodontics ampicillin, and penicillin V are equally effective tooth with a rubber dam and disinfecting the tooth against alpha-hemolytic streptococci; however, surface and rubber dam with sodium hypochlorite amoxicillin is recommended because it is better or other disinfectant. Sterile burs and instruments absorbed from the gastrointestinal tract and provides must be used to gain access to the root canal system. higher and more sustained serum levels.23 Intracanal irrigation should not be used until after For cardiac conditions associated with endocarditis, the microbial sample has been taken. If there is prophylaxis is recommended for both non-surgical drainage from the canal, it may be sampled with a and surgical endodontic procedures.23 Antibiotic pro- sterile paper point or aspirated into a sterile syringe phylaxis is recommended for cardiac conditions asso- with a sterile 18- to 25-gauge needle, depending on ciated with endocarditis at a high or moderate risk the viscosity of the exudate. The aspirate should category (see Chapter 24). Dental procedures for either be taken immediately to a microbiology which antibiotic prophylaxis is recommended (see laboratory in the syringe or injected into pre- Chapter 24) include endodontic instrumentation reduced transport media. To sample a dry root beyond the apex or surgery, but not intracanal endo- canal, a sterile syringe should be used to place some dontic treatment, post-placement and buildup.23 pre-reduced transport medium into the canal. A From a practical standpoint, it is difficult to deter- sterile endodontic instrument is then used to scrape mine with certainty that endodontic instruments do the walls of the canal to suspend microorganisms not pass beyond the apical foramen. Also included for into the medium. prophylaxis antibiotics is intraligamentary period- To prevent contamination by the normal oral flora, ontal ligament (PDL) local anesthetic injections, but a microbial sample from a soft tissue swelling should not non-intraligamentary ones.23 be obtained before making an I&D. Once profound In 2003, a joint committee of the American Dental anesthesia is achieved, the surface of the mucosa Association and American Academy of Orthopaedic should be dried and disinfected with an iodophor Surgeons published their first advisory statement on swab. A sterile 16- to 20-gauge needle and syringe is antibiotic prophylaxis for patients with prosthetic used to aspirate the exudate. The aspirate should be joints. The dental procedures of concern and the handled as described above. A sample can be collected antibiotic regimens are the same as for endocarditis on a swab after the I&D has been made, but great care Chapter 24. Patients of potential increased risk of must be taken to prevent microbial contamination having a hematogenous total joint infection include with normal oral flora. After collecting the specimen all patients during the first 2 years following joint on a swab, it should be quickly placed in pre-reduced replacement, immunocompromised/immunosuppressed medium for transport to the laboratory. patients, and patients with comorbidities as shown in Good communication with the laboratory personnel Chapter 24.32 is important. The sample should be Gram-stained to demonstrate which types of microorganisms predomi- nate. The culture results should show the prominent COLLECTION OF A MICROBIAL SAMPLE isolated microorganisms and not just be identified as Adjunctive antibiotic therapy for endodontic infec- ‘‘normal oral flora.’’ Antibiotics can usually be chosen tions is most often prescribed empirically based on to treat endodontic infections based on the identifica- knowledge of the bacteria most often associated tion of the prominent microorganisms in the culture. with endodontic infections. At times, culturing With persistent infections, susceptibility testing can be may provide valuable information to better select undertaken to establish which antibiotics are the most theappropriateantibioticregimen.Forexample,an effective against resistant microbial isolates. At present, immunocompromised/immunosuppressed patient it may take 1 to 2 weeks
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