Clindamycin in dentistry: More than just effective prophylaxis for endocarditis?

Antimicrobial therapy in the management of odontogenic infections: the penicillin-allergic patient

This retrospective analysis was performed to investigate whether clindamycin remains the preferred antibiotic for penicillin-allergic patients with odontogenic infections. The medical records of 311 patients admitted to the study department with odontogenic infections between 2018 and 2022 and treated with either intravenous amoxicillin-clavulanic acid (Augmentin) or intravenous clindamycin were analyzed. The Augmentin-treated group included 268 patients (86.2%) and the clindamycin-treated group included 43 patients (13.8%). Severity parameters did not differ significantly between the two groups, except for a higher prevalence of abscesses in the clindamycin-treated group (58.1% vs 41.0% in the Augmentin-treated group; P = 0.035). The clindamycin-treated group required a longer duration of intravenous antibiotics (P = 0.001) and had a higher rate of treatment failure (14.0% vs 2.2%; P = 0.002) when compared to the Augmentin-treated group, with a seven-fold increased risk of treatment failure. Moreover, significantly more isolated organisms in the clindamycin-treated group were resistant to clindamycin (P = 0.015); these were all Streptococcus anginosus group. Given the higher risk of treatment failure with clindamycin, it is necessary to choose the antibiotic treatment for penicillin-allergic patients carefully. A detailed history and allergy testing followed by combination therapy is recommended, especially in severe cases.

Does thePenicillin Allergy Label Affect Outcomes of Complicated Odontogenic Infections?

PURPOSE

Penicillins are a potent antibiotic in managing odontogenic infections, but 10% of the population is labelled as allergic to these drugs. This has limited their use and resulted in increased utilization of health care resources as well as complications associated with alternative antibiotics. The purpose of the study was to measure the association between patients labeled as penicillin allergic and treatment outcomes in a sample of patients treated for complicated odontogenic infections. Additionally, we sought to investigate antibiotic resistance patterns in these patients.

MATERIALS AND METHODS

A retrospective cohort study was performed at the Michigan Medicine health care system to include patients who were treated for complicated odontogenic infections by oral and maxillofacial surgery between 2016 and 2020. Complicated odontogenic infection was defined as any odontogenic infection requiring admission and surgical management in the operating room. The primary predictor variable was the penicillin allergy label, which was determined by chart review and not confirmed with formal testing. Outcomes were measures of disease severity. The primary outcome variable was hospital length of stay. Secondary outcome variables were ICU admission (yes/no), repeat computed tomography scan(s), repeat surgery (yes/no), and re-admission (yes/no). Co-variates included were age, sex (male/female), tobacco use status, diabetes, immunocompromised state, number of spaces involved, white blood cell count upon admission and insurance status. For our secondary aim, the primary predictor variable was again penicillin allergy and outcome variable was antibiotic resistance as determined by wound culture results following surgical intervention. Negative binomial regression and logistic regression analyses were performed. P < .05 was considered significant.

RESULTS

A total of 150 patients met the inclusion criteria and of those 17.3% reported as penicillin allergic. Patients labelled as penicillin allergic did not differ significantly from patients without penicillin allergy label in terms of treatment outcomes. Age, diabetes, and immunosuppression were associated with an increased length of stay. Patients labelled as penicillin allergic were at significantly higher risk for antibiotic resistance (relative risk = 2.34; 95% confidence interval, 1.66 to 3.32; P < .001), specifically clindamycin resistance (relative risk = 3.17; 95% confidence interval, 1.93 to 5.18; P < .001).

CONCLUSIONS

Penicillin allergy was significantly associated with clindamycin resistance. There were similar outcomes amongst patients with and without a penicillin allergy label despite antibiotic differences. Delabeling efforts for patients with a reported penicillin allergy must be considered and local nomograms for antibiotic selection should be used by providers when seeking alternative antibiotics.

Antimicrobial Transformation Products in the Aquatic Environment: Global Occurrence, Ecotoxicological Risks, and Potential of Antibiotic Resistance

The global spread of antimicrobial resistance (AMR) is concerning for the health of humans, animals, and the environment in a One Health perspective. Assessments of AMR and associated environmental hazards mostly focus on antimicrobial parent compounds, while largely overlooking their transformation products (TPs). This review lists antimicrobial TPs identified in surface water environments and examines their potential for AMR promotion, ecological risk, as well as human health and environmental hazards using in silico models. Our review also summarizes the key transformation compartments of TPs, related pathways for TPs reaching surface waters and methodologies for studying the fate of TPs. The 56 antimicrobial TPs covered by the review were prioritized via scoring and ranking of various risk and hazard parameters. Most data on occurrences to date have been reported in Europe, while little is known about antibiotic TPs in Africa, Central and South America, Asia, and Oceania. Occurrence data on antiviral TPs and other antibacterial TPs are even scarcer. We propose evaluation of structural similarity between parent compounds and TPs for TP risk assessment. We predicted a risk of AMR for 13 TPs, especially TPs of tetracyclines and macrolides. We estimated the ecotoxicological effect concentrations of TPs from the experimental effect data of the parent chemical for bacteria, algae and water fleas, scaled by potency differences predicted by quantitative structure-activity relationships (QSARs) for baseline toxicity and a scaling factor for structural similarity. Inclusion of TPs in mixtures with their parent increased the ecological risk quotient over the threshold of one for 7 of the 24 antimicrobials included in this analysis, while only one parent had a risk quotient above one. Thirteen TPs, from which 6 were macrolide TPs, posed a risk to at least one of the three tested species. There were 12/21 TPs identified that are likely to exhibit a similar or higher level of mutagenicity/carcinogenicity, respectively, than their parent compound, with tetracycline TPs often showing increased mutagenicity. Most TPs with increased carcinogenicity belonged to sulfonamides. Most of the TPs were predicted to be mobile but not bioaccumulative, and 14 were predicted to be persistent. The six highest-priority TPs originated from the tetracycline antibiotic family and antivirals. This review, and in particular our ranking of antimicrobial TPs of concern, can support authorities in planning related intervention strategies and source mitigation of antimicrobials toward a sustainable future.

Advanced pharmacy practice of a doctor of pharmacy student at an allied surgical ward in a hospital in Africa

Introduction

The pharmacy profession is undergoing transformational change in Ghana. The role of pharmacists has become more patient-focused with increased accountability and responsibility.

Aim

This study is aimed at reporting the experiential learning on the clinical interventions made and documented at the Allied Surgical Wards of Korle-Bu Teaching Hospital (KBTH).This involves a review of patient's medical records during the Advanced Pharmacy Practice Experience (APPE) learning. One case each from Eye, Ear, Nose, Throat, (ENT) and Dental units' subspecialty were reviewed from October 7, 2019 to November 15, 2019 b y a Pharm D student.

Conclusion

The student was able to make prompt clinical interventions that contributed to patient care in clinical wards assigned during her clinical clerkship.

A global science mapping analysis on odontogenic infections

OBJECTIVES

Odontogenic infections are common and a topic of core interest for dentists, and maxillofacial surgeons. The aim of this study was to conduct a bibliometric analysis of the global literature on odontogenic infection and explore the top 100 most cited papers to identify the common causes, sequelae and management trends.

METHODS

Following a comprehensive literature search, a list of top 100 most cited papers was created. The VOSviewer software (Leiden University, The Netherlands) was used to create a graphical representation of the data, and statistical analyses were performed to analyze the characteristics of the top 100 most cited papers.

RESULTS

A total of 1,661 articles were retrieved with the first article published in 1947. There is an exponential upward trend on the number of publications (R2 = 0.919) and a majority of papers are in English language (n = 1,577, 94.94%). A total of 22,041 citations were found with a mean of 13.27 per article. The highest number of publications were recorded from developed countries. There was a male predilection in the reported cases and the most common sites included the submandibular and parapharyngeal spaces. Diabetes mellitus was identified as the commonest co-morbidity. Surgical drainage was ascertained to be the preferred method of management.

CONCLUSIONS

Odontogenic infections remain prevalent and have a global distribution. Although prevention of odontogenic infection through meticulous dental care is ideal, early diagnosis and prompt management of established odontogenic infections is important to avoid morbidities and mortality. Surgical drainage is the most effective management strategy. There is lack of consensus regarding the role of antibiotics in the management of odontogenic infections.

The effect of preoperative clindamycin in reducing early oral implant failure: a randomised placebo-controlled clinical trial

OBJECTIVES

To assess the effect of preoperative oral clindamycin in reducing early implant failure in healthy adults undergoing conventional implant placement.

MATERIALS AND METHODS

We conducted a prospective, randomised, double-blind, placebo-controlled clinical trial in accordance with the ethical principles and Consolidated Standards of Reporting Trials statement. We included healthy adults who underwent a single oral implant without previous infection of the surgical bed or the need for bone grafting. They were randomly treated with a single dose of oral clindamycin (600 mg) 1 h before surgery or a placebo. All surgical procedures were performed by one surgeon. A single trained observer evaluated all patients on postoperative days 1, 7, 14, 28, and 56. Early dental implant failure was defined as the loss or removal of an implant for any reason. We recorded the clinical, radiological, and surgical variables, adverse events, and postoperative complications. The study outcomes were statistically analysed to evaluate differences between the groups. Furthermore, we calculated the number required to treat or harm (NNT/NNH).

RESULTS

Both the control group and clindamycin group had 31 patients each. Two implant failures occurred in the clindamycin group (NNH = 15, p = 0.246). Three patients had postoperative infections, namely two placebo-treated and one clindamycin-treated, which failed (relative risk: 0.5, CI: 0.05-5.23, absolute risk reduction = 0.03, confidence interval: - 0.07-0.13, NNT = 31, CI: 7.2-∞, and p = 0.5). One clindamycin-treated patient experienced gastrointestinal disturbances and diarrhoea.

CONCLUSIONS

Preoperative clindamycin administration during oral implant surgery in healthy adults may not reduce implant failure or post-surgical-complications.

CLINICAL RELEVANCE

Oral clindamycin is not efficacy.

TRIAL REGISTRATION

The present trial was registered (EudraCT number: 2017-002,168-42). It was approved by the Committee for the Ethics of Research with Medicines of Euskadi (CEIm-E) on 31 October 2018 (internal code number: 201862) and the Spanish Agency of Medicines and Medical Devices (AEMPS) on 18 December 2018.

Clinical features and antimicrobial susceptibility of oral bacteria isolated from the blood cultures of patients with infective endocarditis

Background/purpose

The epidemiology of infective endocarditis (IE) is under constant change due to the aging society and increases in antimicrobial-resistant pathogens. However, IE remains severe. This study aimed to review the current clinical characteristics of IE and the antimicrobial susceptibility of oral bacteria (OB) isolated from blood cultures to implement appropriate antimicrobial prophylaxis.

Materials and methods

We retrospectively investigated the clinical features of 180 patients with IE in whom OB and pathogens except OB (eOB) were identified as causative microorganisms via blood cultures. The susceptibility of the OB group to eight antibiotics was examined by broth microdilution.

Results

Among causative microorganisms, the isolation rate of staphylococci was slightly higher than that of OB; however, the difference was not significant (36.7% vs. 33.8%, p = 0.3203). The number of patients with underlying cardiac disease was significantly higher in the OB group than in the eOB group (53.7% vs. 34.1%, p = 0.0113). Only one ampicillin-resistant OB was detected (2.0%). OBs were significantly less susceptible to clarithromycin and azithromycin than to ampicillin (98.0% vs. 66.7% and 98.0% vs. 60.0%, p = 0.0003 and p = 0.0003, respectively). Moreover, OBs were significantly less susceptible to clarithromycin and azithromycin than to clindamycin (66.7% vs. 88.2% and 60.0% vs. 88.2%, p = 0.0301 and p = 0.0217, respectively).

Conclusion

OBs were susceptible to ampicillin. However, the susceptibility of OBs to clarithromycin and azithromycin was significantly lower than that to ampicillin and clindamycin. These results are important and should help decisions regarding guide antimicrobial prophylaxis.

Nano-Architectonics of Antibiotic-Loaded Polymer Particles as Vehicles for Active Molecules

Recently, nanotechnology research studies have been proven that use of various nanoparticles as drug delivery systems to target and to annihilate pathogenic microorganisms may be a good solution for prevention and treatment of severe infection. In the last few years, antimicrobial drug encapsulation into nano-sized systems has materialized as a promising alternative that increased drug efficacy and minimized adverse effects. Physicochemical properties of erythromycin-loaded polymer nanoparticles were assessed using particle size distribution, HPLC, FTIR, TG/DTA, and SEM characterization techniques. The as-prepared samples exhibited an average particle size of 340 and 270 nm, respectively, with erythromycin content of 99.7% in both samples. From the release profile of erythromycin from PLA/PLGA, a prolonged drug release can be observed from both Ery-PLA and Ery-PLGA nanostructures. Morphology images exhibited spherical, rigid, and ring-shaped nanoparticles. Thermal analytical study in the case of Ery-PLA and Ery-PLGA samples showed that pure drug has an endothermic peak at around 150 °C assigned to a melting point. The antibiotic melting peak disappeared for both antibiotic-loaded PLA and PLGA nanoparticles thermographs, denoting the presence of erythromycin. This indicates that the antibiotic is uniformly dispensed throughout the host polymer matrix at nanometer scale. FTIR spectra of Ery-PLA and Ery-PLGA nano-architectures with almost similar peaks indicated no alteration in chemical structure of drug-loaded polymer nanoparticles.

Comparing Antibiotic Pastes with Electrospun Nanofibers as Modern Drug Delivery Systems for Regenerative Endodontics

Nanomaterials have various features that make these types of materials able to be applied in different biomedical applications like, diagnosis, treatment, and drug delivery. Using such materials in endodontic filed both to face the challenges that occur during treatment processes and to make these materials have an antibacterial effect without showing any harm on the host cells. The approach of nanofibers loaded with various antibacterial drugs offers a potential treatment method to enhance the elimination procedure of intracanal biofilms. Clinically, many models of bacterial biofilms have been prepared under in vitro conditions for different aims. The process of drug delivery from polymeric nanofibers is based on the principle that the releasing ratio of drug molecules increases due to the increase in the surface area of the hosted structure. In our review, we discuss diverse approaches of loading/releasing drugs on/from nanofibers and we summarized many studies about electrospun nanofibers loaded various drugs applied in the endodontic field. Moreover, we argued both the advantages and the limitations of these modern endodontic treatment materials comparing them with the traditional ones.

Determination of crown discoloration and fluorescence induced by different medications used in regenerative endodontic procedures: An ex vivo study

Background

Crown discoloration is an undesirable side effect of the use of triple antibiotic paste (TAP) in regenerative endodontic procedures (REPs). The aim of this ex vivo study was to assess the potential for tooth discoloration and induction of fluorescence associated with the use of TAP containing either doxycycline (DOX) or clindamycin (CLIN), and of calcium hydroxide (Ca(OH)2), by spectrophotometric analysis and confocal laser scanning microscopy (CLSM).

Material and Methods

A total of forty single-rooted human teeth extracted by therapeutic indication were used. The root canals were enlarged using the step-back technique up to a K #80 file and were randomly divided into four experimental groups (10 specimens each): i)Ca(OH)2 group, ii)TAP with DOX group, iii) TAP with CLIN group, iv) Control group (no treatment). To quantify the change of color of the different groups of teeth included, the Vita Easyshade advance 4.0 spectrophotometer was used. CLSM was used to determine fluorescence.

Results

After 28 days of action inside the root canal, no extreme discoloration was visible, to the naked eye, in any of the teeth included in the study. Under the conditions of this ex vivo study, TAP with DOX induced the highest crown discoloration among the medicaments tested. In contrast, Ca(OH)2 and TAP with CLIN did not induce crown discoloration after 28 days. The TAP with DOX group presented the highest fluorescence measurements.

Conclusions

Considering the discoloration potential and fluorescence changes in TAP with DOX or other tetracyclines, and the cytotoxic effect of TAPs, we recommend the use of Ca(OH)2 for REPs.

Key words:Discoloration, doxycycline, clinadamycin, calcium hydroxide, endodontics.

Practical Gram-Scale Synthesis of Iboxamycin, a Potent Antibiotic Candidate

A gram-scale synthesis of iboxamycin, an antibiotic candidate bearing a fused bicyclic amino acid residue, is presented. A pivotal transformation in the route involves an intramolecular hydrosilylation-oxidation sequence to set the ring-fusion stereocenters of the bicyclic scaffold. Other notable features of the synthesis include a high-yielding, highly diastereoselective alkylation of a pseudoephenamine amide, a convergent sp³-sp² Negishi coupling, and a one-pot transacetalization-reduction reaction to form the target compound's oxepane ring. Implementation of this synthetic strategy has provided ample quantities of iboxamycin to allow for its in vivo profiling in murine models of infection.

Clindamycin as an Alternative Option in Optimizing Periodontal Therapy

Periodontal disease is an oral infectious and inflammatory disease caused by microorganisms that determine the host-mediated destruction of soft and hard periodontal tissues, which ultimately leads to tooth loss. Periodontitis affects a large part of the population, with various degrees of severity. Treatment consists of etiologic therapy: the removal of biofilm through mechanical debridement plus microbial elimination by supplementary measures. Antibiotic administration, either systemically or through local delivery, has been shown to improve clinical outcomes after mechanical periodontal treatment. Clindamycin is a lincosamide with a broad spectrum, being active against aerobic, anaerobic, and β-lactamase-producing bacteria. This antibiotic offers several advantages and some disadvantages and has been used in periodontal treatment both systemically and locally with various degrees of success. Among the properties that recommend it for periodontal treatment is the bacteriostatic effect, the inhibition of bacterial proteins synthesis, the enhancement of neutrophil chemotaxis, phagocytosis and the oxidative burst–oxidative stress storm. Furthermore, it is easily absorbed at the level of oral tissues in a considerable amount. This substantial tissue penetration, especially inside the bone, is synergistic with a stimulating effect on the host immune system. The aim of this review is to explore the applicability of this antibiotic agent and to evaluate its antimicrobial potential and limitations at the level of the oral biofilm associated with periodontal disease.

Antibiotic Prescribing Habits and Antimicrobial Resistance Awareness of Dental Practitioners in Primorsko-Goranska County, Croatia

Purpose: The goal of this study was to investigate the differences in dentists' knowledge, attitudes, and practice regarding antibiotic use and resistance among two areas of Primorsko-Goranska County (P-GC), Croatia. Materials and Methods: A cross-sectional study based on a structured questionnaire that was given to 230 dental practitioners in outpatient settings of P-GC in 2018. Results: The overall response rate was 68.3% (157/230) and 72.2% (83/115) in the city of Rijeka and 64.3% (74/115) in the rest of P-GC. Dentists from two areas of P-GC held similar knowledge about prescribing antibiotics and attitudes regarding antibiotic use (p > 0.05). Most of the dental practitioners chose penicillins (65.0% amoxicillin with clavulanic acid and 33.1% amoxicillin) as the first-choice antibiotic in patients with no medical allergies. The trend of prescribing amoxicillin decreases with the age of the dentists (p = 0.046). Clindamycin (86.6%) was the first choice for patients allergic to penicillin. Postgraduate education changed the attitude toward taking more time to consider whether or not an antibiotic is needed. Croatian dentists had a high awareness of antimicrobial resistance (99.4%). The most common situations for which dentists would prescribe antibiotics were periapical abscess (84.7%), periodontal abscess (72.6%), and implant placement (59.9%). Patient request or expectation (43.4%) and treatment uncertainty (41.5%) were found to be the main factors for prescribing antibiotics with more frequency. Conclusions: Although there is a high level of antimicrobial resistance awareness among dental practitioners, there is still too much overuse of antibiotics and personal responsibility for prudent antibiotic use should be increased. The results of this study indicate that antibiotics are frequently prescribed for indications where surgical treatment should be the first option and the broad spectrum antibiotic is the preferred treatment option.

Development of an antibacterial nanocomposite hydrogel for human dental pulp engineering

Hydrogel-based regenerative endodontic procedures (REPs) are considered to be very promising therapeutic strategies to reconstruct the dental pulp (DP) tissue in devitalized human teeth. However, the success of the regeneration process is limited by residual bacteria that may persist in the endodontic space after the disinfection step and contaminate the biomaterial. The aim of this work was to develop an innovative fibrin hydrogel incorporating clindamycin (CLIN)-loaded Poly (d,l) Lactic Acid (PLA) nanoparticles (NPs) to provide the hydrogel with antibacterial properties. CLIN-PLA-NPs were synthesized by a surfactant-free nanoprecipitation method and their microphysical properties were assessed by dynamic light scattering, electrophoretic mobility and scanning electron microscopy. Their antimicrobial efficacy was evaluated on Enteroccocus fæcalis by the determination of the minimal inhibitory concentration (MIC) and the minimal biofilm inhibition and eradication concentrations (MBIC and MBEC). Antibacterial properties of the nanocomposite hydrogel were verified by agar diffusion assays. NP distribution into the hydrogel and release from it were evaluated using fluorescent PLA-NPs. NP cytotoxicity was assessed on DP mesenchymal stem cells (DP-MSCs) incorporated into the hydrogel. Type I collagen synthesis was investigated after 7 days of culture by immunohistochemistry. We found that CLIN-PLA-NPs displayed a drug loading of 10 ± 2 μg per mg of PLA polymer and an entrapment efficiency of 43 ± 7%. Antibiotic loading did not affect NP size, polydispersity index and zeta potential. The MIC for Enterococcus fæcalis was 32 μg mL-1. MBIC50 and MBEC50 were 4 and 16 μg mL-1, respectively. CLIN-PLA-NPs appeared homogenously distributed throughout the hydrogel. CLIN-PLA-NP-loaded hydrogels clearly inhibited E. faecalis growth. DP-MSC viability and type I collagen synthesis within the fibrin hydrogel were not affected by CLIN-PLA-NPs. In conclusion, CLIN-PLA-NP incorporation into the fibrin hydrogel gave the latter antibacterial and antibiofilm properties without affecting cell viability and function. This formulation could help establish an aseptic environment supporting DP reconstruction and, accordingly, might be a valuable tool for REPs.

A novel antimicrobial-containing nanocellulose scaffold for regenerative endodontics

Objectives

The aim of this study was to evaluate bacterial nanocellulose (BNC) membranes incorporated with antimicrobial agents regarding cytotoxicity in fibroblasts of the periodontal ligament (PDLF), antimicrobial activity, and inhibition of multispecies biofilm formation.

Materials and Methods

The tested BNC membranes were BNC + 1% clindamycin (BNC/CLI); BNC + 0.12% chlorhexidine (BNC/CHX); BNC + nitric oxide (BNC/NO); and conventional BNC (BNC; control). After PDLF culture, the BNC membranes were positioned in the wells and maintained for 24 hours. Cell viability was then evaluated using the MTS calorimetric test. Antimicrobial activity against Enterococcus faecalis, Actinomyces naeslundii, and Streptococcus sanguinis (S. sanguinis) was evaluated using the agar diffusion test. To assess the antibiofilm activity, BNC membranes were exposed for 24 hours to the mixed culture. After sonicating the BNC membranes to remove the remaining biofilm and plating the suspension on agar, the number of colony-forming units (CFU)/mL was determined. Data were analyzed by 1-way analysis of variance and the Tukey, Kruskal-Wallis, and Dunn tests (α = 5%).

Results

PDLF metabolic activity after contact with BNC/CHX, BNC/CLI, and BNC/NO was 35%, 61% and 97%, respectively, compared to BNC. BNC/NO showed biocompatibility similar to that of BNC (p = 0.78). BNC/CLI showed the largest inhibition halos, and was superior to the other BNC membranes against S. sanguinis (p < 0.05). The experimental BNC membranes inhibited biofilm formation, with about a 3-fold log CFU reduction compared to BNC (p < 0.05).

Conclusions

BNC/NO showed excellent biocompatibility and inhibited multispecies biofilm formation, similarly to BNC/CLI and BNC/CHX.

Potential Anti-COVID-19 Therapeutics that Block the Early Stage of the Viral Life Cycle: Structures, Mechanisms, and Clinical Trials

The ongoing pandemic of coronavirus disease-2019 (COVID-19) is being caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The disease continues to present significant challenges to the health care systems around the world. This is primarily because of the lack of vaccines to protect against the infection and the lack of highly effective therapeutics to prevent and/or treat the illness. Nevertheless, researchers have swiftly responded to the pandemic by advancing old and new potential therapeutics into clinical trials. In this review, we summarize potential anti-COVID-19 therapeutics that block the early stage of the viral life cycle. The review presents the structures, mechanisms, and reported results of clinical trials of potential therapeutics that have been listed in clinicaltrials.gov. Given the fact that some of these therapeutics are multi-acting molecules, other relevant mechanisms will also be described. The reviewed therapeutics include small molecules and macromolecules of sulfated polysaccharides, polypeptides, and monoclonal antibodies. The potential therapeutics target viral and/or host proteins or processes that facilitate the early stage of the viral infection. Frequent targets are the viral spike protein, the host angiotensin converting enzyme 2, the host transmembrane protease serine 2, and clathrin-mediated endocytosis process. Overall, the review aims at presenting update-to-date details, so as to enhance awareness of potential therapeutics, and thus, to catalyze their appropriate use in combating the pandemic.

Efficacy of clindamycin compared with amoxicillin-metronidazole after a 7-day regimen in the treatment of periodontitis in patients with diabetes: a randomized clinical trial

OBJECTIVE

To determine the efficacy of clindamycin compared with amoxicillin-metronidazole after a 7-day regimen during nonsurgical treatment of periodontitis in patients with type 2 diabetes mellitus.

RESEARCH DESIGN AND METHODS

In this double-blind, randomized clinical trial, a total of 42 patients with chronic periodontitis and type 2 diabetes were included. Patients were randomly assigned to treatment with either clindamycin or amoxicillin-metronidazole three times a day during 7 days. Clinical determinations (probing depth, bleeding on probe, and plaque index) were performed to determine the extent and severity of periodontitis before and after the pharmacological treatment.

RESULTS

After 7 days of administration of clindamycin or amoxicillin-metronidazole, no differences were observed between the clinical determinations, probing depth (0.44 vs 0.50 mm, p=0.624), plaque index (17.62 vs 15.88%, p=0.910), and bleeding on probing (16.12 vs 22.17%, p=0.163), respectively. There were no adverse events in either group.

CONCLUSION

The administration during 7 days of clindamycin or amoxicillin/metronidazole showed the same efficacy for the reduction of probing depth, plaque index, and bleeding on probing in patients with periodontitis and type 2 diabetes.

Antibiotics in Dentistry: A Narrative Review of Literature and Guidelines Considering Antibiotic Resistance

Background:

Antibiotic resistance is an important issue for public health.

Objective:

The aim of this work is to investigate the clinical situations which require the administration of antibiotics in dentistry.

Methods:

The authors want to do a review of the literature and a comparison of guidelines in dentistry among different countries. The research method was based on the use of Pubmed and the research of indexed articles and documents published by authorities and boards about the antibiotic prescription in dentistry. The paper is an analysis deep inside the physiological and pathological situations that, according to different guidelines, require the use of antimicrobics. The spirit is a clinical one because this paper wants to be a guide for dentists, especially before the administration, in order to moderate the use of antimicrobials. We must remember that the World Health Organisation organizes each year the World Antibiotic Awareness Week, in order to fight against the improper administration of antibiotics in medicine, dentistry, veterinary medicine, and industrial livestock.

Results:

Different guidelines converge on a very calibrate and proper administration of antibiotics. Antibiotics should be used only in recommended situations for risk patients. The authorities and boards should investigate the habits of antibiotic administration, which according to some papers seem to be large and diffused use, not only limited to situations described in guidelines.

Conclusion:

Dentists, together with the General Practitioners and Paediatricians, should be cautious and accurate and should administrate antibiotics only if recommended by guidelines and effective and safe.

Myiasis in patients with oral squamous cell carcinoma-a systematic review and protocol for management

BACKGROUND

Oral squamous cell carcinoma results in various morbidities like pain, bleeding on provocation, loss of function, facial disfigurement, extra oral fungation, and tissue necrosis. Other than these dreadful complications, sometimes in advanced and incurable stage, the wound gets infested with maggots. Oral myiasis in association with OSCC is rare, and a very few reports have been mentioned in the literature.

MATERIAL AND METHODS

A literature search was performed on PubMed, Medline, and Cochrane databases on 1st November 2018 for all the articles focusing on oral myiasis in patients with oral squamous cell carcinoma.

RESULTS

A total number of nine cases with oral myiasis in association with OSCC have been reported till date. Out of these nine cases, five cases have been reported from India and four from Brazil.

CONCLUSION

Oral myiasis is a possible risk for the patient with Oral squamous cell carcinoma. Good hygiene and general cleanliness along with educating the patients must be a practice to avoid this dreadful condition.

Prevention of infective endocarditis and bacterial resistance to antibiotics: A brief review

The purpose of this statement is to debate the recommendations of the American Heart Association (AHA) for the prevention of infective endocarditis through an antibiotic prophylaxis protocol and its relation with bacterial resistance to antibiotics. Since dental infections involve biofilms that include several bacterial species (Gram-negative and Gram-positive), it is essential, from the dental point of view, to consider the frequency, magnitude, and duration of bacteremia associated with active dental infections before applying antibiotic prophylaxis. The actual guidelines for antibiotic prophylaxis should be revised according to recent evidence of bacterial resistance. Amoxicillin/clavulanic acid and moxifloxacin should be considered due to their effectiveness against bacteria associated with oral, GU, and GI infections and the low rates of antibiotic resistance associated with these antibiotics, instead of the actual protocol, which includes amoxicillin (2 g) or clindamycin (600 mg) administered an hour before the dental procedures. The breaking point to test the antibiotic bacterial resistance (ABR) had a wide range in the different studies that were analyzed, which could explain the widely varied ABR percentages reported for the various antibiotics used for antibiotic prophylaxis.

Management of Malignant Wound Myiasis with Ivermectin, Albendazole, and Clindamycin (Triple Therapy) in Advanced Head-and-Neck Cancer Patients: A Prospective Observational Study

INTRODUCTION

Myiasis, tissue infestation by housefly larvae, is commonly found in malignant fungating wounds of cancer patients from climatic condition and lower socio-economic strata.

AIM OF STUDY

It was aimed to study the effectiveness of systemic Ivermectin, Albendazole& Clindamycin (Triple Therapy) in reducing signs & symptoms associated with maggots in malignant head and neck wounds.

METHOD

25 adult, advanced head and neck cancer patients presenting with maggots either from wound, oral cavity or nostril, with ECOG score 3 or less were enrolled in this study. Symptoms were assessed using Edmonton Symptom Assessment Scale (ESAS) and wound by Wound Assessment Tool - Hospice, at baseline and then Days 1, 3, 5, and 7. All patients received 3 days course of oral Ivermectin 12 mg per day, Albendazole 400 mg twice per day and Clindamycin 300 mg three times per day for 5 days along with Terpentine oil dressing. All patients received oral Morphine as per their pain score.

RESULTS

Mean age (yrs) and weight (Kg) were 42.15 ± 8.23 and 52.31 ± 5.18 respectively. 84% patients were male. Mean oral morphine dose was 100.38 mg. There was significant decrease in number of maggots from day 0 (77.28 ± 13.465) to day 1 (20.60 ± 7.263; 73.34% reduction) to day 3 (1.52 ± 2.104; 92.62% reduction). We found statistically significant improvement (P = <0.05) in scores of wound and all other related symptoms on days 1, 3, 5 & 7, except bleeding, edema, nausea, anxiety, appetite loss and feeling of wellbeing, which remained same on Day 1, but improved afterward. Side effects were self-limiting.

CONCLUSION

Systemic treatment with Ivermectin, Albendazole and Clindamycin (Triple Therapy) enhances the removal of maggots, early recovery and relief from distress and associated symptoms.

Clindamycin-modified Triple Antibiotic Nanofibers: A Stain-free Antimicrobial Intracanal Drug Delivery System

INTRODUCTION

A biocompatible strategy to promote bacterial eradication within the root canal system after pulpal necrosis of immature permanent teeth is critical to the success of regenerative endodontic procedures. This study sought to synthesize clindamycin-modified triple antibiotic (metronidazole, ciprofloxacin, and clindamycin [CLIN]) polymer (polydioxanone [PDS]) nanofibers and determine in vitro their antimicrobial properties, cell compatibility, and dentin discoloration.

METHODS

CLIN-only and triple antibiotic CLIN-modified (CLIN-m, minocycline-free) nanofibers were processed via electrospinning. Scanning electron microscopy, Fourier-transform infrared spectroscopy (FTIR), and tensile testing were performed to investigate fiber morphology, antibiotic incorporation, and mechanical strength, respectively. Antimicrobial properties of CLIN-only and CLIN-m nanofibers were assessed against several bacterial species by direct nanofiber/bacteria contact and over time based on aliquot collection up to 21 days. Cytocompatibility was measured against human dental pulp stem cells. Dentin discoloration upon nanofiber exposure was qualitatively recorded over time. The data were statistically analyzed (P < .05).

RESULTS

The mean fiber diameter of CLIN-containing nanofibers ranged between 352 ± 128 nm and 349 ± 128 nm and was significantly smaller than PDS fibers. FTIR analysis confirmed the presence of antibiotics in the nanofibers. Hydrated CLIN-m nanofibers showed similar tensile strength to antibiotic-free (PDS) nanofibers. All CLIN-containing nanofibers and aliquots demonstrated pronounced antimicrobial activity against all bacteria. Antibiotic-containing aliquots led to a slight reduction in dental pulp stem cell viability but were not considered toxic. No visible dentin discoloration upon CLIN-containing nanofiber exposure was observed.

CONCLUSIONS

Collectively, based on the remarkable antimicrobial effects, cell-friendly, and stain-free properties, our data suggest that CLIN-m triple antibiotic nanofibers might be a viable alternative to minocycline-based antibiotic pastes.

Enhanced efficacy of clindamycin hydrochloride encapsulated in PLA/PLGA based nanoparticle system for oral delivery

Clindamycin hydrochloride (CLH) is a clinically important oral antibiotic with wide spectrum of antimicrobial activity that includes gram-positive aerobes (staphylococci, streptococci etc.), most anaerobic bacteria, Chlamydia and certain protozoa. The current study was focused to develop a stabilised clindamycin encapsulated poly lactic acid (PLA)/poly (D,L-lactide-co-glycolide) (PLGA) nano-formulation with better drug bioavailability at molecular level. Various nanoparticle (NPs) formulations of PLA and PLGA loaded with CLH were prepared by solvent evaporation method varying drug: polymer concentration (1:20, 1:10 and 1:5) and characterised (size, encapsulation efficiency, drug loading, scanning electron microscope, differential scanning calorimetry [DSC] and Fourier transform infrared [FTIR] studies). The ratio 1:10 was found to be optimal for a monodispersed and stable nano formulation for both the polymers. NP formulations demonstrated a significant controlled release profile extended up to 144 h (both CLH-PLA and CLH-PLGA). The thermal behaviour (DSC) studies confirmed the molecular dispersion of the drug within the system. The FTIR studies revealed the intactness as well as unaltered structure of drug. The CLH-PLA NPs showed enhanced antimicrobial activity against two pathogenic bacteria Streptococcus faecalis and Bacillus cereus. The results notably suggest that encapsulation of CLH into PLA/PLGA significantly increases the bioavailability of the drug and due to this enhanced drug activity; it can be widely applied for number of therapies.

Surgical Site Infections Following Bimaxillary Orthognathic, Osseous Genioplasty, and Intranasal Surgery: A Retrospective Cohort Study

PURPOSE

Frequency estimates of surgical site infection (SSI) after orthognathic surgery vary considerably. The purpose of this study was to determine the incidence and site of SSIs and associated risk factors after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery.

MATERIALS AND METHODS

The authors executed a retrospective cohort study of patients with a bimaxillary developmental dentofacial deformity (DFD) and symptomatic chronic obstructive nasal breathing. All patients underwent at a minimum Le Fort I osteotomy, bilateral sagittal ramus osteotomies (SROs), septoplasty, inferior turbinate reduction, and osseous genioplasty. The primary outcome variable studied was the incidence and site of SSI. Predictor variables were type and extent of prophylactic antibiotic used, demographic (age and gender), and anatomic (pattern of DFD, surgical site, and presence of third molar).

RESULTS

Two hundred sixty-two patients met the inclusion criteria. Their average age at surgery was 25 years (range, 13 to 63 yr) and there were 134 female patients (51%). The major presenting patterns of DFD included long face (30%) and maxillary deficiency (25%). Forty percent of patients undergoing an SRO and 47% of those undergoing a Le Fort I osteotomy underwent simultaneous removal of a third molar. Ninety percent of patients received cefazolin or cephalexin antibiotics. Overall, 5 of 1,048 (0.5%) osteotomy sites sustained an infection, including 1 chin and 4 ramus SSIs. There were no delays in bone healing. Fixation hardware removal was not required in any patient who developed an infection. Two of the 25 patients (8%) given clindamycin prophylaxis developed an SSI, whereas 3 of 237 patients (1%) receiving cefazolin did. Three of the 4 patients who developed an SRO SSI underwent simultaneous removal of an erupted or partially erupted mandibular third molar (P < .05).

CONCLUSIONS

In this study, the incidence of SSI was limited to 1% of patients who were given cefazolin or cephalexin extended for 5 days. The removal of an erupted or partially erupted mandibular third molar in conjunction with an SRO was associated with risk of SSI, but the incidence remains low.

Amoxicillin/Clavulanic Acid for the Treatment of Odontogenic Infections: A Randomised Study Comparing Efficacy and Tolerability versus Clindamycin

Background. Treatment of odontogenic infections includes surgical drainage and adjunctive antibiotics. This study was designed to generate efficacy and safety data to support twice daily dosing of amoxicillin/clavulanic acid compared to clindamycin in odontogenic infections. Methods. This was a phase IV, randomised, observer blind study; 472 subjects were randomised to receive amoxicillin/clavulanic acid (875 mg/125 mg BID, n = 235) or clindamycin (150 mg QID, n = 237) for 5 or 7 days based on clinical response. The primary endpoint was percentage of subjects achieving clinical success (composite measure of pain, swelling, fever, and additional antimicrobial therapy required) at the end of treatment. Results. The upper limit of two-sided 95% confidence interval for the treatment difference between the study arms (7.7%) was within protocol specified noninferiority margin of 10%, thus demonstrating noninferiority of amoxicillin/clavulanic acid to clindamycin. Secondary efficacy results showed a higher clinical success rate at Day 5 in the amoxicillin/clavulanic acid arm. Most adverse events (raised liver enzymes, diarrhoea, and headache) were similar across both arms and were of mild to moderate intensity. Conclusion. Amoxicillin/clavulanic acid was comparable to clindamycin in achieving clinical success (88.2% versus 89.7%) in acute odontogenic infections and the safety profile was consistent with the known side effects of both drugs. Trial Registration. This trial is registered with Clinicaltrials.gov identifier: NCT02141217.

Antibiotic prophylaxis patterns of Finnish dentists performing dental implant surgery

BACKGROUND

The peri-operative use of prophylactic antibiotics in clinically healthy patients undergoing dental implant surgery is very common in Finland. While antibiotics are prescribed with the hope of preventing both local and systemic complications, their application and utilization is not uniform.

OBJECTIVE

The aim of this study was to assess the variation in prescribing patterns among Finnish dentists performing dental implant placement operations. This study also aimed to examine the possible relationship between early implant removal and the use of the prophylactic antibiotics in Finland.

MATERIALS AND METHODS

The National Institute for Health and Welfare in Finland granted permission to access the Finnish Dental Implant Register. The peri-operative antibiotic prophylaxis prescribing patterns were assessed in a total of 110 543 dental implant placement procedures and 1038 dental implant removal operations performed in Finland between April 1994 and April 2012.

RESULTS

A total of 61 different antibiotics or combinations were prescribed peri-operatively during implant placements in Finland between 1994-2012. Phenoxymethylpenicillin was the most commonly prescribed drug (72.2%). No statistically significant difference in early implant removal rates could be found between patients who had or had not received peri-operative prophylaxis. However, patients who had received peri-operative prophylaxis had statistically significant longer implant survival rates.

CONCLUSION

There is a variation in antibiotic prescribing patterns among Finnish dentists placing dental implants. The results suggest that the use of prophylactic antibiotics has little effect on the prevention of primary implant surgery-related complications and, hence, success rates.

Diagnosis and anti-infective therapy of periodontitis

Periodontal diseases (gingivitis and periodontitis) are chronic bacterial infections with a remarkably high prevalence and morbidity. Periodontitis, in contrast to gingivitis, is not reversible, is associated with certain bacterial species and affects all of the soft tissue and bone that support teeth. Among the periodontal pathogens, species, such as Aggregatibacter (Actinobacillus) actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythensis, and several forms of uncultivable spirochetes play the major role in the pathogenesis. In severe chronic, recurrent and especially aggressive forms of periodontitis, diagnosis of the species involved and, whenever possible, an optimized evidence-based antimicrobial treatment is indicated. In order to monitor alarming bacterial changes in the periodontal pocket, several techniques, namely microscopy, culture, immunoassays, enzyme tests and DNA-based techniques, have been established and the methods are described in the first part of this review. In the second part, the selection and use of locally delivered (topical) and systemic antibiotics used adjunctively in periodontal therapy are discussed.

Odontogenic infections: an 8-year epidemiologic analysis in a dental emergency outpatient care unit

OBJECTIVES

The purpose of this investigation was to analyze epidemiological patterns, clinical features and the management of odontogenic infections in patients undergoing treatment in a dental emergency outpatient care unit.

STUDY DESIGN

A retrospective analysis of 58 161 case records of patients presenting to an emergency outpatient unit in Hamburg, Germany between 2000-2007 was performed. From this pool, patients with odontogenic infections were identified using an ICD-10 code, analyzing age, gender, medical co-morbidities, duration of pain, ratio of infiltrates/abscesses, affected teeth, management of infection and administered antibiotics.

RESULTS

Of the 58 161 patients, 5357 (9.2%) were identified as having odontogenic infections, with 2689 (50.2%) inflammatory infiltrates and 2668 (49.8%) abscesses. Mean age was 34.8 ± 16.8 years. As the primary site of odontogenic infection, the most significantly affected teeth were the maxillary and mandibular first molars. Patients in age-group 20-29 years (25.1%) utilized the emergency care unit more frequently than other age groups. Clindamycin was the most frequently administered antibiotic.

CONCLUSIONS

Early recognition, diagnosis and management of odontogenic infections are requisite for avoiding or minimizing the development of potential complications. Strategies and evidence-based protocols should be developed within the dental ambulatory care sector, advancing interdisciplinary cooperation between general dentists and oral or maxillofacial surgeons.

Dental infection simulating skin lesion

Orocutaneous fistulas or cutaneous sinus, a tract of dental origin, is an uncommon but well-documented condition that usually requires emergency treatment. Such condition may be misdiagnosed by physicians and dentists and may sometimes be confused with bone and skin tumor, osteomyelitis, congenital fistula, salivary gland fistula, pyogenic granuloma, infected cyst, deep mycotic infection, and other pathologies. A case of facial sinus tract that was initially misdiagnosed by a physician as a nonodontogenic lesion is presented. Nonsurgical endodontic therapy was the treatment of choice for this case. Facial cutaneous sinus tracts must be considered of dental origin. Early diagnosis and prompt treatment minimize patient discomfort and esthetic problems, reducing the possibility of further complications such as sepsis and osteomyelitis.

The use of free autogenous rib grafts in maxillofacial reconstruction

SUMMARY BACKGROUND

Hard tissue defects in the maxillofacial region due to trauma or ablative surgery result in functional and cosmetic problems. State-of-the-art methods for reconstruction include the use of vascularised tissue.

OBJECTIVE

To review our results with the use of non-vascularised rib grafts for maxillofacial reconstruction.

METHOD

Patients who underwent maxillofacial reconstruction using rib at the Komfo Anokye Teaching Hospital during 1996-2004 were studied. The technique for rib harvest and implantation of the graft was standardized. Clindamycin was administered peri-operatively and the harvested rib was temporarily stored in clindamycin/saline before implantation. The graft was successful if it survived beyond 6 months after placement. Follow-up was for at least 12months postoperatively.

RESULTS

A total of 29 patients were studied. The indications for grafting included ameloblastoma, malignant disease, cyst, ankylosis, and trauma. Either rib bone only or with cartilage were used. In 90% of patients (26/29) the graft healed uneventfully. Two patients had dehiscence of the wound with exposure of the graft intraorally within two weeks of surgery and were successfully managed with antibiotics.

CONCLUSION

Free autogenous rib was successfully used to reconstruct defects in the maxillofacial region. Further stabilization of the graft by intermaxillary fixation and the prophylactic use of clindamycin may have helped to minimize complications.

Osteomyelitis after bilateral sagittal split osteotomy: case report and a review of the management

OBJECTIVES

The purpose of this paper is to report a case of osteomyelitis following a bilateral sagittal split osteotomy in a patient who underwent 2-jaw surgery. A review of the management of osteomyelitis is included, with a discussion of implications for the reconstruction of the mandible after treatment for osteomyelitis.

STUDY DESIGN

A case of a rapidly progressing osteomyelitis is presented with a detailed review of the management of osteomyelitis, using this case to illustrate key points of management.

RESULTS

In a very short period of time the patient lost a significant portion of the left side of her mandible. The actual management that she underwent, as well as some of the controversies that are present with the treatment of osteomyelitis, is discussed.

CONCLUSION

Although osteomyelitis of the mandible usually is seen after odontogenic infections and trauma, it can occur in patients undergoing elective osteotomies. When recognized, it should be aggressively treated.

Spread of odontogenic infections in Port Harcourt, Nigeria

PURPOSE

Odontogenic infections constitute a substantial portion of diseases encountered by oral and maxillofacial surgeons. Infections start from dental tissues and sometimes rapidly spread to contiguous spaces. The consequence is a fulminant disease with significant morbidity and mortality. The study was aimed at studying the pattern of spread, approach to management, and outcome of these infections at a Nigerian teaching hospital.

PATIENTS AND METHODS

A retrospective study of all patients with orofacial infections who presented to our center over an 18-month period was carried out. The medical records were reviewed to retrieve the following: age, gender, source of infection, anatomic fascial spaces involved, associated medical conditions, various treatment modalities, types of antibiotics administered, causative micro-organisms, length of stay in the hospital, and any complications encountered. Infections were classified into 2 categories: those that are confined to the dentoalveolar tissues belong to category I, and those that have spread into the local/regional soft tissue spaces and beyond belong to category II.

RESULTS

Odontogenic infections constituted 11.3% of the total oral and maxillofacial surgery cases. A total of 261 patients were treated for odontogenic infections. There were 146 female patients (59.8%) and 98 male patients (40.2%) in the first category, whereas the second category comprised 10 male patients (58.8%) and 7 female patients (41.2%). The fascial spaces involved, in descending order, were submasseteric in 10 (22.7%), submandibular in 9 (20.5%), and sublingual in 6 (13.6%). The causative micro-organisms commonly found were Klebsiella and Streptococcus spp. Incision and drainage were performed in the 17 cases with spreading infection. Amoxicillin, amoxicillin/clavulanate, and metronidazole were the most routinely administered antibiotics.

CONCLUSIONS

Our experience shows that delay in presentation, self-medication, aging, male gender, and unusual causative agents are some of the factors associated with spread. Therefore efforts must be made to further improve public dental awareness.

The role of phenoxymethylpenicillin, amoxicillin, metronidazole and clindamycin in the management of acute dentoalveolar abscesses--a review

Antibiotics are the most widely prescribed category of drugs issued on prescription by general dental practitioners. Despite this there remains little evidence-based literature on what should be prescribed for any given clinical situation, at what dosage and for how long. Given the current climate of evidence-based research, the need to keep antibiotic prescribing to an acceptable minimum, increasing levels of resistance of micro-organisms and widespread hospital infections with 'superbugs', there is a distinct need for appropriate prescribing guidelines. Considering best practice, an extensive review of the literature and a thorough understanding of current empirical treatment regimes, an attempt has been made to recommend suitable antibiotic prescribing for the adult patient suffering from acute dentoalveolar infections based on evidence.

Penetration of moxifloxacin into rat mandibular bone and soft tissue

OBJECTIVE

Based on its in vitro activity and spectrum of activity, the new 8-methoxyquinolone antibiotic moxifloxacin (MXF) seems suited for the antibiotic therapy of odontogenic infections. Penetration into the relevant tissue is another prerequisite for clinical efficacy. For this reason, the levels of MXF in plasma, soft tissue, and mandibular bone were determined in an animal model with Wistar rats.

MATERIAL AND METHODS

Samples of 49 rats were analyzed. Tissue samples were homogenized and proteins were precipitated. The pharmacokinetic evaluation was conducted based on non-compartmental analysis.

RESULTS

The concentration-time courses of tissues show a more plateau-shaped curve compared to plasma. Calculated AUC (area under the curve) ratios tissue:plasma were M. masseter:plasma = 2.64 and mandibles:plasma = 1.13.

CONCLUSIONS

Administration of antibiotics is considered an important part of therapy during and/or after surgical procedures in the maxillofacial area. Because of the good penetration into bone and muscle tissues demonstrated in Wistar rats, MXF might be an option for clinical application in this indication.

Treatment of anaerobic infection

Anaerobic bacteria are the predominant flora in the normal human skin and mucous membranes and are, therefore, a common cause of endogenous infections. Since anaerobic infections are generally polymicrobial, where anaerobes are mixed with aerobic organisms, therapy should provide coverage of both types of pathogens. The isolation of anaerobes requires appropriate methods of collection, transportation and cultivation of specimens. The lack of use of any of these methods can lead to inadequate recovery of anaerobes and inappropriate therapy. Treatment of anaerobic infection is complicated by the slow growth of these organisms and the growing resistance of anaerobic bacteria to antimicrobials. The primary role of antimicrobials is to limit the local and systemic spread of infection. Surgical drainage is of primary importance. This includes debriding of necrotic tissue, draining the pus, improving circulation, alleviating obstruction and increasing tissue oxygenation. The most effective antimicrobials against anaerobic organisms are metronidazole, the carbapenems (imipenem, meropenem and ertapenem), chloramphenicol, the combinations of a penicillin and a beta-lactamase inhibitor (ampicillin or ticarcillin plus clavulanate, amoxicillin plus sulbactam, and piperacillin plus tazobactam), tigecycline and clindamycin.

Update on clindamycin in the management of bacterial, fungal and protozoal infections

Lincomycin and clindamycin are the only members of the relatively small lincosamide antimicrobial class marketed for use in humans. This paper only reviews data regarding clindamycin, with an emphasis on data published over the last decade. Clindamycin exhibits a broad spectrum of antimicrobial activity, including Gram-positive aerobes/anaerobes, Gram-negative anaerobes and select protozoa (Toxoplasma gondii, Plasmodium falciparum, Babesia spp.) and fungi (Pneumocystis jiroveci). It still enjoys use in the therapy and prophylaxis of a large number of bacterial, protozoal and fungal infections, despite > 40 years of clinical use. However, the spectre of resistance by an increasing number of microorganisms is beginning to cast a shadow over the future use of this valuable agent. With the emergence and spread of infections due to community-acquired methicillin-resistant Staphylococci (for which clindamycin is a first-line agent), it is hoped that the issues of resistance can be mitigated and the use of clindamycin extended for at least the foreseeable future.

Severe odontogenic infections, part 1: prospective report

PURPOSE

The purpose of this study was to prospectively evaluate a series of patients with severe odontogenic infections (OI).

PATIENTS AND METHODS

In this study, 37 consecutive hospitalized patients with odontogenic infection were treated with intravenous penicillin (PCN) (unless allergic), and prompt incision and drainage. Standardized data collection included demographic, preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications information. Appropriate descriptive statistics were computed.

RESULTS

The sample consisted of 37 subjects (38% female) with a mean age of 34.9 years. Three subjects (8%) had immunocompromising diseases. Caries was the most frequent dental disease (65%) and the lower third molar was the most frequently involved tooth (68%). Trismus and dysphagia were present on admission in over 70% of cases. The masticator, perimandibular (submandibular, submental, and/or sublingual), and peripharyngeal (lateral pharyngeal, retropharyngeal, and/or pretracheal) spaces were infected in 78%, 60%, and 43% of cases, respectively. Abscess was found in 76% of cases. PCN-resistant organisms were identified in 19% of all strains isolated and in 54% of patients with sensitivity data. PCN therapeutic failure occurred in 21% of cases and reoperation was required in 8%. Length of hospital stay was 5.1 +/- 3.0 days. No deaths occurred.

CONCLUSIONS

This study indicated that PCN resistance, resulting in PCN therapeutic failure, was unacceptably high in this sample. Alternative antibiotics, such as clindamycin, should be considered in hospitalized patients with OI. Masticator space infection occurred much more frequently than previously reported. Trismus and dysphagia should be appreciated as significant indicators of severe OI.