Efficacy of azithromycin compared with spiramycin in the treatment of odontogenic infections

The Use of Antibiotics in Odontogenic Infections: What Is the Best Choice? A Systematic Review

PURPOSE

Odontogenic infections are a common problem in dentistry, and their treatment often requires the use of antibiotics besides the removal of the source of infection, which frequently makes it more difficult for clinicians to make a decision regarding the choice of antibiotic. This study aimed to answer the following questions through the Patient, Intervention, Comparison, Outcome (PICO) format: When should antibiotics be used in dental infections (DIs)? Which are the most effective drugs? How long should antibiotics be administered?

MATERIALS AND METHODS

This was a systematic review using the PubMed, Scopus, and Cochrane databases without restriction as to the period researched. The variables analyzed in each article were the number of odontogenic infections in each study, type of study, surgical intervention performed, antibiotics administered, statistical differences between groups studied, and patients' evolution after treatment.

RESULTS

The search included 1,109 articles. After the full reading of 46 articles, 16 were included in the final review and 30 were excluded. A sample of 2,197 DI cases was obtained, in which 15 different antibiotics were used, with a 98.2% overall cure rate.

CONCLUSIONS

The studies showed that antibiotics were prescribed only in situations of regional and/or systemic body manifestations. In the case of DIs, once drainage has been performed and/or the cause of infection has been removed, all antibiotics tested are equally effective with respect to clinical cure, and the choice of antibiotics is not as successful as the local intervention treatment procedure. When the real need for antibiotic therapy is detected, antibiotics should be used for the shortest time possible until the patient's clinical cure is achieved.

Comparison of Systemic Flurithromycin Therapy and Clinical Procedures in the Treatment of Periodontal Diseases

The purpose of the present investigation was to evaluate, in 20 periodontal patients, the microbial and clinical effects of flurithromycin therapy plus scaling and root planning (SRP) in comparison with SRP alone. Clinical assessments of plaque, bleeding on probing and pocket depth were made prior to SRP alone and SRP plus flurithromycin therapy (375 mg twice daily for 5 days) and after both treatments. Subgingival plaque samples (n. 180) were taken prior to and after both treatments and analyzed by conventional bacteriological procedures. Differences in pocket depth and prevalence of bacterial species were analyzed pre- and post-therapies using statistical analyses. A significant decrease (p<0.001) was seen for pocket depth post SRP alone and post SRP plus flurithromycin. After two treatments, Actinobacillus actinomycetemcomitans, Bacteroides forsythus and Prevotella melaninogenica were eradicated from all tested sites. If we compare the prevalence of the species isolated after SRP alone and after SRP plus flurithromycin statistically significant differences were detected for P. gingivalis and for Fusobacterium nucleatum (p<0.05 and p<0.01, respectively). Flurithromycin can be considered a useful adjunct to mechanical periodontal treatment since it is more efficient in eliminating periodontal pathogens.

What are the antibiotics of choice for odontogenic infections, and how long should the treatment course last?

In the everyday practice of oral and maxillofacial surgeons, empiric antibiotics are prescribed in the face of uncertainty. Is there a highly resistant organism present? Are the old-line antibiotics no longer effective? Should a broad-spectrum antibiotic be used just to cover all the bases in this case? The surprising result of this systematic review is that when combined with appropriate surgery, the usual antibiotics are all effective. Safety and cost become the differentiating factors in this clinical decision.

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

Clindamycin is a broad-spectrum antibiotic with activity against aerobic, anaerobic, and beta-lactamase-producing pathogens. This antibiotic has been used for many years as prophylactic treatment during dental procedures to prevent endocarditis. However, the spectrum and susceptibility of the bacteria species involved in dental infections indicate that clindamycin would also be an effective treatment option for these conditions. In addition to its antiinfective properties, clindamycin has high oral absorption, significant tissue penetration, including penetration into bone, and stimulatory effects on the host immune system. This review discusses the microbiologic and clinical evidence supporting the efficacy and safety of clindamycin for the successful management of dental infections.

Azithromycin and dentistry - a useful agent?

OBJECTIVES

Azithromycin has recently replaced clindamycin oral suspension for prop hylaxis of infective endocarditis (IE) in children. It is also currently recommended by the American Heart Association as an alternative to penicillin, along with clindamycin for prophylaxis of infective endocarditis in adults. The objectives of this paper were to firstly, review the current literature on the efficacy of azithromycin as a suitable prophylactic agent in the prevention of infective endocarditis; and secondly, to review its pharmacological properties as a suitable therapeutic agent in the management of odontogenic infections.

DESIGN

A review of the literature.

CONCLUSIONS

The available evidence from animal models on infective endocarditis supports the efficacy of this drug as a prophylactic agent against oral streptococci. The pharmacological properties of this agent would make it a very promising therapeutic adjunct in the management of odontogenic infections. At present there are only a small number of studies available with valuable data on the efficacy of this relatively new drug. Further investigations comparing this compound with other commonly used adjuncts would be of great benefit.

The clinical significance of anaerobic bacteria in acute orofacial odontogenic infections

A review of the literature on orofacial odontogenic infections indicates that the underlying microflora is typically polymicrobial, predominantly involving strictly anaerobic gram-positive cocci and gram-negative rods, along with facultative and microaerophilic streptococci. Although no single species has been consistently implicated in all of these infections, the pathogenic potential of some of these organisms has been documented by many studies. This potential can be explained by a number of virulence factors demonstrated in anaerobic bacteria, as well as by synergistic interrelationships with other members of the infectious flora. Awareness of the anaerobic component of orofacial odontogenic infections dictates to a large extent the selection of antimicrobial therapy, mainly because of the frequency of beta-lactamase production by anaerobic gram-negative rods.

Interaction between piroxicam and azithromycin during distribution to human periodontal tissues

BACKGROUND

Non-steroidal anti-inflammatory drugs and antibiotics are important in the prevention of infections and pain associated with periodontal surgery as well as in the adjunctive therapy of periodontal disease. In this study, patients undergoing oral surgery were treated with piroxicam and azithromycin to examine the interactions of these drugs on periodontal tissues.

METHODS

Sixty-six patients were assigned to 3 groups and treated for 3 days as follows: 1) piroxicam 20 mg/day; 2) azithromycin 500 mg/day; or 3) piroxicam 20 mg/day plus azithromycin 500 mg/day. Samples of blood, saliva, gingiva, and alveolar bone were collected during surgery and at days 0.5, 2.5, 4.5, and 6.5 after last dose. Piroxicam concentrations were assayed by high-performance liquid chromatography and azithromycin concentrations by microbiological assay.

RESULTS

In patients treated with piroxicam alone, the highest drug concentrations were found in plasma at each time point, but consistent piroxicam levels were also detected in gingival samples up to 4.5 days. The combined treatment with piroxicam plus azithromycin was associated with a reduction of piroxicam concentrations in periodontal tissues. In patients receiving azithromycin alone, high drug levels were measured in periodontal tissues up to 6.5 days. This distribution pattern did not vary in patients treated with piroxicam plus azithromycin.

CONCLUSIONS

Treatment with piroxicam or azithromycin alone ensures a favorable distribution of these drugs into periodontal tissues. However, upon combined administration, azithromycin interferes negatively with the periodontal disposition of piroxicam. This interaction might depend on the displacement of piroxicam from acceptor sites at the level of periodontal tissues.

Periodontal tissue disposition of azithromycin in patients affected by chronic inflammatory periodontal diseases

BACKGROUND

The recognition that periodontal diseases are associated with specific pathogens has led to interest in the use of antibacterial drugs for inhibition of these microorganisms. On these bases, the present study was aimed at evaluating the tissue distribution of the new macrolide antibiotic azithromycin in patients subjected to oral surgery for chronic inflammatory diseases of both marginal and periapical periodontium.

METHODS

Thirty-two patients were treated with azithromycin 500 mg/day orally for 3 consecutive days, and drug concentrations in plasma, saliva, normal gingiva, and pathological periodontal tissues were evaluated. For this purpose, samples of blood, saliva, normal gingiva, granulation tissue, and radicular granuloma or cyst wall (from dentigerous cyst) were collected during oral surgery or 0.5, 2.5, 4.5, and 6.5 days after the end of pharmacological treatment; then, azithromycin levels were measured by a microbiological plate assay, using Micrococcus luteus NCTC 8440 as the indicator organism.

RESULTS

The concentrations of azithromycin in plasma, saliva, normal gingiva, and pathological tissues reached the highest values 12 hours after the last dose (0.37+/-0.05 mg/l, 2.12+/-0.30 mg/l, 6.30+/-0.68 mg/kg, and 11.60+/-1.50 mg/kg, respectively) and then declined gradually. Consistent levels of the drug in normal gingiva and pathological tissues could be detected, however, up to 6.5 days, indicating that azithromycin was retained in target tissues for a long time after the end of treatment. Moreover, azithromycin levels in both normal gingiva and pathological tissues exceeded the minimum inhibitory concentrations of most pathogens involved in the pathophysiology of chronic inflammatory periodontal diseases. Notably, azithromycin levels in pathological tissues were significantly higher than those in normal gingiva 0.5, 2.5, and 4.5 days after the last dose.

CONCLUSIONS

The present results indicate a marked penetration of azithromycin into both normal and pathological periodontal tissues, suggesting that azithromycin represents a promising option in both adjunctive and prophylactic treatments of chronic inflammatory periodontal diseases.

Comparative tolerability of erythromycin and newer macrolide antibacterials in paediatric patients

The macrolides are a well established group of antibacterials frequently used in general practice. The most frequently used macrolides in paediatric patients are erythromycin, a naturally occurring compound, and clarithromycin and azithromycin, recently developed macrolides. Overall adverse effect rates of 7 to 26% for erythromycin, 14 to 26% for clarithromycin, and 6 to 27% for azithromycin have been described in children. Adverse gastrointestinal effects, including nausea, vomiting, diarrhoea and abdominal cramps, are the most common problems in children. Allergic reactions, hepatotoxicity, ototoxicity and adverse effects involving the central and peripheral nervous systems have also been observed in children. Stevens-Johnson, Schonlein-Henoch and Churg-Strauss syndromes have been rarely described in children. Treatment-related laboratory abnormalities have been recorded in 2 to 4% of erythromycin- and in 0 to 1% of both clarithromycin- and azithromycin-treated children. Elevation in liver function tests was the most common abnormality cited. Increased macrolide use in children in recent years has resulted in a growing potential for drug interactions between them and other pharmacologically active agents via the inhibition of cytochrome P450 (CYP) microsomal enzymes. Drug interactions with theophylline, cyclosporin, carbamazepine, terfenadine and warfarin limit erythromycin use. Clarithromycin is a weak inducer of CYP and exhibits fewer drug-drug interactions than erythromycin. However, its use with theophylline, carbamazepine and terfenadine is contraindicated. In contrast, no significant interactions have been reported with azithromycin to date. Macrolides have been proven to be well tolerated in the treatment of upper and lower respiratory tract infections, skin and soft tissue infections, and also in less frequent infections occurring in paediatric patients. In addition, clarithromycin and azithromycin have shown good tolerability profiles in immunocompromised paediatric patients. In conclusion, macrolides antibacterials have proven to be well tolerated in paediatric patients. Although the incidence of adverse effects is similar with the use of erythromycin and the newer macrolides, drug interactions occur significantly less when clarithromycin or azithromycin are administered.

Comparison of the efficacy, safety and tolerability of azithromycin and co-amoxiclav in the treatment of acute periapical abscesses

The activity, safety and tolerability of the azalide azithromycin were compared with those of co-amoxiclav in the treatment of acute periapical abscesses in adults in an open, randomized, multicentre comparative study. Patients of either sex, recruited from 106 dental practices in Belgium, were aged between 18 and 75 years and had acute periapical abscesses not requiring drainage, confirmed by radiology. Azithromycin was administered as a 500-mg tablet orally once daily for 3 days (n = 150) and co-amoxiclav as a 625-mg capsule three times daily, for 5-10 days (n = 153). Both before and after treatment, masticatory pain, percussion pain, headache, and oedema and redness of soft tissue were graded on a four-point scale. Overall clinical success (cure plus improvement) was seen in 131/144 (91%) evaluable patients receiving azithromycin and in 142/148 (96%) receiving co-amoxiclav (difference not significant). There was no significant difference between the two groups in the incidence or severity of adverse events or in the number of discontinuations because of adverse events.

Periodontal tissue disposition of azithromycin

The tissue penetration of azithromycin, the prototype of a new class of macrolide antibiotics named azalides, was studied in patients undergoing surgery for third-molar removal. Drug concentrations in plasma, saliva, and periodontal tissues were evaluated in 28 patients treated with azithromycin 500 mg/day per os for 3 consecutive days. Samples of blood, saliva, gingiva, and alveolar bone were collected during oral surgery, 12 hours, and 2.5, 4.5, and 6.5 days after the last dosing, and the azithromycin concentration was measured microbiologically by using Micrococcus luteus NCTC 8440 as the reference organism. The highest concentrations of azithromycin were observed 12 hours after the last dose in plasma, saliva, gingiva, and bone (0.33 +/- 0.04 mg/l, 2.14 +/- 0.30 mg/l, 6.47 +/- 0.57 mg/kg, and 1.86 +/- 0.15 mg/kg, respectively) and then declined gradually. However, consistent levels of the drug in saliva and periodontal tissues could be detected up to 6.5 days, indicating that azithromycin was retained in target tissues and fluids for a long time after the end of treatment. Among the samples examined, the highest concentration of azithromycin was found in the gingiva at each time studied. Moreover, the ratios of salivary or periodontal tissue levels versus plasma concentrations remained nearly unmodified from 12 hours up to 6.5 days. Overall, these results indicate a favorable disposition of azithromycin into saliva and periodontal tissues and suggest that this macrolide antibiotic represents a valuable option in the pharmacologic treatment of odontogenic infections.

Azithromycin in the treatment of periodontal disease. Effect on microbial flora

Azithromycin is an azalide antibiotic with excellent in vitro activity against a wide variety of oral bacteria. It has a long half-life, good tissue penetration and is preferentially taken up by phagocytes. We investigated the microbiological efficacy of azithromycin as an adjunct to the non-surgical treatment of adult chronic periodontitis; its clinical efficacy is dealt with in a separate paper. 46 patients were treated in a double-blind placebo controlled trial. Microbiological assessment of the same periodontal pocket (initially > 6 mm) was made at weeks 0, 2, 3, 6, 10 and 22. Either azithromycin 500 mg 1 x daily for 3 days or placebo was given at week 2. Particular attention was paid to the numbers of black pigmented anaerobes and spirochaetes present since these are the most commonly implicated pathogens in periodontal disease. Pigmented anaerobes were significantly reduced at weeks 3 and 6 in patients who received azithromycin compared to placebo and remained lower, although not significantly so, throughout the study. Counts of spirochaetes were significantly reduced throughout the study in patients who received azithromycin compared to placebo. Our microbiological study suggests that azithromycin may be useful as an adjunct in the treatment of periodontal disease.

Azithromycin. A review of its pharmacological properties and use as 3-day therapy in respiratory tract infections

The azalide antibacterial agent azithromycin is a semisynthetic acid-stable erythromycin derivative with an expanded spectrum of activity and improved tissue pharmacokinetic characteristics relative to erythromycin. The drug is noted for its activity against some Gram-negative organisms associated with respiratory tract infections, particularly Haemophilus influenzae. Azithromycin has similar activity to other macrolides against Streptococcus pneumoniae and Moraxella catarrhalis, and is active against atypical pathogens such as Legionella pneumophila, Chlamydia pneumoniae and Mycoplasma pneumoniae. Once-daily administration of azithromycin is made possible by the long elimination half-life of the drug from tissue. Azithromycin is rapidly and highly concentrated in a number of cell types after absorption, including leucocytes, monocytes and macrophages. It undergoes extensive distribution into tissue, from where it is subsequently eliminated slowly. A 3-day oral regimen of once-daily azithromycin has been shown to be as effective as 5- to 10-day courses of other more frequently administered antibacterial agents [such as erythromycin, amoxicillin-clavulanic acid and phenoxymethylpenicillin (penicillin V)] in patients with acute exacerbations of chronic bronchitis, pneumonia, sinusitis, pharyngitis, tonsillitis and otitis media. Adverse effects of azithromycin are mainly gastrointestinal in nature and occur less frequently than with erythromycin. Azithromycin is likely to prove most useful as a 3-day regimen in the empirical management of respiratory tract infections in the community. Its ease of administration and 3-day duration of therapy, together with its good gastrointestinal tolerability, should optimise patient compliance (the highest level of which is achieved with once-daily regimens). Azithromycin is also likely to be useful in the hospital setting, particularly for outpatients and for those unable to tolerate erythromycin.