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Journal of Stomatology
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Guidelines/recommendations

Polish Dental Association And National Programme To Protect Antibiotics Working Group recommendations for administration of antibiotics in dentistry

Tomasz Kaczmarzyk
,
Karolina Babiuch
,
Elżbieta Bołtacz-Rzepkowska
,
Marzena Dominiak
,
Tomasz Konopka
,
Mariusz Lipski
,
Dorota Olczak-Kowalczyk
,
Adam Szeląg
,
Mariusz Szuta
,
Waleria Hryniewicz

J Stoma 2018; 71, 6: 457-465
Online publish date: 2019/06/06
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RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS

GENERAL RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN ORAL AND MAXILLOFACIAL SURGERY

Maintaining proper oral hygiene and using aseptic and antiseptic techniques are of paramount importance for prevention of oral and maxillofacial infections.
Routine administration of antibiotic prophylaxis in immunocompetent patients is not recommended; the decision of administration of antibiotic prophylaxis should be very prudent.
Antibiotic prophylaxis is recommended in immunocompromised patients, in consultation with the attending physician.
Antibiotic prophylaxis should be administered 30-60 minutes before commencement of surgery.
For prophylaxis, it is recommended to administer only one dose of an antibiotic (one-shot prophylaxis) and no further doses after completion of surgery should be administered, with the exceptions presented in certain detailed recommendations (ultra-short, short-term and long-term prophylaxis).
Unless otherwise specified in the detailed recommendation, for antibiotic prophylaxis in dentistry amoxi-cillin without clavulanic acid in a single dose of 2000 mg is recommended; patients allergic to penicillins should be given cefazolin in a single dose of 1000 mg or clindamycin in a single dose of 600 mg.
Unless otherwise specified in the detailed recommendation, for antibiotic prophylaxis in pediatric patients amoxicillin without clavulanic acid in a single dose of 50 mg/kg is recommended; patients allergic to penicillins should be given cefazolin2 in a single dose of 50 mg/kg or clindamycin in a single dose of 20 mg/kg.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN THIRD MOLAR SURGERY

Routine administration of antibiotic prophylaxis in third molar surgery in immunocompetent patients is not recommended; antibiotic prophylaxis should be considered in immunocompromised patients in consultation with the attending physician or whenever it is necessary to perform surgery in the course of acute pericoronitis.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN IMPLANT SURGERY

Routine administration of antibiotic prophylaxis in implant surgery in immunocompetent patients is not recommended; antibiotic prophylaxis should be considered in immunocompromised patients in consultation with the attending physician.
It is recommended to consider administration of anti¬biotic prophylaxis in implant procedures involving bone grafting.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN BONE GRAFTING SURGERY

It is recommended to consider administration of anti¬biotic prophylaxis in bone grafting surgery.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN DENTO-ALVEOLAR SURGERY

Routine administration of antibiotic prophylaxis in dento-alveolar surgery (e.g. surgical extraction, cystectomy or intraosseous bone tumor removal) in immunocompetent patients is not recommended; antibiotic prophylaxis should be considered in immunocompromised patients, in consultation with the attending physician.
It is recommended to administer one dose of antibiotic prophylaxis in case of dento-alveolar surgery involving exposure of antral or nasal mucosa as well as involving removal of extensive bone cysts and tumors.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN ENDODONTIC SURGERY

Routine administration of antibiotic prophylaxis in endodontic surgery in immunocompetent patients is not recommended; antibiotic prophylaxis should be considered in immunocompromised patients, in consultation with the attending physician.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN PERIODONTAL SURGERY

Routine administration of antibiotic prophylaxis in periodontal surgery in immunocompetent patients is not recommended; antibiotic prophylaxis should be considered in immunocompromised patients, in consultation with the attending physician.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN ORTHOGNATHIC SURGERY

It is recommended to administer antibiotic prophylaxis in orthognathic procedures with intraoral surgical approach or involving exposure of antral or nasal mucosa.
In this indication IV ampicillin/sulbactam administration 30-60 minutes before commencement of surgery is recommended: in adults in a dose of 1500 mg and in children in a dose of 50 mg/kg, and:
■ during prolonged (> 4 h) procedures another dose of antibiotic should be administered;
■ in extensive procedures involving high blood loss (> 1000 ml) it is recommended to continue admi¬nistration of antibiotic prophylaxis every 6-8 h during the first 24 h after the first dose (ultra-short prophylaxis).
Patients allergic to penicillin should be given clindamycin in a dose of 600 mg (adults) or 20 mg/kg (children), according to the abovementioned design.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN MAXILLOFACIAL SURGERY

Routine administration of antibiotic prophylaxis in soft tissue procedures involving extraoral surgical approach (e.g. parotidectomy) or in neck dissections without opening of airways is not recommended.
Antibiotic prophylaxis is recommended in maxillofacial procedures involving: bone resection, free or pediculated flaps, neck dissections with opening of airways and bone grafting.
In these indications IV ampicillin/sulbactam administration 30-60 minutes before commencement of surgery is recommended: in adults in a dose of 1500 mg and in children in a dose of 50 mg/kg, and:
■ during prolonged (> 4 h) procedures another dose of antibiotic should be administered;
■ in extensive procedures involving high blood loss (> 1000 ml) it is recommended to continue administration of antibiotic prophylaxis every 6-8 h during the first 24 h after the first dose (ultra-short prophylaxis).
Patients allergic to penicillin should be given clindamycin in a dose of 600 mg (adults) or 20 mg/kg (children), according to the abovementioned design.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST SURGICAL SITE INFECTIONS IN PATIENTS ON ANTIRESORPTIVE/ANTIANGIOGENIC THERAPY OR WITH A HISTORY OF MAXILLOFACIAL RADIOTHERAPY

It is recommended to administer antibiotic prophyla¬xis in patients taking bisphosphonates, denosumab or bevacizumab before any surgical procedure involving bone surgery (e.g. exodontia, dento-alveolar surgery, endodontic or periodontal surgery); antibiotic therapy should be initiated one day before surgery and continued until the 3rd postoperative day (short-term prophylaxis), with the exception of cases of concurrent risk factors for medication-related osteonecrosis of the jaw (therapy with zoledronic acid, intravenous route of bis¬phosphonate administration, therapy > 3 years, previous episode of osteonecrosis of the jaw) where antibiotic prophylaxis should be continued up until the 14th postoperative day (long-term prophylaxis).
It is recommended to administer antibiotic prophylaxis in patients with a history of maxillofacial radiotherapy before any surgical procedure involving bone surgery (e.g. exodontia, dento-alveolar surgery, endodontic or periodontal surgery); antibiotic therapy should be initiated one day before surgery and continued until the 3rd postoperative day (short-term prophylaxis).
In these indications amoxicillin/clavulanic acid is recommended: in adults – 1000 mg (875 mg + 125 mg) BID and in children – (45 mg + 6.4 mg)/kg/day in 2 divided doses; patients allergic to penicillins should be medicated with clindamycin: in adults 300 mg TID and in children – 8-16 mg/kg/day in 3-4 divided doses.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST INFECTIONS OF WOUNDS OF FACIAL SKIN OR ORAL MUCOSA

Antibiotic prophylaxis against infections of minor, fresh (< 12 h) wounds in immunocompetent patients is not recommended.
Antibiotic prophylaxis is recommended in the case of wounds following:
■ blunt injury,
■ gunshot, bite or avulsion injury,
■ injury inflicted with dirty object,
■ dirty wounds, > 12 h old with no previous dressing,
■ injuries in immunocompromised patients, in consultation with the attending physician.
In these indications it is recommended to administer a single dose of either IV ampicillin/sulbactam: adults – 1500 mg, children – 50 mg/kg or PO amoxi¬cillin/clavulanic acid: adults – 2000 mg, children – (45 mg + 6.4 mg)/kg.

SPECIFIC RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST INFECTIONS OF BONE FRACTURES

Antibiotic prophylaxis against infection of closed fractures (e.g. fractures of condyle or mandible ramus) in immunocompetent patient is not recommended, insofar as conservative or surgical treatment involving the extraoral approach is applied.
Antibiotic prophylaxis is recommended in the case of:
■ open fractures (e.g. mandible body fracture),
■ fractures with delayed treatment,
■ pathologic fractures,
■ surgically treated fractures involving the intraoral approach,
■ comminuted fractures,
■ fractures involving nasal or paranasal sinuses mucosa exposure,
■ fractures in immunocompromised patients, in consultation with the attending physician.
In these indications clindamycin in a single dose of 600 mg in adults or 20 mg/kg in children is recommended.

RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS AGAINST DISTANT INFECTIONS

RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS (IE) FOLLOWING DENTAL PROCEDURES

Strict oral hygiene and frequent dental follow-up in IE high-risk patients are decidedly recommended.
It is recommended that patients with cardiac conditions at the highest risk of IE, including:
■ patients with any prosthetic valve, including a trans¬catheter valve, or those in whom any prosthetic material was used for cardiac valve repair;
■ patients with congenital heart disease (CHD):
- any type of cyanotic CHD,
- any type of CHD repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt or valvular regurgitation remains;
■ patients with a previous episode of IE,
■ 30-60 minutes before commencement of a dental procedure requiring manipulation of the gingival or periapical region of the teeth or perforation of oral mucosa should receive:
- PO amoxicillin (without clavulanic acid) or IV ampicillin (without sulbactam): adults – 2000 mg, children – 50 mg/kg;
■ in patients allergic to penicillins one of the following should be administered 30-60 minutes before the procedure:
- PO or IV clindamycin: adults – 600 mg, children – 20 mg/kg,
- IV cefalexin : adults – 2000 mg, children – 50 mg/kg,
- IV cefazolin5: adults – 1000 mg, children – 50 mg/kg,
- IV ceftriaxone5: adults – 1000 mg, children – 50 mg/kg.
Antibiotic prophylaxis is not recommended in any other congenital or acquired heart disease or in patients with a history of myocardial or cerebral infarction, bypass surgery or patients with a implanted pacemaker.
Antibiotic prophylaxis is not recommended for local anesthetic injections in non-infected tissues, treatment of dental caries, removal of sutures, placement or adjustment of removable prosthodontic or orthodontic appliances or braces and following the shedding of deciduous teeth or trauma to the lips or oral mucosa.

RECOMMENDATION FOR ANTIBIOTIC PROPHYLAXIS AGAINST PERIPROSTHETIC JOINT INFECTIONS FOLLOWING DENTAL PROCEDURES

Antibiotic prophylaxis in patients with artificial joint prostheses before any dental procedure is not recommended.

RECOMMENDATION FOR ANTIBIOTIC THERAPY OF ODONTOGENIC INFECTIONS

Antibiotic therapy is not recommended for treatment of limited, non-spreading odontogenic infections which are not associated with the impaired general state in immunocompetent patients.
Local treatment consisting of pus drainage and extraction or endodontic therapy of a causative tooth is fundamental for treatment of odontogenic infections.
Antibiotic therapy of odontogenic infections is indicated in immunocompromised patients (in consultation with the attending physician where possible); however, in immunocompetent patients antibiotic therapy is only complementary to the local treatment and should be administered solely in patients with an impaired general state (high fever, malaise, vertigo, dehydration, tachycardia) or in cases of inflammation involving extraoral anatomical spaces with a tendency to spread.
Only in exceptional circumstances, when there is no possibility of immediate causative treatment (e.g. high trismus, lack of efficacy of local anaesthesia), may administration of antibiotic to reduce inflammation be considered; however, causative treatment should be implemented without any further delay.
In the case of empirical antibiotic therapy (without results of laboratory testing for bacterial sensitivity) amoxicillin without clavulanic acid should be administered as the first-line therapy (Table 1).
Clindamycin is recommended only in patients allergic to penicillins, and it should be administered every 6-8 h (but not every 12 h), and a single dose should not exceed 300 mg (Table 1).
It is recommended that every patient treated with antibiotic should be followed up on a regular basis and the first follow-up should take place not later than 48-72 h after commencement of antibiotic therapy.
Antibiotic therapy should be continued until significant improvement in the patient’s general state (decrease of body temperature, wellbeing), in which case antibiotic therapy should be ceased.
It is recommended that if there is no improvement in the patient’s general state after 72 h of antibiotic therapy a second-line antibiotic should be considered, and the efficacy of drainage should be re-evaluated.
The list of recommended antibiotics in empirical therapy is annexed to this recommendation (Table 1).

RECOMMENDATION FOR ANTIBIOTIC THERAPY IN PERIODONTITIS AND PERIIMPLANTITIS

Routine administration of antibiotics for the treatment of periodontitis and peri-implantitis in immu-nocompetent patients is not recommended; mecha¬nical therapy involving removal of supra- and sub¬gingival deposits of calculus and dental plaque by means of scaling and root planing (SRP) plays a fundamental role in periodontal therapy.
Systemic antibiotic administration is recommended in patients with acute symptoms of the periodontal disease such as multiple periodontal abscesses and necrotizing periodontal diseases with systemic involvement (high fever, malaise, vertigo, dehydration, tachycardia).
Administration of antibiotic therapy should also be considered in the case of A. actinomycetemcomitans and/or P. gingivalis infection in the course of refractory periodontitis in stage IV of the disease (according to the 2017 classification of periodontal and peri-implant diseases)[11].
It is recommended to consider systemic antibiotic administration for treatment of periodontitis and peri-implantitis in immunocompromised patients (in consultation with the attending physician).
Administration of systemic antimicrobials should be preceded by culture and sensitivity microbiological testing whenever possible.
In the case of empirical antibiotic therapy of multiple periodontal abscesses amoxicillin/clavulanic acid is recommended: in adults and children over 40 kg – 1000 mg (875 mg + 125 mg) BID for 5 days, and in children up to 40 kg – (45 mg + 6.4 mg)/kg/day in two divided doses for 5 days; in patients allergic to penicillins azithromycin is recommended: in adults – 500 mg QD for 3 days, and in children – 10 mg/kg QD for 3 days; in this indication administration of antibiotic should be simultaneous with mechani¬cal therapy.
In the case of empirical antibiotic therapy of necrotizing periodontal diseases administration of metronidazole is recommended: in adults and children over the age of 12 – 250 mg TID for 7 days, and in children up to 12 years of age – 7.5 mg/kg TID for 7 days; in this indication administration of antibiotic should be simultaneous with mechanical therapy.
In the case of empirical antibiotic therapy of stage IV of periodontitis, co-administration of amoxicillin (without clavulanic acid) and metronidazole for 7 days is recommended according to the following scheme:
■ in adults and children over 40 kg amoxicillin should be administered in a dose of 500 mg TID, and in children up to 40 kg – 40 mg/kg/day in 3 divided doses,
■ in adults and children over the age of 12 metronidazole should be administered in a dose of 250 mg TID, and in children up to 12 years of age – 7.5 mg/kg TID,
■ in patients allergic to penicillins, administration of metronidazole alone according to the above scheme is recommended,
■ it is recommended to commence antibiotic therapy on the day of completion of mechanical therapy.

RECOMMENDATIONS FOR THE USE OF ANTIBIOTICS IN ENDODONTICS

RECOMMENDATION FOR SYSTEMIC ANTIBIOTIC PROPHYLAXIS IN ENDODONTICS

Routine administration of antibiotic prophylaxis before root canal treatment in immunocompetent patients is not recommended.
Antibiotic prophylaxis before root canal treatment is recommended only in:
■ immunocompromised patients, after considering the state and control of the disease, risk of infection-related complications and risk of adverse drug reactions,
■ patients with cardiac conditions at the highest risk of IE,
■ patients with previous radiotherapy of the maxillofacial region.
In the event of a decision of antibiotic prophylaxis administration before root canal treatment, antibiotic selection and dosing should follow “Recommendation for antibiotic prophylaxis against infective endocarditis (IE) following dental procedures”.

RECOMMENDATION FOR SYSTEMIC ANTIBIOTIC THERAPY IN ENDODONTICS

Local treatment plays a fundamental role in therapy of endodontic infections, whereas adjunctive systemic antibiotic treatment is indicated only in the following conditions:
■ acute periapical abscess in immunocompromised patients,
■ acute periapical abscess with systemic involvement (high fever, malaise, vertigo, dehydration, tachycardia) or advanced local signs (lymphadenopathy, extensive swelling, severe trismus), irrespective of patient’s immunological status,
■ progressive infections (rapid onset of severe infection in less than 24 h, cellulitis/phlegmon, acute osteomyelitis).
Adjunctive systemic antibiotic treatment is not recommended in the following conditions:
■ symptomatic irreversible pulpitis (pain with no other signs and symptoms of infection),
■ pulp necrosis,
■ symptomatic periapical periodontitis (spontaneous pain, pain to percussion and biting, widening of periodontal ligament space),
■ chronic periapical periodontitis/chronic periapical abscess (periapical radiolucency, sinus tract),
■ acute periapical abscess without systemic involvement (normal body temperature, patient well-being) and with mild localized symptoms (e.g. localized swelling).
In the event of a decision of antibiotic therapy of endodontic infection, antibiotic selection and dosing should follow “Recommendations for antibiotic therapy of odontogenic infections”.

RECOMMENDATION FOR LOCAL ANTIBIOTIC APPLICATION IN ENDODONTICS

Antibiotics are not recommended in pulp capping procedures or for root canal disinfection.
Due to the fact that the antibiotic mixture composed of ciprofloxacin, metronidazole and minocycline known as triple antibiotic paste (TAP) may cause dentine discoloration and that there is a lack of strong evidence to support the use of antibiotics in regenerative endodontic procedures, the use of calcium hydroxide for pulp revascularization is recommended.

RECOMMENDATION FOR THE USE OF ANTIBIOTICS IN DENTAL TRAUMA

Routine administration of antibiotics is not recommended in the following conditions:
■ crown fracture, root fracture, concussion, subluxation and partial luxation of a permanent tooth,
■ trauma to primary dentition.
Avulsion of a permanent tooth is an indication for systemic antibiotic administration, in which case tetracycline is recommended in the dose of 25 mg/kg/day for the first week after the replantation procedure; due to the risk of discoloration of permanent teeth, in non-penicillin-allergic children up to 12 years of age phenoxymethylpenicillin (penicillin V) or amoxicillin (without clavulanic acid) should be considered in an appropriate dose for the age and weight; in the case of replantation of an immature tooth, topical application of antibiotic (minocycline or doxycycline, 1 mg per 20 ml of saline for 5 min) on the root surface before replantation should be considered.
The decision about the systemic use of an antibiotic may be dictated by associated injuries and the patient’s medical status.

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