Prescribing antibiotics, analgesics, and antifungals Flashcards
Why should we prescribe appropriately?
Inappropriate prescribing leads to ineffective and unsafe treatment, exacerbates or prolongs illnesses, and can cause distress or harm to patients.
How is treatment with prescribing done appropriately?
Treatment involves defining the problem, specifying the therapeutic objective and choosing the treatment.
Drug choice is based on efficacy, safety, suitability and cost
What must be done before prescribing?
Be familiar with guidelines for quality use of medicine in Australia’s National medicines Policy.
Obtain full medical and medication history prior
Give the patient reasons and clear instructions about treatment.
Write an appropriate and accurate prescription
What should be included in a legal prescription?
Prescriber’s name, address, telephone, and qualifications
Patient’s full name
Drug strength and form
Drug dose, route of administration, frequency and duration of treatment.
Quantity of the drug
Signed and dated
For dental treatment only
What are the considerations to make with antimicrobial prescriptions?
MINDME
Microbiology guides therapy wherever possible
Indications should be evidence-based
Narrowest spectrum required
Dosage appropriate to site and type of infection
Minimize duration of therapy
Ensure monotherapy in most situations
How are antibiotics prescribed for prophylactic use?
A single perioperative dose is sufficient to achieve therapeutic tissue concentrations. Repeat dose is only required in cases where the drug has a short half life and procedure is prolonged.
When should antimicrobials be used prophylactically?
To prevent infection in clinical situations where there is a significant risk of infection.
Use is restricted to situations in which prophylaxis is shown to be effective or consequences of infection are disastrous.
Which cardiac conditions require endocarditis prophylaxis?
Prosthetic cardiac valve / valve repair
Previous infective endocarditis
Cardiac transplantation with valvulopathy
Rheumatic heart disease in indigenous Australians
Congenital heart disease - unrepaired cyanotic defects and residual defects at site of prosthetic patch or device
When are surgical antibiotics used for prophylaxis in dentistry?
Rarely indicated to prevent surgical site infection.
Maxillofacial procedures
In immunocompromised patients
In patients on immunosuppressive therapies
What patients often have immunocompromisation?
End stage renal disease
End stage liver disease
Malignancies
Untreated or end stage HIV infection
Malnutrition
Autoimmune and inflammatory conditions
Organ transplants
Which antibiotics are provided for surgical antibiotic prophylaxis in dentistry?
Phenoxymethylpenicillin 2g (Child: 40mg/kg) orally 1 hour before procedure
Or Amoxicillin 2g (child 40mg/kg) orally 1 hour before procedure
Or if hypersensitive to penicillin: Clindamycin 600mg (child: 15mg/kg) 1 hour before procedure
What is antimicrobial use for empirical therapy?
Causative organism not proven and treatment commences before culture susceptibility results available.
When should antimicrobial be used for empirical therapy?
Use where proven benefits are substantial
Avoid in self-limiting illness
What should empirical therapy be based on?
Base therapy on most likely pathogen and their antimicrobial susceptibility. Use narrowest spectrum antimicrobial.
What should be done before empirical therapy is commenced?
Obtain specimens for culture.
Gram stain results can be used to direct therapy at the start
What should be done with empirical treatment if the diagnosis was confirmed to be non-infective?
Cease therapy immediately
What should be done with empirical therapy if there is no proven causative organism at 48 hours?
Evaluate the clinical and microbiological justification for continuing therapy.
Liase with local path lab for up-to-date information on local antimicrobial resistance patterns.
What is used to guide directed therapy?
Culture susceptibility results used to guide therapy
What should infection be distinguished from when critically evaluating the culture and microbiological results?
From colonisation or contamination (these do not require antimicrobial treatment)
How should antimicrobials be used for dental treatment?
Use single drug unless combination therapy is required
Keep duration as short as possible. For most odontogenic infections 5 days with appropriate dental treatment is sufficient.
What route of administration should be used for antibiotics?
Oral route is preferred (less serious side effects, cheaper and lower cost of administration, high oral bioavailability)
Topical therapy is restricted to proven indications (eg miconazole 2% gel for oral candidosis
Used within tooth (eg intra-canal antibiotic and corticosteroid paste)
What are the adverse effects of antimicrobials?
Hypersensitivity, rash or diarrhoea
Disrupted microbiome (eg candidiasis)
Multidrug resistant bacteria
DDIs (eg patients on warfarin)
How should anti-fungal therapy be administered topically?
(If anti-fungal therapy is indicated, use amphotericin 10mg lozenge 4 times daily after food for 7 - 14 days)
Which periodontal disease requires antibiotic treatment and what else must be done?
Acute necrotizing ulcerative gingivitis.
Should be treated by:
Debridement
Smoking cessation
Metronidazole 400mg orally, 12 hourly for 5 days plus chlorhexidine 0.2% mouthwash 10mL 8 - 12 hourly
ANALGESICS
How should acute necrotizing ulcerative gingivitis be treated in immunocompromised patients?
Metronidazole 400mg orally, 12-hourly for 5 days
+
Phenoxymethylpenicillin 500mg orally, 6 hours for 5 days or amoxicillin 500mg orally, 8 hourly for 5 days.
Clindamycin 300mg orally (if hypersensitive to penicillin)
How should acute odontogenic infections be treated?
Drain pus, remove cause, support patient with analgesia and rehydration, and consider antibiotics
What causes acute odontogenic infections?
Arise from dental pulp, periodontal tissues or pericoronal tissues.
If not treated appropriately, the localised infection spreads beyond jaws to facial or neck soft tissues
What antibiotics are used for severe superficial odontogenic infections?
Phenoxymethylpenicillin 500mg orally, 6 hourly for 5 days. Children = 12.5mg/kg)
Or Amoxicillin, 8 hourly for 5 days.
Clindamycin 300mg (If hypersensitive). Children = 7.5mg/kg)
What antibiotics should be prescribed for odontogenic infections if unresponsive to conventional treatment?
•Metronidazole 400mg (child: 10mg/kg) orally, 12-hourly for 5 days plus
•Phenoxymethylpenicillin 500mg (child :
12.5mg/kg) orally, 6-hourly for 5 days
Or
Amoxycillin 500mg, 8-hourly for 5 days
Or
Single drug (Augmentin) Amoxycillin + clavulanate 875 +125mg (child: 22.5+3.2 mg/kg) orally, 12-hourly for 5 days
If hypersensitive to penicillin, use Clindamycin 300mg (child: 7.5mg/kg) orally, 8-hourly for 5 days
How are deep odontogenic infections treated?
Odontogenic infections that spread to spaces in the neck are potentially life threatening and risk airway obstruction.
They need to be assessed by an oral maxillofacial surgeon and hospital management. They treat these infections by using intravenous fluids and antibiotics
How is infection from a tooth avulsion managed/prevented?
Assess patients immunisation status
Antibiotics are indicated although there is limited evidence it reduces inflammatory root resorption.
Chlorhexidine mouthwash
Which antibiotics have been seen to have antiresorptive activity following tooth avulsion?
Doxycycline has some anti-resorptive activity
How should doxycycline be prescribed?
Once daily for 7 days.
Adult: 100mg
Child 8 years+ and less than 26 kgs: 50 mg
Child 8+ and 26 - 35 kg: 75mg
Child 8+ and More than 35kg: 100mg
OR amoxicillin 1g first dose then 500mg 8 hourly for 7 days. (child 12.5mg/kg)
What are the 3 Ds for pain management?
Diagnose and determine cause
Dental treatment: Remove cause
Drugs: After cause of disease has been addressed, appropriate treatment can be used.
What are the drugs that can be used for dental and oral pain? When should they be used?
Anti-inflammatory (Analgesic and anti-inflammatory action)
Paracetamol (combined with NSAID or use alone in patients who cannot take NSAIDs)
Opioids (For severe pain when nonopioid analgesics are unlikely to provide adequate pain relief)
What drugs should be carefully monitored before giving analgesics?
Sedatives, hypnotics, antipsychotics can increase sedation and respiratory depression effects.
What are NSAIDs most useful for?
Acute dental pain. Should not be used for more than 5 days.
Why can’t NSAIDs be prescribed long term?
Can cause significant renal cardiovascular, and gastrointestinal adverse effects
Respiratory and haematological adverse effects occur with nonselective NSAIDs but not COX-2 selective NSAID
What is paracetamol prescribed for?
Acts within the central nervous system as an analgesic and antipyretic but has no anti-inflammatory effect.
It is the drug of choice when NSAIDs are contraindicated.
Acts as a component of multimodal analgesia, paracetamol reduces the need for opioids.
How can opioids be prescribed safely?
Use only when indicated (Acute pain)
Suitability of opioid for use in specific population
Weigh potential benefits vs potential harm
Manage DDIs and provide verbal and written education to patients about sedative effects.
Lowest dose for the shortest duration
Read the legislation about prescription and prescribing of drugs of dependence
Which opioids are used in dentistry for pain managemetn?
Oxycodone
tramadol
Tapentadol
How should mild/moderate pain be managed in adults?
Nonopioid analgesics should be taken regularly rather than as required to achieve continuous pain relief.
Ibuprofen 400mg every 6 - 8 hours for no more than 5 days without review.
+
Paracetamol 1000mg orally every 4 - 6 hours (max 4g/25 hours)
As the tissue heals, stop ibuprofen and use paracetamol as a single drug
If a COX-2 selective NSAID is preferred based on patient
risk factors,
Celecoxib 100mg orally, every 12 hours for no more than 5 days without review
+
Paracetamol 1000mg orally, every 4-6 hours ( Max of
4g/24 hours)
As the tissue heals, stop celecoxib and use paracetamol as a single drug.
How should severe pain be managed?
•Ibuprofen 400 mg orally, every 6-8 hours for no more than 5 days without review
OR
Celecoxib 100 mg orally, every 12 hours for no more
than 5 days without review
+
Paracetamol 1000 mg orally, every 4-6 hours (Max
dose of 4g/24 hours) for the shortest duration possible
+
Oxycodone immediate-release 5 mg orally, every 4-
6 hours as required for no more than 3 days
How should pain management be prescribed for children?
Ibuprofen 5 - 10mg/kg up to 400mg orally, 6 - 8 hourly
OR
Paracetamol 15mg/kg up to 1000mg orally, 4 - 6 hourly
Ibuprofen and paracetamol can be combined
What should never be prescribed to children under 16? Why?
Aspirin due to Reye’s syndrome
