Impact of antibiotic prophylaxis on the incidence,nature, magnitude,and duration of bacteremia associated with dental procedures: A systematic review

BackgroundAntibiotic prophylaxis (AP) is used routinely in high-risk groups of patients to reduce bacteremia and the risk of developing infective endocarditis (IE). In this systematic review, the authors evaluated the efficacy of AP on the incidence, nature, magnitude, and duration of post-dental procedure bacteremia.MethodsThe authors conducted a systematic search of the literature using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials up to and including May 2019. They included randomized clinical trials in which researchers compared antibiotics with a placebo or no treatment (as the control). They undertook random-effects meta-analyses to evaluate the incidence of bacteremia after dental procedures.ResultsThe authors included 12 studies in the review. The studies evaluated the incidence of bacteremia after AP with American Heart Association (AHA) protocol antibiotics (amoxicillin, clindamycin, cephalosporin, and azithromycin) or non-AHA protocol antibiotics (moxifloxacin and intravenous [IV] amoxicillin-clavulanic acid). The pooled analysis revealed that antibiotics significantly reduced the bacteremia incidence, but their effectiveness was moderate (risk ratio, 0.50; 95% confidence interval, 0.38 to 0.67). IV amoxicillin-clavulanic acid promoted a considerable reduction in bacteremia. However, in patients with penicillin allergies, antibiotics (that is, clindamycin and cephalosporin) had lower efficacy.Practical ImplicationsOral amoxicillin is still the antibiotic of choice to reduce bacteremia. IV amoxicillin-clavulanic acid could be used for patients at high risk of developing IE who require invasive dental procedures, have high levels of dental infection, and are to be treated under general anesthesia. In patients with penicillin allergies, oral azithromycin showed a higher efficacy for the reduction of bacteremia and the use of clindamycin should be reviewed. Antibiotic premedication should be limited to patients at high risk of developing IE, according to the indications of the AHA guide.     

Prophylaxis with cefazolin plus clindamycin in clean-contaminated maxillofacial surgery.

PURPOSE: Infections after maxillofacial surgery are usually due to aerobic and anaerobic gram-positive cocci and gram-negative bacilli. Various antimicrobials, including cephalosporins, beta-lactams/beta-lactamase inhibitors, aminoglycosides, lincosamides, and fluoroquinolones, have been tested for use for perioperative prophylaxis in maxillofacial surgery. However, the best regimen has not been determined. We tested the safety and the efficacy of clindamycin plus cefazolin as perioperative prophylaxis for patients undergoing major maxillofacial procedures. PATIENTS AND METHODS: Intravenous cefazolin and clindamycin in 3 doses were administered to 155 patients undergoing major maxillofacial procedures. After surgery, patients were monitored for the presence of infection and side effects. RESULTS: No patient experienced a fever or infection after surgery. No side effects related to these antibiotics were observed. CONCLUSIONS: The antibiotics used as prophylaxis in maxillofacial surgery should possess an adequate coverage against gram-positive aerobic and anaerobic cocci as well as gram-negative bacilli. Prophylaxis with cefazolin plus clindamycin in major maxillofacial seems safe and effective.     

Hierarchy of surgical stability in orthognathic surgery: overview of systematic reviews

The purpose was to perform an overview of systematic reviews in order to create a hierarchical scale of stability in orthognathic surgery with the aid of the highest level of scientific evidence. The systematic search was conducted in the PubMed, Embase, and Cochrane Library databases. The grey literature was investigated in Google Scholar and a manual search was done of the references lists of included studies. Fifteen studies were included in the final sample, of which eight were systematic reviews and seven were meta-analyses. These were assessed for methodological quality using the AMSTAR 2 tool and all were considered to be of medium to high methodological quality. The clinical studies included in the 15 reviews and meta-analyses were classified by the review authors as having a moderate to high potential for risk of bias. The hierarchical pyramid of stability in orthognathic surgery was established, with two surgical procedures considered highly unstable: (1) maxillary expansion with semi-rigid internal fixation evaluated at the dental level in the posterior region, and (2) clockwise rotation of the mandible with rigid internal fixation of bicortical screws in the sagittal direction.     

Antimicrobial resistance of Staphylococcus aureus and oral streptococci strains from high-risk endocarditis patients

This study sought to determine the antimicrobial susceptibility of Staphylcoccus aureus and viridans group streptococci strains collected from the forearm skin and saliva of 30 patients at high risk of endocarditis. Agar susceptibility tests of antibiotics routinely utilized in dentistry were used to verify antimicrobial resistance of bacterial strains. Of the Staphylcoccus aureus strains, 50% were resistant to ampicillin, 53.3% to amoxicillin, 60.0% to penicillin G, 13.3% to amoxicillin/clavulanate, 20.0% to azithromycin, 27.6% to clarithromycin, 23.3% to erythromycin, 3.3% to cefazolin, and 6.7% to clindamycin. Regarding streptococci, 16.7% of the strains were resistant to ampicillin, 16.7% to amoxicillin, 23.3% to azithromycin, 23.3% to clarithromycin, 30.0% to erythromycin, 13.3% to cefazolin, 26.7% to clindamycin, 16.7% to penicillin G, and 3.3% to amoxicillin/clavulanate. Pathogens associated with bacterial endocarditis exhibited elevated resistance rates against the antibiotics used for prophylaxis in dentistry.     

Antibiotic prophylaxis for orthognathic surgery: a prospective, randomised clinical trial

A prospective, randomised, placebo-controlled double-blind clinical trial, compared short-term (1 day) and long-term (5 days) antibiotic prophylaxis after orthognathic surgery. Thirty four patients had single jaw or bimaxillary osteotomies and were given two perioperative doses of amoxycillin. Patients were then randomised to receive either placebo or amoxycillin for 5 days in a double-blind manner. Postoperatively the patients were monitored for infection by scoring a series of validated measurements of infection. In the postoperative period four patients required additional antibiotics in the short-term group and two in the long-term group (P = 0.67). Morbidity scores were higher in the short-term group, at 406 to 264 (P = 0.04), and when individual variables were compared there was a significant difference in the degree of swelling (P = 0.04). Although a 5-day regimen of antibiotic prophylaxis in orthognathic surgery did not decrease the incidence of postoperative infection significantly, it may decrease the morbidity of the operation.     

A prospective study on infectious complications in orthognathic surgery.

AIM: According to an earlier study in 2000, 4.7% of patients undergoing corrective facial orthopaedic surgery in this unit suffered a postoperative wound infection. In 1998, the Belgian Government recommended stricter rules for infection prophylaxis and a new antibiotic protocol similar to that proposed by Peterson (1990) was implemented in this unit. The new protocol was to be evaluated. MATERIAL AND METHODS: Eight hundred and ten consecutive patients were selected receiving orthognathic surgery (Le Fort I-type osteotomies, sagittal split osteotomies, segmental and chin osteotomies). Cefazolin 1g was administered intravenously on induction of general anaesthesia and repeated at 4h intervals for the duration of surgery. No antibiotics were administered postoperatively. The observation period was 6 weeks. When an infection occurred, appropriate culture specimens were obtained according to a standardized protocol. RESULTS: Fifty-one infections (6.8%) were diagnosed, 33 with purulent exudates occurring spontaneously or after incision and drainage. Ninety-two per cent of these infections occurred in the sagittal split area, 6% in the maxillary region and 2% in the chin region. Infections in the sagittal split area were further analysed. A reduction in infection rate from 6.6 to 2.6% was noted following a change in practice when fibrin glue was used in the wound instead of a drain in the sagittal split wound. Of the 30 aerobic cultures, 12 contained normal mucosal flora, of which 9 were Streptococcus species. In 11 of the 30 anaerobic cultures the identified species belonged to the Bacteroides group. This bacterium is resistant to cefazolin but sensitive to amoxicillin-clavulanate and for a high percentage also to clindamycin. All the other cultures were sterile. CONCLUSION: The infections occurring almost exclusively in the sagittal split osteotomy site can be partially explained by wound contamination upon removal of the drain. It is suggested that for prophylaxis cefazolin is replaced by amoxicillin-clavulanate.     

口腔颌面外科医院感染的病原菌分布及耐药性研究

目的探讨口腔颌面外科医院感染的病原菌分布和耐药情况。方法回顾152例口腔颌面外科医院感染患者的病案资料，分析病原菌种类及抗生素的耐药情况。结果革兰氏阴性杆菌占58．43％，革兰氏阳性球菌占29．52％，真菌占12．05％；肺炎克雷伯菌和大肠埃希菌对亚胺培南100％敏感；铜绿假单胞菌对头孢唑林100％耐药，对亚胺培南较敏感；金黄色葡萄球菌对青霉素和氨苄西林96．67％耐药，对万古霉素、替考拉宁敏感。结论为减少口腔颌面外科医院感染的发生率及控制其耐药性，须加强对抗生素的合理应用。     

Prevalence of postoperative complications after orthognathic surgery: a 15-year review.

PURPOSE: This study was conducted to determine the prevalence of postoperative complications after orthognathic surgery and evaluate the use of antibiotic prophylaxis in relation to the infection rate. PATIENTS AND METHODS: All patients undergoing orthognathic procedures between 1990 and 2004 were studied retrospectively by retrieving their individual medical records. Demographic data, intraoperative data (specific orthognathic procedures and duration of operation), and postoperative data (type and duration of antibiotic prophylaxis and presence of postoperative complications) were recorded. Patients noted to have suffered any postoperative complications were studied in detail, and various factors, including gender, age, duration of operation, and use of prophylactic antibiotics, were analyzed using statistical tests in relation to postoperative infection. RESULTS: A total of 2,910 orthognathic procedures were performed on 1,294 consecutive patients in the 15-year period, with 1,070 patients undergoing bimaxillary procedures and 224 patients undergoing single-jaw surgery. The orthognathic surgery-related complication rate was 9.7%, of which 7.4% was related to postoperative infection. Of the cases of infection, 58.3% were acute infection and 41.7% were chronic infection. Patients who received a single preoperative dose of antibiotics had a significantly higher infection rate (17.3%) than those who received postoperative antibiotics for various durations. CONCLUSIONS: The prevalence of infection after orthognathic surgery was relatively low given the complexity of the procedures. No particular orthognathic procedure was more susceptible to infection. A preoperative dose of prophylactic antibiotics together with at least 2 days of postoperative doses was useful in reducing the infection rate compared with only a single dose of prophylactic antibiotics.     

Are postoperative intravenous antibiotics necessary after bimaxillary orthognathic surgery? A prospective, randomized, double-blind, placebo-controlled clinical trial

Postoperative antibiotic prophylaxis is often administered intravenously, despite an increased morbidity rate compared with oral application. This study investigates whether a postoperative oral antibiotic regimen is as effective as incorporation of intravenous antibiotics after bimaxillary orthognathic surgery. 42 patients who underwent bimaxillary orthognathic surgery between December 2008 and May 2010 were randomly allocated to 2 placebo-controlled postoperative antibiotic prophylaxis groups. Group 1 received oral amoxicillin 500 mg three times daily; group 2 received intravenous ampicillin 1 g four times daily, during the first two postoperative days. Both groups subsequently took oral amoxicillin for three more days. Clinically, the infection rate was assessed in both study groups for a period of 6 weeks after the surgery. 9 patients (21.4%) developed infection. No adverse drug event was detected. No significant difference (p = 0.45) was detected in the infection rate between group 1 (3/21) and group 2 (6/21). Age, type of surgical procedures, duration of the operative procedure, surgical procedure-related events, blood loss, and blood transfusion were all found not related to infection (p > 0.05). Administration of more cost-effective oral antibiotic prophylaxis, which causes less comorbidity, can be considered to be safe in bimaxillary orthognathic surgery with segmentalizations.     

Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery.

BACKGROUND: Perioperative antibiotic prophylaxis has significantly reduced wound infection rates in clean-contaminated head and neck surgical procedures but controversy still remains regarding the optimal antibiotic regime. OBJECTIVE: To examine the efficacy of different antibiotics in head and neck oncological surgery prophylaxis. PATIENTS AND METHODS: In this prospective, double-blind clinical trial, 189 patients with carcinoma of the upper aerodigestive tract were randomized to receive amoxicillin-clavulanate or cefazolin intravenously up to 1h before surgery and at 8-h intervals for an additional three doses. RESULTS: An overall wound infection rate of 22% was observed. The infection rate in patients receiving cefazolin was 24% (22/92) vs. 21% (20/97) in those receiving amoxicillin-clavulanate; the difference was not statistically significant. Postoperative overall non-wound infection developed in 12% (22/189) patients; the rate of infection was 9.8% (9/92) in patients receiving cefazolin vs. 13.4% (13/97) in those receiving amoxicillin-clavulanate, without a statistically significant difference between the two groups. Gram-negative bacteria were more often isolated with Pseudomonas aeruginosa as the dominant species. The risk of postoperative infection was more influenced by the type of surgical procedure than by disease stage. CONCLUSION: In clean-contaminated head and neck oncologic surgery amoxicillin-clavulanate prophylaxis was at least as efficient as cefazolin. However, when taking into account the fact that beta-lactamase containing strains have recently been spreading, amoxicillin-clavulanate should be the logical first choice.     

Management of condylar resorption before or after orthognathic surgery: A systematic review

BackgroundOrthognathic surgery is a surgical procedure for the correction of maxillofacial deformities. The existence of condylar resorption before orthognathic surgery affects the selection of surgery time and plan. Besides, condylar resorption after orthognathic surgery often leads to the recurrence of deformities and affects the long-term effect of surgery. The purpose of this study was to perform a systematic review of the management of condylar resorption before or after orthognathic surgery.MethodsA systematic review of the scientific literature listed on PubMed, Embase, and Cochrane Controlled Trials Register was performed, up to October 2018. The outcome of the search was reviewed with a chart.ResultsTen articles with 180 patients were included in this study based on inclusion and exclusion criteria. We compared these studies to examine the effectiveness of the management of condylar resorption.ConclusionThe occurrence of condylar resorption can be influenced by complex factors. The management of condylar resorption before or after orthognathic surgery should base on the severity of condylar resorption. As the eligible studies with small sample sizes, heterogeneity in management method and outcome, high-quality clinical study concerning condylar resorption treatment is needed.     

Bone grafting in orthognathic surgery: a systematic review

Bone grafting has been used in orthognathic surgery to fill the gaps created by jaw repositioning, with the intention of improving healing and stability. Since the majority of orthognathic cases have a satisfactory result, the decision to graft or not is a clinical dilemma. A systematic review of the literature was performed on the use of bone grafts in orthognathic surgery. A search of PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials yielded 1927 articles published up until 2018. An additional 10 articles were retrieved through manual searching of the reference lists and citations. After title and abstract screening, 58 articles were potentially eligible; full-text screening excluded 10 of these. Thus 48 articles were included in this review. The present literature highlights the benefits of grafting bony gaps during orthognathic surgery in terms of healing, stability, and aesthetic outcomes. Generally, there was no difference between the various types of bone graft, although calcium phosphate cement and hydroxyapatite were found to increase the rate of infection. The conclusion of this review is that there remains a lack of evidence in the literature regarding the grafting of osteotomy sites in orthognathic surgery. Guidelines are proposed based on the present evidence; however, future research is needed to validate these.     

Systemic antibiotics in endodontics—International questionnaire study: Choice of types,dosage, loading and duration

The aim of the study was to investigate the systematic antibiotics (SAs) prescribing practices in the endodontic practice worldwide. 7500 general practitioners, postgraduate students and endodontists from Israel and the former Soviet Union (FSU) states were invited to fill in an online questionnaire. The first-choice SA was amoxicillin (80.12%) among the Israeli (p < 0.05) and amoxicillin + clavulanic acid (88.92%) among the FSU respondents (p < 0.05). The first-choice SA for patients with penicillin allergy was clindamycin (78.2%) among Israeli and azithromycin (35.96%) among the FSU respondents (p < 0.05). Most of the respondents from Israel as well as from the FSU reported prescribing SA for 5–7 days. Only 6.24% of the former and 2.59% of the latter reported prescribing SA until the symptoms disappeared (p > 0.05). The usage of SAs is often not in accordance with existing international guidelines and differs among different dentist's populations.     

A prospective double-blind evaluation of penicillin versus clindamycin in the treatment of odontogenic infections

In a prospective, double-blind trial, penicillin and clindamycin were compared in treatment of moderate to severe orofacial infections of odontogenic origin, which yielded pus on aspiration. Among 27 patients randomized to receive penicillin, 22 (81%) had a successful outcome, and five (19%) were improved. In the 28 clindamycin-treated patients, 23 (82%) had a successful outcome, and five (18%) were improved. No failures were noted in either group. One patient who was receiving penicillin and two who were receiving clindamycin developed diarrhea. Bacteriologic results showed an average of 6.1 organisms per culture (2.5 aerobes and 3.6 anaerobes). Resistance rates for anaerobic isolates were 8.9% to penicillin and 1.9% to clindamycin. It was concluded that penicillin and clindamycin produce similar good results in treating odontogenic infection when the rate of penicillin resistance among oral anaerobic bacteria is at a relatively low level.     

Antimicrobial resistance in patients with endodontic infections: A systematic scoping review of observational studies

The aim of this study was to assess the prevalence and proportions of antimicrobial-resistant species in patients with endodontic infections. A systematic scoping review of scientific evidence was accomplished involving different databases. Nine investigations were selected including 651 patients. Enterococcus faecalis was resistant to tetracycline (30%–70%), clindamycin (100%), erythromycin (10%–20%), ampicillin (9%) and azithromycin (60%). On the contrary, Prevotella spp., Fusobacterium spp., Peptostreptococcus spp. and Streptococcus spp. were resistant to penicillin, tetracycline, doxycycline, ciprofloxacin, amoxicillin, erythromycin, metronidazole and clindamycin in different proportions. Fusobacterium nucleatum showed high resistance to amoxicillin, amoxicillin plus clavulanate and erythromycin. Prevotella oralis presented a predisposition to augment its resistance to clindamycin over time. Tanerella forsythia exhibited resistance to ciprofloxacin and rifampicin. Lactococcus lactis presented robust resistance to cephalosporins, metronidazole, penicillin, amoxicillin and amoxicillin–clavulanic acid. It was observed high levels of resistance to antimicrobials that have been utilised in the local and systemic treatment of oral cavity infections.     

Effectiveness and clinical implications of the use of topical antibiotics in regenerative endodontic procedures: a review

Regenerative endodontic procedures (REPs) are biologically based procedures planned to replace damaged tissues, including dentinee and root structures, as well as cells of the pulp–dentine complex. Effective sterilization of the root canal is essential in REPs, and antibiotics have been widely used to disinfect root canals. The aim of this paper was to review the scientific literature on (i) Effectiveness of antibiotics used in REPs against bacteria implicated in endodontic disease; (ii) Scientific evidence supporting the use of topical antibiotics in REPs; (iii) Clinical implications of the use of antibiotics in REPs and the possible side effects; (iv) Effect of antibiotics on dental pulp stem cells; and (v) Ongoing research on the use of antibiotics in REPs. Antibiotics used in REPs are effective against bacteria implicated in endodontic infections. Triple antibiotic pastes with minocycline attain complete disinfection of immature teeth with necrotic pulps, without affecting SCAP. Experimental studies carried out in dogs support the use of antibiotics in REPs. Clinical studies report high success rates of RET using antibiotics as intracanal dressings. However, tooth discolouration is an important side effect of the use of TAP. An antibiotic paste containing only metronidazole and ciprofloxacin could be a good alternative to the use of TAP. The use of antibiotic‐containing scaffolds or clindamycin‐modified triple antibiotic (metronidazole, ciprofloxacin and clindamycin) polymer could be a biologically safe antimicrobial drug delivery system in REPs.     

The role of preoperative prophylactic antibiotic administration in periapical endodontic surgery: a randomized, prospective double-blind placebo-controlled study

AIM: To determine the value of clindamycin prophylaxis in the prevention of postoperative wound infections in patients undergoing endodontic surgery. METHODOLOGY: This study included 256 patients undergoing endodontic surgery in a prospective double-blind placebo-controlled trial comparing oral administration of an oral placebo versus a preoperative 600 mg dose of clindamycin. After randomization the study medication was administered orally 1 h before surgery in a double-blind fashion. For a period of 4 weeks the postoperative course was observed according to clinical parameters of infection. Primary end-point was infection at the surgical site. RESULTS: The mean age of the study population was 44.4 years (SD 11.4, range 18-82 years) with a sex distribution of 147 females (47.4%) and 109 males (42.6%). Mean age of the patients in the clindamycin group was 44.7 years (SD 12.0), and the mean age in the placebo group was 44.1 years (SD 10.8) (P = 0.49). In the clindamycin group, the mean duration of surgery was 32.3 min (SD 8.8) and in the placebo group the mean duration of surgery was 32.5 min (SD 8.4) (P = 0.89). Two infections [1.6%; 95 confidence interval (CI): 0.48-4.72] were identified in the clindamycin group and four (3.2%; 95 CI: 0.42-1.33) in the placebo group (P = 0.448). CONCLUSIONS: No statistically significant difference was found between clindamycin prophylaxis and placebo with regard to the prevention of postoperative infection in endodontic surgical procedures.     

Condylar changes after orthognathic surgery for class III dentofacial deformity: a systematic review

After orthognathic surgery for class II dentofacial deformity, remodelling of the mandibular condyle will take place. In a number of cases, this may evolve towards a phenomenon of condylar resorption. Yet, studies on the occurrence of this complication after the correction of a class III deformity are scarce. A systematic review of the literature was performed with the aim of identifying reports on condylar resorption or remodelling after orthognathic surgery for class III dentofacial deformity. A search of the international databases yielded 12 eligible studies. Eight studies reported some degree of postoperative condylar remodelling, while symptoms of condylar resorption were only described in a limited group of patients. Thus, the literature may show evidence of condylar remodelling after orthognathic treatment of class III patients, and anecdotal reports of condylar resorption exist. The small sample sizes, heterogeneity in methods and outcomes, and use of two-dimensional radiographs indicate the need for updated long-term research. In the future, the use of cone beam computed tomography data for volumetric and morphological condylar analysis in combination with three-dimensional cephalometry may provide the opportunity to further elucidate this phenomenon and better characterize its aetiology.