JAC Advance Access originally published online on January 29, 2008
Journal of Antimicrobial Chemotherapy 2008 61(4):960-962; doi:10.1093/jac/dkn030
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Research letters |
‘Grandmother penicillin’—not in vogue, but clinically still effective
1 Department of Oral and Maxillofacial Surgery, University of Kiel, Germany 2 Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia 3 Institute for Infection Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany 4 Department of Medicine, Royal North Shore Hospital, University of Sydney, Australia
* Corresponding author. Department of Oral and Maxillofacial Surgery, University of Kiel, Arnold-Heller-Str. 16, 24105 Kiel, Germany. Tel: +49-431-597-2821; Fax: +49-431-597-4084; E-mail: warnke{at}mkg.uni-kiel.de
Keywords: abscess , antibiotics , antimicrobial agents , antimicrobial management , antimicrobial resistance surveillance , antimicrobials , β-lactams , dental , in vitro susceptibility , oral
Sir,
Although dental health in the developed world is improving, patients with acute dentoalveolar or odontogenic abscesses still present frequently at dental surgeries or emergency units.1 Following its discovery by Fleming in 1928,2 penicillin has long been recognized as an effective standard therapy in patients with orofacial infections. However, penicillin is no longer in favour3 due to the more frequent isolation of resistant bacteria from abscesses of odontogenic origin.4,5 Therefore, alternative antibiotics such as erythromycin, clindamycin, tetracycline and levofloxacin have been considered and recommended for patients with failure of penicillin regimen or allergy.4,6 Newer studies recommend levofloxacin or moxifloxacin, modern 8-methoxyquinolone antibiotics, as potential rational choices for odontogenic infections, due to high in vitro activity against oral pathogens.7 Therefore, we are ascending the ladder of our antibiotic weaponry, unfortunately simultaneously increasing the risk of further resistance to these additional classes of drugs. But do these in vitro investigations correlate with common day-to-day clinical experience?
We examined the spectrum of oral pathogens found in acute odontogenic abscesses and their susceptibility to penicillin as well as to other antibiotics recommended in dental practice, including clindamycin, doxycycline, amoxicillin with clavulanic acid and moxifloxacin.
One hundred and eighty-eight swabs were obtained from 94 patients with acute odontogenic abscesses in the years 2002–04. None of the patients received antibiotic treatment prior to the collection of specimens. The same patients who provided the bacterial swabs were investigated retrospectively for their clinical outcome, as the in vitro tests were performed separately from the clinical treatment. The clinical treatment followed a standard regimen. In minor dentoalveolar abscesses, no antibiotic cover was administered after incision. Only in severe abscesses with risk of progression and signs of systemic involvement or in immunocompromised patients was penicillin administered following surgical intervention. If multiple intra- and extra-oral incisions were required and the condition of the patient was deteriorating, amoxicillin with clavulanic acid was given. Clindamycin was the first choice in the case of β-lactam antibiotic allergy. This study investigated whether the described standard treatment regimen was sufficient or if an alternative newer antibiotic such as moxifloxacin was necessary in any case.
The study was performed in the Department of Oral and Maxillofacial Surgery and the Institute for Infection Medicine at the University of Kiel, Germany. The protocol adhered to the ethical tenets of the Declaration of Helsinki. After appropriate informed consent, each subject signed a declaration to confirm accordance to participate.
A total of 517 bacterial strains were isolated from 94 patients with odontogenic abscesses. Ninety-two of 94 abscesses (98%) were polymicrobial. Three hundred and sixteen (61%) of the isolates were aerobes or facultative aerobes, and 201 (39%) of the isolates were anaerobes. The average number of isolates was 5.5 per patient. The most prevalent bacteria were the viridans streptococci group (170 isolates) representing 53.8% of the aerobic/facultative anaerobic bacteria. Prevotella spp. (106 isolates) comprised 52.7% of the strict anaerobes and were the predominant species in that group. Other bacteria identified were present at significantly lower levels. In no patient were any multiresistant strains such as methicillin-resistant Staphylococcus aureus (MRSA) identified (Table 1).
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Susceptibility testing revealed that over 98% of the aerobes/facultative aerobes and 95.5% of the anaerobes were susceptible to moxifloxacin in vitro. Amoxicillin with clavulanic was less effective against aerobes and facultative aerobes with 71.2% found to be susceptible, but showed the greatest efficacy against the anaerobes with 99.5% being susceptible. Doxycycline (69.3%/93.5%) and clindamycin (64.2%/97.0%) demonstrated moderate efficacy against the first-named aerobes and facultative aerobes, but good efficacy against the secondary anaerobes. The corresponding values for penicillin were lowest at 62% and 77.6%, respectively. However, it is important to note that penicillin was effective against more than 80% of the viridans streptococci and
75% of Prevotella spp., which were identified as the dominant strains in oral abscesses. In the clinical collective, patients with minor abscesses received surgical treatment but no antibiotics (36.4%). Penicillin was administered to 30.4% of the patients. Amoxicillin with clavulanic acid was given in 18.2% and clindamycin in 15.1%. Ninety-two of the 94 patients showed significant recovery with the described treatment. Only two cases required the use of other antibiotics. An advanced antibiotic such as moxifloxacin was not required in any case.
This study demonstrates that penicillin is not the most potent antibiotic against odontogenic abscesses flora in vitro when compared with amoxicillin with clavulanic acid, clindamycin, doxycycline or the modern moxifloxacin. Moxifloxacin proved the most potent in vitro against isolated aerobic bacteria (>98%) and returned good results for anaerobic bacteria (>95%). However, it also does show that the dominant strains of the majority of oral abscesses are still susceptible to traditional penicillin. These observations are in accordance with our clinical experience. We suggest that in addition to adequate surgical abscess drainage, an additional intravenous penicillin regimen is sufficient for the rapid resolution of clinical symptoms in the majority of patients with severe odontogenic abscesses.
Therefore, we still stick to the long-standing ‘grandmother’ penicillin as our antibiotic of first choice in patients with severe odontogenic abscess even though, through the results of in vitro analyses, it would no longer seem to be in vogue.
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This study was supported in part (first 30 patients) by Bayer Vital GmbH, Leverkusen, Germany.
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None to declare.
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1 Lewis MA, Meechan C, MacFarlane TW, et al. Presentation and antimicrobial treatment of acute orofacial infections in general dental practice. Br Dent J (1989) 166:41–5.[CrossRef][Web of Science][Medline]
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3 Durack DT, Littler WA. Letter: failure of ‘adequate’ penicillin therapy to prevent bacterial endocarditis after tooth extraction. Lancet (1974) ii:846–7.
4 Guralnick W. Odontogenic infections. Br Dent J (1984) 156:440–7.[CrossRef][Web of Science][Medline]
5 Sands T, Pynn BR, Katsikeris N. Odontogenic infections: part two. Microbiology, antibiotics and management. Oral Health (1995) 85:11–21. 23.[Medline]
6 Rasmussen BA, Bush K, Tally FP. Antimicrobial resistance in anaerobes. Clin Infect Dis (1997) 24(Suppl 1):S110–20.[Web of Science][Medline]
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Sobottka I, Cachovan G, Sturenburg E, et al. In vitro activity of moxifloxacin against bacteria isolated from odontogenic abscesses. Antimicrob Agents Chemother (2002) 46:4019–21.
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