消化器の先生よりご相談
肝硬変の患者が、39度の熱発と歯の痛みを訴えている
患者さんは「前も同じような歯の感染があった」といっており
歯医者で処置等を行っていたようです。
そこで、歯科受診までの抗菌薬投与をどうするか？
基本的な菌としては
In the healthy periodontium, the microflora are sparse and consist mainly of gram-positive organisms, such as Streptococcus sanguinis and Actinomyces spp. In the presence of gingivitis, the predominant subgingival flora shift to a greater proportion of anaerobic gram-negative bacilli, with Prevotella intermedia as the predominant isolate.
歯周病としては
Periodontal disease is caused by tissue destruction due to inflammation induced by a predominantly anaerobic periodontopathic subgingival plaque flora. In well-established periodontitis, the flora further increase in complexity with a preponderance of anaerobic gram-negative bacilli and motile organisms. Aggregatibacter (Actinobacillus) actinomycetemcomitans (a HACEK infection), Porphyromonas gingivalis, Prevotella intermedia, Treponema denticola, and Tannerella forsythensis (formerly, Bacteroides forsythus) are the predominant isolates.
忘れてはいけないのが心臓関連性
Chronic poor oral health and tooth loss may be associated with modest increases in coronary and cerebrovascular disease; this effect appears to persist after adjustment for known cardiovascular disease risk factors.
そして、抗菌薬選択
| Clinical entity | Common causative organisms | Antimicrobial regimens |
| Supragingival dental plaque and dental caries prevention | Streptococcus mutans, other streptococci, Actinomyces spp | Fluoride-containing toothpaste (sodium fluoride, 1.1 percent or stannous fluoride, 0.4 percent) two or three times daily AND/OR |
| Fluoride-containing varnishes (sodium fluoride, 5 percent) applied three or four times yearly AND/OR | ||
| Chlorhexidine, 0.12 percent oral rinse | ||
| Gingivitis 歯肉炎 | ||
| Acute simple gingivitis | Streptococci, Actinomyces spp, spirochetes | Penicillin G 2 to 4 MU IV every four to six hours (OR penicillin V 500 mg every six to eight hours), PLUS metronidazole 500 mg PO every eight hours OR |
| Amoxicillin-clavulanate 875 mg PO every 12 hours or 500 mg PO every eight hours OR | ||
| Ampicillin-sulbactam 1.5 to 3 g IV every six hours OR | ||
| Clindamycin 450 mg PO or 600 mg IV every six to eight hours | ||
| Ulcerative or acute necrotizing ulcerative gingivitis | Prevotella intermedia, Fusobacterium spp, Tannerella forsythia, Treponema denticoli, other oral spirochetes | Metronidazole 500 mg PO or IV every eight hours OR |
| Amoxicillin-clavulanate 875 mg PO every 12 hours or 500 mg PO every eight hours OR | ||
| Ampicillin-sulbactam 1.5 to 3 g IV every six hours OR | ||
| Clindamycin 450 mg PO or 600 mg IV every six to eight hours | ||
| Periodontitis 歯周炎 | ||
| Early onset, "aggressive" or "localized juvenile" periodontitis | Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, Prevotella intermedia | Doxycycline 200 mg PO or IV every 12 hours (only in patients eight years of age or older) OR |
| Metronidazole 500 mg PO or IV every eight hours | ||
| Adult periodontitis | Treponema denticoli, other oral spirochetes, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia | Topical minocycline microspheres (Aristin®) OR |
| Topical doxycycline hyclate periodontal extended-release liquid (Atridox®) | ||
今回は、肝硬変のため、肝代謝薬剤は使用せず、また水分制限があったため経口が難しいと医師の考えもあり、Ampicillin-sulbactam 1.5 IV every six hours を提案した。
基礎疾患がなく、経口可能であれば、軽症 MINO 重症 サワシリン＋フラジール
を想定しました。
問題点は、投与前の培養検査をどうするか？
血液培養以外は？口腔膿瘍以外は難しいか。