歯の感染

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

Antimicrobial regimens for the prevention of dental caries and the treatment of periodontal disease in adults

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®)

IV: intravenous; MU: million units; PO: by mouth.

Graphic 77718 Version 5.0

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。