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|Newsletters: Antibiotic Prophylaxis for TPNers Undergoing Dental and Other Procedures|
Antibiotic Prophylaxis for TPNers Undergoing Dental and Other Procedures
Suzanne Treen, PharmD Candidate
Many dental, surgical and diagnostic procedures involving the mucosal surfaces lead to bacteria in the bloodstream that rarely lasts more than 15 minutes. But for people with indwelling venous catheters such as “permanently” placed central lines, there is a risk of bacteria seeding the line and causing line contamination and bloodstream infection or sepsis. (Fortunately, consumers of enteral nutrition don’t run this kind of risk because they don’t have an IV line.)
Symptoms usually develop a couple of days to two weeks after the procedure. Bacterial seeding is most common with dental procedures, including cleaning, and less common with gastrointestinal diagnostic procedures. Because of the potential dangers, TPN consumers should discuss this issue with their physician before undergoing any dental, surgical and other procedures.
To reduce the potential for bacterial seeding, the best possible oral health should be maintained. This requires daily brushing, flossing and fluoride rinsing, and a chlorhexidine gluconate mouth rinse before a dental procedure.
Antibiotics are also recommended for all dental procedures, including cleanings. The following regimens are recommended to prevent the most likely bacteria from lodging on venous catheter lines.
Oral antibiotics for patients able to absorb some food:
1. Amoxicillin (from the penicillin family) is the drug of choice. Three grams should be taken one hour before the procedure and 1.5 grams should be taken six hours after the first dose. Amoxicillin is well absorbed in the upper part of the gastrointestinal tract and provides high serum levels of long duration.
2. Erythromycin* is an alternative antibiotic for patients allergic to penicillin. A dose of 800 mg of erythromycin ethylsuccinate or 1 gram of erythromycin stearate should be taken two hours before the procedure, and half the dose six hours after the first dose. These two forms of erythromycin have the fastest and most reliable absorption. Erythromycin is absorbed in the upper part of the gastrointestinal tract. The absorption of the ethylsuccinate form is enhanced by food.
3. Clindamycin is another alternative. A dose of 300 mg should be taken one hour before the procedure and 150 mg should be taken six hours after the first dose. The bioavailability of clindamycin is increased in patients with inflammatory bowel diseases such as Crohn’s disease.
Parenteral antibiotics for patients not able to take oral medications:
1. Ampicillin (from the penicillin family) is the drug of choice. Two grams IV or IM should be given 30 minutes before the procedure and 1 gram should be administered six hours after the first dose.
2. Clindamycin is an alternative antibiotic for patients allergic to the penicillins. A dose of 300 mg IV should be given 30 minutes before the procedure and 150 mg should be given six hours after the first dose.
Antibiotic coverage for gastrointestinal procedures is not routine but may be desirable for patients with a history of sepsis involving organisms of gastrointestinal origin, such as gram negative bacilli. Antibiotic coverage for gastrointestinal procedures may also be desirable for patients with a severe bowel inflammation or probable bacterial overgrowth.
*In the above article, erythromycin is recommended as an oral antibiotic prophylactic for HPN patients who are penicillin sensitive and undergoing dental procedures. Please note there is a potential drug interaction between erythromycin and cisapride (Propulsid), a drug used frequently by HPNers with bowel dismotility syndromes. Cisapride uses the same disposal mechanism (hepatic 450 system 3A4 isoenzyme) as several antibiotics, including erythromycin, fluconazole, clarithromycin and miconazole. Use of cisapride with these antibiotics over an extended period of time, can lead to cisapride build up and cardiotoxicity. If you have questions about this or other drug interactions we suggest you check with your physician and/or pharmacist.