Amoxicillin for wisdom tooth infection

The lesions are associated with fever and toxicity and are noted to spread outward. The rash itself is a scarlet-red or salmon color with well-defined borders. Facial erysipelas may spontaneously resolve in 4 to 10 days (7).

Superficial infections may be treated orally for 10 days, while more aggressive infections require parenteral therapy.

Typical antimicrobial regimens include clindamycin , nafcillin , or a third generation cephalosporin. C ellulitis : Streptococcal cellulitis is an acute inflammation of the skin and subcutaneous tissues resulting from infection of burns, wounds, or surgical sites or following minor trauma.

Symptoms include fever and toxicity and may be associated with lymphangitis or bacteremia.

Cellulitis can be differentiated from erysipelas by noting that the skin lesion of cellulitis is not raised and the demarcation between involved and uninvolved skin is indistinct.

Therapy should consist of a semisynthetic, penicillinase-resistant penicillin, since it is often difficult to differentiate streptococcal from staphylococcal cellulitis (7). In patients who are penicillin allergic, a first generation cephalosporin may be used.

Therapy can be given orally, unless there is evidence of lymphangitic spread. If lymphangitis is noted, parenterally administered antimicrobials should be used until there is marked clinical improvement. Oral antimicrobials can then be used to complete 10 days of therapy.

N ecrotizing Fasciitis (Streptococcal Gangrene): GAS necrotizing fasciitis is a rapidly progressing infection of the deep subcutaneous tissues and fascia with extensive and rapidly spreading necrosis.

Infections often spare the skin, but 50% of patients may have associated myonecrosis.

Necrotizing fasciitis is often associated with severe systemic involvement and an associated high mortality rate (7,80,87). As in other invasive streptococcal and staphylococcal skin infections, the site of inoculation is usually at area of minor trauma or the skin lesions of varicella.

Like streptococcal bacteremia, there is a clear association between varicella and necrotizing fasciitis.

Varicella is characterized by full-thickness dermal lesions that may induce selective immunosuppression to GAS, though this amoxicillin ambimox 500mg has not been substantiated (7).

Necrotizing fasciitis caused by mixed infections, involving both aerobic and anaerobic Gram negative bacteria, is more likely to occur in the abdominal wall, following abdominal surgery or in diabetic patients. Early and aggressive surgical debridement of the site of infection as well as appropriate antimicrobial therapy is required.

Due to the "inoculum effect," penicillin may be less effective in the treatment of necrotizing fasciitis (83). Appropriate antibiotics include nafcillin and clindamycin (7,83). M yositis /Myonecrosis: Myositis is a purulent infection of the muscles, normally occurring in the tropics and caused by S. Infections of the muscles are rarely caused by group A streptococcus but can occur.

Infections occur following mild trauma, in toxic shock, and spontaneously. It is often difficult to differentiate streptococcal myonecrosis from necrotizing fasciitis, as the clinical features overlap, and the two entities often occur together. Fatality rates have been reported to be as high as 80 and 100% (78,80). Therapy includes extensive debridement of the infected muscle and parenterally administered antimicrobials. Penicillin has poor efficacy in the treatment of GAS myonecrosis, and aggressive surgical debridement remains the most important factor in treatment (83). The failure of penicillin is attributed to decreased expression of penicillin-binding proteins during the stationary growth phase and the slow growth of group A streptococcus. This is known as the Eagle effect and has been described elsewhere (83). Clindamycin , erythromycin , and ceftriaxone have been more effective than penicillin in experimental models (83). L ymphangitis : Lymphangitis may occur in association with cellulitis or after a clinically minor skin infection.

When group A streptococcus is implicated as the etiologic agent, therapy consists of parenterally administered penicillin .

When the cause of the infection is in doubt, nafcillin can be used to provide coverage for S. Patients allergic to penicillin can be treated with a first generation cephalosporin, clindamycin , or vancomycin (8). P uerperal Sepsis: Puerperal sepsis occurs during pregnancy or during an abortion, when group A streptococcus colonizing the patient invades the endometrium and surrounding structures as well as the lymphatics and bloodstream.

Endometritis and septicemia result and can be complicated by pelvic cellulitis, thrombophlebitis, peritonitis, or pelvic abscess. Therapy consists of aggressive surgical exploration and parenterally administered penicillin or clindamycin (see section on myositis/myonecrosis).

Patients allergic to penicillin can be treated with a first generation cephalosporin, clindamycin, or vancomycin (8). V ulvovaginitis : Group A streptococcus is a common cause of vulvovaginitis in the prepubertal female. Symptoms include a serous vaginal discharge, erythema of the vulvar area, and intense pruritus.

Therapy consists of orally administered penicillin for 10 days. Patients allergic to penicillin can be treated with erythromycin .

P roctitis : Perianal cellulitis (proctitis or asymptomatic anal infection) has been associated with several reported outbreaks of hospital-acquired streptococcal infection.

Because it is difficult to differentiate streptococcal cellulitis from staphylococcal cellulitis, it is advisable to use a first generation cephalosporin, such cephalexin , for therapy. F unisitis and Omphalitis: Omphalitis is an infection of the umbilical cord and surrounding tissues.

aureus , group B streptococcus, and Gram negative enteric organisms. Combination therapy is normally provided while culture results are pending and consists of a semisynthetic penicillin , such as oxacillin and gentamicin .

Patients allergic to penicillin can be treated with a first generation cephalosporin.

Group A Streptococcal Toxic Shock Syndrome (StrepTSS) StrepTSS usually occurs secondary to soft tissue infections, particularly as a secondary infection of varicella lesions or as a complication of necrotizing fasciitis, myositis, pneumonia, or post-partum infection.

M-type l GAS has been the predominant serotype associated with StrepTSS, but types 3, 12, and 28 have been implicated as well (7,80,87).

Recent interest in the pathophysiology of this disorder has focused on the role of streptococcal pyrogenic exotoxins (SPEs), extracellular products of group A streptococci that mediate not only scarlatiniform-like rashes but also multi-organ damage and shock. These toxins were rarely associated with GAS strains in the United States until the recent increase in the number of cases of StrepTSS (7,87). SPEA is the most common exotoxin found in the United States and has been shown to be both a superantigen and a potent inducer of tumor necrosis factor (7). SPEB has also been implicated but more commonly occurs in episodes of StrepTSS in European countries (7,80,87). Recently, nicotine adenine glycohydrolase (NADase) has been linked with the resurgence of severe invasive group A streptococcal infections (86).

The patient with StrepTSS requires intensive management of hemodynamic abnormalities and vital functions. Patients with a soft tissue focus of infection may require surgical intervention.

Broad spectrum antibiotic coverage should be instituted until the presence of group A streptococcus has been confirmed. Therapy may then consist of parenterally administered clindamycin . In StrepTSS, tissue destruction continues despite high concentrations of penicillin .

Penicillin is known to be relatively ineffective in the treatment of soft tissue infections with a high concentration of organisms (the Eagle effect) (83,85).

This is thought to be due to the slow rate of replication of group A streptococci, decreased expression of penicillin-binding proteins, and the fact that penicillin acts by interfering with cell wall synthesis (83,85).

Clindamycin inhibits protein synthesis, decreases the production of M proteins and toxins, and is unaffected by slow growing toxin-producing streptococci (83,85).

showed that by the 4th day of therapy, the frequency of capsular expression by GAS was significantly lower in patients treated with clindamycin than in patients treated with penicillin (9).

A mouse model of a soft tissue infection with GAS showed clindamycin to be more effective than penicillin (83). Erythromycin and ceftriaxone may also be more effective than penicillin in such cases.

Accompanying the increase in number and severity of invasive group A streptococcal infections is an increase in the incidence of group A streptococcal bacteremia. There have been a number of cases associated with intravenous drug abuse as well as nosocomial outbreaks in nursing homes.

Intravenous drug use has become the leading cause of GAS bacteremia in individuals between the ages of 14 and 40 years (78).

Bacteremia usually follows a cutaneous focus of infection but may follow an upper respiratory infection.

In addition, the number of children with varicella who develop GAS bacteremia has increased (26). reported an increased incidence of GAS bacteremia in patients with varicella from 7% to 50% at their institution (26). GAS bacteremia in varicella is thought to occur secondary to a superinfected cutaneous lesion.

Serotypes M1 and M3 have been most commonly isolated in patients with GAS bacteremia. Serotypes M1, M3, and M18 are more invasive and are associated with higher morbidity and mortality rates than M4 and M12, which are generally considered less virulent. M type 1 strains produce pyrogenic exotoxins A and B, and the latter toxin also has associated proteinase activity (7).

Therapy for GAS bacteremia consists of parenterally administered penicillin . Patients allergic to penicillin can be treated with clindamycin , vancomycin, or a first generation cephalosporin. Pneumonia secondary to group A streptococcus is frequently associated with preceding or concurrent viral infections such as measles, varicella, or influenza. Since the mid 1980s, the number of reports describing this association has increased. Up to 30% of patients with GAS pneumonia have a history of group A streptococcal upper respiratory tract infection (8).

Empyema develops in 40% of patients, and bacteremia in 15%. Other complications include mediastinitis, pericarditis, pneumothorax, and bronchiectasis.

Therapy consists of surgical drainage of an empyema and parenteral penicillin . Adequate drainage of pleural infection may be difficult and frequently requires prolonged chest tube drainage, thoracoscopy or pleural surgery.

P eritonsillar Abscess (AQuinsy@): Peritonsillar abscess results from direct extension of group A streptococcus from an acute pharyngitis.

However, a peritonsillar abscess may yield mixed flora as well. Needle aspiration or surgical drainage of the abscess as well as antimicrobials are usually required. Indications for needle aspiration include severe pain and trismus, difficulty swallowing, and poor response to antimicrobials alone. Patients can be treated orally for 10 days with either a first generation cephalosporin such as cephalexin , clindamycin , or amoxicillin-clavulanic acid, if they appear nontoxic and can maintain adequate hydration.

Some patients may require initial treatment with a parenteral antibiotic and be discharged to home on oral antibiotics to complete a 10 day course. Tonsillectomy at the time of surgical incision and drainage can provide improved drainage, prevent recurrences, and permit earlier discharge.

Patients with a known allergy to cephalosporins can be treated with clindamycin.

P eritonsillar Cellulitis: Occasionally, peritonsillar cellulitis occurs without development of a localized abscess. Like peritonsillar abscesses, peritonsillar cellulitis results from direct extension of an acute tonsillopharyngitis and may result solely from group A streptococcus but can include mixed oral flora as well.

Patients with mild symptoms who can maintain adequate hydration can be treated orally with a first or second generation cephalosporin such as cephalexin or cefazolin . Patients with a known allergy to cephalosporins can be treated with clindamycin .

Patients with severe trismus or inadequate hydration can be treated parenterally with clindamycin or a first generation cephalosporin

such

Tonsillectomy can ensure complete recovery and prevent recurrences.

R etropharyngeal Abscess: Retropharyngeal abscess also occurs from direct extension of an acute pharyngitis.

Causative organisms include both aerobes and anaerobes. Therapy consists of parenterally administered antimicrobials such as a first generation cephalosporin or clindamycin . Patients who do not respond to antimicrobial therapy or who have impaired respiratory function may require surgical incision and drainage under general anesthesia.

O titis Media and Sinusitis: Otitis media and sinusitis due to group A streptococcus normally are secondary to direct extension from a streptococcal infection occurring in the upper respiratory tract.

With persistent infection, an appropriate alternative would be amoxicillin/clavulanate . In patients allergic to amoxicillin, erythromycin or clindamycin is an acceptable alternative. Oral cephalosporins can be effective as well in patients who have not had amoxicillin and contraceptive pill immediate hypersensitivity reactions to penicillin .

U vulitis : Uvulitis can occur alone or in association with acute pharyngitis or epiglottitis (50).

influenzae type b infection, recent immunization strategies have greatly decreased its incidence.

However, uvulitis can occur secondary to group A streptococcus, usually as a complication of an acute pharyngitis (50).

Parenteral therapy should be used, directed against both group A streptococcus and H. Patients can be discharged on an oral antibiotic to complete a 10 day course of therapy. C ervical Lymphadenitis: Cervical lymphadenitis secondary to group A streptococcus infection can result from direct extension from an acute pharyngitis or direct inoculation. Since the etiologic agent is not always known, therapy is initially directed against the most common organisms, which include S. Therefore, a first generation cephalosporin, such as cephalexin , or a ?-lactamase-resistant penicillin should be given enterally for 10 days. If the infection persists or the patient develops signs of systemic toxicity, parenteral antibiotics should generally be used.