What alternative antibiotic should be used for periodontal disease with persistent fevers despite treatment with amoxicillin (Amoxicillin)?

From the Guidelines

For persistent fevers after periodontal procedures despite amoxicillin treatment, azithromycin is the recommended alternative antibiotic, given its significant beneficial effects on probing depth, clinical attachment level, and bleeding on probing, as evidenced by the most recent study 1. When considering the management of periodontal disease with persistent fevers after a procedure, despite being on amoxicillin, it's crucial to prioritize the patient's morbidity, mortality, and quality of life. The current evidence suggests that azithromycin offers significant benefits in reducing probing depth and improving clinical attachment levels, making it a preferable choice over other antibiotics in this context. Key points to consider in the management of such cases include:

• The use of azithromycin as an adjunct to scaling and root planning (SRP) has shown significant reductions in probing depth and improvements in clinical attachment levels 1.
• The choice of antibiotic should be guided by the most recent and highest-quality evidence, which currently supports the use of azithromycin in the treatment of periodontal disease, especially in cases not responding to amoxicillin 1.
• It's essential to continue supportive measures, including good oral hygiene, warm salt water rinses, and adequate hydration, alongside the antibiotic treatment.
• If symptoms do not improve within 48-72 hours on the new antibiotic regimen, immediate reassessment is necessary, and hospitalization for IV antibiotics might be required.
• Collecting samples for culture and sensitivity testing before changing antibiotics, if possible, can help guide the choice of the most appropriate antibiotic therapy.

From the FDA Drug Label

Clindamycin is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. Bacteriologic studies should be performed to determine the causative organisms and their susceptibility to clindamycin The patient should be switched to clindamycin if they are allergic to penicillin or if amoxicillin is not effective, and the infection is suspected to be caused by anaerobic bacteria, streptococci, staphylococci, or pneumococci that are susceptible to clindamycin 2.

• The choice of antibiotic should be based on bacteriologic studies and susceptibility patterns.
• Clindamycin should only be used to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.

From the Research

Periodontal Disease Treatment

• The use of systemic antimicrobials as an adjunct to non-surgical periodontal therapy has been explored in several studies 3, 4, 5.
• For patients with persistent fevers after procedure despite being on amoxicillin, alternative antibiotic options may be considered.

Alternative Antibiotic Options

• Metronidazole may be used as an alternative or in combination with amoxicillin 3, 4, 5.
• Azithromycin is another option that has been studied as an adjunct to non-surgical periodontal therapy 4, 5.
• Other antibiotics such as doxycycline, tetracycline, and clindamycin have also been investigated 4.

Considerations for Antibiotic Selection

• The choice of antibiotic should be based on the specific needs of the patient and the severity of the periodontal disease 6, 7.
• The potential for adverse events and antibiotic resistance should also be considered when selecting an antibiotic 3, 4, 5.

Combination Therapy

• The combination of amoxicillin and metronidazole has been shown to be effective in reducing probing pocket depth and improving clinical outcomes 3, 5.
• Other combinations, such as metronidazole alone or azithromycin, may also be effective 4, 5.