Alternative Antibiotics for Tooth Infections in Patients Allergic to Clindamycin and Penicillin
For patients allergic to both clindamycin and penicillin, azithromycin or clarithromycin are the recommended first-line alternatives for treating tooth infections. 1
First-Line Options
- Azithromycin is typically given for 5 days and is a reasonable option for patients with allergies to both penicillin and clindamycin 2, 1
- Clarithromycin is an alternative macrolide that requires a 10-day course of therapy 2, 1
- These macrolides have activity against most common odontogenic pathogens, though their effectiveness is somewhat more limited than clindamycin 1, 3
Treatment Considerations
- Macrolide resistance rates among oral pathogens in most areas of the United States are approximately 5%-8%, which should be considered when prescribing these medications 2
- Erythromycin is another macrolide option but is associated with substantially higher rates of gastrointestinal side effects than azithromycin or clarithromycin 2, 4
- Dosing recommendations:
Important Precautions
- Macrolides (especially erythromycin and clarithromycin) can cause prolongation of the QT interval in a dose-dependent manner 2
- These medications should not be taken concurrently with inhibitors of cytochrome P-450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitor antidepressants 2
- Monitor for treatment response and consider alternative therapy if no improvement is seen within 2-3 days 1, 3
Medications to Avoid
- Tetracyclines should not be used due to high prevalence of resistant strains and high incidence of gastrointestinal disturbances 2, 4
- Sulfonamides and trimethoprim-sulfamethoxazole are not effective against many oral pathogens and should not be used 2
- Older fluoroquinolones (e.g., ciprofloxacin) have limited activity against common oral pathogens and should be avoided 2
- Newer fluoroquinolones (e.g., levofloxacin, moxifloxacin) are active against oral pathogens but have an unnecessarily broad spectrum and are expensive, so they are not recommended for routine treatment 2
Special Situations
- For severe infections with systemic symptoms, consultation with an infectious disease specialist may be warranted 1
- In cases of treatment failure with macrolides, culture and sensitivity testing should be performed to guide antibiotic selection 1
- Drainage of abscesses and other appropriate dental interventions should always accompany antibiotic therapy for optimal outcomes 3, 4