Journal of Indian Academy of Oral Medicine and Radiology

: 2018  |  Volume : 30  |  Issue : 2  |  Page : 100--101

Pre-antibiotics era to post-antibiotic era

Sadaksharam Jayachandran 
 Department of Oral Medicine and Radiology, Tamil Nadu Govt. Dental College, Tamil Nadu Dr. MGR Medical University, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. Sadaksharam Jayachandran
Department of Oral Medicine and Radiology, Tamil Nadu Govt. Dental College and Hospital, Tamil Nadu Dr. MGR Medical University, Chennai - 600 003, Tamil Nadu

How to cite this article:
Jayachandran S. Pre-antibiotics era to post-antibiotic era.J Indian Acad Oral Med Radiol 2018;30:100-101

How to cite this URL:
Jayachandran S. Pre-antibiotics era to post-antibiotic era. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2023 Jan 28 ];30:100-101
Available from:

Full Text



Microorganisms have threatened humanity with infection since time immemorial. During the pre-antibiotic era, infections had high morbidity and mortality. Virulent organisms with the potential to spread infection at a very rapid rate used to cause widespread outbreak, epidemics, or pandemics. Alexander Fleming discovered first antibiotic, “the magic bullet” penicillin in the year 1928, with which patients were effectively treated in life-threatening infections. This was a huge relief to the medical practitioners. Next three decades there was development and discovery of a wide variety of antimicrobial agents. The pace of discovery of newer molecules saw a downfall from 1970 to 1987. Since then there is discovery void level till now noting the post-antibiotic era. Many drugs useful in the prime of antibiotics era are becoming less effective owing to mutations in the microorganisms. Now medical and dental practitioners have to treat and manage infections with equal or greater efficiency with same amount of antibiotic resources available.

 Rationale of Using Antibiotics for Oral Infections

Oral cavity harbors highest number of microorganisms compared to any other part of the human body, comprising protective and harmful bacteria. The balance between them decides health or disease state of oral cavity and body per se. Antibiotics are prescribed in dentistry for treatment as well as prevention of infection. When prescribed rationally, antibiotics are beneficial in patient care. However, the widespread use of antibiotics has led to development of resistance in common bacteria to drugs that once controlled them. Selection and spread of resistant microorganisms in the presence of antimicrobials is facilitated by irrational use of drugs, self-medication, and misuse of drugs. These factors lead to the development of altered mechanisms in the pathophysiology of microbes as a survival strategy. Now the antibiotic kills the susceptible microbes and allows elective replication of resistant bacteria that already existed or susceptible bacteria acquired resistance. As a result resistant bacteria multiply abundantly to replace the susceptible bacteria and this leads to treatment failure or ineffective management.

Resistant microorganisms survive antibiotics, antifungals, antivirals, and antimalarials; standard treatments become ineffective and infections persist, increasing the risk of spread to others. It is a good practice to do appropriate investigations in all suspected infections for diagnosis, prognosis, and follow-up of these infections. Prior to starting antimicrobial therapy, samples should be sent for microbiological investigations. Choice of antibiotics should be made based on antibiotic susceptibility of the causative organism and in case of spectrum of antibiotics being available to choose the factors like toxicity, efficacy, rapidity of action, pharmacokinetics, and cost of available drug spectrum should be considered and most effective, least toxic, and least expensive antibiotic should be chosen. If the causative agent is not known and delay in initiating therapy may be a threat to life or risk serious morbidity empirical antimicrobial therapy based on a clinically defined infection is justified however in such cases as well the necessary specimens should be collected before commencing empirical therapy.[1]

Deviation from standard treatment line is required while treating certain groups of patients. These include pregnant and lactating mothers, pediatric, and geriatric group of patients, patients with compromised immune status and heart ailments. While dealing with pregnant lady or lactating mother, considerations should be undertaken regarding the teratogenic potential of the prescribed medicine. To determine this risk the United States Food and Drug Administration has classified drugs based on the level of risk they pose to the fetus. Drugs in categories A and B are considered safe for use, whereas drugs in category C may be used only if the benefits outweigh the risks. Drugs in category D are avoided with some exceptional circumstances, while drugs in category X are strictly avoided in pregnant women. Choice of antibiotic to be prescribed should be made based on risk versus benefit status.[2]

In pediatric patients, conservative use of antibiotics is indicated to minimize the risk of developing resistance to current antibiotic regimens. Dental infection should be treated with drainage through root canal or incision alone if no systemic signs are present. Dose alterations should be based on age and weight of patient.[3]

Geriatric patients are usually at high risk for infectious diseases due to combination of factors, including immune senescence, altered skin and mucosal barrier function, degenerative changes in bone and cartilage, and reduction in respiratory capacity. Their multiple comorbidities, polypharmacotherapy, impending disabilities, and functional impairments are unique challenge. Early administration of appropriate antimicrobials is a key strategy in management of infectious diseases in geriatric patients.[4]

Use of antibiotics is recommended as prophylactic measure for cardiac patients at the risk of developing infectious endocarditis (IE). Cardiac conditions that require prophylactic antibiotics include prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts, prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords; previous IE, unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device and cardiac transplant. Other conditions that may require consideration for antibiotic prophylaxis include the patients with previous late artificial joint infection, increased morbidity associated with joint surgery, patients undergoing treatment of severe and spreading oral infections, patient with increased susceptibility for systemic infection, congenital or acquired immunodeficiency, patients on immunosuppressive medications, diabetics with poor glycemic control, patients with systemic immunocompromising disorders, patient in whom extensive and invasive procedures are planned, and prior to surgical procedures in patients at a significant risk for medication-related osteonecrosis of the jaw.[5]

For patients already receiving an antibiotic that is also recommended for IE prophylaxis, then a drug should be selected from a different class; for example, a patient already taking oral penicillin for other purposes may likely have in their oral cavity viridians group streptococci that are relatively resistant to beta-lactams.[6]

In addition to choice of drug, selection of mode of administration also should be given importance and drugs that can be effective locally should be avoided to be administered systemically that can be beneficial to patient in terms of decreased systemic toxicity, decreased chances of resistance, convenience, and cost effectiveness. Various local drug delivery systems are available including mucoadhesive polymer films, mucoadhesive buccal slow-release tablet formulation periochip, etc.


Decision to use of antibiotics and choice of antibiotics to be prescribed are important in order to treat the condition as well as prevention of resistance. Rational use of antibiotics is demand of our time. It is important to treat the patient as a whole rather than treating just a disease, as multiple systems are at work influencing the treatment.


1National Treatment Guidelines for Antimicrobial Use in Infectious Diseases, Version 1.0. National Centre For Disease Control, Ministry of Health & Family Welfare Government of India; 2016.
2Cengiz SB. The pregnant patient: Considerations for dental management and drug use. Quintessence Int 2007;38:e133-42.
3American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on use of antibiotic therapy for pediatric dental patients. Pediatr Dent 2010-2011;33(Suppl):262-4.
4Beckett CL, Harbarth S, Huttner B. Special considerations of antibiotic prescription in the geriatric population. Clin Microbiol Infect 2015;21:3-9.
5Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA,et al. 2017. AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017;135:e1159-e1195.
6Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736-54.