Eficacia de la monoterapia con Piperacilina-tazobactam en infecciones del área maxilofacial
Efficacy of single drug therapy with piperacillin-tazobactam in infections of the maxillofacial area

Whatever the surgical speciality, infection is always one of the complications most feared by the surgeon. In the Maxillofacial Surgery area, this is no less true and its extremely serious complications, derived from the cervico-facial anatomy complex, to which these infections may give rise are well known.¹

In the development and registry process of new antibiotics, experiments in maxillofacial area infections are not generally included. The most modern antibiotics are generally late in incorporating these infections into the treatment and when they do so, it is generally the analogue with another type of polymicrobian infections that determines its incorporation. Thus, the study published in this number of the journal,² that provides experience with the use of piperacillintazobactam in maxillofacial area infections, is well received and constitutes an example of that mentioned.

Piperacillin-tazobactam is the association of a penicillin with antipseudomonal activity with a beta-lactamase inhibitor that extends the spectrum against enterobacterias and staphylococci while providing very wide coverage against anaerobic bacterias. Its efficacy has been documented in neutropenic patients as well as in respiratory, skin, soft tissue and intraabdominal infections.³

It is true that most of the bacteria that form a part of the «normal» native flora of the oral cavity are usually sensitive to penicillin and thus, resistance to antibiotics is not one of the essential problems invoked in maxillofacial infections. However, sooner or later, the maxillofacial surgeon faces resistant pathogens, either due to the appearance of nosocomial post-surgical infections or to care of weakened patients who have pathogens such as resistant enterobacteria or Pseudomonas aeruginosa among their oral flora. The oral flora is made up of a combination of multiple species in delicate equilibrium. Weakening diseases, systemic stress conditions and, above all, antibiotic treatment, condition the alteration of this microflora complex.⁴ Infections that are produced in this context may be protagonized, therefore, by enterobacteria or non-fermenting gram-negative bacteria, resistant to the antibiotics generally used to treat orofacial infections.

Several studies have demonstrated that, in serious infections with bacteriemias⁵ and nosocomial pneumonias,⁶ inadequate choice of antibiotic (understood as such the choice of an empiric treatment that does not cover the finally isolated pathogen) conditions greater mortality independently of other factors. Repeatedly, in addition, these studies show that correction after receiving the microbiological report is of little use. There is nothing that leads us to think that when the infection is serious, the same does not occur in maxillofacial area infections. Thus, in certain contexts, the choice of empiric antibiotic treatment for orofacial infections should be wide spectrum. The Delgado Sánchez et al.² study makes it possible to verify piperacillin-tazobactam as an adequate option for the empiric treatment of serious maxillofacial area infections in which the participation of enterobacteria or Pseudomonas aeruginosa is suspected.

In anticipation of the most likely pathogens and their potential resistances, three considerations are essential: baseline pathology, epidemiological setting of resistances and background of previous administration of antibiotics. In this way, choice of treatment of the same anatomical-clinical entity could vary considerably, depending on the patient context in which it takes place.

However, the optimum administration of antibiotic treatment goes beyond the simple choice of a drug active against infection causing pathogens. We now increasingly speak about «optimization» of the antibiotic treatment.⁷ With this term, we include those strategies that make it possible to obtain the maximum benefit of the antibiotics while minimizing their adverse effects, among which the selection of resistant bacteria is included. Among these strategies, dosing according to pharmacodynamic criteria,⁸ reduction in treatment duration⁹ or intravenous-oral sequential therapy¹⁰ are included. The short duration of the intravenous treatment reported in the study presented in this number is also a good example of individualized administration of the antibiotic treatment, an area in which there is considerable need for investigation.

The antibiotic treatment is, thus, a much more dynamic and complex matter then that which we generally find in the tables appearing in most of the book chapters or reviews and requires much more individualization than generally believed. Strictly, we should not establish antibiotic treatments semiautomatically based on no more than an anatomic territory. It is better to rationally respond to a series of systematically posed questions. These include the anticipation of the most likely involved pathogens, the selection of the antibiotic based on suspicion and the characteristics of the host, relevance of the combined therapy, optimized choice of dosage, rational selection of the administration route, necessary treatment duration and adaptation to the correctly interpreted microbiological results. 

Prescription based on the correct response to each one of these questions would be the best antibiotic policy and would provide the patients the maximum benefit of these excellent drugs, threatened by the emergence of new resistances originated by their not always careful use.

J. Cobo Reinoso
Servicio de Enfermedades Infecciosas
Hospital Ramón y Cajal. Madrid, España

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