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Antimicrobial Stewardship (AMS)

Resources to help you ensure the safe and effective use of antimicrobials in NSHA patients.

Dental Abscess

  • Dental abscess is characterized by spontaneous pain, formation of purulent material, and localized swelling in the mouth and is caused by an infection of the dental pulp (nerve inside the tooth).
  • It is distinct from irreversible pulpitis, or a toothache, which occurs when the dental pulp becomes inflamed (not infected) due to decay, trauma, or large fillings.

Last reviewed June 2025

  • Viridans group streptococci (VGS):
    • S. mutans
    • S. sanguinis
    • S. mitis
    • S. salivarius
    • Streptococcus anginosus group (S. anginosus, S. intermedius, S. constellatus)
  • Anaerobes

Last reviewed June 2025

  • The mainstay of therapy is definitive, conservative dental treatment (DCDT), e.g., incision and drainage, root canal therapy, or extraction.
    • Antimicrobials prescribed before or after DCDT do NOT appear to improve outcomes like pain or swelling during the procedure.
  • In addition to urgent referral for DCDT, antimicrobials are only recommended if systemic complications are present (e.g., fever, lymphadenopathy, or spreading infection, trismus), or for an immunocompromised patient. Antimicrobials are NOT indicated for toothache or localized dental abscess without systemic symptoms.
  • If DCDT is not imminently available (within 1-2 days) or not feasible, a delayed antibiotic prescription may be considered. Patients may be instructed to fill the antibiotic if systemic symptoms develop while awaiting DCDT.
  • Refer to the hospital or consult OMF or ENT if red flags identified:
    • stridor, odynophagia, rapid progression and the involvement of multiple spaces and secondary anatomic spaces.

Last reviewed June 2025

Antibiotic Adult Regimen Consider additional anaerobic coverage if little improvement after 48 hrs of usual adult regimen
Preferred

Amoxicillin 500 mg PO TID

or

Penicillin VK 300-600 mg PO QID

 Add metronidazole 500 mg PO BID
Penicillin/amoxicillin 
IgE-mediated allergy		 Cefuroxime 500 mg PO BID Add metronidazole 500 mg PO BID
Unable to use any beta-lactam:*

Doxycycline 100 mg PO BID

  • Less activity for oral pathogens compared to beta-lactams
 Add metronidazole 500 mg PO BID
* should be reserved for patients with a history of severe delayed skin reaction/organ dysfunction (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms) to any beta-lactam antimicrobial OR a history of anaphylaxis to cefuroxime (or other cross-reacting beta-lactam) (refer to NS Health beta-lactam allergy document).
  • If none of the recommended antibiotic regimens above can be used, alternatives of last-resort include macrolides like azithromycin (which locally have high rates of resistance to oral pathogens), or clindamycin (which carries a high risk of C. difficile).
  • Note that although amoxicillin/clavulanic acid covers anaerobes, it is excessively broad for treatment of most dental abscesses. Amoxicillin with metronidazole is the preferred alternative.

Last reviewed June 2025

  • 3-5 days as adjunct to DCDT; 7 days maximum
    • Patients can be instructed to discontinue antibiotics 24 hours after symptoms resolve.

Last reviewed June 2025

1. Choosing Wisely Canada: Taking the Bite out of Tooth Pain. A Toolkit on Using Antibiotics Wisely for Managing Tooth Pain in Adults. November 2024. https://choosingwiselycanada.org/toolkit/taking-the-bite-out-of-tooth-pain/

2. Bugs and Drugs. Recommended Empiric Therapy of Selected Dental Infections. https://www.bugsanddrugs.org/

3. The Canadian Association of Hospital Dentists. Choosing Wisely Canada. Hospital Dentistry – Eight Tests and Treatments to Question. May 2024. https://choosingwiselycanada.org/recommendation/hospital-dentistry/

4. Chao T, Lee C, Faculty of Dentistry, Dalhousie University. Antibiotics in Dentistry. Available from: Antibiotic-and-analgesics-summary-sheet-1.pdf

5. Cope AL, et al. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database of Systematic Reviews. 2024(5). https://doi.org/10.1002/14651858.CD010136.pub4

6. Lockhart PB, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal-and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. The Journal of the American Dental Association. 2019 Nov 1;150(11):906-21

Last reviewed June 2025

Infective Endocarditis Prophylaxis Before Dental Procedures

  • Historically, preventative antibiotics were prescribed to patients with a range of heart conditions undergoing dental procedures, as transient bacteremia induced by the procedure from oral bacteria, like viridans group streptococci, was felt to significantly increase the risk of infective endocarditis (IE) or other infections. Evidence and guidance have changed with time.
  • Antibiotic prophylaxis is NOT recommended for those with prosthetic joints undergoing dental procedures to prevent prosthetic joint infection.

Last reviewed June 2025

  • Most people with a cardiovascular condition do not require routine preventative antibiotics before a dental procedure to reduce the risk of IE.
    • The risks of adverse effects of antibiotics and development of drug resistance generally outweigh the benefits of prophylaxis.
  • IE is more likely to develop from routine activities like toothbrushing and chewing food than from infrequent dental procedures.
    • Maintaining good oral health through regularly scheduled dental visits and daily oral hygiene should be recommended to all patients to decrease the incidence of bacteremia associated with daily activities.
  • A single dose of preventative antibiotics (Table 2) is recommended only in the following populations at highest risk for poor outcomes of IE (Table 1a), when undergoing select dental procedures (Table 1b).
Table 1a. Populations for whom dental prophylaxis should be prescribed Table 1b. Dental procedures warranting antibiotic prophylaxis in high risk populations
  • Prosthetic cardiac valve or material
  • History of endocarditis
  • Certain congenital heart disease (CHD)*
  • Cardiac transplant recipients who develop cardiac valvulopathy
 Procedures involving manipulation of gingival tissue, dental periapical regions, or perforation of the oral mucosa
*Unrepaired cyanotic CHD (i.e., Tetralogy of Fallot, Transposition of Great Arteries, Tricuspid Atresia, Total Anomalous Pulmonary Venous Return), including palliative shunts and conduits; completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by transcatheter during the first 6 months after the procedure; repaired CHD with residual defects at the site of or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization); surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit.

Last reviewed June 2025

Give as a single dose 30 to 60 minutes pre-procedure

Place in Therapy Antibiotic Regimen

 

Oral

 Preferred Amoxicillin 2 g PO
Penicillin/amoxicillin IgE-mediated allergy Cefuroxime 500 mg PO
Unable to use any beta lactam* Doxycycline 100 mg PO

 

Unable to take oral medication

 Preferred Ampicillin 2 g IV
Penicillin/amoxicillin IgE-mediated allergy Ceftriaxone 1 g IV
Unable to use any beta lactam* Clindamycin 600 mg IV
* should be reserved for patients with a history of severe delayed skin reaction/organ dysfunction (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms) to any beta-lactam antimicrobial OR a history of anaphylaxis to cefuroxime (or other cross-reacting beta-lactam) (refer to NS Health beta-lactam allergy document).

Last reviewed June 2025

1. Choosing Wisely Canada: Taking the Bite out of Tooth Pain. A Toolkit on Using Antibiotics Wisely for Managing Tooth Pain in Adults. November 2024. https://choosingwiselycanada.org/toolkit/taking-the-bite-out-of-tooth-pain/ 

2. Wilson WR, et al. Prevention of viridans group streptococcal infective endocarditis: a scientific statement from the American Heart Association. Circulation. 2021 May 18;143(20):e963-78.

3. Chao T, Lee C, Faculty of Dentistry, Dalhousie University. Antibiotics in Dentistry. Available from: Antibiotic-and-analgesics-summary-sheet-1.pdf

4. CDA Board of Directors. CDA Position on Prevention of Infective Endocarditis, revised February 2024. Available at: https://www.cda-adc.ca/en/about/position_statements/infectiveendocarditis/

5. Bugs and Drugs. Recommended Empiric Therapy of Selected Dental Infections. https://www.bugsanddrugs.org/

Last reviewed June 2025