PCP prophylaxis and Dental cleaning prophylaxis

[Wendy Beltrami]

Hi All,
I posted this message on the Aplastic Central site and thought I'd double post here to see what experiences you all have had with prophylactic meds.

I have encountered some AA patients who were not prescribed any type of prophylaxis for PCP although for the majority, it certainly seems to be standard. Grant was on Bactrim/Septra for about 7 years and then when we switched to another doc, they immediately took him off that and put him on Pentamidine which he hated (the taste of the vapor during treatment). The new docs felt that Bactrim/Septra carried some risk of marrow suppression. I had questioned his other doctors many times and they assured me that it was standard protocol. I think it is standard for leukemia patients and many other cancers but the doctors more experienced in dealing with AA, tend to lean toward pentamidine (at least that has been my experience). Now that he is off cyclosporine and prograf and taking no immunosuppressant meds, we have also been allowed to stop the pentamidine (much to his delight).

However, he is still prescribed prophylactic antibiotics when he has a dental cleaning if his ANC is below 1000. Which brings us to the situation that we encountered last week. Since Grant's ANC is still in the 700-900 range, his docs felt it was still important to use prophy with dental cleaning. So, he took a big blast of amoxicillin one hour prior to cleaning (I think it was 2500mg) which is the standard protocol. He had counts done 3 days prior and his hgb was 8.1. Three days after the cleaning, his hgb was 6.5 and his ALT and AST (liver enzymes) were also flagged high, being triple and quadruple what they normally are. I looked back six months prior when he had his last cleaning and followed the same protocol with amoxicillin. Sure enough, the SAME drastic drop in counts within the same time frame. In addition to the drop in hgb which was the most significant, plts and ANC also dropped.

We will certainly NOT use amoxicillin again for dental prophylaxis. We hadn't done a chem panel last time so I couldn't determine whether the AST and ALT also were affected but I'm guessing that they were since one done 3.5 weeks later showed AST and ALT at the very highest end of normal.

Jeeze! Another example of the treatment contributing more to the problem than to the cure! This always seems to be the problem with AA.

Also wanted to mention that the wbc count is really not very important. It's really all about the ANC. You can have a low wbc and still be in good shape with a decent ANC. Anything above 1000 and you're home free. It's when you start to go below 500 that gets really dicey.

For example, even though Grant's wbc was 3.0 a while back (low), his ANC was 1500 (normal). On last check, his wbc was only 1.6 but ANC was still 700 which isn't great but is certainly no reason for him to stay home from school or avoid crowds. Handwashing is always important as is staying away from sick people, but the number of neutrophils is most important. Actually, I have also been told by hemo that adding the number of monocytes to the number of neutrophils can also be factored in when determining your degree of protection.

Anybody else have experience with dental prophylaxis meds?

Wendy/mom to Grant

[Jbsx19]

Hi Wendy,

Although I can't specifically respond to your question about the dentist, I can tell you that, as a patient at NIH, I was not put on Bactrim.As long as I was on the Cyclosporine, I was required to go once a month for Pentamidine treatments for the prevention of Pneumocystis,(which I'm sure you are aware is a life threatening Pneumonia that even an adequate neutrophil count does not protect against). I have spoken with other people who have raised the issue of Bactrim, so I looked it up in the PDR and this is what I found:

Sulfamethoxazole, an ingredient in Bactrim, is one of a group of drugs called sulfonamides, which prevent the growth of bacteria in the body. Rare but sometimes fatal reactions have occurred with use of sulfonamides. These reactions include Stevens-Johnson syndrome (severe eruptions around the mouth, anus, or eyes), progressive disintegration of the outer layer of the skin, sudden and severe liver damage, a severe blood disorder (agranulocytosis), and a lack of red and white blood cells because of a bone marrow disorder.

Notify your doctor at the first sign of an adverse reaction such as skin rash, sore throat, fever, joint pain, cough, shortness of breath, abnormal skin paleness, reddish or purplish skin spots, or yellowing of the skin or whites of the eyes.

Frequent blood counts by a doctor are recommended for patients taking sulfonamide drugs

Pretty scary that a drug that can cause blood disorders,bone marrow failure,etc is prescribed for patients already suffering from bone marrow failure
disease and blood disorders.

Anyway, I believe that my VSAA was at least partially caused by an antibiotic I was on, Dynacin, which also states in the PDR can cause blood and bone marrow disorders..one of which is neutopenia...I was not on any antibiotics when sent home from NIH..just temperature taking and some Levaquin in the house "just in case my temp went over 101" and instructed to then go to the ER..Needless to say ..Everything went fine ..never needed the Levaquin or the ER and my blood counts never dropped, once I was home from NIH.I have had some dental issues (mostly gums) probably from the AA or some of the medications.

SO , I hope that I helped in some small way and hope that you and your family are doing well.
Take care, Judi

[Andrea Pecor]

Wendy,

Hi, an old friend here, I just wanted to respond regarding amoxicillin for dental work. I'm afraid my experience doesn't lend much to the discussion but I wanted to throw it out there anyway. I always take amoxicillin an hour before I go to the dentist, even just for a cleaning, not because of my AA but because I have had a hip replacement (due to avascular necrosis from Prednisone). It is easy for infection to get into the system through the gums and go right to a prosthesis. I have never had an adverse reaction to the antibiotic. That being said, my hematologist usually recommends that I forego a visit to the dentist, unless it is an emergency, if the ANC is low - below 1000, as you say.

I am so sorry to hear of Grant's ongoing problems - I wish you all the best.

Andrea Pecor