Antibiotic resistance in odontogenic infections: A systematic review of current evidence and implications for guideline-based therapy

OBJECTIVES: This review aims to summarize and evaluate the current evidence on antibiotic resistance in odontogenic infections, with a special focus on empirical therapy, resistance patterns, and guideline-based recommendations. The update of the German S3 guideline “Odontogenic Infections” provides the clinical and methodological framework for this review. MATERIALS AND METHODS: A systematic literature search was performed to identify studies published between 2016 and 2025 on antibiotic resistance in odontogenic infections. Both retrospective and prospective studies were included. Special attention was given to resistance rates of commonly used antibiotics and the differentiation of therapy in patients with suspected penicillin allergy. The selected studies were integrated into the German guideline development process to ensure relevance and consistency with current clinical practices. RESULTS: The review confirms increasing resistance rates for Penicillin G/V and aminopenicillins, particularly against Staphylococcus spp. In contrast, the combination of an aminopenicillin with a beta-lactamase inhibitor remains effective in most cases. Clindamycin shows notable resistance and is associated with higher rates of adverse effects. Recent studies suggest that certain cephalosporins, such as cefazolin, may be safe alternatives for patients with non-confirmed penicillin allergies. Clinical strategies such as PEN-FAST scoring and de-labeling are gaining increasing importance in managing suspected allergies. CONCLUSIONS: Empirical antibiotic therapy in odontogenic infections should be based on current resistance data and individualized patient risk profiles. Aminopenicillins with beta-lactamase inhibitors remain the first-line choice; clindamycin should be reserved for selected cases with a justified suspicion of penicillin allergy. CLINICAL RELEVANCE: This review supports evidence-based antibiotic selection and promotes individualized therapy decisions to improve outcomes and minimize the development of antibiotic resistance. The findings have been integrated into the updated German S3 guideline, providing practical recommendations for dental and surgical care.