Dentists are writing too many antibiotic prescriptions before dental procedures—approximately 80.9%, to be exact—for patients who do not need them, according to a University of Illinois (UIC) College of Pharmacy study. The findings indicate dental practices should ramp up their antibiotic stewardship efforts.
In the study, “Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015,” published in JAMA Network Open, researchers analyzed 168,420 adult dental visits by 91,438 patients in which antibiotic prophylaxis was prescribed. The team reviewed American Heart Association (AHA) and American Dental Association (ADA) guidelines to decide whether the patients and procedures were suitable for antibiotic prophylaxis, and determined which patients were issued appropriate prescriptions. Of those patients, 42.5% had prosthetic devices, and 20.9% had cardiac conditions associated with a high risk of adverse outcomes from endocarditis.
Overall, however, investigators determined only 19.1% of the antibiotic prescriptions were appropriate per guidelines. These findings are significant, as dentists are the number one prescribers of clindamycin in the United States, which is associated with Clostridioides difficle infection.
The factors associated with unnecessary antibiotic prophylaxis included patients with prosthetic joint devices, dental visits with tooth implant procedures, female patients, prescriptions for clindamycin, and visits occurring in urban areas and the Western United States.
“While these results may seem shocking, unfortunately, they are consistent with unnecessary antibiotic prescribing by dentists in other countries,” says Katie Suda, PharmD, MS, associate professor at the UIC College of Pharmacy. “However, our results should initiate a call to action to professional organizations, public health and advocacy groups to improve prescribing of antibiotic prophylaxis prior to dental procedures. As high prescribers of antibiotics, dentists should be included in the national antibiotic stewardship conversation.”
Physicians in the Southern United States were found to have the highest antibiotic prescribing rates and the highest unnecessary prescribing rates. However, when the team looked at dentists, they found the majority of antibiotics prescribed were in the Midwest, and the highest unnecessary prescribing of preventive antibiotics occurred in Western states.
In clinical practice, oral health professionals should base a decision on whether to prescribe antibiotic prophylaxis after reviewing a patient’s medical and dental history. They should also use the AHA’s and ADA’s recommendations for guidance on what antibiotic to prescribe to prevent an adverse effect.
“Dentists are the experts on preventive antibiotics for oral health care. Thus, dentists can also assist in educating physicians on when antibiotics are, or are not, recommended by professional guidelines,” says Suda. “Dental hygienists can assist dentists with screening patients for appropriate preventive antibiotics. Dental hygienists can also set patient expectations that an antibiotic may not be necessary and may, in fact, cause harm.”
Prior to 2013, the ADA and American Academy of Orthopedic Surgeons recommended antibiotic prophylaxis before dental procedures for certain patients with prosthetic joints. The guidelines have since been revised. The AHA 2007 recommendations suggest antibiotic prophylaxis prior to a dental procedure only for patients with underlying cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, but not for those at moderate risk.
The authors did note one positive finding: unnecessary prescribing decreased over the study period, which indicates guideline changes are being implemented in clinical care. But more work is needed, and UIC College of Dentistry, in collaboration with UI Health, is leading these efforts. The college is the first to document the development of comprehensive Antibiotic Stewardship Programs in dental practice. “The ability to inform future providers about evidence-based concepts of appropriate prescribing can help turn the tide as these practitioners enter clinical practice and share the knowledge with colleagues,” says Susan A. Rowan DDS, executive associate dean and associate dean for clinical affairs at UIC College of Dentistry.
Dental offices can find more strategies for fighting antibiotic resistance in the U.S. Centers for Disease Control and Prevention’s Antibiotic Resistance Threats in the United States, 2013.
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