Antibiotic prescribing by general dentists in the United States, 2013

Antibiotics Prescribing Pattern and Quality of Prescribing in Croatian Dental Practices-5-Year National Study

PURPOSE

Antibiotic resistance is one of the biggest threats to global health today. The aim of this study was to analyze antibiotic prescribing patterns and quality of prescribing in Croatian dental practices over a 5-year period.

METHODS

This is a retrospective observational study based on the analysis of the electronic prescriptions (medicines in ATC groups J01 and P01) from dental practices in Croatia prescribed from 1 January 2015 to 31 December 2019. Prescriptions were retrieved from the Croatian Health Insurance Fund (HZZO). The analyses included the number of prescriptions, type and quantity of prescribed drugs, indication, and the patient's and prescriber's characteristics.

RESULTS

The consumption increased from 1.98 DID in 2015, to 2.10 DID in 2019. The most prescribed antibiotic was Amoxicillin with clavulanic acid followed by Amoxicillin, Clindamycin, Metronidazole and Cefalexin. The analyses showed that 29.79% of antibiotics were not prescribed in accordance with the contemporary guidelines for the proper use of antibiotics. Additionally, 22% of antibiotics were prescribed in inconclusive indications.

CONCLUSION

The research showed an increase in antibiotic consumption over five years along with unnecessary prescribing of antibiotics in cases with no indications for its use. The development of national guidelines for antibiotic use is necessary.

Impact of stewardship intervention on antibiotic prescribing prior to dental procedures in a veteran population

BACKGROUND

Dentists are an overlooked group of prescribers but are responsible for up to 10% of antibiotic prescriptions written in the United States annually, most of which are for prophylaxis. Dental prophylaxis in orthopedic patients has been an area of confusion, with discordance among societal guidelines. In 2020, an antimicrobial stewardship (AS) group spearheaded a collaborative effort among dental, orthopedic surgery, and infectious diseases specialties to develop a protocol for the use of dental antibiotic prophylaxis for patients with total joint replacements (TJRs) based on the most current American Dental Association-American Academy of Orthopaedic Surgeons statement.

OBJECTIVE

This study aimed to assess antibiotic prescribing for dental prophylaxis before and after an AS intervention.

METHODS

This study is an interventional, pre-post review of dental encounters with patients with a history of TJR before (October 2019 to July 2021) and after (August 2021 to April 2023) the intervention. Charts were reviewed to determine the frequency and appropriateness of dental procedure prophylactic antibiotics.

RESULTS

A total of 1587 encounters from October 2019 to April 2023 were identified. Notably, 179 encounters in the pre- and 183 encounters in the postgroup were analyzed, 31 encounters (17%) in the pregroup versus 33 (18%) in the postgroup had a prophylactic antibiotic associated with it (P > 0.05), 26 of 31 antibiotics (84%) in the pregroup were prescribed for prosthetic joint infection prophylaxis compared with 18 of 33 (55%) in the postgroup (P > 0.05), and 151 of 179 encounters (84.3%) were guideline adherent in the preintervention group compared with 160 of 183 encounters (87.4%) in the postintervention group (P > 0.05).

CONCLUSION

This study observed a shift in the distribution of antibiotic indications and a decreased rate of inappropriate prophylactic prescriptions in dental patients with a history of TJR after an AS-led, collaborative intervention. Although the overall rate of prophylactic antibiotic prescribing remained the same and the changes did not reach statistical significance, lessons learned through this process can help inform future interventions in our institution and for others.

Antibiotic prescribing practices for prophylaxis and therapy of oral/dental infections in pediatric patients - results of a cross-sectional study in Turkey

Aim

Antibiotics are often prescribed for the treatment of various infections and prophylactic purposes in dental practice. Their improper use can cause microbial resistance to antibiotics, which poses a world-wide threat. The aim of this cross-sectional study was to evaluate the knowledge and attitudes of dentists and dentistry students about antibiotic prescription practices for prophylaxis and the treatment of dental infections in pediatric patients.

Methods

A questionnaire was e-mailed to 2,100 dentists and 300 senior dentistry students. The questionnaire was filled out by the participants within a 2-month period (May-June 2020). A 30-point scoring system was developed to assess the knowledge levels of the dentists according to the guidelines. Descriptive statistical analyses were performed. One-way ANOVA test and the Chi-Squared test were used to compare qualitative variables.

Results

The response rate was found to be 24.2% for dentists and 49% for senior dentistry students. 19.4% of the participants were found to be moderately knowledgeable and 80.6% of them were highly knowledgeable. Students' knowledge scores were found to be higher than the general dentists and other specialists (p<0.05). There was no significant difference between students and pedodontists.

Conclusion

Dentists were found to have sufficient knowledge about the usage of antibiotics in children, but there is still a lack of information about circumstances under which antibiotics should not be prescribed. Dentists and dentistry students should attend continuing education programs to keep their information up-to-date and should also prescribe antibiotics in adherence with the current guidelines to prevent antibiotic resistance.

Antibiotic prescriptions for oral diseases in India: evidence from national prescription data

INTRODUCTION

The key objective of this research was to describe the prescription rate of various antibiotics for dental problems in India and to study the relevance of the prescriptions by analysing antibiotic types associated with different dental diagnoses, using a large-scale nationally representative dataset.

METHODS

We used a 12-month period (May 2015 to April 2016) medical audit dataset from IQVIA (formerly IMS Health). We coded the dental diagnosis provided in the medical audit data to the International Statistical Classification of Diseases and Related Health Problems (ICD-11) and the prescribed antibiotics for the diagnosis to the Anatomic Therapeutic Chemical (ATC) -2020 classification of the World Health Organization. The primary outcome measure was the medicine prescription rate per 1,000 persons per year (PRPY₁₀₀₀).

RESULTS

Our main findings were-403 prescriptions per 1,000 persons per year in the year 2015 -2016 for all dental ailments. Across all ATC level 1 classification, 'Diseases of hard tissues' made up the majority of the prescriptions. 'Beta-lactam', 'Penicillin,' and 'Cephalosporins' were the most commonly prescribed antibiotics for dental diagnoses followed by 'Macrolides' and 'Quinolones'. 'Dental caries', 'Discoloration of tooth', and 'Toothache' were the most common reasons for 'Beta-Lactams' and 'Penicillin' prescriptions.

CONCLUSION

To conclude our study reports first ever country (India) level estimates of antibiotic prescription by antibiotic classes, age groups, and ICD-11 classification for dental ailments.

Antibiotic prescription after tooth extraction in adults: a retrospective cohort study in Austria

BACKGROUND

Broad spectrum antibiotics are often used for the prophylaxis of infectious endocarditis and treatment of odontogenic infections, but there are limited data related to antibiotic use and adherence to prescription guidelines.  METHODS: Data from patients with tooth extraction between 2014 and 2018 were selected from a database of a regional health insurance fund. We created three data sets, one based on all tooth extractions, one on multiple teeth extractions, and one including only single tooth extraction. After data collection, descriptive analysis was carried out. The differences in prescription pattern of antibiotic medicine were tested by χ² test, Student´s t-test or ANOVA.

RESULTS

From 43,863 patients with tooth extraction, 53% were female, and 3,983 patients (9.1%) filled a prescription for antibiotic medicine. From 43,863 patients, 157 patients (0.4%) had endocarditis risk, but only 8 patients of these (5.1%) filled an antibiotic prescription. In total, 9,234 patients had multiple and 34,437 patients had only one tooth extraction. Patients with more than one tooth extraction received more often antibiotic treatment (10.7%) compared to those with single tooth extractions (χ² = 36; p < 0,001). Patients with more than one tooth extraction were older, however, younger patients received antibiotics more frequently (t = 28,774, p = 0.001). There was no relationship with endocarditis risk status. Clindamycin and amoxicillin/clavulanic acid were the most frequently prescribed antibiotic medicines.

CONCLUSIONS

In this retrospective cohort study, dentists did not discriminate prophylactic antibiotic prescription with regard to endocarditis risk status. A factor influencing prescribing behaviour of antibiotic medicines was the number of extracted teeth.

Evaluation of antibiotic prescribing for ambulatory patients seeking primary dental care services in a public hospital in Ghana: a clinical audit study

Background

One in 10 of all antibiotic prescriptions globally are for dental conditions with 80% of them being inappropriate, making it a potential driver of antimicrobial resistance.

Objectives

To evaluate the appropriateness of antibiotic use among ambulatory patients seeking dental care services in a public hospital in Ghana.

Methods

A retrospective clinical audit was conducted by extracting the medical records of all patients seeking dental care at the ambulatory care clinic of Keta Municipal Hospital (KMH) from January 2020 to December 2020 using the hospital’s electronic database. Descriptive statistics, bivariate and multivariate analysis were performed on the data collected.

Results

Overall, 1433 patient medical records were extracted from the database within the study period. The mean age of the patients identified was 39.9 years with almost two-thirds being female. The majority (91.1%, n = 1306) of them were attended to by a dental nurse. In total, 88.6% (n = 1269) of the patients received antibiotics and 87.5% (n = 1254) of antibiotics prescribed were non-compliant with Ghana Standard Treatment Guidelines. Three-quarters of the dental conditions were managed with dual antibiotics comprising amoxicillin and metronidazole. Antibiotic prescription was associated with age, gender, type of prescriber and type of dental condition diagnosed.

Conclusions

There is a high usage of antibiotics for dental conditions managed at the outpatient section of the hospital and most are inappropriate. Development of local guidelines supported by education of dental clinicians on empirical use of antibiotics is a suitable target for the antimicrobial stewardship team to address in KMH.

Opportunities for penicillin allergy evaluation in dental clinics

OBJECTIVE

To evaluate opportunities for assessing penicillin allergies among patients presenting to dental clinics.

DESIGN

Retrospective cross-sectional study.

SETTING

VA dental clinics.

PATIENTS

Adult patients with a documented penicillin allergy who received an antibiotic from a dentist between January 1, 2015, and December 31, 2018, were included.

METHODS

Chart reviews were completed on random samples of 100 patients who received a noncephalosporin antibiotic and 200 patients who received a cephalosporin. Each allergy was categorized by severity. These categories were used to determine patient eligibility for 3 testing groups based on peer-reviewed algorithms: (1) no testing, (2) skin testing, and (3) oral test-dose challenge. Descriptive and bivariate statistics were used to compare facility and patient demographics first between true penicillin allergy, pseudo penicillin allergy, and missing allergy documentation, and between those who received a cephalosporin and those who did not at the dental visit.

RESULTS

Overall, 19% lacked documentation of the nature of allergic reaction, 53% were eligible for skin testing, 27% were eligible for an oral test-dose challenge, and 1% were contraindicated from testing. Male patients and African American patients were less likely to receive a cephalosporin.

CONCLUSIONS

Most penicillin-allergic patients in the VA receiving an antibiotic from a dentist are eligible for penicillin skin testing or an oral penicillin challenge. Further research is needed to understand the role of dentists and dental clinics in assessing penicillin allergies.

Clinical features and antimicrobial susceptibility of oral bacteria isolated from the blood cultures of patients with infective endocarditis

Background/purpose

The epidemiology of infective endocarditis (IE) is under constant change due to the aging society and increases in antimicrobial-resistant pathogens. However, IE remains severe. This study aimed to review the current clinical characteristics of IE and the antimicrobial susceptibility of oral bacteria (OB) isolated from blood cultures to implement appropriate antimicrobial prophylaxis.

Materials and methods

We retrospectively investigated the clinical features of 180 patients with IE in whom OB and pathogens except OB (eOB) were identified as causative microorganisms via blood cultures. The susceptibility of the OB group to eight antibiotics was examined by broth microdilution.

Results

Among causative microorganisms, the isolation rate of staphylococci was slightly higher than that of OB; however, the difference was not significant (36.7% vs. 33.8%, p = 0.3203). The number of patients with underlying cardiac disease was significantly higher in the OB group than in the eOB group (53.7% vs. 34.1%, p = 0.0113). Only one ampicillin-resistant OB was detected (2.0%). OBs were significantly less susceptible to clarithromycin and azithromycin than to ampicillin (98.0% vs. 66.7% and 98.0% vs. 60.0%, p = 0.0003 and p = 0.0003, respectively). Moreover, OBs were significantly less susceptible to clarithromycin and azithromycin than to clindamycin (66.7% vs. 88.2% and 60.0% vs. 88.2%, p = 0.0301 and p = 0.0217, respectively).

Conclusion

OBs were susceptible to ampicillin. However, the susceptibility of OBs to clarithromycin and azithromycin was significantly lower than that to ampicillin and clindamycin. These results are important and should help decisions regarding guide antimicrobial prophylaxis.

Postextraction infection and antibiotic prescribing among veterans receiving dental extractions

OBJECTIVE

To characterize postextraction antibiotic prescribing patterns, predictors for antibiotic prescribing and the incidence of and risk factors for postextraction oral infection.

DESIGN

Retrospective analysis of a random sample of veterans who received tooth extractions from January 1, 2017 through December 31, 2017.

SETTING

VA dental clinics.

PATIENTS

Overall, 69,610 patients met inclusion criteria, of whom 404 were randomly selected for inclusion. Adjunctive antibiotics were prescribed to 154 patients (38.1%).

INTERVENTION

Patients who received or did not receive an antibiotic were compared for the occurrence of postextraction infection as documented in the electronic health record. Multivariable logistic regression was performed to identify factors associated with antibiotic receipt.

RESULTS

There was no difference in the frequency of postextraction oral infection identified among patients who did and did not receive antibiotics (4.5% vs 3.2%; P = .59). Risk factors for postextraction infection could not be identified due to the low frequency of this outcome. Patients who received antibiotics were more likely to have a greater number of teeth extracted (aOR, 1.10; 95% CI, 1.03-1.18), documentation of acute infection at time of extraction (aOR, 3.02; 95% CI, 1.57-5.82), molar extraction (aOR, 1.78; 95% CI, 1.10-2.86) and extraction performed by an oral maxillofacial surgeon (aOR, 2.29; 95% CI, 1.44-3.58) or specialty dentist (aOR, 5.77; 95% CI, 2.05-16.19).

CONCLUSION

Infectious complications occurred at a low incidence among veterans undergoing tooth extraction who did and did not receive postextraction antibiotics. These results suggest that antibiotics have a limited role in preventing postprocedural infection; however, future studies are necessary to more clearly define the role of antibiotics for this indication.

Antibiotic prescribing at a periodontal residency practice in Connecticut

BACKGROUND

Antibiotics are important in the treatment of odontogenic infections and the prevention of infection following dental procedures in high-risk situations. Little is known about antibiotic prescribing in periodontal practice. This study describes prescribing practices by periodontal faculty and residents in an academic setting in order to identify opportunities to optimize prescribing behaviors.

METHODS

This cross-sectional study analyzed all antibiotic prescriptions from residents or faculty in an academic periodontal clinic from 2014-2017. Information was manually extracted from the electronic health record. Antibiotic prescriptions were stratified into three indication categories: pre-procedural prophylaxis, post-procedural prophylaxis, and treatment.

RESULTS

Out of 275 prescriptions analyzed, 266 met inclusion criteria. The most frequent antibiotic indication was post-procedural prophylaxis (n = 130, 48.87%). Amoxicillin was the most frequently prescribed antibiotic across all groups (n = 236, 88.72%), followed by clindamycin (n = 22, 8.27%). Most patients presented in a non-emergent setting (n = 200, 75.19%), without pain (n = 210, 78.95%), and had restorative/endodontic-related clinical findings (n = 55, 20.68%). Among the 35 patients receiving antibiotics for infection treatment, 8 (22.86%) underwent a surgical intervention on the date of antibiotic prescription. Of the 130 patients receiving post-procedural prophylaxis, 121 (93.08%) received surgical interventions on the day of antibiotic prescription.

CONCLUSIONS

Antibiotics are prescribed in various situations in periodontal practice, most frequently as post-procedural prophylaxis, an indication for which data is limited. There is an urgent need to study the role of post-procedural prophylactic antibiotics and understand antibiotic prescribing in the management of periodontal disease in order to optimize prescribing practices.

Healthcare Challenges and Future Solutions in Dental Practice: Assessing Oral Antibiotic Resistances by Contemporary Point-Of-Care Approaches

Antibiotic resistance poses a global threat, which is being acknowledged at several levels, including research, clinical implementation, regulation, as well as by the World Health Organization. In the field of oral health, however, the issue of antibiotic resistances, as well as of accurate diagnosis, is underrepresented. Oral diseases in general were ranked third in terms of expenditures among the EU-28 member states in 2015. Yet, the diagnosis and patient management of oral infections, in particular, still depend primarily on empiric means. On the contrary, on the global scale, the field of medical infections has more readily adopted the integration of molecular-based systems in the diagnostic, patient management, and antibiotic stewardship workflows. In this perspective review, we emphasize the clinical significance of supporting in the future antibiotic resistance screening in dental practice with novel integrated and point-of-care operating tools that can greatly support the rapid, accurate, and efficient administration of oral antibiotics.

Prescribing antibiotics by dentists in Colombia: Toward a conscientious prescription

OBJECTIVES

Inappropriate prescription of antibiotics contributes to antibiotic resistance. Therefore, the objective of this study was to determine the awareness, attitudes, and intention to practice of dentists prescribing antibiotics in Colombia in order to design a virtual learning environment on this subject.

METHODS

In a descriptive study across seven cities, 700 dentists from different Colombian cities were requested to complete a validated questionnaire containing five sections: general information, awareness on antibiotic effectiveness and antibiotic resistance, attitudes regarding prescription decision, intention to practice concerning clinical cases, and complementary information. The level of awareness, attitudes, and intention to practice was determined and Chi-square test was used to determine the existence of significant differences among cities.

RESULTS

The majority of dentists showed a medium level regarding the number of correct answers on awareness (62.4 percent) and attitudes (88.7 percent) and a high level on intention to practice (91.7 percent). Common errors within the awareness section included the meaning of the term "antibiotic resistance" (35 percent) and most dentists were not convinced that such resistance could be derived from prescription of antibiotics (51.2 percent). In the attitudes section, only 45 percent declared that they prescribe antibiotics based mainly on symptoms, and the intention to practice section showed a significant percentage of unnecessary prescription (51 percent for pacemaker users) or absence of prescription (53.9 percent for ventricular septal defect) in antibiotic prophylaxis for infectious endocarditis (IE).

CONCLUSION

The dentists interviewed should be trained and made aware of antibiotic resistance, microbiological and clinical foundations, and current antibiotic prophylaxis guidelines.

Carbapenemase Producers Among Extensive Drug-Resistant Gram-Negative Pathogens Recovered from Febrile Neutrophilic Patients in Egypt

Purpose

This study aimed to detect the prevalence of carbapenemase producers (CPs) among extensive drug-resistant (XDR)-carbapenemase producing Gram-negative bacteria (GNB) recovered from various clinical specimens of hospitalized neutrophilic febrile patients in two major tertiary care hospitals in Egypt.

Methods

Standard methods were used to evaluate the antimicrobial susceptibility of clinical isolates according to the guidelines of the Clinical and Laboratory Standards Institute (CLSI). Phenotypic and genotypic analysis of CPs were carried out and statistically analyzed using standard methods.

Results

Three hundred and forty-two GNB were obtained from 342 clinical specimens during the period of the study, where 162 (47%) were enterobacterial isolates, including, 63 (18.4%) Escherichia coli, 87 (25.4%) Klebsiella spp., 5 (1.46%) Enterobacter cloacae, 5 (1.46%) Salmonella spp. and 2 (0.6%) Proteus and 180 (53%) were non-fermentative bacilli including, 129 (37.7%), Acinetobacter baumannii, and 51 (14.9%), Pseudomonas spp. Out of the 342 GNB, 188 (54.9%) isolates were multi-drug resistant (MDR). Of these, 52 (27.6%) were XDR as well as CPs as confirmed phenotypically. The MIC of imipenem against the XDR GNB against showed either low (11 isolates; 21.1%; MIC range =4–32 µg/mL) or high levels of resistance (41 isolates; 78.8%; MIC range = 64-≥1024). The most prevalent carbapenem resistance (CR) genes were blaKPC (63.5%) followed by blaOXA-48 (55.7%) and blaVIM (28.8%). No significant association could be observed between the MIC level and the presence of CR genes (P value >0.05).

Conclusion

High prevalence of MDR (54.9%) and XDR (27.6%) GNB pathogens associated with high levels of resistance to carbapenems were observed. All XDR GNB were CPs and tested positive for at least one of the CR genes. However, most of them (78.8%) showed a high level of CR (MIC range = 64-≥1024) with no significant association with the CR genes.

Antibiotic prescribing habits of the clinicians dealing with dental implant surgery in Turkey: a questionnaire study

PURPOSE

Although various prophylactic and/or postoperative systemic antibiotic regimens have been suggested to minimize failure after dental implant placement and postoperative infection, the role of antibiotics in implant dentistry is still controversial. The purposes of this questionnaire study were to determine the current antibiotic prescribing habits of clinicians in conjunction with dental implant placement and to understand whether any consensus has been reached among implant surgery performing clinicians.

METHODS

An electronic questionnaire was sent by electronic mail to all members of the Turkish Dental Society. The questions were related to whether antibiotics were routinely prescribed either pre- or/and postoperatively during routine dental implant placement. The respondents were also asked to specify their workplace and education. The results were analyzed using SPSS software. Descriptive and chi-square analyses were used to compare categorical data; Kruskal-Wallis test was used to compare the quantitative data by category.

RESULTS

A total of 429 members responded to the questionnaire. The clinicians having more experience had a greater tendency to prescribe preoperative antibiotics (p < 0.001), but there was no statistically significant difference between the postoperative antibiotic prescription choice of the clinician according to the clinicians' experience (p > 0.05). A total of 175 of the clinicians preferred to prescribe preoperative antibiotics when there was systemic comorbidity; 99 of the clinicians preferred to prescribe antibiotics before every implant surgery. The aminopenicillins were the most commonly prescribed antibiotics by the clinicians. A total of 38.58% of the respondents (n = 130) who were prescribing preoperative antibiotics, 2000 mg aminopenicillin was given 1 h before the surgical procedure. Dentists and solo private practitioners were prescribing more preoperative antibiotics (p < 0,05).

CONCLUSIONS

There was no consensus among clinicians regarding the use of antibiotics in association with routine dental implant placement. Aminopenicillins were the most commonly prescribed antibiotics for both pre- and postoperatively. Furthermore, most of the antibiotic regimens being used are not in accordance with the current published data.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2019

Staying current on literature related to antimicrobial stewardship can be challenging given the ever-increasing number of published articles. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship–related peer-reviewed literature that detailed an actionable intervention for 2019. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the actionable intervention used by antimicrobial stewardship programs to provide key stewardship literature for teaching and training and to identify potential intervention opportunities within one’s institution.

Tailored Helicobacter pylori eradication based on prior intake of macrolide antibiotics allows the use of triple therapy with optimal results in an area with high clarithromycin resistance

BACKGROUND

the previous intake of macrolide antibiotics is associated with a failure to eradicate Helicobacter pylori (H. pylori) with clarithromycin-containing regimens. However, the standard triple therapy achieves eradication rates of over 90% in patients without a previous use of macrolides in our health area. The aim of this study was to evaluate the efficacy of an H. pylori eradication strategy based on the intake of macrolides by the patient during the previous years.

METHODS

one hundred and sixty-nine patients with H. pylori infection were prospectively included in the study. The electronic medical record of each patient was reviewed at the time of inclusion. Depending on their previous intake of macrolides, patients were assigned to one of two eradication regimens: group A) patients without a previous intake of macrolides received an optimized triple therapy for 14 days; and group B) patients with a previous intake of macrolides received bismuth quadruple therapy for ten days.

RESULTS

ninety-one patients (53.84%) without a previous intake of macrolides received an optimized triple therapy (group A) and 78 patients (46.15%) with a previous intake of macrolides received bismuth quadruple therapy (group B). In group A, the H. pylori eradication rates were 90.11% in the intention-to-treat and 95.35% in the per-protocol analysis. In group B, the H. pylori eradication rates were 85.89% in the intention-to-treat and 98.5% in the per-protocol analysis. The overall eradication rates obtained using this strategy were 88.16% (95% CI: 82.32-92.02%) in the intention-to-treat and 96.75% (95% CI: 92.59-98.94%) in the per-protocol analysis.

CONCLUSIONS

an H. pylori eradication strategy based on the intake of macrolides during the previous years achieves overall eradication rates close to 90% and allows the use of standard triple therapy in more than half of the patients from a health area with a high level of clarithromycin resistance.

Prescribing patterns in a US dental school from 2010 to 2017

OBJECTIVE

Dental education has an essential role in helping combat the opioid and antibiotic resistance crises. This study evaluates the prescribing practices of clinical instructors, advanced graduate residents, and predoctoral students in an academic dental setting.

METHODS

A retrospective chart review was conducted of electronic dental records from the years 2010 to 2017. The proportions of prescriptions for each drug group was calculated by prescribers' training level and specialty. Descriptive statistics were calculated for the daily opioid Morphine Milligram Equivalent (MME) dose prescribed across years and provider characteristics.

RESULTS

Over the 8 years, 65,160 prescriptions were written for 10,374 patients by 625 prescribers. The most commonly prescribed drugs were for fluoride-based medications (30%) and antibiotics (24%). Periodontists had the greatest absolute number of opioid analgesics prescriptions (n = 2712); oral maxillofacial surgeons (OMFS) prescribed more opioids than other classes of drug (49%) as a proportion of within-specialty prescriptions. Antibiotics were the most common drugs prescribed by endodontists (46%) and second most common drugs prescribed by periodontists (25%), OMFS (28%), and prosthodontists (21%). From 2010 to 2017, the proportion of prescriptions for antibiotics remained unchanged, while that of fluoride-based drugs increased from 2010 to 2014 and plateaued thereafter. The proportion of prescriptions for opioid analgesics decreased from 18% to 7%. The median daily MME dose across year and provider characteristics stayed constant (<50 MME).

CONCLUSION

These results demonstrate encouraging prescription trends for opioid and fluoride-based drugs. Due to the high prevalence of antibiotic prescriptions in academic dental settings, stewardship approaches should be emphasized.

Analysis of a high-prescribing state's 2016 outpatient antibiotic prescriptions: Implications for outpatient antimicrobial stewardship interventions

OBJECTIVE

To identify prescriber characteristics that predict antibiotic high-prescribing behavior to inform statewide antimicrobial stewardship interventions.

DESIGN

Retrospective analysis of 2016 IQVIA Xponent, formerly QuintilesIMS, outpatient retail pharmacy oral antibiotic prescriptions in Tennessee.

SETTING

Statewide retail pharmacies filling outpatient antibiotic prescriptions.

PARTICIPANTS

Prescribers who wrote at least 1 antibiotic prescription filled at a retail pharmacy in Tennessee in 2016.

METHODS

Multivariable logistic regression, including prescriber gender, birth decade, specialty, and practice location, and patient gender and age group, to determine the association with high prescribing.

RESULTS

In 2016, 7,949,816 outpatient oral antibiotic prescriptions were filled in Tennessee: 1,195 prescriptions per 1,000 total population. Moreover, 50% of Tennessee's outpatient oral antibiotic prescriptions were written by 9.3% of prescribers. Specific specialties and prescriber types were associated with high prescribing: urology (odds ratio [OR], 3.249; 95% confidence interval [CI], 3.208-3.289), nurse practitioners (OR, 2.675; 95% CI, 2.658-2.692), dermatologists (OR, 2.396; 95% CI, 2.365-2.428), physician assistants (OR, 2.382; 95% CI, 2.364-2.400), and pediatric physicians (OR, 2.340; 95% CI, 2.320-2.361). Prescribers born in the 1960s were most likely to be high prescribers (OR, 2.574; 95% CI, 2.532-2.618). Prescribers in rural areas were more likely than prescribers in all other practice locations to be high prescribers. High prescribers were more likely to prescribe broader-spectrum antibiotics (P < .001).

CONCLUSIONS

Targeting high prescribers, independent of specialty, degree, practice location, age, or gender, may be the best strategy for implementing cost-conscious, effective outpatient antimicrobial stewardship interventions. More information about high prescribers, such as patient volumes, clinical scope, and specific barriers to intervention, is needed.

Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: Systematic review and meta-analysis-a report of the American Dental Association

BACKGROUND

Patients with pulpal and periapical conditions often seek treatment for pain, intraoral swelling, or both. Even when definitive, conservative dental treatment (DCDT) is an option, antibiotics are often prescribed. The purpose of this review was to summarize available evidence regarding the effect of antibiotics, either alone or as adjuncts to DCDT, to treat immunocompetent adults with pulpal and periapical conditions, as well as additional population-level harms associated with antibiotic use.

TYPE OF STUDIES REVIEWED

The authors updated 2 preexisting systematic reviews to identify newly published randomized controlled trials. They also searched for systematic reviews to inform additional harm outcomes. They conducted searches in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. Pairs of reviewers independently conducted study selection, data extraction, and assessment of risk of bias and certainty in the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

The authors found no new trials via the update of the preexisting reviews. Ultimately, 3 trials and 8 additional reports proved eligible for this review. Trial estimates for all outcomes suggested both a benefit and harm over 7 days (very low to low certainty evidence). The magnitude of additional harms related to antibiotic use for any condition were potentially large (very low to moderate certainty evidence).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Evidence for antibiotics, either alone or as adjuncts to DCDT, showed both a benefit and a harm for outcomes of pain and intraoral swelling and a large potential magnitude of effect in regard to additional harm outcomes. The impact of dental antibiotic prescribing requires further research.

Longitudinal antibiotic prescribing trends among US dental specialists within a pharmacy benefits manager, 2013 through 2015

BACKGROUND

Reducing inappropriate antibiotic prescriptions (Rxs) is a major quality improvement initiative in the United States. Tracking antibiotic prescribing trends is 1 method of assessing improvement in antibiotic prescribing. The purpose of this study was to assess longitudinal antibiotic prescribing practices among dental specialists.

METHODS

This was a retrospective ecological longitudinal trend study. The authors calculated monthly systemic antibiotic Rx counts, and rates per 100,000 beneficiaries, from a pharmacy benefits manager in the United States from 2013 through 2015. The authors calculated average annual antibiotic Rx rates (AARs) for the 3-year study period. The authors used a quasi-Poisson regression model to analyze antibiotic Rx trends. The authors quantified seasonal trends, when present, via peak-to-trough ratios (PTTRs).

RESULTS

Dental specialists prescribed 2.4 million antibiotics to the cohort of 38 million insurance beneficiaries during the 3-year study period (AAR = 2,086 Rxs per 100,000 beneficiaries). Oral and maxillofacial surgeons prescribed the most antibiotics (1,172,104 Rxs; AAR = 1,018 Rxs per 100,000 beneficiaries), followed by periodontists (527,038 Rxs; AAR = 457 Rxs per 100,000 beneficiaries), and endodontists (447,362 Rxs; AAR = 388 Rxs per 100,000 beneficiaries). Longitudinal antibiotic prescribing trends were stable among all dental specialties in the regression models (P > .05). The authors observed substantial seasonal variation in antibiotic Rxs in 2 specialties: pediatric dentistry (PTTR, 1.18; 95% confidence interval, 1.13 to 1.25) and orthodontics and dentofacial orthopedics (PTTR, 1.41; 95% confidence interval, 1.21 to 1.71), with the highest rates of antibiotic Rxs in the spring and winter.

CONCLUSIONS

Antibiotic prescribing practices for dental specialists remained stable. The authors observed seasonal trends in 2 specialties.

PRACTICAL IMPLICATIONS

Public health efforts are needed improve antibiotic prescribing among dental specialties.

Knowledge of antibiotics and antimicrobial resistance amongst final year dental students of Polish medical schools-A cross-sectional study

INTRODUCTION

Antimicrobial resistance has been one of the biggest global concerns. Dentists constitute an important group of antibiotic prescribers, and it was shown that their therapeutic decisions are not always rational. In this paper, we present knowledge of antibiotics prescription rules and antimicrobial resistance amongst graduating dentistry students from all dentistry faculties of medical universities in Poland, who will soon join the group of antibiotics prescribers.

MATERIALS AND METHODS

A questionnaire consisting of 28 questions was developed. The survey was conducted in May-June 2015.

RESULTS

The study group comprised a total of 752 students. About 54% expressed the opinion that dentists overprescribe antibiotics. One-tenth thought that they can be used for the treatment of flu (7%) and common cold (11%). Respondents pointed to amoxicillin (46%) and clindamycin (44%) as the first-choice treatment of dentoalveolar abscess, if medically indicated. More than half of the students (58%) suggested using doxycycline and metronidazole in aggressive periodontitis in an individual allergic to penicillin. The vast majority of students (97%) indicated that penicillins and cephalosporins were suitable for treatment of dental infections in pregnant women. The majority of participants (82%) said that rheumatic disease, chronic immunosuppression, chronic kidney failure and a history of infective endocarditis required a prophylactic administration of antibiotics before or during endodontic treatment.

CONCLUSIONS

The research showed variable levels of understanding of antibiotics use amongst dental students in medical universities in Poland. Our results emphasise the need to educate dental students further regarding antibiotics and risks related to antibiotic misuse, especially in dental practice.

Factors associated with antibiotic prescribing for adults with acute conditions: an umbrella review across primary care and a systematic review focusing on primary dental care

INTRODUCTION

One way to slow the spread of resistant bacteria is by improved stewardship of antibiotics: using them more carefully and reducing the number of prescriptions. With an estimated 7%-10% of antibiotic prescriptions globally originating from dental practices and up to 80% prescribed unnecessarily, dentistry has an important role to play. To support the design of new stewardship interventions through knowledge transfer between contexts, this study aimed to identify factors associated with the decision to prescribe antibiotics to adults presenting with acute conditions across primary care (including dentistry).

METHODS

Two reviews were undertaken: an umbrella review across primary healthcare and a systematic review in dentistry. Two authors independently selected and quality assessed the included studies. Factors were identified using an inductive thematic approach and mapped to the Theoretical Domains Framework (TDF). Comparisons between dental and other settings were explored. Registration number: PROSPERO_CRD42016037174.

RESULTS

Searches identified 689 publications across primary care and 432 across dental care. Included studies (nine and seven, respectively) were assessed as of variable quality. They covered 46 countries, of which 12 were low and middle-income countries (LMICs). Across the two reviews, 30 factors were identified, with 'patient/condition characteristics', 'patient influence' and 'guidelines & information' the most frequent. Two factors were unique to dental studies: 'procedure possible' and 'treatment skills'. No factor related only to LMICs.

CONCLUSIONS

A comprehensive list of factors associated with antibiotic prescribing to adults with acute conditions in primary care settings around the world has been collated and should assist theory-informed design of new context-specific stewardship interventions.

Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice

BACKGROUND

Most antibiotic use in the United States occurs in the outpatient setting, and 10% of these prescriptions are generated by dentists. The development of comprehensive antibiotic stewardship programs (ASPs) in the dental setting is nascent, and therefore we describe the implementation of a dental ASP.

METHODS

A collaborative team of dentist, pharmacist, and physician leaders conducted a baseline needs assessment and literature evaluation to identify opportunities to improve antibiotic prescribing by dentists within Illinois' largest oral health care provider for Medicaid recipients. A multimodal intervention was implemented that included patient and provider education, clinical guideline development, and an assessment of the antibiotic prescribing rate per urgent care visit before and after the educational interventions.

RESULTS

We identified multiple needs, including standardization of antibiotic prescribing practices for patients with acute oral infections in the urgent care clinics. A 72.9% decrease in antibiotic prescribing was observed in urgent care visits after implementation of our multimodal intervention (preintervention urgent care prescribing rate, 8.5% [24/283]; postintervention, 2.3% [8/352]; P < .001).

CONCLUSIONS

We report the successful implementation of a dental ASP that is concordant with the Centers for Disease Control and Prevention Core Elements of Antibiotic Stewardship in the Outpatient Setting. Our approach may be adapted to other dental practices to improve antibiotic prescribing.

Dental Infection and Resistance-Global Health Consequences

Antibiotics are widely used in dental caries and another dental related issues, both for therapeutic and prophylactic reasons. Unfortunately, in recent years the use of antibiotics has been accompanied by the rapid emergence antimicrobial resistance. Dental caries and periodontal diseases are historically known as the top oral health burden in both developing and developed nations affecting around 20⁻50% of the population of this planet and the uppermost reason for tooth loss. Dental surgeons and family practitioners frequently prescribed antimicrobials for their patients as outpatient care. Several studies reported that antibiotics are often irrationally- and overprescribed in dental diseases which is the basis of antimicrobial resistance. The aim of this review is to evaluate the use of antibiotics in dental diseases. Almost certainly the promotion of primary oral health care (POHC) in primary health care program especially among the least and middle-income countries (LMIC) may be the answer to ensure and promote rational dental care.

Evaluation and Management of Penicillin Allergy: A Review

IMPORTANCE

β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.

OBSERVATIONS

Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases, less than the 8% reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources.

CONCLUSIONS AND RELEVANCE

Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.

Antibiotic Prescriptions Associated With Dental-Related Emergency Department Visits

STUDY OBJECTIVE

The frequency of antibiotic prescribing and types of antibiotics prescribed for dental conditions presenting to the emergency department (ED) is not well known. The objective of this study is to quantify how often and which dental diagnoses made in the ED resulted in an antibiotic prescription.

METHODS

From 2011 to 2015, there were an estimated 2.2 million (95% confidence interval [CI] 1.9 to 2.5 million) ED visits per year for dental-related conditions, which accounted for 1.6% (95% CI 1.5% to 1.7%) of ED visits. This is based on an unweighted 2,125 observations from the National Hospital Ambulatory Medical Care Survey in which a dental-related diagnosis was made.

RESULTS

An antibiotic, most often a narrow-spectrum penicillin or clindamycin, was prescribed in 65% (95% CI 61% to 68%) of ED visits with any dental diagnosis. The most common dental diagnoses for all ages were unspecified disorder of the teeth and supporting structures (44%; 95% CI 41% to 48%; International Classification of Diseases, Ninth Revision, Clinical Modification[ICD-9-CM] code 525.9), periapical abscess without sinus (21%; 95% CI 18% to 25%; ICD-9-CM code 522.5), and dental caries (18%; 95% CI 15% to 22%; ICD-9-CM code 521.0). Recommended treatments for these conditions are usually dental procedures rather than antibiotics.

CONCLUSION

The common use of antibiotics for dental conditions in the ED may indicate the need for greater access to both preventive and urgent care from dentists and other related specialists as well as the need for clearer clinical guidance and provider education related to oral infections.

Does the use of amoxicillin/amoxicillin-clavulanic acid in third molar surgery reduce the risk of postoperative infection? A systematic review with meta-analysis

The objectives of this systematic review were to investigate the efficacy of amoxicillin/amoxicillin-clavulanic acid for reducing the risk of postoperative infection after third molar surgery and to evaluate the adverse outcomes in these patients, as well as in healthy volunteers. A systematic search of four databases was performed on May 26, 2017. Eleven studies qualified for the qualitative analysis and eight were found suitable for meta-analysis. The results suggest that both amoxicillin-clavulanic acid and amoxicillin significantly reduce the risk of infection after third molar extraction (overall relative risk (RR) 0.25, P<0.001). However, with the exclusion of randomized controlled trials with a split-mouth design (due to an inadequate crossover period after antibiotic treatment), only amoxicillin-clavulanic acid was found to be effective (RR 0.21, P<0.001). The risk of adverse effects was significantly higher in the amoxicillin-clavulanic acid group (RR=4.12, P=0.023) than in the amoxicillin group (RR 1.57, P=0.405). In conclusion, amoxicillin-clavulanic acid and amoxicillin may significantly reduce the risk of infection after third molar extraction. However, their use in third molar surgery should be viewed with caution, as recent clinical trials on healthy volunteers have shown evidence of the negative impact of amoxicillin use on bacterial diversity and antibiotic resistance.

Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States

BACKGROUND

The purpose of this study was to assess dental antibiotic prescribing trends over time, to quantify the number and types of antibiotics dentists prescribe inappropriately, and to estimate the excess health care costs of inappropriate antibiotic prescribing with the use of a large cohort of general dentists in the United States.

METHODS

We used a quasi-Poisson regression model to analyze antibiotic prescriptions trends by general dentists between January 1, 2013, and December 31, 2015, with the use of data from Express Scripts Holding Company, a large pharmacy benefits manager. We evaluated antibiotic duration and appropriateness for general dentists. Appropriateness was evaluated by reviewing the antibiotic prescribed and the duration of the prescription.

RESULTS

Overall, the number and rate of antibiotic prescriptions prescribed by general dentists remained stable in our cohort. During the 3-year study period, approximately 14% of antibiotic prescriptions were deemed inappropriate, based on the antibiotic prescribed, antibiotic treatment duration, or both indicators. The quasi-Poisson regression model, which adjusted for number of beneficiaries covered, revealed a small but statistically significant decrease in the monthly rate of inappropriate antibiotic prescriptions by 0.32% (95% confidence interval, 0.14% to 0.50%; P = .001).

CONCLUSIONS

Overall antibiotic prescribing practices among general dentists in this cohort remained stable over time. The rate of inappropriate antibiotic prescriptions by general dentists decreased slightly over time.

PRACTICAL IMPLICATIONS

From these authors' definition of appropriate antibiotic prescription choice and duration, inappropriate antibiotic prescriptions are common (14% of all antibiotic prescriptions) among general dentists. Further analyses with the use of chart review, administrative data sets, or other approaches are needed to better evaluate antibiotic prescribing practices among dentists.

The effect of interventions aiming to optimise the prescription of antibiotics in dental care-A systematic review

BACKGROUND

Abundant evidence in dentistry suggests that antibiotics are prescribed despite the existence of guidelines aiming to reduce the development of antibiotic resistance. This review investigated (1) which type of interventions aiming to optimise prescription of antibiotics exist in dentistry, (2) the effect of these interventions and (3) the specific strengths and limitations of the studies reporting on these interventions.

METHOD

Literature search was based on Medline, Embase, Global Health, Cochrane CENTRAL, ClinicalTrials.gov and Current Controlled Trials. Studies with one of the two primary outcomes were included: (1) The number of antibiotics prescribed and/or (2) the accuracy of the prescription, commonly measured as a percentage of adherence to local clinical guidelines.

RESULTS

Nine studies met these inclusion criteria. Five studies reported on the prescription of antibiotics in primary dental care and four studies focused on outpatient dental care. Interventions used in primary dental care included a combination of audit, feedback, education, local consensus, dissemination of guidelines and/or academic detailing. Trials in the outpatient setting made use of expert panel discussions, educational feedback on previous acts of prescribing, the dissemination of guidelines and the establishment of internal guidelines. All studies successfully reduced the number of antibiotics prescribed and/or increased the accuracy of the prescription. However, most studies were confounded by a high risk of selection bias, selective outcome reporting and high variance across study groups. In particular, information relating to study design and methodology was insufficient. Only three studies related the prescriptions to the number of patients treated with antibiotics.

CONCLUSIONS

This systematic review was able to offer conclusions which took the limitations of the investigated studies into account. Unfortunately, few studies could be included and many of these studies were confounded by a low quality of scientific reporting and lack of information regarding study methodology. High-quality research with objective and standardised outcome reporting, longer periods of follow-up, rigorous methodology and adequate standard of study reporting is urgently needed.

An evaluation of dental antibiotic prescribing practices in the United States

BACKGROUND

Antibiotic prescribing practices among general dentists and dental specialists in the United States remains poorly understood. The purpose of this study was to compare prescribing practices across dental specialties, evaluate the duration of antibiotics dentists prescribed, and determine variation in antibiotic selection among dentists.

METHODS

The authors performed a retrospective cross-sectional analysis of dental care provider specialties linked to deidentified antibiotic claims data from a large pharmacy benefits manager during the 2015 calendar year.

RESULTS

As a group, general dentists and dental specialists were responsible for more than 2.9 million antibiotic prescriptions, higher than levels for several other medical and allied health care provider specialties. Antibiotic treatment duration generally was prolonged and commonly included broad-spectrum agents, such as amoxicillin clavulanate and clindamycin. Although amoxicillin was the most commonly prescribed antibiotic among all dental specialties, there was substantial variation among other antibiotics each specialty selected. The most common antibiotic treatment durations were 7 and 10 days.

CONCLUSIONS

This study's results demonstrate that dentists frequently prescribe antibiotics for prolonged periods and often use broad-spectrum antibiotics. Further studies are necessary to evaluate the appropriateness of these antibiotic prescribing patterns.

PRACTICAL IMPLICATIONS

The clinically significant variation in antibiotic selection and treatment duration identified among all dental specialties in this study population implies that further research and guidance into the treatment of dental infections is necessary to improve and standardize antibiotic prescribing practices.