The first national survey of antimicrobial use among dentists in Japan from 2015 to 2017 based on the national database of health insurance claims and specific health checkups of Japan

Antimicrobial susceptibility surveillance of bacterial isolates recovered in Japan from odontogenic infections in 2018

BACKGROUND

This study reports the findings of the second antimicrobial susceptibility surveillance study of isolates recovered from odontogenic infections in Japan.

METHODS

A total of 164 odontogenic infections samples including periodontitis (group 1, n = 33), pericoronitis (group 2, n = 7), jaw inflammation (group 3, n = 83), and phlegmon in the jawbone area (group 4, n = 42) from 21 facilities were included in the study.

RESULTS

Antimicrobial susceptibility testing was performed on 515 isolates, consisting of 120, 115, 173, 38, and 69 Streptococcus spp., anaerobic gram-positive cocci, Prevotella spp., Porphyromonas spp., and Fusobacterium spp. isolates, respectively. The ratio of susceptible bacteria to causative agents of odontogenic infections was determined in accordance with the guidelines of the Clinical and Laboratory Standards Institute. The susceptibility rates of Streptococcus anginosus were as follows: ampicillin, 98.6 %; cefcapene, ceftriaxone, meropenem, and doripenem, 100 %; clarithromycin and azithromycin, 71.2 %; and clindamycin, 87.7 %. The MIC90 value for ampicillin for Prevotella spp. was 32 μg/mL, with a susceptibility rate of 65.3 %. The MIC90 value for sulbactam/ampicillin was 2 μg/mL, with a susceptibility rate of 100 %.

CONCLUSIONS

The findings of the present study indicate that the resistance to the combination of penicillins and β-lactamase inhibitors, the first-line antimicrobial agents for odontogenic infections and oral infections caused by anaerobic flora, are low.

Antimicrobial prescriptions for older patients in dental medicine: A four-year retrospective study in Japan

BACKGROUND

Antimicrobial use (AMU) in Japan is characterized by a high prevalence of oral third-generation cephalosporin prescriptions, especially in dental medicine. However, few studies have examined the time trends and factors influencing AMU in older individuals seeking dental care. Therefore, in this study, we aimed to investigate AMU, particularly third-generation cephalosporin, in a cohort of older adults.

METHODS

This retrospective study analyzed the dental prescription health insurance claims data of patients aged ≥75 years in one metropolitan area from 2018 to 2021. The antimicrobials were categorized, and the number of defined daily doses (DDDs) per 1000 inhabitants per day (DID) was calculated to assess trends over this period. Multivariate logistic regression analysis was performed to identify factors associated with third-generation cephalosporin prescriptions.

RESULTS

This database contains 58,655 patients, of whom 15,038 were prescribed antimicrobials from dentistry. Our findings suggest that third-generation cephalosporins accounted for 44.8 % of all antimicrobial prescriptions, with a noticeable decreasing trend in DID over the study period. Factors significantly associated with third-generation cephalosporin prescriptions included dental association membership (adjusted odds ratio [AOR] 0.72, 95 % confidence interval [CI] 0.63-0.82), fiscal year (AOR 0.86, 95 % CI 0.83-0.89), and their interaction.

CONCLUSIONS

The findings suggest that the pattern of prescribing third-generation cephalosporins in dental medicine might be shifting owing to heightened awareness of antimicrobial resistance (AMR) and educational initiatives by groups, such as dental associations. Effective educational and policy interventions by professional associations could reduce inappropriate antimicrobial prescriptions, thereby mitigating AMR on a large scale.

Antibiotic Prescription Trends in Dentistry: A Descriptive Study Using Japan's National Database

OBJECTIVES

Antibiotic prescription trends in dentistry in Japan remain underexplored. This study aimed to describe these trends and evaluate the impact of the national antimicrobial stewardship program launched in 2016.

METHODS

Using Japan's national administrative claims database from fiscal year (FY) 2015 to FY 2020, this cross-sectional study comprehensively analyzed trends in antibiotic prescription by dentists. Prescription rates were computed per 1000 inhabitants yearly and standardized to the FY 2015 national population. Changes in prescription rates were evaluated using Poisson regression analysis.

RESULTS

In FY 2020, the total number of antibiotic prescriptions was 134.4 per 1000 inhabitants per year, showing a 6% decline over the 6-year period (95% confidence interval, 6%-6%). Third-generation cephalosporins constituted 52.3% of dental antibiotic prescriptions in FY 2020, though the proportion had slightly decreased. In hospitals, prescriptions of third-generation cephalosporins decreased from 64.9% in 2015 to 20.3% in 2020, being replaced by penicillin (from 15.0% to 64.0%). However, in clinics, the magnitude of the change was small (third-generation cephalosporins, 60.5%-53.1%; penicillin, 10.2%-22.2%).

CONCLUSIONS

Third-generation cephalosporins continue to dominate dental antibiotic prescriptions. The increase in penicillin use was much more pronounced in hospitals than in clinics. Strengthening antimicrobial stewardship, particularly in clinics where the majority of dental care is provided, is crucial.

Mapping Worldwide Antibiotic Use in Dental Practices: A Scoping Review

Antibiotic resistance is a critical issue today, necessitating the monitoring of antibiotic usage across various sectors. To determine the defined daily doses (DDDs) of antibiotics prescribed by dentists globally, a comprehensive search was conducted in PubMed, ProQuest, ScienceDirect, Web of Science, Scopus, and EBSCOhost, resulting in the inclusion of 15 documents in this scoping review. The DDD per 1000 inhabitants per day (DID) for oral antibiotics prescribed by dentists for the studied countries was generally below 2.11, with the exception of South Korea, which had a DDD per 1000 patients per day (DPD) of less than 6.97. Most countries, except Croatia and Belgium, demonstrated a decreasing trend in DID before the COVID-19 pandemic, but restrictions during the pandemic led to an increase in these numbers. Penicillin-derived antibiotics were the most commonly prescribed antibiotic among dentists in most countries. This study highlights significant gaps and missing data regarding antibiotics prescribed by dentists worldwide. However, it also indicates that the publication of guidelines, education, and evaluation of antibiotic use can lead to more controlled and appropriate prescriptions among dental professionals.

Amoxicillin vs third-generation cephalosporin for infection prophylaxis after third molar extraction

OBJECTIVES

Although amoxicillin is the first-line prophylactic drug for impacted mandibular third molar extraction, third-generation cephalosporins are widely prescribed in Japan. The lack of real-world evidence may be one reason for this inappropriate use. We evaluated differences in the incidence of surgical site infection between amoxicillin and third-generation cephalosporins for impacted mandibular third molar extraction.

METHODS

Using the JMDC Claims Database, we identified dental visits with fully or horizontally impacted mandibular third molar extraction from April 2015 to March 2020. One-to-one propensity-score matching was conducted between amoxicillin and third-generation cephalosporin groups. The incidence of surgical site infection following extraction was compared in the matched pairs using McNemar's test.

RESULTS

We identified 109,266 dental visits, including 39,514 (36.2%) patients who received amoxicillin and 69,752 (63.8%) patients who received third-generation cephalosporins. In the 39,514 matched pairs, the incidence of surgical site infection was 3.5% (n = 1399) for amoxicillin group and 3.7% (n = 1467) for third-generation cephalosporin group (p = 0.003).

CONCLUSIONS

Amoxicillin was associated with a lower incidence of surgical site infection after impacted mandibular third molar extraction compared with third-generation cephalosporins. This result supports current guidelines and strengthens the importance of disseminating and implementing antimicrobial resistance control in dentistry.

The five-year trends in antibiotic prescription by dentists and antibiotic prophylaxis for tooth extraction: a region-wide claims study in Japan

BACKGROUND

Antimicrobial stewardship in dentistry and antibiotic prophylaxis for tooth extraction have been areas of concern in Japan, with limited research available.

METHODS

This cross-sectional study utilized the regional health insurance claims database in Japan to examine antibiotic prescription trends by dentists, including antibiotic regimens, timing of prescription, and days of supply for prophylactic antibiotic use during tooth extraction. Antibiotic prophylaxis for patients with prosthetic heart valves was also investigated.

FINDINGS

Antibiotic prescriptions by dentists decreased by 7% in 2019 compared to those in 2015, with third-generation cephalosporins still accounting for 48.5% in 2019. Amoxicillin prescription increased 3.9 times in 2019, although it only accounted for 8.4% of all antibiotic prescriptions. In 2019, amoxicillin was prescribed for 17.1% of all prophylactic antibiotics associated with tooth extraction, and 80% of prophylactic antibiotics were prescribed for 3 days or more, with 85% prescribed on the day of the procedure. However, only 60-70% of patients with prosthetic heart valves received antibiotic prophylaxis.

INTERPRETATION

Despite the increasing trend after the implementation of the National Action Plan on antimicrobial resistance, the proportion of amoxicillin prescriptions in dentistry remains low. Antimicrobial stewardship issues related to long-term prescription and timing of administration of prophylactic antibiotics for tooth extraction should be addressed. Dentists must recognize the risks associated with high-risk patients with prosthetic heart valves who require antibiotic prophylaxis, and physicians providing valve replacement therapy should inform patients of the requirement for prophylaxis before invasive dental procedures.

Antibiotics in Dentistry: A Narrative Review of the Evidence beyond the Myth

Antibiotics have undoubtedly revolutionized medicine and the health and survival of patients with life-threatening infections, being nonetheless free from potential adverse effects, and the risk of intestinal dysbiosis, antimicrobial resistance, and the resulting consequences for the patient's health and the public purse. The present study narratively reviewed the epidemiological data on worldwide antibiotic consumption and administration in dental practice, patients' adherence to prescriptions, the antimicrobial resistance phenomenon in dentistry, and the evidence supporting and recommending appropriate antibiotic use in dental care. Eligible systematic reviews and original studies in humans published in the English language from January 2000 to 26 January 2023 were considered. A total of 78 studies, 47 on the epidemiology of antibiotic use and prescription in dentistry, 6 on antibiotic therapy in dentistry, 12 on antibiotic prophylaxis in dentistry, 0 on adherence of dental patients to antibiotic prescription, and 13 on antimicrobial resistance in dentistry, were presently considered. Retrieved evidence revealed that antibiotics are frequently overused and misused in dental practice, dental patients frequently do not adhere to prescriptions, and antimicrobial resistance in dentistry is a still rising phenomenon also secondary to improper oral antiseptics use. The present findings highlighted the need to establish more evidence-based and accurate antibiotic prescriptions to sensitize dentists and dental patients to minimize and rationalize the use of antibiotics only when it is indicated and necessary, improve patients' adherence, and enhance knowledge and awareness of the antimicrobial resistance in dentistry.

Pharmacist-led multi-faceted intervention in an antimicrobial stewardship programme at a dental university hospital in Japan

BACKGROUND

Antimicrobials are commonly prescribed in dentistry. However, inappropriate antimicrobial prescriptions are common in this field. Optimizing antimicrobial prescriptions in dentistry requires an effective strategy for modifying prescribing behaviour.

AIM

To assess the efficacy of pharmacist-led multi-faceted intervention for the proportion of monthly antimicrobial prescriptions in each drug group per 100 oral antimicrobial prescriptions.

METHODS

A before-after trial was performed at a university hospital outpatient dental clinic. A pharmacist-led, multi-faceted intervention, including immediate and direct feedback to the prescribers, an explanation of the rules of antimicrobial prescriptions for patients with penicillin allergy, tutorials for dentistry students, and a review of hospital-approved antimicrobials, was implemented from April 2017 to March 2022. Antimicrobials were classified into eight groups, namely, penicillins, first- and second-generation cephalosporins, third-generation cephalosporins, fluoroquinolones, macrolides, clindamycin, carbapenem, and others.

FINDINGS

In total, there were 2,643,988 visits to the outpatient dental clinic during the study period. The monthly mean proportion of prescriptions for penicillins increased from 45.6 to 84.1 per 100 oral antimicrobial prescriptions (P<0.001) while that of third-generation cephalosporins decreased from 43.0 to 7.3 (P<0.001) from the pre-intervention to the intervention period. Moreover, the monthly mean proportion of fluoroquinolones, macrolides, and carbapenems decreased from 11.2 to 7.44 (P<0.001).

CONCLUSION

The intervention modified dentists' antimicrobial prescribing behaviours, leading to an immediate increase in the number of monthly prescriptions for penicillins and a simultaneous decrease in the number of monthly prescriptions for third-generation cephalosporins and other broad-spectrum, oral antimicrobials.

Comparing the effects of antimicrobial stewardship at primary emergency centers

BACKGROUND

Antimicrobial prescription rates tend to be high in outpatient settings and Primary Emergency Medical Centers (PECs) in Japan encounter difficulties in implementing antimicrobial stewardship programs (ASPs). While a nudge-based ASP publishing monthly newsletters reduces inappropriate prescription of oral third-generation cephalosporins (3GCs), which requires considerable effort. Therefore, developing more preferable ASP models in PECs is essential.

METHODS

We conducted a three-center, retrospective observational study. Himeji City Emergency Medical Center (Site A) introduced a facility-specific guideline for antimicrobial stewardship with reference to national guidelines. The Kobe Children's Primary Emergency Medical Center (Site B) provided the results of monitoring antibiotics prescription in a monthly newsletter. The Hanshin-Kita Children's First-Aid Center (Site C) did not perform a specific ASP. Prescription rates for 3GCs were categorized into pre- and post-intervention and compared using Poisson regression analysis. The difference-in-difference method was used to assess the effect of these interventions.

RESULTS

The numbers of patients pre- and post- intervention were 177,126 and 91,251, respectively. The 3GCs prescription rate at Site A, Site B, and Site C decreased from 6.7%, 4.2%, and 6.1% in 2016 to 2.3%, 1.0%, and 2.0% in 2019, respectively. Site B had a greater reduction than Site A and Site C (relative risk [RR] 0.71 [95% confidence interval (CI): 0.62-0.82]; p < 0.001, RR 0.71, [95% CI: 0.62-0.81]; p < 0.001). There was no significant difference between Site A and Site C (RR 1.00 [95% CI 0.88-1.13]; p = 0.963).

CONCLUSION

A facility-specific guideline was less effective than a nudge-based ASP for decreasing oral 3GC prescriptions in PECs.

Exploration of Trends in Antimicrobial Use and Their Determinants Based on Dispensing Information Collected from Pharmacies throughout Japan: A First Report

The purpose of this study was to evaluate the defined daily doses (DDD)/1000 prescriptions/month (DPM) as a new indicator that can be used in pharmacies, and to describe antimicrobial use patterns in pharmacies nationwide in Japan. Dispensing volumes, number of prescriptions received, and facility information were obtained from 2638 pharmacies that participated in a survey. DPM was calculated based on the dispensing volume and number of prescriptions, which are routinely collected data that are simple to use. Use of third-generation cephalosporins, quinolones, and macrolides in pharmacies that received prescriptions primarily from hospitals or clinics decreased from January 2019 to January 2021. In particular, the antimicrobial use was higher in otorhinolaryngology departments than in other departments, despite a decrease in the antimicrobial use. In the linear multiple regression analysis, otorhinolaryngology department was independently associated with the third-generation cephalosporin, quinolone, and macrolide prescription in all periods. This study reveals for the first-time trends in antimicrobial use through a new indicator using the volume of drugs dispensed in pharmacies throughout Japan. Antimicrobial use differed by the medical department, suggesting the need to target interventions according to the department type.

Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada)

OBJECTIVE

Our objective was to compare patterns of dental antibiotic prescribing in Australia, England, and North America (United States and British Columbia, Canada).

DESIGN

Population-level analysis of antibiotic prescription.

SETTING

Outpatient prescribing by dentists in 2017.

PARTICIPANTS

Patients receiving an antibiotic dispensed by an outpatient pharmacy.

METHODS

Prescription-based rates adjusted by population were compared overall and by antibiotic class. Contingency tables assessed differences in the proportion of antibiotic class by country.

RESULTS

In 2017, dentists in the United States had the highest antibiotic prescribing rate per 1,000 population and Australia had the lowest rate. The penicillin class, particularly amoxicillin, was the most frequently prescribed for all countries. The second most common agents prescribed were clindamycin in the United States and British Columbia (Canada) and metronidazole in Australia and England. Broad-spectrum agents, amoxicillin-clavulanic acid, and azithromycin were the highest in Australia and the United States, respectively.

CONCLUSION

Extreme differences exist in antibiotics prescribed by dentists in Australia, England, the United States, and British Columbia. The United States had twice the antibiotic prescription rate of Australia and the most frequently prescribed antibiotic in the US was clindamycin. Significant opportunities exist for the global dental community to update their prescribing behavior relating to second-line agents for penicillin allergic patients and to contribute to international efforts addressing antibiotic resistance. Patient safety improvements will result from optimizing dental antibiotic prescribing, especially for antibiotics associated with resistance (broad-spectrum agents) or C. difficile (clindamycin). Dental antibiotic stewardship programs are urgently needed worldwide.

Trends in prophylactic antibiotic use for tooth extraction from 2015 to 2018 in Japan: An analysis using a health insurance claims database

INTRODUCTION

To describe patterns in antibiotic prophylaxis for tooth extraction following the 2016 Japanese National Action Plan on Antimicrobial Resistance.

METHODS

Using a health insurance claims database, we retrospectively identified tooth extraction visits by patients aged ≥18 years from September 2015 to August 2018 and classified patients as undergoing extraction of a fully impacted or horizontally impacted mandibular wisdom tooth, being at risk of infective endocarditis or surgical site infection, or being at low risk. Antibiotic use and type of antibiotics prescribed on the day of tooth extraction were evaluated across the study period, with stratification by tooth extraction category and facility type (hospital or dental clinic).

RESULTS

We identified 662,435 patients with tooth extraction. The mean age was 42.7 years, and 57% were male. Twelve percent underwent wisdom tooth extraction, 32% were high risk, and 10% visited hospitals. The proportion of antibiotic use was 83% overall and 82% among low-risk patients. This proportion remained similar throughout the study period. A shift from third-generation cephalosporins to amoxicillin was observed from 2015 to 2018: the proportion prescribed third-generation cephalosporins decreased from 58% to 34% in hospitals and from 57% to 56% in clinics, and the proportion prescribed amoxicillin increased from 16% to 37% in hospitals and from 6% to 10% in clinics.

CONCLUSIONS

The pattern of prophylactic antibiotic use for tooth extraction gradually changed after the initiation of the National Action Plan. Further efforts are required to reduce potentially inappropriate prescriptions for low-risk patients, especially in dental clinics.

Validity of diagnoses and procedures in Japanese dental claims data

BACKGROUND

Dental claims data have been used for epidemiological studies without establishing the validity of the recorded diagnoses or procedures. The present study aimed to examine the accuracy of diagnoses, procedures, operation time, and the number of teeth recorded in dental claims data.

METHODS

We reviewed the charts of 200 patients who visited and 100 patients who were hospitalized in the Department of General Dentistry, Orthodontics, and Oral and Maxillofacial Surgery in an academic hospital between August 2012 and December 2017. The sensitivity and specificity of the dental claims data for five diseases and 15 procedures were evaluated. We assessed the difference in the number of teeth and duration of general anesthesia between claims data and chart reviews.

RESULTS

Sensitivity was more than 86% for six out of seven diagnoses except for pericoronitis (67%). Specificity ranged from 72% (periodontal disease) to 100% (oral cancer for inpatient). The sensitivity of procedures ranged from 10% (scaling for inpatient) to 100%, and the specificity ranged from 6% (food intake on the day of the surgery) to 100%. The mean (standard deviation [SD]) number of teeth in the chart review was 22.6 (6.8), and in the dental claims was 21.6 (8.6). The mean (SD) operation time was 171.2 (120.3) minutes, while the duration of general anesthesia was 270.9 (171.3) minutes.

CONCLUSIONS

The present study is the first study to validate dental claims data, and indicates the extent of usefulness of each diagnosis and procedure for future dental research using administrative data.