Posted on May 15, 2020 in: Professional Practice
Elaine M. Bailey, Pharm.D., Executive Director, Michigan Antibiotic Resistance Reduction Coalition
Antibiotic resistance is a serious public health threat requiring a multifaceted approach. Approximately 10 percent of outpatient antibiotics in the U.S. are prescribed by dentists, amounting to nearly 25 million courses each year.1 Approximately 1.5 million additional antibiotic courses are prescribed to patients presenting in emergency departments with dental pain.2. There are increasing reports of inappropriate antibiotic prescribing in dental patients as well as dental patients experiencing Clostridiodes (formerly Clostridium) difficile diarrhea. 3,4. Given these findings, the American Dental Association (ADA) committed to the U.S. Antimicrobial Resistance Challenge by creating and disseminating guidance to help clinicians appropriately prescribe antibiotics. 5 The American Academy of Orthopedic Surgeons (AAOS) also committed to increase awareness of when antibiotics should and should not be used for patients with hip and knee implants who are undergoing dental procedures. (https://www.cdc.gov/drugresistance/intl-activities/amr-challenge.html
The ADA guideline for treatment of oral infections addresses many stewardship principles. The guideline encourages a paradigm shift in the use of antibiotics in dentistry from a “just in case” approach to using only when absolutely necessary. For example, when the patient is able to obtain interventional treatment (e.g. pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage) within 24 hours, antibiotics are generally not recommended. The ADA suggests practicing “Delayed Prescribing/Watchful Waiting” in situations where antibiotic treatment is unlikely to be of benefit. If a decision is made to prescribe antibiotics, then the maximum duration is seven days and the patient should discontinue antibiotics after they have been symptom-free for 24 hours. The ADA has also attempted to curb the use of clindamycin, which has been shown to be highly associated with Clostridiodes Difficile Infection (CDI)6, by following the guidance of the CDC in terms of evaluating penicillin allergy and suggesting the use of azithromycin as an alternative to prescribing clindamycin in the face of a true (anaphylactic) penicillin allergy.
For infective endocarditis prophylaxis in patients undergoing dental procedures, current guidelines support premedication for only a small subset of patients.7 Unfortunately, in the case of patients with prosthetic joint replacements who are undergoing dental procedures, the guidelines developed by the ADA and AAOS have changed over the past 17 years, at times being incongruent particularly related to how long after the implant the patient should continue to receive prophylaxis before a dental procedure. The AAOS Appropriate Use Criteria (AUC) online tool indicates that it is rarely appropriate to prophylax patients who have undergone joint replacement more than one year before the dental procedure. The antibiotics prescribed are generally aligned with the American Hospital Association (AHA) guidelines with the exception of the removal of clindamycin as a choice (Table 2). Unfortunately, several dental providers in Michigan have shared that their orthopedic colleagues are often not in compliance with the AAOS guidance.
Comprehensive guidelines exist for the development of stewardship programs in inpatient settings but despite the majority of antibiotics being prescribed in the outpatient setting, stewardship guidelines are generally lacking. The CDC include dentists in their list of intended audiences in the Core Elements of Antibiotic Stewardship for outpatient settings. 8 However, guidance is not provided on how to implement the Antimicrobial Stewardship Program (ASP) in the unique setting of dental offices.
Dentists have little opportunity to observe firsthand the adverse events associated with antibiotic prescribing, such as CDI, so they are generally unaware of the impact of their prescribing habits. The majority of dentists are solo practitioners with variably trained support staff and collectively the dental office has limited knowledge of antibiotic pharmacology. 9 Here are just a few suggestions of how our profession can support dentists, their staff and patients, to be better antibiotic stewards:
Given the numerous stakeholders involved, implementing antibiotic stewardship in dentistry is going to be challenging. Pharmacy has an opportunity to positively influence dental stewardship by educating all the stakeholders, particularly the patients. Please review these helpful resources.