Understanding Antibiotic Prescribing and Stewardship by General Dentists
A recently published report by authors from the Centers for Disease Control and Prevention (CDC) states that in 2011, general dentists prescribed 10% of all antibiotics in the community. This compares to:
- Family physicians: 24%
- Pediatricians: 12%
- Internists: 12%
The authors state that not much is known about the specifics of antibiotic prescribing practices in dentistry. This new study, using 2013 data, was done to characterize antibiotic prescribing by dentists according to the specific drug, antibiotic category, patient demographic characteristics, and geographic region. It was the first broad study describing outpatient antibiotic prescribing by general dentists in the United States and an important step to understanding how antibiotics are used in dentistry.
CDC Study on Prescribing
The study can be accessed at: Roberts RM, et al. “Antibiotic prescribing by general dentists in the United States, 2013.” JADA 2017; 148(3):172-178.
The study utilized a commercial database called Xponent to identify oral antibiotic prescriptions written by general dentists and dispensed by pharmacies during 2013. Prescribing rates were calculated using the total number of prescription and census population denominators. The authors also analyzed prescribing according to individual drug, drug category, and patient demographic characteristics. They used the total number of prescriptions, corresponding to the county-level location of the prescribing provider, and census denominators to calculate per capita (1,000 people) prescribing rates according to state and U.S. census region.
In 2013, dentists in general practice prescribed 24.5 million courses of outpatient antibiotics, which was a prescribing rate of 77.5 prescriptions per 1,000 people. Most of the prescriptions were for adults older than 19 years, and fewer than 10% of all the antibiotics dentists prescribed were for children aged 19 years or younger. As for adult prescribing, most antibiotics went to those 40-64 years.
- Prescribing rate for ages 10-19: 26.5 prescriptions per 1,000 people
- Prescribing rate for ages 3-9: 26.1
- Prescribing rate for ages 2 and younger: 2.8
Highest prescription numbers by geographic region:
- Northeast region: 87 prescriptions per 1,000 people
- District of Columbia: 99.5
- Mississippi: 97.3
- Arkansas: 96.7
Lowest prescription numbers by geographic region:
- Delaware: 50.7 prescriptions per 1,000 people
- Alaska: 55.3
- Hawaii: 57.2
Most prescribed antibiotics:
- Amoxicillin: 43.6 prescriptions per 1,000 people or 13.8 million prescriptions overall (56.3% of all antibiotic scripts)
- Clindamycin: 3.6 million prescriptions (14.4%)
- Penicillin V: 3.2 million prescriptions (13.2%)
- Cephalexin: 1.2 million prescriptions (4.9%)
- Azithromycin: 1.1 million prescriptions (4.7%)
Other antibiotics at lower rates of prescribing were amoxicillin clavulanate (Augmentin), doxycycline, ciprofloxacin, and erythromycin.
Discussion and Conclusions
The study was done to characterize antibiotic prescribing in order to evaluate, where possible, room for improvement. There was a fairly large geographic variability in prescribing by dentists. The states with the highest prescribing rates per 1,000 people had nearly double the rates of the states with the lowest prescribing rates. According to the authors, this suggests differences in dentists’ prescribing behavior across the country, although it was unclear why such a large geographic variation exists. The authors noted that states with higher antibiotic prescribing by dentists have a population different from that of the states with lower prescribing in terms of access to dental care and the general health of the population. For example, data from the CDC show that regular preventive dental care is less common in the southeastern United States and that tooth loss due to infections is higher in this part of the country.
The authors found that some categories of antibiotics were prescribed that generally are not indicated in dentistry. These were the quinolones, sulfonamide-type antibiotics, and urinary tract anti-infective agents, thus suggesting opportunity for improvement. On the other hand, of the 10 antibiotics general dentists most commonly prescribed in 2013 and the categories they represent, most are mentioned in either prophylaxis or treatment guidelines as acceptable agents for antibiotic prescribing.
The authors expressed concern that although some treatment guidelines may exist for improving antibiotic prescribing and decreasing bacterial resistance for patients seeking care for oral wounds and infections, they lack specific recommendations as to what agent should be used as first line treatment and when a procedure may be a better course of action than a prescription.
The authors concluded the report by encouraging prescribers, including dentists, to examine prescribing behaviors for appropriateness and the effectiveness of guidelines to identify opportunities to optimize antibiotic use.
ADA Report on Stewardship
Prior to the publication of the above study, the American Dental Association (ADA) published a report in its journal calling for antibiotic stewardship on the part of the dental community. This stewardship refers to activities that aim to promote the appropriate use of antibiotics, improve patient outcomes, lower costs, reduce antibiotic resistance, and decrease the spread of infections caused by multi-drug-resistant organisms.
The report can be accessed at: Fluent MT, et al. “A safer dental visit. Considerations for responsible antibiotic use in dentistry.” JADA 2016; 147(8):683-686.
The authors were from the Organization for Safety, Asepsis and Prevention (OSAP) and the CDC in Atlanta, GA.
According to the authors, antibiotics are among the most commonly prescribed medications. However, study results indicate that 20% to 50% of prescribed antibiotics are either not necessary or not optimally prescribed. Further, the authors commented that there are few studies in which the investigators evaluate the appropriateness of antibiotic prescribing in dentistry and that there are opportunities to improve prescribing practices.
Guidelines have been published for antibiotic prophylaxis for prevention of infective endocarditis and prosthetic joint infections. However, there are no national guidelines for treatment of specific dental infections. Dentists must decide independently when an antibiotic is indicated, which antibiotic to use, and what dose and duration to prescribe.
The authors suggest a number of steps that practitioners can take to understand, develop, and support antibiotic stewardship in dentistry:
- Identify data/reference sources that are useful to better understand and characterize antibiotic prescribing by dentists
- Develop and update national prescribing recommendations for the treatment of dental infections
- Develop educational tools, resources, and messages for dentists and patients about the importance of antibiotic stewardship in dentistry
- Foster collaboration among the ADA, dental specialty organizations, and other relevant stakeholders in order to provide consistent messaging regarding antibiotic use in dentistry
- Encourage the ADA and dental specialty organizations to work together to develop and adopt antibiotic stewardship policies that are relevant to dentistry
- Incorporate national prescribing recommendations within dental software management prescription templates
The authors go on to comment that until national prescribing guidelines are endorsed by the ADA and dental specialty organizations, dentists must continue to use their judgment to optimize antibiotic prescribing and should consider the clinical tips outlined in the report:
- Recognize that antibiotics are rarely helpful for effective control of a localized infection
- Therapies such as incision and drainage, extraction, or endodontic therapy are appropriate first steps in treating most oral bacterial infections
- Recognize that toxicity, allergy, adverse effects, and Clostridium difficile infections can occur even with a single dose. The potential benefits versus risks should be considered prior to prescribing the antibiotic
- Do not prescribe antibiotics for oral viral infections, fungal infections, or oral ulcerations related to trauma or aphthae
- Avoid prescribing based on historical practices, patient demand, and pressure from other healthcare professionals
- Educate your patient about taking the antibiotic exactly as prescribed, taking only the antibiotic prescribed for themselves, and not saving the antibiotic for future illness
In conclusion, the intent of antibiotic stewardship in dentistry is to bring to the forefront the importance of proper but judicious use of antibiotic therapy in order for dentistry to do its part to perhaps slow the spread of antibiotic resistant bacteria.
Richard L. Wynn, BS Pharm, PhD, is professor of pharmacology at the Baltimore College of Dental Surgery, Dental School, University of Maryland Baltimore.
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