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80% of antibiotics prescribed before dental visits are unnecessary
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Around 80% of antibiotics prescribed for infection prophylaxis before dental visits are unnecessary, findings from a large retrospective cohort study published today in JAMA Network Open suggest.
Dentists prescribe approximately 10% of antibiotics in the United States and are the primary prescriber of clindamycin, which is associated with a high risk for Clostridioides difficile infection, explained Katie Suda, PharmD, MS, associate professor at the University of Illinois at Chicago’s College of Pharmacy.
“Clinical guidelines recommend that patients with specific high-risk cardiac conditions receive a dose of antibiotics prior to undergoing invasive dental procedures to prevent infective endocarditis,” Suda told Infectious Disease News. “Starting in 2007, antibiotic prophylaxis guidelines were narrowed secondary to poor evidence on the effectiveness of prophylaxis and the risk of antibiotic-related adverse events.”
A large number of studies have highlighted the issue of antibiotic overprescribing in the outpatient setting, but not many have described the appropriateness of antibiotic prescribing by dentists, Suda said.
For their study, Suda and colleagues used Truven MarketScan, a national integrated health claims database, to analyze antibiotic prophylaxis prescriptions for 91,438 patients covering 168,420 dental visits from 2011 to 2015. They defined appropriate antibiotic prophylaxis as “a prescription dispensed before a dental visit with a procedure that manipulated the gingiva or tooth periapex in patients with an appropriate cardiac diagnosis.”
According to the findings, more than 90% of visits included a procedure that would necessitate antibiotic prophylaxis in a high-risk cardiac patient, but just 20.9% of patients “had a cardiac condition at the highest risk of adverse outcome from infective endocarditis,” Suda and colleagues wrote. Per guidelines, 80.9% of the antibiotic prescriptions were unnecessary, they reported.
“The factors associated with unnecessary antibiotic prophylaxis included patients with prosthetic joint devices, dental visits with tooth implant procedures, female patients, prescriptions for clindamycin and visits occurring in urban areas and in the Western United States,” Suda said.
Dentists in other countries also are prescribing unnecessary antibiotics at rates of 58% to 81%, according to the study.
Suda and colleagues reported a significant decrease in antibiotic prophylaxis over the study period, which may have resulted from the application of 2013 guidelines for the prevention of prosthetic joint infections, they wrote.
Antibiotic stewardship programs also may decrease unnecessary prescribing in dental practices, a conclusion reinforced by a recent example from a large academic dental practice that experienced a 73% reduction in antibiotic prescriptions after implementing a program consistent with the CDC’s Core Elements of Outpatient Antibiotic Stewardship.
“A first step is to provide additional resources to aid dentists in their prescribing decisions,” Suda said. “While antibiotic stewardship strategies have been assessed in medical practices, there is only one example in dental practices in the United States. Dentists also need implementation strategies specific to oral health and dental practice. The CDC and [American Dental Association (ADA)] have provided tools for dentists to apply to their practices. The ADA is currently working on new antibiotic prescribing guidelines focused on oral health and dental practice.”
In a 2016 literature review published in Clinical Infectious Diseases, Emily Spivak, MD, MHS, and colleagues emphasized the clinical importance of reducing unnecessary antibiotic prescriptions.
“Indiscriminate antimicrobial use has plagued medicine since antibiotics were first introduced into clinical practice [more than] 70 years ago,” they wrote. “Infectious diseases physicians and public health officials have advocated for preservation of these life-saving drugs for many years. With rising burden of antimicrobial-resistant organisms and [Clostridioides] difficile infections, halting unnecessary antimicrobial use has become one of the largest public health concerns of our time.” – by Joe Gramigna
Reference:
Spivak K, et al. Clin Infect Dis. 2016;doi:10.1093/cid/ciw658.
Disclosures: Suda reports receiving funding from the Agency for Healthcare Research and Quality, U.S. Department of Veterans Affairs Heal Services Research and Development, VA Quality Enhancement Research Initiative, CDC and Roybal Foundation. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Brad Spellberg, MD
The study by Suda and colleagues highlights a very important, and underappreciated, contributor to inappropriate antibiotic use in the U.S., which is dental prophylaxis. The conditions that require antibiotics to be given for prophylaxis for dental procedures are quite limited. The fact that 80% of such prescriptions were inappropriate or unnecessary is not surprising, but it is disappointing and sobering. Society needs to do much better with this.
Antibiotic stewardship programs rarely consider dental practices, and this is clearly an area of unmet need. We should focus outpatient stewardship on dental practices, just as for physician practices.
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