5. antibiotic stewardship in dentistry

when do we prescribe antibiotics?

30% out-patient prescribing is inappropriate

✓Indication
✓Diagnosis
✓Dosage
✓Duration

Appropriate antibiotic prescribing means antibiotics are only prescribed when needed

When needed, the right antibiotic is selected

Prescribed at the right dose and for the right duration

Appropriate antibiotic prescribing should be in accordance with evidence-based national and local clinical practice guidelines

signs antibiotic is necessary

Oral bacterial infections: pain, swelling, redness, purulent exudate, fever, systemic spread, immunosuppression

Focus on eliminating the pathology

Use radiographic identification

Clean periodontal infection

Provide endodontic treatment

Incise and drain abscess

Prevent transition of cellulitis into abscess

Differential: Fungal, Viral, Ulcers, Chemical and Trauma

Why Do We Prescribe Antibiotics?

Dental pain and intraoral swelling

Pulpal and periapical conditions resulting from caries

Bacteria associated with caries can cause symptomatic irreversible pulpitis (SIP) inflammation of the pulpal tissue

Occasional sharp pain, usually stimulated by temperature change

Worsens to spontaneous, constant, dull or severe pain

Most cited oral health−related reason for a patient contacting an emergency department (ED) or physician

What Do We Prescribe For?

SAP (Symptomatic apical periodontitis) Progressive pulp inflammation in the apical region

Results in necrotic pulp [PN-SAP]

The infection can continue to move into and through the alveolar bone to the soft tissues surrounding the jaw

Localized acute apical abscess

Depending on location and patient status, this can further develop into systemic infection

Challenges Faced by the Dentist

When should I prescribe an antibiotic?

Antibiotic adverse effects

Interactions with food, medications and recreational drugs

Lack of awareness of published guidelines

Cardiac conditions requiring antibiotic prophylaxis

Prosthetic joints requiring antibiotic prophylaxis

Providers overestimate patient demand for antibiotics

Hospital ER visits: Antibiotics / Opioids

Decreased preventative dental care

What Should the Dentist Do?

Promote best practice guidelines when prescribing

Prioritize antibiotic resistance

Continuing education and recertification

Include updates on Bacterial endocarditis, joint prosthesis, new data on preventing infection of adjacent tissue

Evidence based guidelines in the practice

Engage and promote consistency when prescribing antibiotics

Determine trends in antibiotic prescribing by Physicians

Consult with Infectious Disease physicians, Cardiologists and Orthopedic surgeons

Optimal Antibiotic Prescribing

Benefit to Risk Ratio

Toxicity, Allergy, Adverse effects, Drug interactions

CDI: Clostridioides difficile infection

Patient comorbidity

Cytochrome p450 hepatic enzyme inhibition

Patients on multiple medications

Substance Use Disorder

Recreational Drugs

ADA: Optimal Antibiotic Prescribing

Diagnosis of oral bacterial infection

Thorough documentation

Treatment steps with ‘rationale for treatment’ decision

Use of Narrow-spectrum antibiotics

Do NOT combine narrow and broad spectrum

Use for the shortest duration possible

Amoxicillin 500 mg TID/ Augmentin/Clindamycin 300 mg QID

Azithromycin 1 gm stat then 500 mg OD

Adequate Disposal of unused drugs

ADA: Clinical Recommendations

Urgent Situations in Dental Settings where Pulpotomy, Pulpectomy, Nonsurgical Root Canal Treatment, or I & D of abscess are an immediate option
• Symptomatic irreversible pulpitis
• Symptomatic apical periodontitis

Recommendation 1: ADA expert panel recommends dentists do not prescribe oral systemic antibiotics

Recommendation 2: ADA expert panel suggests dentists prescribe oral Amoxicillin (500 mg TID 5-7 days) or oral Penicillin V (500 mg QID 5-7 days) for adults

ADA: Localized Acute Apical Abscess

Localized acute apical abscess characterized by spontaneous pain with or without mastication

Formation of purulent material

Localized swelling

Evidence of fascial space or local lymph node involvemen

Fever or malaise

Good practice statement: ADA panel suggests dentists perform urgent DCDT (Definitive Conservative Dental Treatment)

Oral Amoxicillin (500 mg TID 5-7 days)

If Penicillin allergy: Azithromycin (500 mg Day 1, then 250mg Days 2 and 3)

Best practice guidelines
 

Dentists can apply delayed prescribing practices by giving the patient a post-dated prescription and providing instructions to fill the prescription after a
predetermined period or by instructing the patient to call or return to collect a prescription if symptoms worsen or do not improve

ADA: Best Practice When Prescribing

Amoxicillin and Penicillin V are both first-line treatments

Amoxicillin is preferred over Pen V because it is more effective against various gram-negative anaerobes and its lower incidence of gastrointestinal side effects

Penicillin allergy without a history of anaphylaxis, angioedema or hives the panel suggests oral Cephalexin (500 mg QID 5-7day)
• Beta-Lactam ring is shared
• Macrolides is 2nd line of treatment

what is prescribed if patients have a delayed response to antibiotics

Clinicians may add Metronidazole to Cephalexin therapy in patients with a delayed response to antibiotics.

Alternatively for patients with a history of a Penicillinanaphylaxis, the panel suggests Oral Azithromycin (500 mg on Day 1, 250 mg OD for 2 days)

ADA does NOT recommend: Oral Clindamycin (300 mg QID 5-7 days)

urticaria

raised red welts allergic rxn

Do not prescribe antibiotics based on

Patient demand

Peer pressure

Convenience

Prophylaxis

Social pressure

Claimed allergy: 10% report Penicillin allergy, <1% truly allergic

Little evidence: Shortened course results in antibiotic resistance

Antibiotics do NOT treat pain!