Epidemiology and sab stewardship
Page 1: Title and Presenter
Title: A Brief History of Epidemiology and Antibiotic Stewardship
Presenter: Larry Williams, DDS, MPH, Professor, CDMI 2023-24
Page 2: Objectives
Participants will be able to:
Understand the role of epidemiology in relation to antibiotics.
Discuss issues with the misuse of antibiotics:
When to use antibiotics.
When not to use antibiotics.
Understand the role of dental professionals in antibiotic stewardship.
Page 3: Recent Breakthrough
New Antibiotic: Reported by CNN (1/3, Musa)
A new antibiotic effective against drug-resistant bacteria has been developed.
Kills a significant percentage of those with invasive infections.
Carbapenem-resistant Acinetobacter baumannii (CRAB)
Responsible for 8,500 infections and 700 deaths in 2017.
New antibiotic zosurabalpin is effective against over 100 tested CRAB clinical samples.
Findings published in Nature with coverage from various outlets.
Page 4: Overview of Epidemiology
Definition: Epidemiology studies health-related states/events in populations and applies this study to health problems.
Key Points:
Focused on frequency and patterns of health events in populations.
Searches for determinants influencing disease occurrences.
Applicable to various health areas: chronic diseases, injuries, and environmental health.
Page 5: Role of Epidemiologists
Engagement in evolving science and policy landscapes.
Future involvement in various health processes.
Page 6: Epidemiology Facts About Antibiotics
CDC Statistics:
2 million people in the U.S. face antibiotic-resistant infections yearly.
23,000 deaths annually due to antibiotic-resistant infections.
In 2018, 145,000 hospitalizations resulted from adverse antibiotic reactions, notably:
75% were allergic reactions.
Common allergens: Sulfonamides, Penicillins, Fluoroquinolones.
Prolonged use (>72 hours) increases risk of adverse reactions.
Page 7: Timeline of Antibiotics
Historical discovery milestones:
Tetracyclines: Found in cadavers (2000 years ago).
Qinghaosu: Anti-malarial, 3000 years ago.
Resistance genes have evolved over the past 100 million years.
Early 1900s: Arsenic compounds for syphilis treatment.
1935: Discovery of sulfonamide derivatives.
1940: Penicillin purification and production.
Page 8: Timeline of Resistance
1940: Antibiotic-destroying enzymes discovered in bacteria.
2009: Manifestation of Multi-Drug Resistance (MDR).
25,000 deaths per year from MDR.
63,000 nosocomial (hospital) infection deaths annually.
Cost of managing resistance: billions.
Resistance mechanisms include mutations, enzyme modifications, and ribosomal changes.
Page 9: Placebo Considerations
Placebo: Non-active treatment posing as real medication.
Placebo Effect: Positive or negative physical responses to placebos.
Antibiotic treatments may improve patient symptoms even without indication for antibiotic use.
Page 10: Serious Oral Infections
Periapical Abscess: Accumulation of inflammatory cells at the apex of a nonvital tooth.
Cellulitis: Infection extending beyond a localized area into surrounding soft tissue.
Potentially fatal infections:
Ludwig's Angina: Involves multiple facial spaces.
Cavernous Sinus Thrombosis: Canine space infection spreading to cavernous sinus.
Page 11: MRSA Facts
MRSA: Found both in communities and hospitals.
Risk Factors: Crowded environments, skin contact, shared equipment.
Approximately 5% of U.S. hospital patients carry MRSA.
MRSA skin infections can mimic common spider bites.
Page 12: Definitions
Antibiotic: Bactericidal (kills bacteria) or bacteriostatic (prevents reproduction).
MRSA: Methicillin-resistant Staphylococcus aureus.
MDR: Multi-drug-resistant Gram negatives.
Page 13: Stewardship Definitions
Stewardship: Responsible management of resources.
Antibiotic Stewardship: Efforts to improve antibiotic prescribing practices to combat resistance and reduce patient harm.
Page 14: Human Bacterial Flora
Constant interaction with environmental organisms.
Colonization by various microbial species referred to as normal flora.
Page 15: Questions to Consider
Does dental pain necessitate antibiotics?
Does oral swelling mean antibiotics are required?
Examples of previous antibiotic prescriptions for dental conditions.
Page 16: Dentist's Perspective
Perceived necessity of antibiotics by both dentists and patients.
Patients expecting antibiotics regardless of clinical need.
Concerns about antibiotic resistance may not be prioritized.
Page 17: Outcomes of Dental Infections
Risk of oral infections varies:
Intact immune system vs. non-intact immune system.
Normal flora impact versus systemic infection possibilities.
Page 18: Implications
Anyone can contract an oral infection, but higher risks exist for immunocompromised individuals.
Not every oral infection requires antibiotics:
Differentiation between localized and systemic conditions.
Historical patient dependency on antibiotics for similar issues.
Page 19: Confusion Among Dentists
Different guidelines create unrealistic expectations among patients.
Adoption of the 2019 ADA Evidence-Based Guideline for Antibiotic Stewardship recommended.
Page 20: ADA Key Points
The 2019 ADA Guideline emphasizes prudent antibiotic use to mitigate resistance and adverse reactions.
Antibiotic prophylaxis only for patients at risk for post-procedural complications:
History of infective endocarditis, diabetes.
Use the correct antibiotic, dosage, and duration.
Pain management often best achieved with OTC medications, not antibiotics.
Page 21: Indications for Antibiotics
Adhere to ADA guidelines for various conditions:
Cardiac and joint replacement history guidelines.
Evidence-based guidelines for urgent care management.
Page 22: Infections and Antibiotic Use
Normal flora is crucial in maintaining health.
Imbalance due to factors like diet, stress, infection, and medication leads to complications.
Page 23: Clostridioides difficile Overview
C. difficile: Causes 15-25% of antibiotic-associated diarrhea.
It exists harmlessly until certain triggers upset the balance.
Page 24: C. difficile Infection (CDI)
Increasing in both prevalence and severity.
Healthcare-associated vs. community-associated CDI cases.
Majority in healthcare settings, often post-antibiotic treatment.
Severe consequences may result from CDI, ranging from mild to life-threatening.
Page 25: Antibiotic Odds Ratios for CDI
Odds ratios for various antibiotics increasing CDI risk:
Clindamycin (16.80), Cephalosporins (5.68), Fluoroquinolones (5.50), others for comparison.
Page 26: CDI Clinical Factors
Increased CDI risk correlates with:
Age (over 65 years), underlying disease, recent antibiotic use.
Dentists attributed to 10% of outpatient antibiotic prescriptions.
Page 27: Antibiotic Prophylaxis Considerations
Prophylaxis is limited to patients at significant risk:
Consult orthopedic surgeons for joint replacement patients if pressed for antibiotics.
Page 28: Reasons Antibiotics May Not Be Indicated
Patient pressure for antibiotics against clinical judgment.
Insufficient knowledge can lead to incorrect treatment choices.
Page 29: Therapeutic Antibiotics and Endodontics
Effective treatment includes:
Canal debridement, disinfection, and drainage.
Antibiotics cannot penetrate abscesses or canals effectively.
Page 30: Considerations Before Prescribing
Assess overall health status, preexisting conditions, and infection type/location.
Consider surgical options if necessary and other symptoms presenting.
Page 31: Recommendations for Dentists
Dentists should avoid prescribing antibiotics for most dental conditions.
Focus on treatments like pulpotomy and nonsurgical root canals.
Antibiotics indicated only when systemic involvement is suspected.
Page 32: One Health Perspective
Antibiotic-resistant genes found airborne near cattle yards due to poor absorption and excretion in the environment.
Page 33: Environmental Concerns
Improper disposal of medications leads to contamination of water supplies.
Page 34: Medication Hoarding Issues
Patients often keep medications longer than necessary, leading to misuse and self-medication problems.
Page 35: Guidelines for Dentists
Be familiar with guidelines, discuss care needs with patients, and document clinical judgments.
Page 36: Resources
References:
Oral and Maxillofacial Pathology.
ADA resources on antibiotic stewardship and clinical guidelines.