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Antibiotics for dental procedures linked to C. difficile infection

SAN DIEGO — Researchers in Minnesota identified a potentially overlooked source of Clostridium difficile infection: antibiotics prescribed by dentists.

Antibiotics can kill microbes that protect against infection in the gastrointestinal tract, potentially leading to C. difficile infection (CDI), which the CDC has designated as one of three “high-consequence” antibiotic-resistant threats requiring urgent public health attention. Antibiotics prescribed by dentists may contribute to the problem, according to study findings summarized here by Stacy Holzbauer, DVM, MPH, career epidemiology field officer for the CDC and Minnesota Department of Health (MDH).

Holzbauer and colleagues studied the antibiotic history of over 1,600 patients in Minnesota with community-acquired CDI and found that 15% had taken antibiotics for dental procedures over a 6-year period. Most of these patients — 85% — had taken antibiotics only for dental reasons, Holzbauer said. And for many, the prescriptions did not appear in their medical records, which Holzbauer said illustrates “a disconnect between dental and medical providers.”

“Dentists have often been overlooked as major partners in programs that promote appropriate antibiotic use, and it’s critical that they are included in efforts to improve antibiotic prescribing,” Holzbauer said during a news conference at IDWeek. “Antibiotics are not harmless medications. C. diff is a known complication.”

In 2015, researchers estimated that there were more than 450,000 cases of CDI in the United States in 2011 and around 29,000 associated deaths. The patients at the center of the study by Holzbauer and colleagues had community-acquired CDI. Holzbauer said the issue came to their attention through routine surveillance when they noticed that many patients reporting having received antibiotics from their dentists.

Hilary Babcock
Hilary M. Babcock

“We’ve seen increasing amounts of C. difficile in the community, whereas we used to think of it as mostly a hospital-acquired infection,” said Hilary M. Babcock, MD, associate professor of medicine in the division of infectious diseases at Washington University School of Medicine. “Understanding where and how and from whom people in the community are getting antibiotics that may predispose them to C. difficile is an important part of understanding how to prevent C. diff in a community setting. Some of the answers about where those antibiotics are coming from can be surprising.”

Holzbauer and colleagues interviewed 1,626 patients with confirmed community-acquired CDI reported to the MDH between 2009 and 2015. Among 926 (57%) patients who were prescribed antibiotics, 136 (15%) received them for dental procedures. However, 34% of these patients had medical charts that did not mention the prescriptions, according to Holzbauer and colleagues.

Finding ways to reduce antibiotic use is an important strategy in minimizing the global threat of drug resistance. The researchers said rates of dental antibiotic prescribing are likely underestimated. Holzbauer added that this problem is likely occurring in other states. In addition, many prescriptions are likely unnecessary, possibly because the dentists are confused about current recommendations. A previous study by the MDH found that 36% of dentists prescribed antibiotics in situations in which they were not recommended by the American Dental Association, and some reported being confused about guidelines.

Holzbauer and colleagues recommended that stewardship programs address dental prescribing and that dentists be alerted to subsequent CDI in their patients who were prescribed antibiotics.

“They’re willing to listen, and I think they’re looking for guidance, but nobody goes to their dentist when they have diarrhea, so they don’t get that feedback of knowing that there’s potential consequences to their prescribing practices,” Holzbauer said.

Ebbing Lautenbach
Ebbing Lautenbach

Ebbing Lautenbach, MD, MPH, professor of medicine at the University of Pennsylvania Perelman School of Medicine, agreed that dental medicine has been overlooked.

“What this tells us is there are other areas in which we can focus the overall effort to improve antibiotic use with the ultimate goal of reducing Clostridium difficile and, in addition to that, the emergence of antimicrobial resistance,” he said. – by Gerard Gallagher

References:

Bye M, et al. Abstract 78. Presented at: IDWeek; Oct. 4-8, 2017; San Diego.

Lessa FC, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1408913.

Disclosures: Babcock, Holzbauer and Lautenbach report no relevant financial disclosures.

SAN DIEGO — Researchers in Minnesota identified a potentially overlooked source of Clostridium difficile infection: antibiotics prescribed by dentists.

Antibiotics can kill microbes that protect against infection in the gastrointestinal tract, potentially leading to C. difficile infection (CDI), which the CDC has designated as one of three “high-consequence” antibiotic-resistant threats requiring urgent public health attention. Antibiotics prescribed by dentists may contribute to the problem, according to study findings summarized here by Stacy Holzbauer, DVM, MPH, career epidemiology field officer for the CDC and Minnesota Department of Health (MDH).

Holzbauer and colleagues studied the antibiotic history of over 1,600 patients in Minnesota with community-acquired CDI and found that 15% had taken antibiotics for dental procedures over a 6-year period. Most of these patients — 85% — had taken antibiotics only for dental reasons, Holzbauer said. And for many, the prescriptions did not appear in their medical records, which Holzbauer said illustrates “a disconnect between dental and medical providers.”

“Dentists have often been overlooked as major partners in programs that promote appropriate antibiotic use, and it’s critical that they are included in efforts to improve antibiotic prescribing,” Holzbauer said during a news conference at IDWeek. “Antibiotics are not harmless medications. C. diff is a known complication.”

In 2015, researchers estimated that there were more than 450,000 cases of CDI in the United States in 2011 and around 29,000 associated deaths. The patients at the center of the study by Holzbauer and colleagues had community-acquired CDI. Holzbauer said the issue came to their attention through routine surveillance when they noticed that many patients reporting having received antibiotics from their dentists.

Hilary Babcock
Hilary M. Babcock

“We’ve seen increasing amounts of C. difficile in the community, whereas we used to think of it as mostly a hospital-acquired infection,” said Hilary M. Babcock, MD, associate professor of medicine in the division of infectious diseases at Washington University School of Medicine. “Understanding where and how and from whom people in the community are getting antibiotics that may predispose them to C. difficile is an important part of understanding how to prevent C. diff in a community setting. Some of the answers about where those antibiotics are coming from can be surprising.”

Holzbauer and colleagues interviewed 1,626 patients with confirmed community-acquired CDI reported to the MDH between 2009 and 2015. Among 926 (57%) patients who were prescribed antibiotics, 136 (15%) received them for dental procedures. However, 34% of these patients had medical charts that did not mention the prescriptions, according to Holzbauer and colleagues.

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Finding ways to reduce antibiotic use is an important strategy in minimizing the global threat of drug resistance. The researchers said rates of dental antibiotic prescribing are likely underestimated. Holzbauer added that this problem is likely occurring in other states. In addition, many prescriptions are likely unnecessary, possibly because the dentists are confused about current recommendations. A previous study by the MDH found that 36% of dentists prescribed antibiotics in situations in which they were not recommended by the American Dental Association, and some reported being confused about guidelines.

Holzbauer and colleagues recommended that stewardship programs address dental prescribing and that dentists be alerted to subsequent CDI in their patients who were prescribed antibiotics.

“They’re willing to listen, and I think they’re looking for guidance, but nobody goes to their dentist when they have diarrhea, so they don’t get that feedback of knowing that there’s potential consequences to their prescribing practices,” Holzbauer said.

Ebbing Lautenbach
Ebbing Lautenbach

Ebbing Lautenbach, MD, MPH, professor of medicine at the University of Pennsylvania Perelman School of Medicine, agreed that dental medicine has been overlooked.

“What this tells us is there are other areas in which we can focus the overall effort to improve antibiotic use with the ultimate goal of reducing Clostridium difficile and, in addition to that, the emergence of antimicrobial resistance,” he said. – by Gerard Gallagher

References:

Bye M, et al. Abstract 78. Presented at: IDWeek; Oct. 4-8, 2017; San Diego.

Lessa FC, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1408913.

Disclosures: Babcock, Holzbauer and Lautenbach report no relevant financial disclosures.

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