December 17, 2019
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Communication crucial to reducing antibiotic prescribing in dentistry

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Debbie Goff, PharmD
Debra A. Goff

Debra A. Goff, PharmD, FCCP, recalled what inspired her and several colleagues to review guidelines on the use of antibiotics in dentistry for the prevention of endocarditis and prosthetic joint infections.

Her husband, a dentist in private practice, treated a patient who had undergone hip replacement surgery 20 years earlier and was told by the orthopedic surgeon that she would need to take prophylactic antibiotics before any dental procedure for the rest of her life.

“My husband explained that the [American Dental Association (ADA)] no longer recommends this, plus his wife is an antibiotic stewardship expert, and this is not recommended anymore,” Goff, a clinical associate professor of infectious diseases at The Ohio State University Wexner Medical Center, told Healio. “She was distraught with the conflicting recommendations from her orthopedic surgeon and her dentists. She did not have the dental cleaning.”

The woman is one of many patients “stuck in the middle” between conflicting recommendations from orthopedic surgeons and dentists, Goff and colleagues wrote.

‘A shared goal’

Goff and colleagues reviewed guidelines from The American Heart Association, ADA and American Association of Orthopedic Surgeons (AAOS). Writing in Clinical Infectious Diseases, they discussed ways to engage dentists and orthopedic surgeons in antimicrobial stewardship.

In 2016, the AAOS and ADA developed appropriate use criteria for antibiotic prophylaxis prior to dental procedures in patients with orthopedic implants, noted Alan E. Gross, PharmD, BCIDP, BCPS, clinical associate professor at the University of Illinois at Chicago College of Pharmacy, who was not involved in the review. Consistent with previous recommendations, in most patient scenarios, the criteria still recommend no antibiotic prophylaxis prior to dental procedures in these patients. However, Gross said that in a minority of patients, the criteria indicate that prophylaxis is appropriate or may be appropriate.

“Given these nuances, it is understandable that health care providers may arrive at differing conclusions depending on the patient circumstance,” Gross told Healio. “Every health care provider wants to provide the best care for their patients, and so we — dentists, pharmacists, physicians and patients — all have that shared goal. Bringing these stakeholders together, as was done in the study by Goff and colleagues, is key to understanding the varying perspectives on what the best approach is for our patients and finding opportunities to gain consensus to improve care.”

Goff said bringing dentists and orthopedic surgeons together face to face and giving them access to infectious diseases experts can help them understand there are real risks — such as Clostridioides difficile — in prescribing just a single dose of antibiotics, and can change their antibiotic prescribing behavior.

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In their review, Goff said they also learned that dentists and orthopedic surgeons practice “defensive medicine” in fear of being sued if a patient develops an infection and was not given antibiotics. They recommended that antibiotic stewardship pharmacists and physicians meet with local dental and orthopedic societies to address guidelines and controversies, provide local data on resistance rates, prevalence and mortality from superbugs and C. difficile infection and risk for antibiotic adverse drug reactions, and improve knowledge gaps about antibiotic resistance and consequences associated with antibiotic use.

“All the guidelines in the world won’t change the antibiotic prescribing behavior of dentists and orthopedic surgeons if they do not believe they are not doing any harm to their patients,” Goff said. “Updated information on the risk of C. difficile, the impact of antibiotics on the microbiome, and the profound rates of antibiotic resistance requires every health care profession to rethink their use of antibiotics, its risk vs. benefit. There are no studies that prove dental antibiotic prophylaxis in joint implant patients will prevent an infection.”

‘Important final frontier’

Gross said antibiotic use in dentistry is an “important final frontier” for antimicrobial stewardship efforts. Dentists write 10% of all outpatient antibiotic prescriptions, and previous data suggest that 30% to 85% of antibiotic use in dentistry is either suboptimal or not indicated, Gross noted.

“Antibiotic prescribing in dentistry is frequently driven by multiple stakeholders, including dentists, primary care physicians and surgeons and patients,” he said. “All of those parties should be aware of updated prophylaxis and treatment recommendations and agree that they apply to the individual patient circumstance.

“For example, patients may seek antibiotics because they have always received antibiotics in the past, and from previous work, we know patients’ desires for antibiotics may induce prescribing, even when the prescriber knows it is not indicated. Furthermore, a primary care physician may have a different assessment of the need for prophylaxis prior to dental visits than the dentist. This highlights the need for an open dialogue among all of these parties so that the patient can receive optimal therapy.”

As an example, Gross noted that the University of Illinois at Chicago College of Dentistry implemented an antimicrobial stewardship program in its dental clinics.

“Opening up a line of communication with our dentist colleagues was instrumental, and they have been wonderful collaborators,” he said. “They have been very excited to look at ways to improve antibiotic prescribing in our dental clinics.”

According to Gross, the collaboration led to local treatment guidelines, resulting in a 73% relative decrease in antibiotic prescribing for oral infections in the urgent care dental clinic.

“I think this success was possible just by bringing everyone to the table, formalizing a dental antimicrobial stewardship program, identifying opportunities, and setting goals,” he said. – by Caitlyn Stulpin

Disclosures: Goff reports receiving consulting fees from BioK and Tetraphase, grants to her institution from Merck and Pfizer, and speaking fees from Astellas, all outside the submitted work. Infectious Disease News was unable to confirm relevant financial disclosures from Gross prior to publication.