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Preventing Infections – Antibiotic Prophylaxis

Watch Dr Katie Suda discuss antibiotic prophylaxis within dentistry and how it effects AMR.
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Here in the United States, dentists prescribe 1 out of every 10 antibiotics, with more prescribed for prophylaxis purposes rather than to treat dental infections. Worryingly, antibiotic prescribing by our dentists is increasing, which is discordant with decreasing antibiotic prescribing nationally. So the importance of dentistry to our national efforts to tackle antibiotic resistance is being increasingly recognised. United States clinical guidelines published by the American Heart Association and American Dental Association recommend antibiotic prophylaxis prior to a dental visit in specific circumstances for people at risk of an adverse outcome should they develop infective endocarditis. Guidelines for patients with prosthetic joints no longer recommend the routine administration of antibiotics prior to dental procedures.
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Be aware that guidelines on prophylaxis do differ markedly around the world and do change from time to time. For example, while the United States guidelines are currently similar to those in Australia and Canada, the routine use of prophylactic antibiotics is not recommended in England. Therefore, it is important that you stay up to date with your local guidelines. My research team has been looking at dental antibiotic prescribing in the United States and ways to optimise antibiotic prescribing and use. In our analysis of US dental visits, we found that 80% of antibiotics prescribed for infection prophylaxis prior to dental visits were unnecessary per guidelines.
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Patients with prosthetic joints, dental implant procedures, women, and dental visits occurring in the Western United States were associated with unnecessary antibiotic prophylaxis. Interestingly, unnecessary prescribing was most frequent for Clindamycin. As you heard earlier in this module, antibiotic-related adverse events are well-recognised, especially associated with broad spectrum agents. In our studies, we found that unnecessary antibiotic prophylaxis, that is antibiotics prescribed prior to dental visits not in accordance with guidelines, was associated with serious antibiotic-related adverse events such as anaphylaxis and C. difficile infection. In particular, patients receiving Clindamycin were more likely to experience serious adverse events. We are not alone in this finding. A surveillance study in a Midwestern US state found that 8% of community-acquired C.
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difficile infection cases were related to antibiotic prophylaxis for dental procedures. Studies published in France and England have reported similar findings from their national data sets of voluntary drug safety reports. In fact, one dose of Clindamycin had a similar likelihood of an adverse event as a prolonged course. Collectively, these studies show that even short courses used for antibiotic prophylaxis, regardless of appropriateness of use, are associated with patient harm. I would like to go back and highlight our results on Clindamycin. In the United States, dentists are the primary prescriber of Clindamycin, and Clindamycin is the second most frequent antibiotic prescribed by US dentists. By contrast, dentists in England and Australia rarely prescribe Clindamycin.
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The high prescribing and unnecessary prescribing identified for Clindamycin in my study is concerning because, historically, Clindamycin has been associated with the highest risk of C. difficile infection. Antibiotic prescribing by dentists, even for short durations typically used for prophylaxis, has been associated with C. difficile in the US and England. Data in the US suggests that one of the primary reasons Clindamycin is prescribed is due to penicillin allergy. Given that as much as 95% of self-reported penicillin allergies may not be true allergies that preclude the use of amoxicillin, clarifying and removing penicillin allergy labels is critical to decreasing patient harm associated with Clindamycin. As a result, the American Dental Association now discourages Clindamycin as the first-line agent in penicillin-allergic patients.
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Studies about ways in which the dental profession can optimise the prophylactic prescribing of antibiotics are increasingly being published in the academic literature. This is a fast-evolving field, and I would encourage you to look online to find the latest thinking. Some key papers are included in the additional reading for the final module, where you will be exploring dental antibiotic stewardship in detail. The good news is that we have found that dental antibiotic prescribing did improve during our study period. Also, dentists in the US rarely prescribe broad-spectrum agents, and dentists are becoming more aware of the implications of antibiotic resistance. Thank you for your attention.

In this video, Dr Katie Suda talks about antibiotic prophylaxis within dentistry and its effect on antibiotic resistance. She describes several studies and data about antibiotic prophylaxis.

In an analysis of U.S. dental visits, it was found 80% of antibiotics prescribed for infection prophylaxis prior to dental visits were unnecessary per guidelines. It is important to remember how impactful dental antibiotic prescribing can be, particularly in unnecessary antibiotic prophylaxis, which is associated with serious antibiotic-related adverse events for patients.

Optimising dental prophylactic antibiotic prescribing is a fast-evolving field of study so we encourage you to look online for the most up to date thinking but some of this will be covered later on in the course.

Be aware that guidelines on prophylaxis do differ markedly around the world and do change from time to time. For example, while the U.S. guidelines are currently similar to those in Australia and Canada, the routine use of prophylactic antibiotics is not recommended in England.

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Tackling Antibiotic Resistance: What Should Dental Teams Do?

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