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Antibiotic stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves outcomes, reduces microbial resistance, and decreases the spread of infections caused by multi-drug-resistant organisms.4 This effort aims to ensure that clinicians are prescribing the right antibiotic, at the right dose, at the right time, and for the right duration in order to ensure that there will be effective treatment when needed.
Antibiotic resistance occurs when mutant bacteria no longer respond to antibiotics because they have developed or received mechanisms that make the antibiotics ineffective. The Centers for Disease Control and Prevention (CDC) estimates that someone in the US dies every 15 minutes from antibiotic-resistant infections.5 According to the Association for Professionals in Infection Control and Epidemiology (APIC), "misuse and overuse of antimicrobials is one of the world's most pressing public health problems."4 With dentistry prescribing nearly 10% of outpatient antibiotics,2 it is essential that all dental professionals understand their role in antibiotic stewardship.
What is the Dental Professional's Role When It Comes to Antibiotic Stewardship?
While there is no one-size-fits-all approach to treating and prescribing, as members of the healthcare sector it is dentistry's responsibility to be aware of the risks of antibiotic resistance. By preventing dental infections in the first place, raising awareness of antibiotic overuse, and proper prescribing, dental professionals can not only protect patients but society as a whole.
Overview of Prescribing Guidelines
Dentistry has often gone by the "watch and wait" philosophy when it comes to pain and swelling. The American Dental Association (ADA) now encourages the profession to move from a "just in case" approach of antibiotic prescribing to an "only when absolutely needed" approach.6 Both dental professionals and patients must understand that antibiotics are not a cure. Only definitive conservative dental treatment (DCDT) can completely resolve the root cause of tooth pain and swelling. The ADA has published two flow charts designed to help providers make informed decisions, which are included in an article titled "Evidence-Based Clinical Practice Guideline on Antibiotic Use for the Urgent Management of Pulpal and Periapical-Related Dental Pain and Intraoral Swelling,"6 for use when DCDT is and is not immediately available.
Prescribers can also practice delayed prescribing by giving the patient a post-dated prescription with instructions only to fill it if symptoms develop or worsen. The CDC recommends delayed prescribing "for patients with conditions that usually resolve without treatment but who can benefit from antibiotics if the conditions do not improve."7 The Michigan Antibiotic Resistance Reduction Coalition (MARR) has also developed a "delayed prescribing" notepad8 to help patients understand the practice of delayed prescribing.
If antibiotics are indeed called for, clinicians should consider a prescription for a shorter duration of use. A duration of 3 to 5 days is currently recommended, with discontinuation of use 24 hours after the symptoms have resolved.7 Longer use does not equal better care and increases the risk of complications including antibiotic resistance.
A significant concern with antibiotic overuse is the rise of Clostridioides difficile(C. diff) infections. This bacterium can cause deadly diarrhea and is responsible for almost half a million infections and 30,000 deaths annually.9 Clindamycin has a black box warning for C. diff diarrhea and is no longer recommended for any therapeutic or dental prophylaxis per recommendations from the American Heart Association (AHA) and the American Academy of Orthopaedic Surgeons (AAOS).
Antibiotic Prophylaxis
Pre-medication prior to invasive dental procedures continues to confound clinicians in both dentistry and medicine. When compared with previous recommendations, there are very few instances in which antibiotic prophylaxis is still indicated. However, patients with a history of infective endocarditis, prosthetic valves/materials, congenital heart disease, and/or cardiac transplant are recommended to receive antibiotic prophylaxis, and their cardiologist should be consulted.10
On the other hand, although many patients with joint replacements are told by their surgeon to pre-medicate for two years or for life, that is no longer the ADA's recommendation. In 2014, the ADA's Council on Scientific Affairs recommended that "for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures."11 Additionally, the AAOS stated in its 2016 Appropriate Use Criteria document that, "The chance of oral bacteremia being related to joint infections is extremely low, with no evidence for an association."12
In an effort to educate clinicians and patients, the CDC, MARR, and the Organization for Safety, Asepsis and Prevention (OSAP) developed free printable and shareable resources that provide accurate, evidence-based information (Figure 1 and Figure 2). Included in the resources is an editable letter to the patient's medical provider regarding prophylaxis in patients with prosthetic joint implants with current references.8 The dental clinician or treatment coordinator should share educational materials with patients and their doctors to bring them up to date on the current recommendations. In cases where the orthopedic surgeon deems antibiotics necessary, the surgeon should recommend the appropriate antibiotic regime and write the prescription.11
Penicillin Allergy
First line antibiotic prescribing is an important piece of antibiotic stewardship. According to the CDC, 10% of all US patients report a penicillin allergy, but in reality, less than 1% of the population is truly allergic.13 Meanwhile, patients who are labeled "penicillin allergic" are more likely to receive second-line antibiotics and possibly experience treatment failure or develop C. diff, post-surgical infections, or methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) infections.
The CDC encourages all healthcare professionals to discuss penicillin allergy with patients and help them determine whether further evaluation and potential de-labeling is recommended. Ideally, patients are evaluated long before they need antibiotics so that if the time comes, they can receive the best antibiotic for their situation. OSAP and MARR have developed both the Penicillin Allergy Assessment Tool (PAAT) and the Penicillin Allergy Reassessment for Treatment Improvement (PARTI) Tool (Figure 3 and Figure 4).8,14 These tools will make it easy for dental offices to determine if patients should be referred for further evaluation and provide patients with an informational resource to bring to their healthcare provider.
Steps Toward Antibiotic Stewardship
The CDC outlines effective antibiotic stewardship in the document "The Core Elements of Outpatient Antibiotic Stewardship."7 The entire dental team plays a part in antibiotic stewardship. It begins with understanding the risks and undesirable effects associated with antibiotic therapy and inappropriate prescribing. Then, the tools provided by trusted organizations can be utilized to make evidence-based decisions about prescribing and antibiotic stewardship, while monitoring and adjusting prescribing practices as needed. Lastly, all dental professionals must make a commitment to educate patients and healthcare professionals with the most up-to-date research and recommendations so that antibiotics will be available to all when they are truly needed.
References
1. Talkington K. Watch bacteria evolve to defeat antibiotics in just 11 days. The Pew Charitable Trusts website. https://www.pewtrusts.org/en/research-and-analysis/articles/2016/10/19/watch-bacteria-evolve-to-defeat-antibiotics-in-just-11-days. Published October 19, 2016. Accessed April 3, 2024.
2. Fluent MT, Jacobsen PL, Hicks LA; OSAP, the Safest Dental Visit. Considerations for responsible antibiotic use in dentistry. J Am Dent Assoc. 2016;147(8):683-686.
3. Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Netw Open. 2019;2(5):e193909.
4. Association for Professionals in Infection Control and Epidemiology. Antimicrobial stewardship. APIC website. https://apic.org/professional-practice/practice-resources/antimicrobial-stewardship/. Accessed April 3, 2024.
5. Centers for Disease Control and Prevention. National infection & death estimates for antibiotic resistance. CDC website. https://www.cdc.gov/drugresistance/national-estimates.html. Updated December 13, 2021. Accessed April 3, 2024.
6. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: a report from the American Dental Association. J Am Dent Assoc. 2019;150(11):906-921.e12.
7. Centers for Disease Control and Prevention. Core elements of outpatient antibiotic stewardship. CDC website. https://www.cdc.gov/antibiotic-use/core-elements/outpatient.html. Updated September 8, 2021. Accessed April 3, 2024.
8. Michigan Antibiotic Resistance Reduction Coalition. Resources to support antibiotic stewardship in the dental office. https://www.mi-marr.org/dental-resources/. MARR website. Accessed April 3, 2024.
9. Feuerstadt P, Theriault N, Tillotson G. The burden of CDI in the United States: a multifactorial challenge. BMC Infect Dis. 2023;23:132.
10. American Dental Association. Antibiotic prophylaxis prior to dental procedures. ADA website. https://www.ada.org/resources/ada-library/oral-health-topics/antibiotic-prophylaxis. Updated January 5, 2022. Accessed April 3, 2024.
11. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: evidence-based clinical practice guideline for dental practitioners-a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015;146(1):11-16.e8.
12. American Academy of Orthopaedic Surgeons. Management of patients with orthopaedic implants undergoing dental procedures: appropriate use criteria. AAOS website. aaos.org/dentalauc. Published September 23, 2016. Accessed April 3, 2024.
13. Centers for Disease Control and Prevention. Is it really a penicillin allergy? CDC website. https://www.cdc.gov/antibiotic-use/community/pdfs/penicillin-factsheet.pdf. Published October 2017. Accessed April 3, 2024.
14. Coyne AJK, Holger D, Kennedy E, et al. 1252. Penicillin allergy reassessment for treatment improvement (PARTI): a dental office tool to support appropriate penicillin allergy labeling. Open Forum Infect Dis. 2023;10(Suppl 2):S562.
