WASHINGTON, DC — Antibiotics prescribed for prophylaxis before dental visits can trigger a serious reaction in some patients that leads to a visit to the emergency department after just one or two doses, new research shows.
The findings are particularly troubling because dentists are the top specialty prescribers of antibiotics, but they might not hear about adverse events because those are treated by physicians, said Alan Gross, PharmD, a clinical assistant professor at the UIC College of Pharmacy in Chicago.
Antibiotics have been commonly prescribed 1 or 2 days before a dental visit for certain patients, such as those who have had a hip or knee replaced, to prevent infection.
Prescribing decisions are often made jointly by a dentist and another provider, such as an orthopedic surgeon, said Gross. However, he and his colleagues recently showed that the prophylactic use of antibiotics before most dental procedures is unnecessary (JAMA Netw Open. 2019;2:e193909).
In that study, the researchers assessed the 168,420 dental visits made by patients from 2011 to 2015, which were linked to medical and prescription claims from 2009 to 2015. Of all the prescriptions for antibiotic prophylaxis, 136,177 (80.9%) were deemed unnecessary under current guidelines.
An unnecessary prescription was defined as antibiotics given to patients who did not undergo a procedure that manipulated the gingiva or periapical region of the tooth and did not have a cardiac diagnosis that met the guidelines for prophylaxis.
In their new analysis, presented here at IDWeek 2019, Gross and his colleagues determined that 5260 of the 136,177 (3.8%) unnecessary prescriptions were linked to an antibiotic-related adverse event.
Among these events were 3912 allergic reactions, from rash to a reaction requiring hospitalization; 1568 visits to the emergency department; and nine cases of Clostridium difficile infection.
Clindamycin was associated with more antibiotic-related adverse events than amoxicillin (risk difference, 322.1 per 1000 person-years; 95% confidence interval, 238.5 – 405.8).
Dentists prescribe more clindamycin than any other healthcare provider, said Katie Suda, PharmD, from the Center of Innovation for Complex Chronic Healthcare at the Hines VA Hospital and the UIC College of Pharmacy, who was one of the researchers on the original study and the new analysis.
In fact, dentists prescribe about 10% of all outpatient antibiotics, she reported. For context, “pediatricians and internists prescribe about 10% to 12% of antibiotics annually.”
“We also know, based on data published earlier this year from the CDC, that antibiotic prescribing by dentists has remained stable, whereas we’re seeing decreases in antibiotic prescribing by physicians,” said Suda.
This could be, in part, because patients used to getting antibiotics in accordance with old guidelines might pressure dentists for a prescription, Gross added.
Underestimating Adverse Events
These findings are concerning because the 3.8% of unnecessary prescriptions linked to antibiotic-related adverse events represent more than 5000 prescriptions, and that could be an underestimation, said Emily Sydnor Spivak, MD, medical director of antimicrobial stewardship programs at the University of Utah Hospital and VA Salt Lake City Health Care System.
“That number may be low since it only encompasses allergy, C difficile infection, and ED visits for 14 days,” she pointed out.
The number likely would be higher if organ dysfunction had been included and if patients were followed more than 2 weeks, Spivak told Medscape Medical News.
Suda agreed that harms might be under-represented and acknowledged that the researchers had no data on the drug–drug interactions commonly caused by antibiotics or on any effects such as nausea for which patients did not seek treatment.
Historically, stewardship has not focused on dentistry, “but that is changing,” said Spivak. “Our health system also has a lot of loopholes and a lack of communication.” Plus, a lack of awareness and trust in the guidelines plays a part.
Bringing Antibiotic Stewardship to Dentistry
It will take a coordinated effort to reduce unnecessary antibiotic prescriptions, she said. Prescribers need to be educated about the guidelines and the consequences of unnecessary prescribing, the communication gap needs to be closed so that dentists know about adverse effects when diagnoses are made in the medical setting, and patients need to be educated about the benefits and risks of antibiotic prophylaxis.
Dentists should be part of the stewardship conversation and should have streamlined access to a patient’s medical information, added Suda.
“Very few dental offices have that kind of information available to them,” she said. “Physicians and advanced practice providers can really support dentists. Dentists are the experts on which patients do and do not need prophylaxis.”
A dental stewardship program has been implemented at the UIC College of Dentistry, Gross reported, “and we decreased prescribing by 70% for antibiotics for the treatment of oral infections in our urgent care dental clinic. Dentists took the ball and ran with it.”
Gross, Suda, and Spivak have disclosed no relevant financial relationships.
IDWeek 2019: Abstract 1895. Presented October 3, 2019.