Antibiotic Stewardship: Integrating a Crucial Element for Dental Practices, Education, and Patient Care

GRAPHICAL ABSTRACT

Sir William Osler (1849–1919), a Canadian physician and one of the "Big Four" founding professors of Johns Hopkins Hospital, known as the father of modern medicine, once said, “the desire to take medicine is perhaps the greatest feature which distinguishes man from animals.” Pharmacotherapeutics can be described as the proper selection of a therapeutic agent the biologic effect of which on a living organism is most appropriate to manage or treat a particular disease state. Hence, it requires a careful consideration, amongst others, of dose and concentration, duration of therapy, and adverse/side effects.

Of the available therapeutic agents, antimicrobials are deemed essential to modern medicine and dentistry and can save lives and change quality of life. Dentists are thought to prescribe at least 10% of antibiotics globally. Due to the extensive irrational prescription of antibiotics over a century or so by the medical profession in general, there is now a global threat of emergence of microbial resistance to these drugs at an alarming rate. According to the World Health Organization 2015 Global Action Plan (WHO-GAP) on antimicrobial resistance,^1,2 understanding and being able to explain the risks and benefits of medications is key for our patient care. Following are a few relevant observations pertinent to such a crucial element for all dental teachers and practitioners:

Evidence-based modern medicine and prescribing

In a recent report, the US Centers for Disease Control and Prevention (CDC) estimated that more than 2.8 million antimicrobial-resistant (AMR) infections occur in the US each year, resulting in more than 35,000 lives lost. At a global scale, it is calculated that 700,000 people die from AMR infections annually, and this statistic is predicted to rise to 10 million deaths by 2050 if effective action is not implemented.

Interestingly, the CDC also estimates that about 30% of all antibiotics prescribed in acute care hospitals in the US are either unnecessary or suboptimal. Indeed, the misuse of antibiotics (and antimicrobials) also contributes to drug resistance—a serious threat to public health, globally—rendering evidence-based prescribing or rational antibiotic prescribing critical. Hence, antibiotic stewardship, or ABS, was implemented by the CDC in 2011³ and revised in November 2019.⁴

Briefly, ABS is a systematic effort to educate, measure, and improve how antibiotics (and antimicrobials) are prescribed by clinicians and used by patients. Henceforth, ABS aspires to persuade and improve antibiotic (and antimicrobial) prescribing and use, critical to effectively treat infections, protect patients from harms caused by unnecessary drug use, and combat antibiotic resistance.

ABS interventions cover 3 main categories—broad, pharmacy-driven, and infection- and syndrome-specific—and focuses on the 5 Ds: Drug, Deescalation of therapy, Discontinuation of therapy, Dose, and Diagnosis. To provide the individual patient with an optimum standard of care, correct drug prescription and prescribing decisions (whether prophylactic to prevent infection, preemptive to abort infection, empiric to provide initial infection control in the absence of known etiology, or definitive to cure an infection of known aetiology) should be made based on a systematic review and critical appraisal of accruing clinical research findings. Hence, appropriate drug prescribing should be an integral part of health care programmes and is most effective when coupled with interventions and outcomes. Indeed, the CDC today actually, whilst recognising that there is no “one size fits all” approach, recommends using case-based strategy to provide proper drug prescribing education via didactic (electronic-included) communications, presentations, posters, flyers, and letters.

ABS for dentistry

In a cross-sectional study, in the United Kingdom, Cope et al⁵ found that 80% of antibiotic used for treating acute dental conditions in general dental practise was unnecessary. On the other hand, a study in the US found that 80% of antibiotic prescriptions and use for infection prophylaxis—predental interventions—was inappropriate.⁶ In a 2022 retrospective pharmaco-epidemiologic report, Kjome et al⁷ identified the prescribing patterns and trends amongst Norwegian dentists over a 10-year period (2005–2015), finding a 33% increase in the number of prescriptions, with the majority for antibiotics and analgesics. Alarmingly, the study revealed that antibiotic prescribing by dentists increased in a period when total antibiotic prescribing in Norway decreased. Likewise, in a Croatian study,⁸ there was a ∼6.0% increase in medication prescribing by dentists, dominated by with antimicrobials, with broad-spectrum antibiotics (mainly penicillins) accounting for 80% of all prescriptions made by dentists (January 2014 to December 2018). However, in this report, the analysed data included neither prescriptions dispensed in private or in-hospital patients nor non-prescription medications that can be purchased. Nonetheless, and like the Norwegian report, the study showed an increase in the overall medication prescribing rate by dentists, calling for additional studies to identify the reasons for this increase and to target areas of possible intervention and/or advance, including the creation of coherent evidence-based prescribing guidelines, distinct training for dentists, and ensuring the practical and effective implementation of those guidelines.

In the same vein, in a recent pharmaco-epidemiological Australian study⁹ (cumulative prescription count from 2006 to 2018 was calculated), the increasing dispensing pattern and trends of dentist-prescribed antibiotics, opioids, and benzodiazepines were demonstrated. Furthermore, in the central Asian region, Tuleutayeva et al¹⁰ surveyed 108 dentists online to study the patterns of antibacterial drug prescribing. Analysis revealed that 42.1% of respondents frequently prescribed antibiotics in their practice, 61.3% responded that they are familiar with the principles of rational antibiotic therapy and 84.0% prescribed an antibiotic with an average therapeutic dose. Yet, the authors concluded that 64% of the prescribed antibiotics (and combinations thereof) were deemed irrational or empirical in outpatient dental practice and without any direct indications. Thus, this pattern of drug dispensing and by dentists are global. Indeed, they represent an ongoing cause for concern, requiring perhaps additional measures to increase the awareness and knowledge of dentists (and dental students) in terms of antibiotic drug therapy as well as prescription standardisation.

As mentioned, AMR infections are driven by the overuse and abuse of antibiotics and antimicrobials. Our dental profession has a clear responsibility to commit and contribute to tackling AMR infections at global, national, and local levels. Therefore, the World Dental Federation issued an ABS policy statement^11,12 during the 2019 General Assembly held in San Francisco to address the existing global health problem of antibiotic overuse and the subsequent development of antibiotic-resistant microorganisms. Briefly, it highlights the vital responsibility and crucial role that dentists (both general and specialist), their teams, dental associations, health care policy, legislation and funding agencies—as well as the dental teaching, education, and training institutions—have in the practical engagement of coherent ABS action to ensure the proper, sustainable, and effective use of antibiotics for a minimally invasive treatment plan.

The therapeutic use of antibacterials, antifungals, and antimicrobials in odontogenic infections and indications should be seen as adjunctive to a clinical intervention, not as an alternative.

This is an open call to both the novice and senior dentists and surgeons to consider appropriate antibiotic stewardship to reduce the risk of the global emergence of antibiotic resistance organisms.

Conflict of interest

None disclosed.