Implications of Overprescription of Antibiotics: A Cross-Sectional Study

Abstract

Introduction:

The use of antibiotics in recent years has become more aggressive and more common. The inappropriate use, to be more precise, the abuse of these prescriptions, is the root cause for increasing bacterial resistance and adverse outcomes. Antisepsis can be suggested as an appropriate alternative to antibiotics, to control the increasing antibiotic resistance among individuals.

Objective:

The objective of this study was to compare the awareness of antibiotic prescription and resistance among BDS and MDS practitioners and students.

Materials and Methods:

A total of 361 dental professionals were included in this study. Each of them was given a questionnaire containing questions pertaining to antibiotic prescription and awareness.

Results:

Most of the participants prescribed antibiotics as pre and post treatment management of all the oral diseases during their routine interaction with the patients. Overprescription of antibiotics, amoxicillin being the most common, was significantly more among the BDS practitioners than the MDS practitioners. BDS practitioners (78%) preferred a 3-day antibiotic prescription whereas MDS practitioners (80%) prescribed a 5-day course, which was statistically significant. Mindfulness with respect to antimicrobial prophylaxis and antibiotic resistance was observed to be satisfactory in both the groups. However, there was a general absence of mindfulness with respect to the rules for antibiotic prescription recommendations in both the groups.

Conclusion:

Antibiotic prescription should be given with care to prevent its resistance, an upcoming iatrogenic health hazard.

INTRODUCTION

The therapy of bacterial infections has seen a significant rise in the recent years characterized by several developments in the treatment of bacterial infections. Recent years have seen a sharp rise in the incidence of several bacterial infections that are resistant to antibiotics. The increased prescription of antibiotics may contribute to the bacterial resistance to antibiotics. The measures to control antibiotic resistance became the need of the hour and several measures were taken up to control the same.[1,2]

However, the overuse of antibiotics is now being observed as a major health challenge worldwide due to the increase in the spread of resistant pathogens in various health-care settings. The interests of both, the doctor and the patient, contribute to the unnecessary antibiotic prescription, where the doctor feels pressured and succumbs to the patient’s treatment preferences.[3] Thus, the increase in the bacterial resistance can be the result of inappropriate selection of the antibiotic, abuse/overuse of the availability of drugs over the counter, and subsequent development of less virulent or resistant strains.

In lieu of the increased bacterial resistance and approach in the dental practice, this study was conducted. Prophylactic antibiotics can be used in invasive dental procedures or life-threatening situations; but care should be taken not to prescribe an unnecessarily stronger or longer dose. A misguided prescription may lead to disastrous side effects ranging from gastrointestinal issues to severe anaphylactic shock leading to death. This global issue was taken up by the World Health Organization (WHO), which announced “Antibiotic resistance: No action today, No cure tomorrow” as the theme for the year 2011. Literature on overprescription of antibiotics in children are scarce; this provided us the incentive to conduct our survey.[4]

MATERIALS AND METHODS

A total of 361 dental practitioners who were willing to participate in the questionnaire study were considered. This study was a cross-sectional survey. A validated and self-designed questionnaire was prepared comprising the demographic data of the participants. A total of 209 BDS respondents and 152 MDS respondents were included in the survey. A written-informed consent was obtained from all the participants. The questionnaire had information pertaining to the demographics, current level of training, years of practice, and attitude and awareness toward antibiotic overuse and resistance. The data obtained were compiled, tabulated, and subjected to statistical analysis.

RESULTS

Of all the 361 respondents of the survey, 209 were BDS and 152 were MDS. The responses given by the participants with respect to antibiotic prescriptions for normally experienced oral conditions are accumulated and depicted. At the point when comparisons were made between BDS and MDS practitioners, it was discovered that there was a critical increment in the prescription of antibiotic agents among the BDS practitioners than the MDS practitioners for a large portion of the oral conditions. Further, it was discovered that the lion’s share of both the groups recommended amoxicillin (84% BDS and 70% MDS) as their first choice followed by ofloxacin with ornidazole (7% BDS and 13% MDS), cephalexin (3% BDS and 12% MDS), and clindamycin (7% BDS and 5% MDS). As to the course of antibiotic prescription, 78.5% BDS professionals endorsed for 3 days, whereas only 20% MDS specialists recommended for 3 days, with a statistically significant difference are seen. In our survey, 15% BDS dental practitioners knew the rules of antibiotic prescription when compared with 71% MDS practitioners, whereas the difference was statistically significant. Around 85% BDS and 94% MDS dental practitioners knew about “antibiotic resistance” and a majority of the participants (90% BDS and 96% MDS) were aware about the prophylactic antibiotic prescription with a P = 0.39.

DISCUSSION

India is a country with a population of 1.3 billion people, where 66.5% reside in the rural areas but 65% of hospitals, 77% of clinics, and 84% of physicians are in the urban areas.[3] Antibiotics have brought unquestionable benefits to modern medicine; however, excessive and injudicious use confers a chance for opportunistic pathogens along with inherent side effects causing infections. Antibiotic resistance is now a serious global health concern.[5,6,7] In recent reports, emergence of novel multidrug-resistant bacterial pathogens from India and other South Asian countries is a serious concern.[3] The total response rate on this survey was 100%. Konde et al.[4] stated of all the oral diseases dealt in routine practice, pain is the most common complaint the patients seek the dental practitioner’s advice. Surprisingly, in our study, a significant number of BDS practitioners and MDS practitioners prescribed antibiotics for oral conditions and diseases, which was not required, thus showing a statistical difference.[4] Dental infections that are present in the form of pulpitis and periapical periodontitis require only operative measures such as fillings, root canal therapy, or extraction if the tooth is not restorable as per the American Academy on Pediatric Dentistry (AAPD) guidelines on antibiotic therapy for dental patients.[4,8] The AAPD rules state, antibiotics should be considered as a 5- to 7-day prescription for oral wound management, depending on the suspected infection. Antibiotics should only be considered in cases such as advanced nonodontogenic bacterial infection, acute facial swelling with dental origin and not in cases of pulpitis or apical periodontitis.[9] The study found variable rates of awareness toward the duration of antibiotic course prescribed by BDS participants and the MDS participants/practitioners. With a significant difference (P = <0.001), the BDS participants preferred a 3-day antibiotic course in comparison to the MDS participants, who preferred (80.2%) a 5-day antibiotic course.[9,10]

In recent years, emphasis for the use of antibiotics is laid on the short-term period prescribed to prevent the relapse of both clinical and microbiological situations. At this context, Rubenstein elaborated that the drugs advocated for the short-course antibiotic therapy should have characteristics such as rapid onset of action, bactericidal activity, lack of property to induce resistant mutants, easy penetrability into tissues, action against nondividing bacteria, and effective at an optimal dose and optimal dosing regimen.

Less than half the BDS participants reported awareness of guidelines for antibiotic prescription (15.3%). Intellectual parents understand antibiotic resistance but fail to see the side effects on their child, as an individual.[3,11] In our study, we found that 84% of BDS participants and 70% of MDS participants relied on amoxicillin as the first choice. The awareness of guidelines for prescription of antibiotics was found to be low among the BDS practitioners (15%) in contrast to the MDS practitioners (71%).[4,8,12] Therefore, one could speculate the contribution to the unnecessary prescribing of antibiotics for such a condition.[8,12] Studies have shown increased antibiotic use associated with presence of purulence.[3,12] We found that the majority believe physicians overprescribe antibiotics. A study in Belgium suggested similar findings, including a 54% more inclination of general practitioners prescribing antibiotics than pediatricians. Many factors ranging from physician and patient attitudes to medical, social, and cultural norms can play a role in antibiotic prescribing decision-making process.[3,11]

Williams et al., in 1965, described the eradication of bacteriuria in pregnancy using short course of antibiotics. Other documented studies show that short-term (2–3 days course) antibiotic therapies are justified.[1] In the study, the practitioners reported the most common factors that increase antibiotic prescription as purulent discharge, fever, and prevention of serious complications.[3,8,11] The limitations of this survey are that it relies on the practitioner’s recall and self-reported practices.[3] Prophylactic antibiotics have been suggested to prevent complications such as dry socket and systemic complications such as infective endocardiditis.[4,6,8,12,13] In this study, most of the respondents were aware of the antibiotic resistance. This finding was not an evidence of their awareness of the consequences of antibiotic overuse.[12] Antibiotics are not alternatives to dental treatments but may be treated as adjuvants.[6] The surveyed physicians suggested judicious use of antibiotics and improved awareness of antimicrobial resistance. Education about the use of antimicrobials is a must.[3] These results confirmed the overall overuse of antibiotics in general dental practice and are comparable to other studies.[12] Frequent updating and reinforcement programs have to be conducted focusing on the prescription of antibiotic over usage and educate the practitioners on the harmful effects of antimicrobial resistance.

CONCLUSION

Our survey findings suggested that antibiotics were prescribed with no judicious thinking, indiscriminately and inappropriately. Most treatment periods read in textbooks lack scientific evidence.[1] There was an overprescription among the BDS practitioners when compared to the MDS dentists’ group, for most oral diseases; this may have been due to lack of understanding of the disease, lesser skill, and lesser competency. Dental prescriptions can be improved by increasing the awareness of the recommended guidelines among all dental practitioners.[4,12] Direct and planned interventions to curb antibiotic overuse can create a considerable impact in controlling the increasing burden of bacterial resistance.[2] Increasing bacterial resistance and hospital costs have mandated the reevaluation of the duration of prescription.[1,12]

In our study, we found the major addressing points to a beneficial and effective control of antibiotic resistance as follows:

1. Improving the educational value of antibiotic prescription.

2. Conducting regular review meetings and discussions for the benefit of the practitioners and would be practitioners.

3. Providing and monitoring the feedback on antibiotic resistance.

Rapid implementation of national policies, favoring containment of antimicrobial resistance, is vital to control the spread of antimicrobial resistance in India.[3]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.