COMMENTARY

Antibiotic Overuse Blind Spot: Dental Prescribing

Naveed Saleh, MD, MS

Disclosures

December 20, 2017

Dental Antibiotics and Clostridium difficile

When looking for a potential cause of community-acquired Clostridium difficile infection (CDI), prescription of antibiotics for upper respiratory infections is number one. But there are other causes, too. In hindsight, it makes perfect sense to implicate dental prescriptions for antibiotics as a driver of community-acquired CDI also. After all, dentists routinely prescribe antibiotics to members of the community without follow-up. Patients then show up to their primary care physicians with C difficile antibiotic-associated diarrhea.

It wasn't until recently, however, that an association between antibiotic use in dentistry and community-acquired CDI has been elucidated. This discovery is in large part thanks to the partnership of the Emerging Infections Program (EIP) at the Centers for Disease Control and Prevention (CDC) and state health departments.

Clostridium difficile: An Emerging Infection

At an IDWeek press conference on October 6, 2017, Stacy Holzbauer, DVM, MPH, a career epidemiology field officer for CDC and the Minnesota Department of Health, presented research showing that 15% of patients with community-acquired CDI who reported taking antibiotics took dental antibiotics within the 12 weeks before illness.[1] This research was part of the CDC's EIP, which was established in 1995 for the surveillance, prevention, and control of emerging infectious diseases. The EIP is a network of state and local health departments, academic institutions, other federal agencies, public health and clinical laboratories, infection preventionists, and healthcare providers.

Press conference moderator Ebbing Lautenbach, MD, MPH, MSCE, said, "The type of work presented here is really only possible through the EIP. This program identifies people with community-onset infections of interest. Identifying people who have C difficile in the community is a unique aspect of the EIP—an incredibly important resource as we seek to better understand the relationship between antibiotic use and C difficile and, ultimately, antibiotic resistance as well."

In a study titled "Antibiotic Prescribing by General Dentists in the United States, 2013," Roberts and coauthors[1] report that in 2013, dentists wrote prescriptions for a staggering 24.5 million courses of antibiotics, or 77.5 prescriptions per 1000 people. This accounts for approximately 10% of all antibiotic prescriptions in the outpatient setting. Antibiotics are often prescribed for the management of oral infections and for prophylaxis before dental visits for patients meeting certain clinical criteria. Recent guidance[2] on who should receive antibiotic prophylaxis before dental visits has changed; however, the rate of its adoption is unknown.

In 2013, dentists wrote prescriptions for a staggering 24.5 million courses of antibiotics, accounting for 10% of all antibiotic prescriptions in the outpatient setting.

Dentists who have not made changes to their prescribing habits may be prescribing prophylactic antibiotics unnecessarily, according to Dr Holzbauer. In addition, medical providers may pressure dentists to prescribe antibiotics before invasive dental procedures despite the updated guidance, especially for patients with joint replacements or a history of congenital heart disease.

Between 2009 and 2015, Bay and colleagues[3] interviewed a limited subset of 1626 patients with community-acquired CDI living in five counties in Minnesota. These participants represented diverse populations. Of these patients, 926 (57%) reported being prescribed antibiotics from any source, and 136 (15%) were prescribed antibiotics by a dentist.

On the basis of this information, during interviews, the Minnesota Department of Health started asking patients with CDI about a history of heart conditions and joint replacements. Since July 2015, a total of 76 interviewed patients with community-acquired CDI were prescribed dental antibiotics, 58% of whom received antibiotics for either heart or joint prophylaxis. Only one patient with a heart condition met the current guidelines for antibiotic prescription. "There appears to be in our subset of cases a high amount of potentially inappropriate antibiotic use," says Dr Holzbauer.

Reversing the Trend

On the basis of the results of this study, Dr Holzbauer suggests that the main issue may be good history-taking, which involves all stakeholders. "In Minnesota, we have put the onus back on all people involved—the dentists, the clinicians who are taking care of patients, and the patients themselves. We need dentists to think about the complications of antibiotic prescribing and make sure they are educating their patients about the possibility of CDI when they are prescribing antibiotics. We also need to make sure that dentists are up to date on the most current guidelines and are using them to decide whether the use of antibiotics is appropriate."

Dr Holzbauer continued, "For physicians, when they are seeing their patients, we need them to think about what is not captured in the electronic medical record and ask about other potential sources of antibiotics, such as outpatient surgery or dental prescribing. For patients—because we don't have a universal healthcare record that can capture everything—we need them to let their providers know if they received antibiotics for dental reasons and be willing to ask any provider, including physicians or dentists, whether this antibiotic is really necessary when offered a prescription."

According to Dr Holzbauer, dentists have been receptive to this issue. "Dental antibiotics have been a blind spot in the antibiotic stewardship conversation. Dentists haven't been included, and they're willing to listen, and I think that they're looking for guidance. But nobody goes to a dentist when they have diarrhea; they go to a primary care physician, so the dentist doesn't get the feedback that there are potential consequences to their prescribing practices."

In 2017, the EIP, in association with the Minnesota Department of Health, was responsible for catching this association between community-acquired CDI and dental antibiotics—an association that Dr Holzbauer said was surprising to experts.

One reason why few bothered to consider the association between CDI and dental antibiotic prescription patterns may be that historically, nobody was paying that much attention to the prescribing patterns of dentists. "Dentists have often been overlooked as major partners in programs that promote appropriate antibiotic use, and it's critical that dentists are included in efforts to improve antibiotic prescribing," says Dr Holzbauer.

Nevertheless, there may be no real good answer for why this association, which has been hiding in plain sight, is only now coming to light. According to Hilary M. Babcock, MD, MPH, who also moderated the press conference, "We don't have a great answer for that. In general, it's probably a confluence of factors. As antimicrobial stewardship gains traction, there is more of an in-depth look at where these antibiotics are coming from to quantify where the problems are. That has reminded us of dentists as a prescribing source. In addition, the research going on around Clostridium difficile has moved to a better appreciation of community-onset cases. Five or 10 years ago, we were very focused on Clostridium difficile as a hospital-acquired infection."

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