Antibiotics prescribed for dental patients unnecessary 81% of the time

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Antibiotics prescribed by dentists as a pre-emptive strike against infection are unnecessary 81% of the time, according to a study. The findings are important because dentists are responsible for 10% of all antibiotic prescriptions written in the US.

Antibiotics prescribed when not warranted expose patients to the risk of side effects unnecessarily and also contribute to the problem of antibiotic resistance – bacteria evolving to make the drugs ineffective. Antibiotics are recommended as a prophylactic prior to some dental procedures for patients with certain types of heart conditions.

Researchers including Jessina McGregor of Oregon State University used a national health care claims database to examine nearly 170,000 dentist-written antibiotic prescriptions from 2011 to 2015. The prescriptions involved more than 90,000 patients, 57% female, with a median age of 63.

Greater than 90% of the patients underwent a procedure that possibly warranted taking an antibiotic ahead of time. However, less than 21% of those people had a cardiac condition that made an antibiotic prescription recommended under medical guidelines.
“Preventive antibiotics in these patients gave them risks that outweighed the benefits,” said McGregor, an associate professor in the OSU College of Pharmacy.

Led by corresponding author Katie Suda of the University of Illinois-Chicago, the researchers also looked at the prescriptions regionally and found unnecessary prescriptions to be most prevalent, on a percentage basis, in the West; 11,601 of the 13,735 prescriptions written, or 85%, were out of sync with the guidelines. The other regional percentages were 78% for the Northeast, 83% for the Midwest, and 80% for the South.

Research found that 82% of the unnecessary prescriptions were written in urban population centres, 79% in rural areas.

Among patients who filled prescriptions for unnecessary antibiotics, clindamycin was the most common drug, and joint implants were the most typical reason they were prescribed.

“Dental providers are very thoughtful when they develop care plans for their patients and there are many factors that inform dentists’ recommendations, but this study shows that there is an opportunity for dentists to re-evaluate if necessary,” said Susan Rowan of the Illinois-Chicago College of Dentistry. “I think dental providers should view this study, which is the first to look at preventive antibiotic prescribing for dental procedures, as a powerful call to action, not a rebuke.”

The study was limited to patients with commercial dental insurance and the analysis used a broad definition of high-risk cardiac patients, suggesting the findings may underestimate the unnecessary prescribing of antibiotics.

Five other researchers from Illinois-Chicago and one from Northwestern University also collaborated on the study, which was funded by the Agency for Healthcare Research and Quality.

Abstract
Importance: Antibiotics are recommended before certain dental procedures in patients with select comorbidities to prevent serious distant site infections.
Objective: To assess the appropriateness of antibiotic prophylaxis before dental procedures using Truven, a national integrated health claims database.
Design, Setting, and Participants: Retrospective cohort study. Dental visits from 2011 to 2015 were linked to medical and prescription claims from 2009 to 2015. The dates of analysis were August 2018 to January 2019. Participants were US patients with commercial dental insurance without a hospitalization or extraoral infection 14 days before antibiotic prophylaxis (defined as a prescription with ≤2 days’ supply dispensed within 7 days before a dental visit).
Exposures: Presence or absence of cardiac diagnoses and dental procedures that manipulated the gingiva or tooth periapex.
Main Outcomes and Measures: Appropriate antibiotic prophylaxis was defined as a prescription dispensed before a dental visit with a procedure that manipulated the gingiva or tooth periapex in patients with an appropriate cardiac diagnosis. To assess associations between patient or dental visit characteristics and appropriate antibiotic prophylaxis, multivariable logistic regression was used. A priori hypothesis tests were performed with an α level of .05.
Results: From 2011 to 2015, antibiotic prophylaxis was prescribed for 168 420 dental visits for 91 438 patients (median age, 63 years; interquartile range, 55-72 years; 57.2% female). Overall, these 168 420 dental visits were associated with 287 029 dental procedure codes (range, 1-14 per visit). Most dental visits were classified as diagnostic (70.2%) and/or preventive (58.8%). In 90.7% of dental visits, a procedure was performed that would necessitate antibiotic prophylaxis in high-risk cardiac patients. Prevalent comorbidities include prosthetic joint devices (42.5%) and cardiac conditions at the highest risk of adverse outcome from infective endocarditis (20.9%). Per guidelines, 80.9% of antibiotic prophylaxis prescriptions before dental visits were unnecessary. Clindamycin was more likely to be unnecessary relative to amoxicillin (odds ratio [OR], 1.10; 95% CI, 1.05-1.15). Prosthetic joint devices (OR, 2.31; 95% CI, 2.22-2.41), tooth implant procedures (OR, 1.66; 95% CI, 1.45-1.89), female sex (OR, 1.21; 95% CI, 1.17-1.25), and visits occurring in the western United States (OR, 1.15; 95% CI, 1.06-1.25) were associated with unnecessary antibiotic prophylaxis.
Conclusion and Relevance: More than 80% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary. Implementation of antimicrobial stewardship in dental practices is an opportunity to improve antibiotic prescribing for infection prophylaxis.

Authors
Katie J Suda, Gregory S Calip, Jifang Zhou, Susan Rowan, Alan E Gross, Ronald C Hershow, Rose I Perez, Jessina C McGregor, Charlesnika T Evans

Oregon State University material
JAMA Network Open abstract


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