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Short Courses of Abx Can Cause Big Problems for Dental Patients

WASHINGTON — Some dental patients who were inappropriately given antibiotics prior to procedures suffered adverse events potentially connected to the drugs, such as anaphylaxis and Clostridioides difficile infection, researchers said here.

Of patients inappropriately prescribed antibiotic prophylaxis prior to a dental procedure, almost 4% had adverse events ranging from new allergies and emergency department visits to anaphylaxis and C. difficile infection, reported Alan Gross, PharmD, of the University of Illinois at Chicago (UIC).

Dentists prescribe 10% of antibiotics in the U.S., and are the largest specialty prescriber, said co-author Katie Suda, PharmD, of UIC College of Pharmacy, speaking at a press conference at the IDWeek meeting, with joint sponsorship by the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, the Society for Healthcare Epidemiology of America (SHEA), and the HIV Medicine Association.

To put that into perspective, she added, pediatricians and internists prescribe 10%-12% of all antibiotics in the U.S.

“[We need] awareness of other providers out there that need to be pulled into the fold and have an awareness as part of stewardship,” Thomas Talbot, MD, of SHEA, told MedPage Today. “The layers of the onion of stewardship need to broaden out and there are undoubtedly other clinicians similar to this that we need to identify and help … understand stewardship.”

This was a follow-up analysis to a prior study on inappropriate antibiotic prescribing, which found that over 80% of antibiotic prescriptions for prophylaxis prior to dental visits were unnecessary.

Suda pointed to data from the CDC, which found that antibiotic prescribing among dentists has remained stable, while prescribing among physicians has declined. In fact, she noted that their study found that clindamycin was the most likely to be overprescribed. Dentists are the top prescriber of clindamycin, which is associated with the highest risk for C difficile infection, she said.

“Dentists are a very unique prescriber group. Not only are they pressured to prescribe antibiotics from their patients, but from other clinicians,” Suda said at the press conference.

And in some cases, those guidelines may be outdated. She said that orthopedic surgeons used to recommend one dose of antibiotics prior to a dental visit if the patient had a prosthetic joint, such as a prosthetic knee, but those guidelines have changed.

The American Heart Association guidelines have also narrowed over time, Suda said, with fewer patients with cardiac conditions now indicated to receive an antibiotic prior to a dental visit. These guidelines now apply to patients with cardiac conditions considered to be at the highest risk of adverse outcomes if the patient gets infective endocarditis, such as those with prosthetic heart valves, and generally for “invasive dental procedures.”

“This study illustrates the perception that antibiotics are fairly benign, even if it’s just one dose,” Talbot said at the press conference. “We need to have those conversations … [that] it’s not a harmless decision to give antibiotic prophylaxis for just one dose; there can be some consequences.”

Study Details

Gross and colleagues examined data from 2011 to 2015 of patients with dental visits linked to medical and prescription claims. In this study, researchers looked at unnecessary antibiotic prophylaxis — defined as antibiotic prophylaxis in patients who both did not undergo a procedure that manipulated the gingiva/tooth periapex and did not have an appropriate cardiac diagnosis.

Of the 168,420 dental visits with antibiotic prophylaxis, 136,177 were unnecessary, and of those, 3.8% of unnecessary prescriptions were associated with an antibiotic-related adverse event. The most common adverse events were new allergies (2.9%) and emergency department visits (1.2%).

The researchers also specifically looked at clindamycin versus azithromycin. Suda noted that in their previous study, clindamycin was most likely to be overprescribed and was associated with a 34% increased risk of a serious adverse drug event versus amoxicillin.

Suda noted that their data was a “conservative estimate,” because the study only measured patients where patients sought healthcare, and didn’t include adverse events such as nausea or diarrhea, nor did it include drug/drug interactions.

“If patients have adverse events, they’re not going back to the dentist — they’re seeing their primary care provider or going to the emergency department,” she noted. “Dentists never see those adverse outcomes … but we should try to provide dentists with more streamlined access to a patient’s medical information. Very few dental offices have that available to them.”

Gross and Sudha disclosed no conflicts of interest.

One co-author disclosed support from BioK+.


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