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| 2010-22 |
| 22-1 |
ISSN (Print) 1013-9052
EISSN 1658-3558
P.O. Box 52500,
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Kingdom of Saudi Arabia
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Antibiotic prescription by general dental practitioners in the management of acute dentoalveolar infections Faleh A. Sawair, BDS, FDS RCS (Eng.), PhD Faculty of Dentistry, University of Jordan, Amman, Jordan
Objective: This study was conducted to assess the level of knowledge of the general dental practitioners in the use of antibiotics for patients with acute dentoalveolar infections.
The widespread concern about the increasing problem of antimicrobial resistance has emphasized the need for rationalization of antibiotic use in the treatment of infections.1,2 Although antibiotics, along with analgesics, are the most commonly prescribed medications by general dental practitioners (GDPs), little is known on the knowledge and understanding of GDPs concerning its use in everyday clinical practice. Recent studies have investigated the prescribing of antibiotics by GDPs in acute dentoalveolar infections (ADAIs) and have shown that the prescription of antibiotics in terms of dose, duration and choice of antibiotic is inappropriate and possibly increasing the worldwide problem of antimicrobial resistance.3-5
A questionnaire was devised to investigate general practitioners' knowledge of prescribing of antibiotics. This questionnaire was a modification of that described by Muthukrishnan et al.8 The GDPs were requested to state what antibiotic (s) they would normally use in case of an ADAI. They were asked to write down the antibiotic (s) they would prescribe if they face a young, otherwise healthy, adult male patient as an emergency with an acute dental infection from a carious lower molar tooth. They were informed that the patient was mildly pyrexial, in severe pain and had a localised swelling on that side of the jaw with mouth opening restricted to 2 cms but that the patient could still swallow. Information was sought on the antibiotic dose, frequency and number of days that the practitioner would prescribe for the patient if he was not allergic to penicillin. The GDPs were also asked to state the antibiotic regime they would prescribe if the patient was allergic to penicillin. The next part of the questionnaire sought information on a number of non-clinical factors to determine if they have affected the GDPs' choice of the antibiotic prescribed. Specifically, questions were asked whether or not the cost of the antibiotic, availability in the nearby pharmacy, advertisement, effectiveness and previous experience with the drug, patient's preference of a specific antibiotic, or recommendations by consultants or colleagues would affect their antibiotic prescription. GDPs were also asked if they have ever taken a sample from a dental infection for culture and sensitivity to see the most effective antibiotic. Although the questionnaire was anonymous, respondents were requested to provide information about their age (banded in decades from 21-60 years), gender, work sector (private clinic, hospital), and place of qualification.
Of the 300 GDPs to whom the questionnaires were sent, 230 (76.7%) returned fully completed forms. The demographic and professional characteristics of the respondents are shown in Table 2. The antibiotics prescribed by the GDPs for adult patients with ADAIs who are not allergic to penicillin are shown in Table 3. Around 60% of the GDPs working in hospitals prescribed a combination of amoxycillin and metronidazole as their first choice and 15.1% of them used amoxycillin alone. In contrast, 36.9% of those working in private clinics used clindamycin or lincomycin, 21% used amoxycillin and 9.6% used a combination of amoxycillin and metronidazole. The compliance with the guidelines of the FGDP (UK) (Table 1) first choice of antibiotics (amoxycillin or penicillin ± metronidazole) is shown in Table 2. Female GDPs, young GDPs, GDPs working in hospitals and those graduated from Jordan were significantly more compliant. Table 3 also showed the antibiotics prescribed in the presence of penicillin allergy. Erythromycin was the choice of 50% of the GDPs working in private clinics and of 71.2% of those working in hospitals. However, 30.5% of those working in private clinics used clindamycin or lincomycin compared with 15% of those working in hospitals. Metronidazole alone was used by only 2.2% of the GDPs. Amoxycillin or ampicillin was prescribed by 1.8% of GDPs for patients allergic to penicillin. The second choice (metronidazole) or third choice (erythromycin) of antibiotics according to the guidelines of the FGDP (UK) was followed by 70% of female GDPs compared with 54.1% of males (P= 0.02) and by 75.3% of GDPs working in hospitals compared with 53.3% of those working in private clinics (P=0.001). The use of the second or third choice of antibiotics showed no significant relationship with the age groups of the GDPs and their place of qualification. Table 4 shows the dosages, frequencies and the length of the course of the most commonly prescribed antibiotics by the GDPs. Only those who indicated all the details (dose, frequency and duration) were included. There were wide variations for all the antibiotics. In case of amoxycillin, out of 84 GDPs, none used the recommended dose with correct frequency and duration and 83 (99%) prescribed double the recommended dose. Of the 84 GDPs, 15.5% prescribed amoxycillin for more than 5 days (6 to 12 days). Similarly, out of 74 GDPs who prescribed metronidazole, none used the recommended dose with correct frequency and duration and 50% prescribed at least double the recommended dose. Of the 74 GDPs, 96% prescribed metronidazole for more than 3 days (4 to 7 days). Only 4 out of 82 GDPs used erythromycin in the recommended dose, frequency and duration; around 60% prescribed double the recommended dose and 15.9% prescribed the antibiotic for more than 5 days (7 to 12 days). The non-clinical factors influencing antibiotic prescribing are shown in Figure 1. Majority of the GDPs (95.7%) considered the effectiveness and previous experience with the drug as factors in determining their choice of the antibiotic they prescribed and almost two-thirds considered the cost of the antibiotic to be an important factor. The availability of the antibiotic in the nearby pharmacy was considered an important factor by 22.2% of the GDPs. The patients' preference was taken into consideration by 6.1% of the GPDs. Only 17.8% of the GDPs surveyed ever took sample from a dental infection for culture and antibiotic sensitivity of the causative microorganisms in their entire clinical practice.
GDPs should know when and what antibiotics to prescribe, for how long and in what dosage. This study showed a wide spectrum of antibiotics prescribed for patients with ADAIs with12 different antibiotics given in 21 different prescriptions for patients who are not allergic to penicillin. As first choice recommendation by the FGDP (UK) guidelines,7 44.8% of the GDPs surveyed used either amoxycillin alone or in combination with metronidazole in patients who are not allergic to penicillin. According to the guidelines of the FGDP (UK),7 metronidazole can be added to amoxycillin if there is suspicion that the ADAI is predominately anaerobic or it has been proven microbiologically. Although phenoxymethylpenicillin (penicillin V) with or without metronidazole can be used as first choice antibiotic in ADAI according to the FGDP (UK) guidelines7, this choice was chosen by only 3.4% of the GDPs surveyed. The use of penicillin is gradually reducing as recent studies have shown that the main isolates from dental abscess are a complex mixture of facultative and anaerobic bacteria, many of which are penicillin-resistant.10 In addition, none of the GDPs used the two-dose 3g amoxycillin regime recommended as one of the first choices in the FGDP (UK) guidelines.7 About one-third (33.3%) of the GDPs, particularly those working in private clinics, prescribed clindamycin or lincomycin, alone or in a combination with another antibiotic. According to the Dental Practitioners' Formulary9, these two antibiotics (the lincosamides) should not be used routinely for the treatment of dental infections because of their serious side-effects that include antibiotic-associated colitis, which may be fatal in some patients. Moreover, lincosamides appear to be no more effective than penicillin against anaerobes and there may be cross resistance with erythromycin-resistant bacteria.9,11
In response to the questions on the alternatives for patients who are allergic to penicillin, the overwhelming choice was erythromycin. Erythromycin is weakly active, bacteriostatic, antibiotic and it is not always as effective as penicillin. It has a high incidence of undesirable side effects such as nausea, vomiting, abdominal pain, diarrhoea and anorexia. In addition, resistance is a problem with erythromycin and can even develop during a course.12,13 Therefore, in the guidelines of the FGDP (UK),7 erythromycin is considered third choice in the management of ADAI. Recently, metronidazole is considered the best alternative to penicillin for the treatment of many dental infections in patients allergic to penicillin.9,14 Therefore, in the FGDP (UK) guidelines,7 metronidazole is the second choice in the management of ADAIs if penicillins can not be prescribed. In this study, only 2.2% of the GDPs used metronidazole alone for ADAIs in patients allergic to penicillin. Disappointingly, 1.8% of the GDPs prescribed amoxycillin or ampicillin for patients who are allergic to penicillin and 6.1% prescribed cephalosporins ignoring the information that about 10% of penicillin-sensitive patients will also be allergic to cephalosporins.9 In agreement with previous studies,4,8,15,16 antibiotics were poorly prescribed by GDPs in Jordan and there were considerable variations from the recommended frequencies and doses. In this study, GDPs tended to prescribe high doses of antibiotics, usually double the recommended doses. For example, in the case of amoxycillin, the vast majority of the GDPs surveyed prescribed 500 mg instead of the 250 mg recommended dose. Large doses of amoxycillin (500 mg) are not indicated in ADAIs as the absorption of this antibiotic in standard 250 mg amounts is adequate and therapeutically effective.17 There is increasing evidence that short courses of antibiotics, together with establishing drainage, are adequate for the resolution of ADAIs. It is not, therefore, necessary for the majority of patients to complete a 5-day course of antibiotics.10 This is in keeping with the guidelines of the FGDP (UK)7 where patients should be reviewed in 2-3 days and, if temperature was found to be normal and swelling is resolving, the GDP should discontinue the use of the antibiotics. In this study, antibiotics were recommended by some of the GDPs surveyed for periods up to 12 days. This could be harmful by selecting resistant bacteria and abolishing the ability of the oral flora to resist colonisation of harmful micro-organisms, thereby leading to superimposed infections by multi-resistant bacteria and yeasts.18 The reason for such diverse anti-microbial prescription is unclear. Previous studies suggest that prescription is influenced by undergraduate and postgraduate education, publication and advertising.19,20 In this survey, the choice of the antibiotic by some GDPs was found to be affected by non-clinical factors such as the cost and the availability of the antibiotic in the nearby pharmacy, advertising and the patient's preference of a particular antibiotic. This study has also shown that female GDPs and young GDPs were more compliant with the current guidelines of the FGDP (UK).7 In addition, the compliance with the current guidelines was affected by the place of qualification. Graduates from Jordan and from other Arab countries were more compliant compared with those who graduated from Eastern Europe and Asian countries. GDPs working in private clinics were less compliant compared with those working in hospitals. Lincomycin and clindamycin were prescribed mostly by GDPs working in private clinics while amoxycillin and metronidazole were prescribed mostly by GDPs working in hospitals. Perhaps the adoption of protocols for antibiotic prescription for acute dental infections in hospitals resulted in this better way of prescription. The oral cavity is the habitat for a large number of microbial species, many of which and, often in combination, can cause dental infections.21 Consequently, it is recommended that GDPs should take microbiological samples, particularly in severe infections.9 However, in general practice, antibiotics are usually prescribed on an empirical basis and little use is made of diagnostic microbiology services.22 In this survey, only 17.8% of the GDPs ever took microbiological samples for culture and antibiotic sensitivity throughout their practice. Improving the availability of such services and providing training in their use, should be an integral part of a response to poor antibiotic prescribing. The results of this study showed, considering the rapid development of antibacterial resistance, conscientious use of antibiotics is imperative for all GDPs practising in Jordan. GDPs should follow evidence-based protocols and guidelines in prescribing antibiotics for dentoalveolar infections. The guidelines on antibiotic recommendations and indications for use should be clarified at the undergraduate and graduate levels. Additionally, regular continuing dental education courses in the use of antibiotics are essential to disseminate information to practicing dentists particularly those working in private clinics and these courses should focus on non-Jordanian graduates and those who have been in practice for long time.
The results of this study indicated that the prevalence of dental caries has increased considerably among intermediate schoolchildren in Riyadh, 14 years after the conduct of the Oral Health Survey of Saudi Arabia Phase I.
Address reprint requests to:
Dr. Faleh Sawair
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