Spreading the Word on Antibiotic Stewardship

In the kitchen, the toaster gives off sparks and begins to smoke. What’s your first move? “It isn’t to call the fire department,” says Emily Van Heukelom, DDS, of the Center for Oral Surgery and Dental Implants (COSDI). “You unplug the toaster, turn on the vent fan and open a window. And you turn off the smoke detector.”

That’s the analogy Dr. Van Heukelom uses with some patients to explain why it often makes sense not to prescribe antibiotics—or to prescribe them for a shorter term than expected, or for use only if things don’t improve without them. In some instances, she suggests, an antibiotic—or too much of an antibiotic, too soon—can be an overreaction, like a firehose that needlessly floods the floor.

Risks that outweigh benefits      

Of course, every medication is a risk/benefit trade-off, and science has learned in recent decades that antibiotics carry risks that outweigh their benefits more often than we once knew. They may lose effectiveness through antibiotic resistance—an estimated 2 million antibiotic-resistant infections in the U.S. each year cause some 23,000 deaths and cost the health care system $20 billion to $35 billion. There’s also the danger of side effects, particularly the notorious Clostridiodes difficile, which can trigger severe and recurrent diarrhea and exacts an annual economic price estimated as high as $5.4 billion.1 (Clindamyacin, once used widely in dentistry, is a frequent culprit.)

Yet some dental patients, particularly those who haven’t kept up with recent discoveries, habitually consider a prescription for antibiotics an indispensable element of good dental care whenever pain, swelling or a possible infection is involved—and old habits die hard. Says Dr. Van Heukelom: “I try to help patients understand and think to themselves, ‘OK, I have this problem with my tooth. The solution is really to take the tooth out, or get a root canal or whatever. But meanwhile, my body can handle it. I don’t need to call the fire department yet.’”

The communications challenge

These days, most hospitals have antibiotic “stewardship” programs, which require that antibiotics be prescribed only after the need for them has been carefully assessed. They seek to ensure that prescriptions are given only for “the right drug, dose and duration,” in the words of Elaine M. Bailey, PharmD, and Marie T. Fluent, DDS, co-authors of three recent articles on antibiotics in the Journal of the Michigan Dental Association.1 But such programs haven’t yet reached all smaller outpatient treatment facilities—particularly in dentistry, where 10 percent of antibiotics nationally are prescribed.2 That means Michigan dentists today are called on to carry the message of antibiotic stewardship to patients, explaining that “the historical paradigm has shifted from ‘prescribe just in case’ to ‘prescribe only when necessary.’”

“Traditionally, dentists prescribed ten days of antibiotics for an infection,” says Dr. Bailey. “And most dental software is still coded for a 10-day dispense. We tend to treat by football scores—10 days, seven days, 14 days—without really a lot of scientific support.”

That said, the Bailey–Fluent articles are good resources. They’re available online at the website (mi-marr.org) of the Michigan Antibiotic Resistance Reduction (MARR) coalition, which for 25 years has sought to reduce unnecessary antibiotic prescribing. Dr. Bailey, MARR’s executive director, says the group also offers free explanatory brochures for patients and a “provider commitment poster” for an office wall that can be personalized with the name of your practice.3

Dr. Bailey tells a cautionary tale about c. difficile, and it’s at least as potent as the fire-department example. It’s the true story of the late Peggy Lillis, who in 2011 was a 56-year-old kindergarten teacher in Brooklyn. She was prescribed clindamycin on being treated for a dental abscess—and died seven days later. Her autopsy listed “manner of death” as “therapeutic complication.” Today the New York-based Peggy Lillis Foundation created in her memory strives to “build a nationwide c. diff awareness movement by educating the public, empowering advocates and shaping policy.”4 The point is not to scare patients, but to establish that medications—including antibiotics—have risks. Antibiotics ought not to be prescribed or taken “just in case,” as one carries an umbrella on a grey day.

Dentistry’s response

In November 2019, the ADA Center for Evidence-Based Dentistry released new clinical practice guidelines on antibiotic use in the management of oral infections with pain and swelling, guidelines in the spirit of MARR’s effort.5 But it turned out to be a tough time for anyone in healthcare to disseminate a national message not related to masking and hand-washing. Because of the COVID-19 pandemic that soon followed, says Dr. Bailey, “the guidelines have had a slow uptick in the dental community. There’s been a lack of awareness.”

The pandemic is a reminder of an obstacle facing dentists as communicators: a growing mistrust of science. “In the amount of time I have to spend talking to most of my patients, I don’t usually get that far,” confesses Dr. Van Heukelom. “If I hit on that, I say, ‘It’s good for your family and friends and neighbors that we decrease the amount of antibiotics out there.’”

But even in our COVID-distracted era, dentists are working every day to improve antibiotic stewardship and spread the word. And one technique many use—described in the third Bailey-Fluent article—is “delayed prescribing,” in which they give the patient a prescription, but ask him or her to wait a few days before filling it to see if it’s truly needed. Research has shown that such delays can reduce antibiotic use with no decline in symptom control or patient satisfaction.6

“I’ll say on a Tuesday, ‘In case your symptoms don’t improve by Thursday or Friday, here’s a prescription for some amoxycillin—five days to start,” says Dr. Van Heukelom. “But if you believe then that you need to start taking it, please call me and let me know, because I may want to see you back.”


Reducing Antibiotic Use: A Success Story

The University of Illinois–Chicago tried an all-hands-on-deck approach to cut needless antibiotic prescribing in its dental offices, educating providers and patients, promulgating guidelines and doing “before and after” tracking. Result: From September 2017 to May 2018, antibiotic prescribing dropped 72.9 percent.7


REFERENCES:

1 Elaine A. Bailey, PharmD, and Marie T. Fluent, DDS, “Antibiotic Stewardship in Dentistry: Opportunities and Challenges,” Journal of the Michigan Dental Association, October 2019, p. 40.

2 Rebecca M. Roberts, MS, et al., “Antibiotic Prescribing by General Dentists in the United States, 2013,” Journal of the American Dental Association, March 2017, pp. 172–178, accessed online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814255/, December 16, 2021.

3 The articles are in the journal’s issues of October 2019, pp. 40–44; August 2020, pp. 28–38; and February 2021, pp. 42–44 and may be found at https://mi-marr.org/dental-provider.php. A fourth Bailey–Fluent article coming this March offers a tool for prescribing for patients who are allergic to penicillin—or believe they are.

4 Website of the Peggy Lillis Foundation, https://www.peggyfoundation.org, accessed December 16, 2021.

5 “Evidence-Based Clinical Practice Guideline on Antibiotic Use for the Urgent Management of Pulpal- and Periapical-Related Dental Pain and Intraoral Swelling: A Report from the American Dental Association,” Journal of the American Dental Association, November 2019, pp. 906–921, accessed online at https://pubmed.ncbi.nlm.nih.gov/31668170/, December 16, 2021.

6 Elaine A. Bailey, PharmD, and Marie T. Fluent, DDS, “Delayed Antibiotic Prescribing: A Simple Strategy to Promote Antibiotic Stewardship,” Journal of the Michigan Dental Association, February 2021, pp. 42–44.

7 “Large Dental Practice Cuts Antibiotic Prescribing by 73%,” Healio, February 17, 2019. https://www.healio.com/news/infectious-disease/20190215/large-dental-practice-cuts-antibiotic-prescribing-by-73, accessed December 20, 2021.