Prescribing antibiotics – what are we doing wrong?

Young dentist, Pav Chana, presents her audit review on over prescribing antibiotics.

Antibiotics play a fundamental part in dentistry and when indicated can be a useful adjunct when treating patients. They do, however, come with their downfalls including side effects, allergic reactions and of course, antibiotic resistance. Antibiotic resistance is now considered a major threat to public health.

Many GDPs may feel that they do not contribute to the worldwide problem of antibiotic resistance, but according to the Faculty of General Dental Practitioners, dentists who work in primary care prescribe 10% of all the oral antimicrobials prescribed in England. Reported by the British Dental Association, the UK government estimated that if this problem is not addressed it could result in 10 million deaths globally by 2050 and cost the economy £66 trillion.

Guidance has been published to aid dentists in prescribing. Authors of these guidelines include the Faculty of General Dental Practitioners and the Scottish Dental Clinical Effectiveness Programme. More recently an antimicrobial stewardship toolkit has been developed, which includes a patient information leaflet, poster and an antibiotic guardian website.

How are dentists to blame?

There are a number of ways dentists contribute to the problem, such as prescribing unnecessarily, the incorrect choice of antibiotic, the incorrect duration and the incorrect dosage.

However, it’s not all dentists’ fault. There is a common misconception amongst patients about when they should be prescribed antibiotics. Many patients believe when they present to the dentist with a toothache, they should be prescribed antibiotics. 

A patient’s expectations along with the convenience of prescribing are not justifiable reasons, but these are probable reasons as to why dentists often prescribe. Therefore, it is important that not only us as dentists become more aware of when to prescribe, but patients also become aware of when they need antibiotics. Patient education can be aided by displaying the patient poster from the antimicrobial stewardship toolkit in primary care, shown above.

Antibiotic resistance audit

Due to the increasing problem of antibiotic resistance, an audit was carried out at Manchester University Dental Hospital to assess whether antibiotics prescribed on ground floor restorative clinic adhere to the FGDP antimicrobial prescribing guidelines. This audit was carried out retrospectively from May 2016 to December 2016; as this is not an emergency clinic, there are not vast amounts of antibiotics prescribed.

Prescriptions of amoxicillin 500mg and metronidazole 400mg were assessed. Both amoxicillin 500mg and metronidazole 400mg were being prescribed appropriately in 70% of cases, meaning the justification for which they were prescribed was in line with FGDP guidelines. Justifications for prescribing when not indicated were only included in 11% of prescriptions.

The correct dosage of amoxicillin and metronidazole were always being prescribed on ground floor restorative. It was noted when patients were given a prescription on ground floor restorative, patients were dispensed 21 capsules of either amoxicillin or metronidazole. It is unclear whether practitioners who were prescribing the antibiotic advised the patient only to take the antibiotics for the duration recommended in the FGDP guidelines, or if the patient ended up taking the whole course of antibiotics.

Correct dose, correct duration

Following conclusions from the audit, it is important that practitioners should familiarise themselves with the current guidelines for antibiotic prescribing and always ensure they are prescribing the correct dose, for the correct duration. If a course of 21 capsules is going to be dispensed to the patient, then it should be clear to the patient when to stop taking the antibiotic.

As an undergraduate fifth-year student I, like so many of my colleagues, will definitely be thinking twice before prescribing antibiotics. There has been a definite emphasis placed on not prescribing antibiotics as a first line of treatment.

Current primary care dentists need to change bad prescribing habits and hopefully new dentists can stick to what they learnt at university. Both current and future dentists have a responsibility to prescribe appropriately to ensure that antibiotics remain an effective treatment.

Pav Chana is a fifth year BDS student at the University of Manchester and is hoping to graduate in July 2017. She will then go on to complete her dental foundation training in the North Central London Scheme.

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