Antibiotic Stewardship: A healthy Antibiotic future for dentists and patients starts today.

Could we be close to entering a post-antibiotic age?We are already in it. 

If you get certain Clostridioides difficile infections, there are no longer antibiotics to treat them successfully. Other infecting organisms are rapidly developing resistance. The CDC lists 16 bacteria and fungi as urgent or serious threats, and treatment options are extremely limited.

The overuse and misuse of antibiotics is having dire consequences and should be something every healthcare provider is aware of and working to correct through better prescribing practices, the foundation of antibiotic stewardship. 

In the first 15 years of use, antibiotics saved an estimated 220 lives per 100,000 people. All other medical technologies combined in the next 45 years saved 20 lives per 100,000 people. Antibiotics have changed the healthcare world. But studies now show over 30% of all antibiotic prescriptions are unnecessary. Many antibiotic prescriptions are given for viral infections against which antibiotics are powerless. They will not help, but they can cause harm. In dentistry, over 80% of antibiotics prescribed for prophylaxis, either to prevent a distant site infection or to reduce the risk of a post-operative infection, are inappropriate or unnecessary. 

What most dentists were, and too often still are, taught in dental school and residency about antibiotic use has been shown to be wrong. Antibiotics should not be taken “until gone.” They should be stopped 24 hours after the clinical signs and symptoms of infection are gone.  (Which, by the way, is when most people stop taking them anyhow.)  More importantly, most clinicians and patients believe that using antibiotics “just in case” to prevent an infection is a low-risk approach that causes no harm. Antibiotics are not benign. They always disrupt the GI flora, a disruption that can last for months. This GI disruption can alter the patient’s immune system and increase the risk for C. difficile infections and antimicrobial-resistant superbug infections.

These and other misconceptions by healthcare professionals about antibiotic use have led to antimicrobial resistance at a global level, leading to superbug infections.  Currently, it is estimated that there are nearly 1.3 million deaths worldwide every year directly attributable to antimicrobial resistance and an additional 4.95 million yearly deaths associated with antimicrobial resistance.  Antibiotic related superbug infection deaths are estimated to be between 8-10 million per year by 2050!  The latest CDC report estimates that there are over 2.8 million antibiotic resistant infections each year in the US, resulting in 35,000 deaths.  Antibiotic related C. difficile infections account for another 500,000 infections and 300,000 hospitalizations every year, and an additional 29,000 deaths.  That’s a death related to antibiotics every 8-10 minutes. 

Dentists are responsible for 10% of all health care provider antibiotic prescriptions meaning we may contribute to over 6,400 antibiotic related deaths every year.  The reason we don’t recognize the problem is that it may not occur at the time we prescribe the antibiotic.  C. difficile infections can occur up to 90 days after a single dose of an antibiotic and antimicrobial resistance related superbug infections may take months or years to develop.  We must, as a profession and as individual clinicians, be aware of the risks of antibiotic use and best practices for antibiotic prescribing to preserve the effectiveness of current antibiotics. 

We must understand the importance of prescribing therapeutic antibiotics only when there is evidence of systemic symptoms of infection, such as facial swelling, cellulitis, lymphadenopathy, fever or malaise.  Additionally, antibiotic prophylaxis should be used only for those at the highest risk of poor outcomes from Infective Endocarditis. 

The primary treatment of an odontogenic infection is appropriate surgical intervention, either I&D, extraction, or endodontic therapy. Surgical intervention should be done as quickly as possible and antibiotics should  be used only as an adjunct. It is not necessary to use antibiotics to reduce inflammation or swelling prior to surgical intervention. When therapeutic antibiotics are indicated, they should be used for the shortest duration possible and stopped 24hours after systemic symptoms have resolved. 

All dentists should commit to implementing an antibiotic stewardship program in their office or clinic.  This program should ensure that the dentist and team are knowledgeable about and adhering to the current best practices and guidelines for appropriate antibiotic use. This includes tracking prescribing practices to verify the proper drug, dose, and duration are used, minimizing Clindamycin use and questioning patients about penicillin allergy. 

An intentional focus on being better antibiotic stewards can lessen the likelihood of exacerbating this emerging post-antibiotic era.  Dentists and dentistry should be leaders in Antibiotic Stewardship. 

For further information on appropriate antibiotic use, please read Antibiotic Stewardship in DentalTown.

Dr. Paumier is the director of the Antibiotic Stewardship Program. The program and his lectures can be found at his website .