Antibiotic prescribing by general dentists in the United States, 2013

doi:10.1016/j.adaj.2016.11.020

The Journal of the American Dental Association

Volume 148, Issue 3, March 2017, Pages 172-178.e1

https://doi.org/10.1016/j.adaj.2016.11.020 Get rights and content

Abstract

Background

Dentists prescribe approximately 10% of outpatient antibiotics, but little is known about dentists’ antibiotic prescribing patterns. The authors conducted a study to characterize prescribing by dentists according to antibiotic agent and category, patient demographic characteristics, and geographic region in the United States.

Methods

The authors identified oral antibiotic prescriptions dispensed during 2013 in the Xponent (QuintilesIMS) database. The authors used the total number of prescriptions and county-level census population denominators to calculate prescribing rates. In addition, the authors analyzed prescribing according to individual agent, drug category, and patient demographic characteristics and the total number of prescriptions calculated for general dentists overall.

Results

Dentists prescribed 24.5 million courses of antibiotics in 2013, a prescribing rate of 77.5 prescriptions per 1,000 people. Penicillins were the most commonly prescribed antibiotic category. Dentists prescribed most antibiotics for adults older than 19 years. The Northeast census region had the highest prescribing rate per 1,000 people. The District of Columbia had the highest prescribing rate of 99.5 per 1,000 people, and Delaware had the lowest prescribing rate of 50.7 per 1,000 people.

Conclusions

Dentists prescribe large quantities of antibiotics in outpatient settings, and there is considerable geographic variability. Additional study is needed to better understand the reasons for this variability and identify areas of possible intervention and improvement.

Practical Implications

Continued efforts to combat antibiotic resistance will require all prescribers, including dentists, to examine prescribing behaviors for appropriateness and the effectiveness of guidelines to identify opportunities to optimize antibiotic use.

Section snippets

Methods

We identified oral antibiotic prescriptions dispensed during 2013 from the Xponent (QuintilesIMS) database. The Xponent database captures more than 75% of all outpatient prescriptions in the United States, reconciles them to wholesaler deliveries, and projects to 100% coverage of all prescription activity by using a patented projection methodology that is based on a sample of patient deidentified prescription transactions collected from pharmacies that report their entire pharmacy business to

Results

Dentists prescribed 24.5 million courses of outpatient antibiotics in 2013, a prescribing rate of 77.5 prescriptions per 1,000 people (Table). Dentists prescribed more antibiotics for female patients than they did for male patients in 2013 (female patients, 13.7 million; 85.2 per 1,000 female patients; male patients, 10.7 million; 68.9 per 1,000 male patients). Most antibiotics dentists prescribed were for adults older than 19 years; fewer than 10% of all antibiotics dentists prescribed were

Discussion

To our knowledge, we present the first broad description of outpatient antibiotic prescribing by general dentists in the United States, a critical first step to understanding how antibiotics are used in dentistry. Most antibiotic prescriptions were written for women, which is not surprising because results from previous studies have shown that women generally use health care services more than men.13, 14 When looking specifically at dental care visits, women aged 20 to 64 years had more dental

Conclusions

All health care providers who prescribe antibiotics have an important role to play in improving how antibiotics are used in the United States. This study provides a closer look at the specific antibiotics prescribed and geographic variability associated with antibiotic prescribing by dentists. However, additional studies looking more closely at antibiotic prescribing in dentistry are needed, especially in terms of adherence to updated prophylaxis guidelines. Also, identifying data sources to

Ms. Roberts is a public health analyst, Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Atlanta, GA 30329.

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Impact of stewardship intervention on antibiotic prescribing prior to dental procedures in a veteran population
2024, Journal of the American Pharmacists Association
Dentists are an overlooked group of prescribers but are responsible for up to 10% of antibiotic prescriptions written in the United States annually, most of which are for prophylaxis. Dental prophylaxis in orthopedic patients has been an area of confusion, with discordance among societal guidelines. In 2020, an antimicrobial stewardship (AS) group spearheaded a collaborative effort among dental, orthopedic surgery, and infectious diseases specialties to develop a protocol for the use of dental antibiotic prophylaxis for patients with total joint replacements (TJRs) based on the most current American Dental Association-American Academy of Orthopaedic Surgeons statement.
This study aimed to assess antibiotic prescribing for dental prophylaxis before and after an AS intervention.
This study is an interventional, pre-post review of dental encounters with patients with a history of TJR before (October 2019 to July 2021) and after (August 2021 to April 2023) the intervention. Charts were reviewed to determine the frequency and appropriateness of dental procedure prophylactic antibiotics.
A total of 1587 encounters from October 2019 to April 2023 were identified. Notably, 179 encounters in the pre- and 183 encounters in the postgroup were analyzed, 31 encounters (17%) in the pregroup versus 33 (18%) in the postgroup had a prophylactic antibiotic associated with it (P > 0.05), 26 of 31 antibiotics (84%) in the pregroup were prescribed for prosthetic joint infection prophylaxis compared with 18 of 33 (55%) in the postgroup (P > 0.05), and 151 of 179 encounters (84.3%) were guideline adherent in the preintervention group compared with 160 of 183 encounters (87.4%) in the postintervention group (P > 0.05).
This study observed a shift in the distribution of antibiotic indications and a decreased rate of inappropriate prophylactic prescriptions in dental patients with a history of TJR after an AS-led, collaborative intervention. Although the overall rate of prophylactic antibiotic prescribing remained the same and the changes did not reach statistical significance, lessons learned through this process can help inform future interventions in our institution and for others.
Does the Penicillin Allergy Label Affect Outcomes of Complicated Odontogenic Infections?
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Penicillins are a potent antibiotic in managing odontogenic infections, but 10% of the population is labelled as allergic to these drugs. This has limited their use and resulted in increased utilization of health care resources as well as complications associated with alternative antibiotics. The purpose of the study was to measure the association between patients labeled as penicillin allergic and treatment outcomes in a sample of patients treated for complicated odontogenic infections. Additionally, we sought to investigate antibiotic resistance patterns in these patients.
A retrospective cohort study was performed at the Michigan Medicine health care system to include patients who were treated for complicated odontogenic infections by oral and maxillofacial surgery between 2016 and 2020. Complicated odontogenic infection was defined as any odontogenic infection requiring admission and surgical management in the operating room. The primary predictor variable was the penicillin allergy label, which was determined by chart review and not confirmed with formal testing. Outcomes were measures of disease severity. The primary outcome variable was hospital length of stay. Secondary outcome variables were ICU admission (yes/no), repeat computed tomography scan(s), repeat surgery (yes/no), and re-admission (yes/no). Co-variates included were age, sex (male/female), tobacco use status, diabetes, immunocompromised state, number of spaces involved, white blood cell count upon admission and insurance status. For our secondary aim, the primary predictor variable was again penicillin allergy and outcome variable was antibiotic resistance as determined by wound culture results following surgical intervention. Negative binomial regression and logistic regression analyses were performed. P < .05 was considered significant.
A total of 150 patients met the inclusion criteria and of those 17.3% reported as penicillin allergic. Patients labelled as penicillin allergic did not differ significantly from patients without penicillin allergy label in terms of treatment outcomes. Age, diabetes, and immunosuppression were associated with an increased length of stay. Patients labelled as penicillin allergic were at significantly higher risk for antibiotic resistance (relative risk = 2.34; 95% confidence interval, 1.66 to 3.32; P < .001), specifically clindamycin resistance (relative risk = 3.17; 95% confidence interval, 1.93 to 5.18; P < .001).
Penicillin allergy was significantly associated with clindamycin resistance. There were similar outcomes amongst patients with and without a penicillin allergy label despite antibiotic differences. Delabeling efforts for patients with a reported penicillin allergy must be considered and local nomograms for antibiotic selection should be used by providers when seeking alternative antibiotics.
Antibiotic Resistance: The Silent Pandemia (in the COVID-19 Era)
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Antibiotic prescription patterns among US general dentists and periodontists
2022, Journal of the American Dental Association
Citation Excerpt :
Although 80% of the antibiotic use in the United States facilitates agricultural goals in food and animal industry, 20% of the antibiotic use is limited to the medical and dental outpatient setting.29,30 In agreement with the existing evidence,10,14 we observed geographic variations in prescription patterns. Although most AAP and ADA member prescribers were located in the Southeast and Great Lake regions, respectively, we saw no statistical difference between regions in terms of prescription frequencies.
In the absence of a full spectrum of evidence-based guidelines for the appropriate use of antimicrobial agents, dentists, including periodontists, remain a highly frequent antibiotic prescribing group. With the goal of understanding antibiotic prescribing practices, the authors surveyed a convenience sample of dental practitioners and periodontists to identify differences between the 2 cohorts and assess the factors that affect prescribing practices.
An institutional review board–approved 15-item survey was developed to capture antibiotic prescribing practices addressing the main research question, factors affecting systemic antibiotic prescription patterns, and prescription timing. The authors collaborated with the American Dental Association (ADA) and the American Academy of Periodontology (AAP) for survey dissemination. Responses were summarized using descriptive statistics. Multivariable models were developed to identify antibiotic prescription predictors.
Overall, 32.4% of the participants prescribed systemic antibiotics with scaling and root planing. When comparing the 2 groups, the authors found that 46.4% and 18.7% of the AAP and ADA members, respectively, prescribed systemic antibiotics with scaling and root planing (P = .0001). The authors found a significant difference between the AAP and ADA groups in prescription timing (P = .01). The multivariable model revealed that practitioner sex (P = .03), AAP membership (P = .0001), and years of practitioner experience (P = .04) predicted antibiotic prescription practices. The geographic location, practice setting, and occupation type did not predict antibiotic prescription patterns.
The authors found a lack of clarity related to prescription timing, factors determining prescription patterns, and selection of patient population who would benefit more from antibiotics.
This study confirmed a lack of clarity related to antibiotic prescription patterns in combination with nonsurgical periodontal treatment.
Factors that affect dentists’ use of antibiotic prophylaxis: Findings from The National Dental Practice-Based Research Network questionnaire
2022, Journal of the American Dental Association
Little is known about factors that influence dentists’ decision making concerning antibiotic prophylaxis (AP) prescribing. The objective of this study was to determine factors that influence dentists’ AP prescribing habits in patients at risk of developing infective endocarditis and prosthetic joint infections.
A questionnaire was administered to 3,584 dentist members of The National Dental Practice-Based Research Network. In addition to descriptive statistics, ordinal regression models were used to determine the factors most likely to impact dentists’ decisions to prescribe AP.
Overall, 2,169 (61%) dentists in The National Dental Practice-Based Resesarch Network responded. Responders’ decisions to prescribe antibiotics were influenced primarily by official guidelines, scientific literature, and physician or medical specialist opinion. Regarding potential risks, the greatest level of concern was for the development of infective endocarditis or prosthetic joint infections. Although litigation was deemed problematic, more than 90% of responders indicated a strong concern for the best course of action for the patient’s health. Dentists also indicated a high level of concern about the potential for generating antibiotic-resistant bacteria with AP use and increased risk of adverse drug reactions.
Dentists’ AP decision making seems most influenced by official guidelines, scientific literature, and advice from a physician or medical specialist.
These results suggest that one of the most effective means for promoting concordance of dentists clinical practice with the scientific basis for AP is to emphasize the importance and clarity of American Heart Association and American Dental Association recommendations and antimicrobial stewardship regarding prevention of infective endocarditis and prosthetic joint infections.
Clinical features and antimicrobial susceptibility of oral bacteria isolated from the blood cultures of patients with infective endocarditis
2022, Journal of Dental Sciences
Citation Excerpt :
In fact, amoxicillin is the most commonly prescribed antimicrobial agent for IE prophylaxis.14,20 In many countries, including Japan, amoxicillin also tends to be frequently prescribed for odontogenic infection.17,21–24 Accordingly, the incidence of amoxicillin-resistant VGSs may continue to increase.
The epidemiology of infective endocarditis (IE) is under constant change due to the aging society and increases in antimicrobial-resistant pathogens. However, IE remains severe. This study aimed to review the current clinical characteristics of IE and the antimicrobial susceptibility of oral bacteria (OB) isolated from blood cultures to implement appropriate antimicrobial prophylaxis.
We retrospectively investigated the clinical features of 180 patients with IE in whom OB and pathogens except OB (eOB) were identified as causative microorganisms via blood cultures. The susceptibility of the OB group to eight antibiotics was examined by broth microdilution.
Among causative microorganisms, the isolation rate of staphylococci was slightly higher than that of OB; however, the difference was not significant (36.7% vs. 33.8%, p = 0.3203). The number of patients with underlying cardiac disease was significantly higher in the OB group than in the eOB group (53.7% vs. 34.1%, p = 0.0113). Only one ampicillin-resistant OB was detected (2.0%). OBs were significantly less susceptible to clarithromycin and azithromycin than to ampicillin (98.0% vs. 66.7% and 98.0% vs. 60.0%, p = 0.0003 and p = 0.0003, respectively). Moreover, OBs were significantly less susceptible to clarithromycin and azithromycin than to clindamycin (66.7% vs. 88.2% and 60.0% vs. 88.2%, p = 0.0301 and p = 0.0217, respectively).
OBs were susceptible to ampicillin. However, the susceptibility of OBs to clarithromycin and azithromycin was significantly lower than that to ampicillin and clindamycin. These results are important and should help decisions regarding guide antimicrobial prophylaxis.

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Ms. Roberts is a public health analyst, Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Atlanta, GA 30329.

Dr. Bartoces is a statistician, Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

Ms. Thompson is a student, Get Smart: Know When Antibiotics Work Experiential Program, Centers for Disease Control and Prevention, Atlanta, GA.

Dr. Hicks is the director, Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

: Disclosure. None of the authors reported any disclosures.

: ORCID Number. Rebecca Roberts: http://orcid.org/0000-0002-9246-283X.

: The findings and conclusions in this report are those of the authors and do not necessarily represent the official positions of the Centers for Disease Control and Prevention.

: The authors acknowledge the Division of Oral Health at the Centers for Disease Control and Prevention, Robert Hunkler, MBA, (QuintilesIMS), and Natalia Chalmers, DDS, PhD (DentaQuest Institute), for their reviews and thoughtful comments on this manuscript.

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Original ContributionsAntibioticsAntibiotic prescribing by general dentists in the United States, 2013

Abstract

Background

Methods

Results

Conclusions

Practical Implications

Section snippets

Methods

Results

Discussion

Conclusions

Lancet

JADA

JADA

JADA

JADA

JADA

Lancet

JADA

Public Health

Antibiotic Resistance Threats in the United States

Antimicrobial drug use and resistance in Europe

Emerg Infect Dis

Emergency department visits for antibiotic-associated adverse events

Clin Infect Dis

Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA

Emerg Infect Dis

Dentists, antibiotics and Clostridium difficile-associated disease

Br Dent J

Burden of Clostridium difficile infection in the United States

N Engl J Med

Association between outpatient antibiotic prescribing practices and community-associated Clostridium difficilie infection

Open Forum Infect Dis

Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011

JAMA Intern Med

U.S. outpatient antibiotic prescribing, 2010

N Engl J Med

U.S. outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011

Clin Infect Dis

Gender differences in the utilization of health care services

J Fam Pract

Gender differences in the utilization of preventive care services in the United States

J Womens Health (Larchmt)

Trends in oral health status: United States, 1988-1994 and 1999-2004

Vital Health Stat 11

Original Contributions
Antibiotics
Antibiotic prescribing by general dentists in the United States, 2013