INAPPROPRIATE PRESCRIBING OF ANTIBIOTICS IN PRIMARY DENTAL CARE: REASONS AND RESOLUTIONS ANWEN L COPE, IVOR G CHESTNUTT Prim Dent J. 2014;3(4):33-37
ABSTRACT The injudicious use of antibiotics is one of the key contributors to the emergence of antibiotic-resistant bacterial strains. It is therefore imperative that antibiotics are prescribed only when they are likely to result in clinical benefit for a patient. Clinical guidelines have been produced to assist dental practitioners in the appropriate use of antimicrobials. Despite these guidelines, there is evidence that antibiotics are still widely used and misused in the management of acute dental conditions. This article explores the barriers that exist with regard to the implementation of antibiotic prescribing guidelines and discusses some of the interventions that aim to optimise antibiotic prescribing in primary dental care.
Introduction The indiscriminate use of antibiotics may promote the emergence of antibioticresistant bacterial strains,1 increases the likelihood of preventable adverse reactions,2 and represents a waste of healthcare resources. Antibiotic resistance is a serious public health and patient safety issue. Antibioticresistant infections are extremely difficult to treat and frequently recur. Therefore, it has never been more important that antibiotics are used judiciously. Dental professionals prescribe almost 1 in 10 of all antibiotics dispensed in primary care in England and Wales3,4 (Figure 1), and therefore the potential contribution of the dental profession to the development of antimicrobial resistance should not be underestimated. Antibiotics prescribed
AUTHORS
Anwen L Cope BDS, MFDS President’s Research Scholar, Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University
by dentists are frequently broad-spectrum agents, which can predispose for the selection of resistant strains.5 Furthermore, there is evidence that antibiotic-resistant bacteria, such as the Prevotella species (Figure 2), are being isolated from odontogenic infections with increasing frequency.6,7
Figure 1: Amoxicillin and metronidazole are the two antibiotic agents most frequently prescribed in primary dental care Figure 2: Incubated blood agar plate of Prevotella intermedia demonstrating resistance to penicillin
Within the United Kingdom, a number of evidence-based clinical guidelines that advise practitioners on the optimal use of antibiotics in the management of odontogenic infections have been published (Table1; Figure 3).8-10 These guidelines seek to improve the quality of care provided to patients by decreasing inappropriate prescription and expediting the integration of best-practice recommendations into clinical care.11 Guidelines for the use of therapeutic antibiotics within dentistry recommend that their use is limited to situations where: • there is evidence of spreading infection and/or systemic involvement (such as diffuse facial swelling,
Ivor G Chestnutt PhD, BDS, MPH, FDS(DPH), FDS, DDPH, FFPH Professor and Honorary Consultant in Dental Public Health and Associate Dean for Postgraduate Studies, School of Dentistry, Cardiff University
VOL 3 NO 4 NOVEMBER 2014
KEY WORDS Antimicrobial Prescribing, Primary Dental Care, Clinical Guidelines, Antimicrobial Resistance
33
INAPPROPRIATE PRESCRIBING OF ANTIBIOTICS IN PRIMARY DENTAL CARE: REASONS AND RESOLUTIONS
lymphadenopathy, fever, dysphagia, cellulitis, sublingual swelling or trismus); • local measures (such as exodontia, endodontic treatment or incision, and drainage of a swelling) are also attempted; • definitive treatment has to be delayed due to referral to specialist services.8-10 Despite these recommendations, there is evidence that antibiotics are used to treat inflammatory conditions such as irreversible pulpitis12 and as a substitute to performing operative treatment in emergency dental clinics.13 In a recent cross-sectional study of general dental practitioners (GDPs) conducted in Wales, as few as 19% of antibiotic prescriptions were provided in situations indicated as appropriate by clinical guidelines. This compares to a large clinical audit conducted in England between 2002 and 2004, where 29.2% of prescriptions were considered justifiable according to FGDP(UK) guidelines of the time.14
Which dentists do not follow guidelines for antibiotic use?
Table 1: Comparison of the indications for choice and duration of antimicrobial therapy in adult patients with acute dentoalveolar infections according to guidelines published by the (a) Faculty of General Dental Practice (UK), (b) the Scottish Dental Clinical Effectiveness Programme and (c) the Joint Formulary Committee
Figure 3: Clinical guidelines relating to antimicrobial use in dentistry published by the (a) Joint Formulary Committee, (b) Faculty of General Dental Practice (UK), and (c) Scottish Dental Clinical Effectiveness Programme
Wide variation in the antibiotic prescribing practices of dentists engaged in the provision of primary care has been demonstrated,15 therefore identifying dentists who routinely misuse antibiotics may facilitate the targeted application of resources intended to optimise antimicrobial use within primary care. However, previous research has shown that practitioner gender, postgraduate qualification status, number of years since qualification or attendance on postgraduate education courses about antimicrobial prescribing cannot be
a
b
34
c
P R I M A R Y D E N TA L J O U R N A L
reliably used to predict patterns of inappropriate antibiotic use.15,16 It may be more likely that compliance with clinical guidelines on antibiotic use is determined by practitioners’ knowledge, attitudes and the environment in which they work.
Why don’t dentists follow guidelines for antibiotic use? Despite the large amount of time and effort involved in their development, guidelines may have a limited effect on changing clinician behaviour.11,15 The reasons for non-adherence are likely to be multifactorial and may include lack of awareness or familiarity with guidelines, lack of agreement with guidelines, lack of outcome expectancy or self-efficacy, the inertia of previous practice, and external barriers relating to patients and characteristics of the healthcare system.11 Knowledge barriers In order for practitioners to access guidelines they first have to be conscious of their existence. A study suggested that although most GDPs may be aware of the existence of practice-based guidelines, some may have limited familiarity with specific recommendations made within them.17 In a large questionnaire-based study conducted in England and Scotland, the majority of GDPs could identify clinical signs indicating the need to prescribe antibiotics and non-clinical factors that should not influence
REFERENCES 1
2
3
Costelloe C, Metcalfe C, Lovering A, Mant D, Hay A. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:c2096. Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibioticassociated adverse events. Clin Infect Dis. 2008;47:735-43. Health and Social Care Information Centre (HSCIC).
4
5
6
prescribing.18 This suggests that attitudinal and external barriers, rather than knowledge barriers, may be more pivotal in accounting for why antibiotic prescribing practices of primary care dentists deviate from published guidelines. However, subtle differences exist between the current guidelines, particularly with respect to choice of second- and third-line antimicrobials (Table 1). This may cause confusion among practitioners in those instances where first-line antimicrobial agents have failed or are not suitable for a particular patient due to allergies or interactions with other medication. Attitudinal barriers Even if practitioners are familiar with a clinical guideline, if they do not agree with the way it was devised or if their personal interpretation of the evidence differs from that of the guideline developers, it can severely limit the likelihood that they will implement the recommendations. A qualitative study of GDPs has highlighted instances where dentists have expressed reservations in relation to the evidence base on which guidelines are developed or where uncertainty has arisen due to the existence of conflicting recommendations.19 Furthermore, practitioners may also have concerns about the impact of guidelines on their professional autonomy and may therefore resist the introduction of formulaic recommendations.19
Prescribing by Dentists: England, 2013. Leeds: HSCIC; 2014. Available at: www.hscic.gov.uk/catalogue/PU B14016. Accessed Jun 21, 2014. Holyfield G, Karki A. Review of Prescribing by Dentists in Wales. Cardiffé National Public Health Service for Wales; 2009. Sweeney LC, Dave J, Chambers PA, Heritage J. Antibiotic resistance in general dental practice – a cause for concern? J Antimicrob Chemother. 2004;53:567-76. Lewis MAO, MacFarlane TW,
VOL 3 NO 4 NOVEMBER 2014
7
8
Other practitioners may be unwilling or unmotivated to change their practice.11 In a qualitative analysis of experiences of collaborative clinical audit on antibiotic prescribing among GDPs, clinicians reflected on how the general dental practice environment can lead to isolation of practitioners, which can affect both awareness of guidelines and attitudinal barriers to change.12 Diagnostic and prognostic uncertainties may be other explanations as to why practitioners’ prescribing may deviate from published guidelines. Increased antibiotic usage in situations of diagnostic uncertainty is well described in the wider medical literature.20,21 In a questionnaire study of English GDPs, investigators found that 47.3% of practitioners reported that they may prescribe an antibiotic in instances where they were uncertain of a diagnosis.22 In these circumstances, antibiotics may be viewed as a minimally invasive intervention if a practitioner is unable to determine which tooth requires operative treatment yet wishes to provide a patient with a chance of achieving symptomatic relief. Furthermore, even if clinicians do provide operative treatment for an odontogenic infection, they may also prescribe an antibiotic in a situation where one may not be indicated, if they have concerns about the prognosis of treatment, particularly if a patient is due to go on holiday.14
McGowan DA. Antibiotic susceptibilities of bacteria isolated from acute dentoalveolar abscesses. J Antimicrob Chemother. 1989;23:69-77. Kuriyama T, Karasawa T, Williams DW, Nakagawa K, Yamamoto E. An increased prevalence of β -lactamasepositive isolates in Japanese patients with dentoalveolar infection. J Antimicrob Chemother. 2006;58:708-9. Palmer NOA, Longman L, Randall C, Pankhurst CL. Antimicrobial Prescribing for
General Dental Practitioners. London: FGDP(UK); 2012. 9 Joint Formulary Committee. British National Formulary. BNF 67. [online] London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2014. Available at www.medicinescomplete.com. Accessed May 7, 2014. 10 Scottish Dental Clinical Effectiveness Programme (SCDEP). Drug Prescribing for Dentistry. Dental Clinical Guidance. 2nd ed. Dundee; SDCEP; 2011. 11 Cabana MD, Rand CS, Powe NR,
35
INAPPROPRIATE PRESCRIBING OF ANTIBIOTICS IN PRIMARY DENTAL CARE: REASONS AND RESOLUTIONS
that limit their ability to perform the recommended behaviour due to patient or healthcare-system related factors.11
Figure 4: Facial swelling associated with an acute apical abscess. NB: Patient consent was obtained for publication of identifiable clinical images
There may also be situations where a practitioner may be unwilling to attempt an operative treatment due to uncertainties regarding its probability of success (lack of outcome expectancy). A specific example reported anecdotally within the dental literature is that involving a patient with a facial swelling arising from an acute apical abscess (Figure 4). Some practitioners may be concerned that local anaesthetic may be ineffective in this patient, despite reports that this only happens in a minority of cases.23 This belief may
Wu AW, Wilson MH, Abbound PC, et al. Why don’t physicians follow clinical practice guidelines?: A framework for improvement. JAMA. 1999;282:1458-65. 12 Palmer NAO, Dailey YM. General dental practitioners’ experiences of a collaborative clinical audit on antibiotic prescribing: A qualitative study. Br Dent J. 2002;193:46-9. 13 Tulip DE, Palmer NOA. A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract. Br Dent J.
36
be due to undergraduate teaching or previous clinical experience, and although the use of antibiotics in this way is a departure from guideline recommendations, it also represents an educational opportunity by which prescribing could be improved. External barriers Although a clinician may have appropriate knowledge and attitudes towards a guideline, these alone are insufficient to guarantee adherence.24 Practitioners may still encounter barriers
2008;205:659-64; discussion 648. 14 Chate RAC, White S, Hale LRO, Howat AP, Bottomley J, BarnetLamb J, et al. The impact of clinical audit on antibiotic prescribing in general dental practice. Br Dent J. 2006;201:635-41. 15 Seager JM, Howell-Jones RS, Dunstan FD, Lewis MAO, Richmond S, Thomas DW. A randomised controlled trial of clinical outreach education to rationalise antibiotic prescribing for acute dental pain in the primary care setting. Br Dent J. 2006;201:217-22; discussion 216.
Studies from the wider medical literature indicate that physicians’ antibiotic prescribing decisions are affected by their perception of patient expectation for antibiotics.25 In instances where primary care practitioners perceive that there is patient demand for an antibiotic, they are significantly more likely to prescribe one, even after adjustment for clinical signs and symptoms.20,26 In a large clinical audit of antibiotic prescribing among GDPs in England, 3.5% of prescriptions were reported to be written because of perceived patient expectation.14 Furthermore, in a cross-sectional study, 8% of dentists reported that patients’ expectations of a prescription would influence their decision to prescribe antibiotics.22 This becomes clinically important when the proportion of patients that expects or hopes to receive an antibiotic when suffering from an acute dental condition is considered. In a telephone-based follow-up of 156 adult patients who had consulted a GDP for an acute condition, 23% of patients reported that they expected to be prescribed an antibiotic.15 Although patient gender does not appear to influence expectation for an antibiotic, patients who report an expectation for an antibiotic are generally younger than those who do not.15
16 Palmer N, Martin M. An investigation of antibiotic prescribing by general dental practitioners: a pilot study. Prim Dent Care. 1998;5:11-14. 17 Farook SA, Davis AKJ, Khawaja N, Sheikh AM. NICE guideline and current practice of antibiotic prophylaxis for high risk cardiac patients (HRCP) among dental trainers and trainees in the United Kingdom (UK). Br Dent J. 2012;213:E6. 18 Palmer NOA, Martin MV, Pealing R, Ireland RS, Roy K, Smith A, et al. Antibiotic
prescribing knowledge of National Health Service general dental practitioners in England and Scotland. J Antimicrob Chemother. 2001;47:233-7. 19 Soheilipour S, Scambler S, Dickinson C, Dunne SM, Burke M, Jabbarifar SE, et al. Antibiotic prophylaxis in dentistry: Part I. A qualitative study of professionals’ views on the NICE guideline. Br Dent J. 2011;211:E1 20 Coenen S, Michiels B, Renard D, Denekens J, Van Royen P. Antibiotic prescribing for acute cough: the effect of perceived
P R I M A R Y D E N TA L J O U R N A L
Features of the healthcare system, such as clinical time pressures, organisational constraints and lack of reimbursement, may also contribute to dentists’ patterns of antibiotic misuse. The proportion of prescriptions that arise due to healthcaresystem related factors is likely to be highly variable, dependent on the organisation of an individual practice or clinic and the amount of time allowed for unscheduled emergency appointments.14 Qualitative studies have indicated that pressures of time and workload may play a pivotal role in the prescribing practices of some primary dental care clinicians, particularly those whose appointment schedules do not easily accommodate unscheduled care.12 Furthermore, in a cross-sectional study, 30.3% of GDP respondents reported that pressures of time and workload would influence their prescribing patterns.22
What can be done to improve prescribing in primary dental care? Interventions to improve prescribing often seek to do two things: to address the ‘knowledge gap’, in which practitioners are not aware of current evidence-based practice, and to remedy the ‘knowledgeto-doing gap’, in which practitioners are aware of the guidelines but have not yet implemented the recommended changes due to the existence of attitudinal barriers.27 Both clinical audit14,28 and
21
22
23 24
patient demand. Br J Gen Pract. 2006;56:183-190. Kumar S, Little P, Britten N. Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. BMJ. 2003;326:138. Palmer NA, Pealing R, Ireland RS, Martin MV. A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J. 2000;188:554-8. Fleming C. Draining the pus. Br Dent J. 2013;214:273. Solberg LI, Brekke ML, Kouke TE.
pharmacist-delivered academic detailing15 have previously been reported to result in substantial improvements in antibiotic prescribing practices of dentists working in primary care; however, whether these interventions result in long-term sustained improvement is unclear. Although these interventions addressed knowledge and attitudinal barriers, they did not directly seek to change external barriers related to patient expectation and healthcare-system related factors. If these latter factors are strong determinants of practitioner behaviour, long-term change may be elusive. Although it is likely that external barriers will be the hardest to change, a current study being undertaken in Germany (the DREAM trial) may highlight a way to modify patient expectation with regard to antibiotics for dental problems. This trial not only focuses on the education of practitioners (the knowledge gap) but also seeks to develop practitioner communication skills so that clinicians feel empowered to converse with patients regarding the appropriate use of antibiotics (the knowledge-to-doing gap).29 Greater stewardship of antibiotic prescribing in dentistry and actionable, personalised feedback for clinicians may also be pertinent in improving prescribing patterns within dentistry, as they may help overcome the inertia many practitioners experience with regard to their current habits. Enhanced audit and personalised
How important are clinician and nurse attitudes to the delivery of clinical preventive services? J Fam Pract 1997;44:451-61. 25 Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations–a questionnaire study. BMJ 1997;315:520-3. 26 Coenen S, Francis N, Kelly M, Hood K, Nuttall K, Little P, et al. Are patient views about antibiotics related to clinician perceptions, management and outcome? A multi-country study in outpatients
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feedback strategies for dentists, such as those being investigated in the RAPiD trial, can deliver reinforcement to dental practitioners seeking to improve their prescribing profile and provide motivation to those who have not yet taken steps to rationalise their antibiotic use.30
Conclusions Prudent use of antibiotics plays a important role in minimising the impact of antimicrobial resistance on public health. Studies suggest that there is currently limited concordance between clinical guidelines on prescribing and antibiotic use in primary dental care in the UK. This may be due to a number of barriers that exist with regard to the integration of guidelines into clinical practice. These barriers may relate not only to the knowledge of practitioners but also to their attitudes and how much time they have to treat acute cases. Future interventions to optimise prescribing in both primary and secondary care environments should seek to identify the specific factors that most strongly influence antibiotic prescribing within that system, so that appropriate and effective interventions can be designed and implemented. Support for such interventions should be provided by national organisations such as NHS commissioning services and local and regional bodies such as local dental committees and postgraduate deaneries.
with acute cough. PLoS ONE. 2013;8:e76691. 27 Gilbert GH, Williams OD, Korelitz JJ, Fellows JL, Gordan VV, Makhija SK, et al. Purpose, structure, and function of the United States National Dental Practice-Based Research Network. J Dent. 2013;41:1051-9. 28 Palmer NA, Dailey YM, Martin MV. Can audit improve antibiotic prescribing in general dental practice? Br Dent J. 2001;191:253-5. 29 Löffler C, Böhmer F, Hornung A, Lang H, Burmeister U, Podbielski A, et al. Dental care resistance
prevention and antibiotic prescribing modification-the cluster-randomised controlled DREAM trial. Implement Sci. 2014;9:27. 30 Prior M, Elouafkaoui P, Elders A, Young L, Duncan EM, Newlands R, et al. Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): A partial factorial cluster randomised trial protocol. Implement Sci. 2014;9:50.
37
ABSTRACT The injudicious use of antibiotics is one of the key contributors to the emergence of antibiotic-resistant bacterial strains. It is therefore imperative that antibiotics are prescribed only when they are likely to result in clinical benefit for a patient. Clinical guidelines have been produced to assist dental practitioners in the appropriate use of antimicrobials. Despite these guidelines, there is evidence that antibiotics are still widely used and misused in the management of acute dental conditions. This article explores the barriers that exist with regard to the implementation of antibiotic prescribing guidelines and discusses some of the interventions that aim to optimise antibiotic prescribing in primary dental care.
Introduction The indiscriminate use of antibiotics may promote the emergence of antibioticresistant bacterial strains,1 increases the likelihood of preventable adverse reactions,2 and represents a waste of healthcare resources. Antibiotic resistance is a serious public health and patient safety issue. Antibioticresistant infections are extremely difficult to treat and frequently recur. Therefore, it has never been more important that antibiotics are used judiciously. Dental professionals prescribe almost 1 in 10 of all antibiotics dispensed in primary care in England and Wales3,4 (Figure 1), and therefore the potential contribution of the dental profession to the development of antimicrobial resistance should not be underestimated. Antibiotics prescribed
AUTHORS
Anwen L Cope BDS, MFDS President’s Research Scholar, Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University
by dentists are frequently broad-spectrum agents, which can predispose for the selection of resistant strains.5 Furthermore, there is evidence that antibiotic-resistant bacteria, such as the Prevotella species (Figure 2), are being isolated from odontogenic infections with increasing frequency.6,7
Figure 1: Amoxicillin and metronidazole are the two antibiotic agents most frequently prescribed in primary dental care Figure 2: Incubated blood agar plate of Prevotella intermedia demonstrating resistance to penicillin
Within the United Kingdom, a number of evidence-based clinical guidelines that advise practitioners on the optimal use of antibiotics in the management of odontogenic infections have been published (Table1; Figure 3).8-10 These guidelines seek to improve the quality of care provided to patients by decreasing inappropriate prescription and expediting the integration of best-practice recommendations into clinical care.11 Guidelines for the use of therapeutic antibiotics within dentistry recommend that their use is limited to situations where: • there is evidence of spreading infection and/or systemic involvement (such as diffuse facial swelling,
Ivor G Chestnutt PhD, BDS, MPH, FDS(DPH), FDS, DDPH, FFPH Professor and Honorary Consultant in Dental Public Health and Associate Dean for Postgraduate Studies, School of Dentistry, Cardiff University
VOL 3 NO 4 NOVEMBER 2014
KEY WORDS Antimicrobial Prescribing, Primary Dental Care, Clinical Guidelines, Antimicrobial Resistance
33
INAPPROPRIATE PRESCRIBING OF ANTIBIOTICS IN PRIMARY DENTAL CARE: REASONS AND RESOLUTIONS
lymphadenopathy, fever, dysphagia, cellulitis, sublingual swelling or trismus); • local measures (such as exodontia, endodontic treatment or incision, and drainage of a swelling) are also attempted; • definitive treatment has to be delayed due to referral to specialist services.8-10 Despite these recommendations, there is evidence that antibiotics are used to treat inflammatory conditions such as irreversible pulpitis12 and as a substitute to performing operative treatment in emergency dental clinics.13 In a recent cross-sectional study of general dental practitioners (GDPs) conducted in Wales, as few as 19% of antibiotic prescriptions were provided in situations indicated as appropriate by clinical guidelines. This compares to a large clinical audit conducted in England between 2002 and 2004, where 29.2% of prescriptions were considered justifiable according to FGDP(UK) guidelines of the time.14
Which dentists do not follow guidelines for antibiotic use?
Table 1: Comparison of the indications for choice and duration of antimicrobial therapy in adult patients with acute dentoalveolar infections according to guidelines published by the (a) Faculty of General Dental Practice (UK), (b) the Scottish Dental Clinical Effectiveness Programme and (c) the Joint Formulary Committee
Figure 3: Clinical guidelines relating to antimicrobial use in dentistry published by the (a) Joint Formulary Committee, (b) Faculty of General Dental Practice (UK), and (c) Scottish Dental Clinical Effectiveness Programme
Wide variation in the antibiotic prescribing practices of dentists engaged in the provision of primary care has been demonstrated,15 therefore identifying dentists who routinely misuse antibiotics may facilitate the targeted application of resources intended to optimise antimicrobial use within primary care. However, previous research has shown that practitioner gender, postgraduate qualification status, number of years since qualification or attendance on postgraduate education courses about antimicrobial prescribing cannot be
a
b
34
c
P R I M A R Y D E N TA L J O U R N A L
reliably used to predict patterns of inappropriate antibiotic use.15,16 It may be more likely that compliance with clinical guidelines on antibiotic use is determined by practitioners’ knowledge, attitudes and the environment in which they work.
Why don’t dentists follow guidelines for antibiotic use? Despite the large amount of time and effort involved in their development, guidelines may have a limited effect on changing clinician behaviour.11,15 The reasons for non-adherence are likely to be multifactorial and may include lack of awareness or familiarity with guidelines, lack of agreement with guidelines, lack of outcome expectancy or self-efficacy, the inertia of previous practice, and external barriers relating to patients and characteristics of the healthcare system.11 Knowledge barriers In order for practitioners to access guidelines they first have to be conscious of their existence. A study suggested that although most GDPs may be aware of the existence of practice-based guidelines, some may have limited familiarity with specific recommendations made within them.17 In a large questionnaire-based study conducted in England and Scotland, the majority of GDPs could identify clinical signs indicating the need to prescribe antibiotics and non-clinical factors that should not influence
REFERENCES 1
2
3
Costelloe C, Metcalfe C, Lovering A, Mant D, Hay A. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:c2096. Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibioticassociated adverse events. Clin Infect Dis. 2008;47:735-43. Health and Social Care Information Centre (HSCIC).
4
5
6
prescribing.18 This suggests that attitudinal and external barriers, rather than knowledge barriers, may be more pivotal in accounting for why antibiotic prescribing practices of primary care dentists deviate from published guidelines. However, subtle differences exist between the current guidelines, particularly with respect to choice of second- and third-line antimicrobials (Table 1). This may cause confusion among practitioners in those instances where first-line antimicrobial agents have failed or are not suitable for a particular patient due to allergies or interactions with other medication. Attitudinal barriers Even if practitioners are familiar with a clinical guideline, if they do not agree with the way it was devised or if their personal interpretation of the evidence differs from that of the guideline developers, it can severely limit the likelihood that they will implement the recommendations. A qualitative study of GDPs has highlighted instances where dentists have expressed reservations in relation to the evidence base on which guidelines are developed or where uncertainty has arisen due to the existence of conflicting recommendations.19 Furthermore, practitioners may also have concerns about the impact of guidelines on their professional autonomy and may therefore resist the introduction of formulaic recommendations.19
Prescribing by Dentists: England, 2013. Leeds: HSCIC; 2014. Available at: www.hscic.gov.uk/catalogue/PU B14016. Accessed Jun 21, 2014. Holyfield G, Karki A. Review of Prescribing by Dentists in Wales. Cardiffé National Public Health Service for Wales; 2009. Sweeney LC, Dave J, Chambers PA, Heritage J. Antibiotic resistance in general dental practice – a cause for concern? J Antimicrob Chemother. 2004;53:567-76. Lewis MAO, MacFarlane TW,
VOL 3 NO 4 NOVEMBER 2014
7
8
Other practitioners may be unwilling or unmotivated to change their practice.11 In a qualitative analysis of experiences of collaborative clinical audit on antibiotic prescribing among GDPs, clinicians reflected on how the general dental practice environment can lead to isolation of practitioners, which can affect both awareness of guidelines and attitudinal barriers to change.12 Diagnostic and prognostic uncertainties may be other explanations as to why practitioners’ prescribing may deviate from published guidelines. Increased antibiotic usage in situations of diagnostic uncertainty is well described in the wider medical literature.20,21 In a questionnaire study of English GDPs, investigators found that 47.3% of practitioners reported that they may prescribe an antibiotic in instances where they were uncertain of a diagnosis.22 In these circumstances, antibiotics may be viewed as a minimally invasive intervention if a practitioner is unable to determine which tooth requires operative treatment yet wishes to provide a patient with a chance of achieving symptomatic relief. Furthermore, even if clinicians do provide operative treatment for an odontogenic infection, they may also prescribe an antibiotic in a situation where one may not be indicated, if they have concerns about the prognosis of treatment, particularly if a patient is due to go on holiday.14
McGowan DA. Antibiotic susceptibilities of bacteria isolated from acute dentoalveolar abscesses. J Antimicrob Chemother. 1989;23:69-77. Kuriyama T, Karasawa T, Williams DW, Nakagawa K, Yamamoto E. An increased prevalence of β -lactamasepositive isolates in Japanese patients with dentoalveolar infection. J Antimicrob Chemother. 2006;58:708-9. Palmer NOA, Longman L, Randall C, Pankhurst CL. Antimicrobial Prescribing for
General Dental Practitioners. London: FGDP(UK); 2012. 9 Joint Formulary Committee. British National Formulary. BNF 67. [online] London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2014. Available at www.medicinescomplete.com. Accessed May 7, 2014. 10 Scottish Dental Clinical Effectiveness Programme (SCDEP). Drug Prescribing for Dentistry. Dental Clinical Guidance. 2nd ed. Dundee; SDCEP; 2011. 11 Cabana MD, Rand CS, Powe NR,
35
INAPPROPRIATE PRESCRIBING OF ANTIBIOTICS IN PRIMARY DENTAL CARE: REASONS AND RESOLUTIONS
that limit their ability to perform the recommended behaviour due to patient or healthcare-system related factors.11
Figure 4: Facial swelling associated with an acute apical abscess. NB: Patient consent was obtained for publication of identifiable clinical images
There may also be situations where a practitioner may be unwilling to attempt an operative treatment due to uncertainties regarding its probability of success (lack of outcome expectancy). A specific example reported anecdotally within the dental literature is that involving a patient with a facial swelling arising from an acute apical abscess (Figure 4). Some practitioners may be concerned that local anaesthetic may be ineffective in this patient, despite reports that this only happens in a minority of cases.23 This belief may
Wu AW, Wilson MH, Abbound PC, et al. Why don’t physicians follow clinical practice guidelines?: A framework for improvement. JAMA. 1999;282:1458-65. 12 Palmer NAO, Dailey YM. General dental practitioners’ experiences of a collaborative clinical audit on antibiotic prescribing: A qualitative study. Br Dent J. 2002;193:46-9. 13 Tulip DE, Palmer NOA. A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract. Br Dent J.
36
be due to undergraduate teaching or previous clinical experience, and although the use of antibiotics in this way is a departure from guideline recommendations, it also represents an educational opportunity by which prescribing could be improved. External barriers Although a clinician may have appropriate knowledge and attitudes towards a guideline, these alone are insufficient to guarantee adherence.24 Practitioners may still encounter barriers
2008;205:659-64; discussion 648. 14 Chate RAC, White S, Hale LRO, Howat AP, Bottomley J, BarnetLamb J, et al. The impact of clinical audit on antibiotic prescribing in general dental practice. Br Dent J. 2006;201:635-41. 15 Seager JM, Howell-Jones RS, Dunstan FD, Lewis MAO, Richmond S, Thomas DW. A randomised controlled trial of clinical outreach education to rationalise antibiotic prescribing for acute dental pain in the primary care setting. Br Dent J. 2006;201:217-22; discussion 216.
Studies from the wider medical literature indicate that physicians’ antibiotic prescribing decisions are affected by their perception of patient expectation for antibiotics.25 In instances where primary care practitioners perceive that there is patient demand for an antibiotic, they are significantly more likely to prescribe one, even after adjustment for clinical signs and symptoms.20,26 In a large clinical audit of antibiotic prescribing among GDPs in England, 3.5% of prescriptions were reported to be written because of perceived patient expectation.14 Furthermore, in a cross-sectional study, 8% of dentists reported that patients’ expectations of a prescription would influence their decision to prescribe antibiotics.22 This becomes clinically important when the proportion of patients that expects or hopes to receive an antibiotic when suffering from an acute dental condition is considered. In a telephone-based follow-up of 156 adult patients who had consulted a GDP for an acute condition, 23% of patients reported that they expected to be prescribed an antibiotic.15 Although patient gender does not appear to influence expectation for an antibiotic, patients who report an expectation for an antibiotic are generally younger than those who do not.15
16 Palmer N, Martin M. An investigation of antibiotic prescribing by general dental practitioners: a pilot study. Prim Dent Care. 1998;5:11-14. 17 Farook SA, Davis AKJ, Khawaja N, Sheikh AM. NICE guideline and current practice of antibiotic prophylaxis for high risk cardiac patients (HRCP) among dental trainers and trainees in the United Kingdom (UK). Br Dent J. 2012;213:E6. 18 Palmer NOA, Martin MV, Pealing R, Ireland RS, Roy K, Smith A, et al. Antibiotic
prescribing knowledge of National Health Service general dental practitioners in England and Scotland. J Antimicrob Chemother. 2001;47:233-7. 19 Soheilipour S, Scambler S, Dickinson C, Dunne SM, Burke M, Jabbarifar SE, et al. Antibiotic prophylaxis in dentistry: Part I. A qualitative study of professionals’ views on the NICE guideline. Br Dent J. 2011;211:E1 20 Coenen S, Michiels B, Renard D, Denekens J, Van Royen P. Antibiotic prescribing for acute cough: the effect of perceived
P R I M A R Y D E N TA L J O U R N A L
Features of the healthcare system, such as clinical time pressures, organisational constraints and lack of reimbursement, may also contribute to dentists’ patterns of antibiotic misuse. The proportion of prescriptions that arise due to healthcaresystem related factors is likely to be highly variable, dependent on the organisation of an individual practice or clinic and the amount of time allowed for unscheduled emergency appointments.14 Qualitative studies have indicated that pressures of time and workload may play a pivotal role in the prescribing practices of some primary dental care clinicians, particularly those whose appointment schedules do not easily accommodate unscheduled care.12 Furthermore, in a cross-sectional study, 30.3% of GDP respondents reported that pressures of time and workload would influence their prescribing patterns.22
What can be done to improve prescribing in primary dental care? Interventions to improve prescribing often seek to do two things: to address the ‘knowledge gap’, in which practitioners are not aware of current evidence-based practice, and to remedy the ‘knowledgeto-doing gap’, in which practitioners are aware of the guidelines but have not yet implemented the recommended changes due to the existence of attitudinal barriers.27 Both clinical audit14,28 and
21
22
23 24
patient demand. Br J Gen Pract. 2006;56:183-190. Kumar S, Little P, Britten N. Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. BMJ. 2003;326:138. Palmer NA, Pealing R, Ireland RS, Martin MV. A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J. 2000;188:554-8. Fleming C. Draining the pus. Br Dent J. 2013;214:273. Solberg LI, Brekke ML, Kouke TE.
pharmacist-delivered academic detailing15 have previously been reported to result in substantial improvements in antibiotic prescribing practices of dentists working in primary care; however, whether these interventions result in long-term sustained improvement is unclear. Although these interventions addressed knowledge and attitudinal barriers, they did not directly seek to change external barriers related to patient expectation and healthcare-system related factors. If these latter factors are strong determinants of practitioner behaviour, long-term change may be elusive. Although it is likely that external barriers will be the hardest to change, a current study being undertaken in Germany (the DREAM trial) may highlight a way to modify patient expectation with regard to antibiotics for dental problems. This trial not only focuses on the education of practitioners (the knowledge gap) but also seeks to develop practitioner communication skills so that clinicians feel empowered to converse with patients regarding the appropriate use of antibiotics (the knowledge-to-doing gap).29 Greater stewardship of antibiotic prescribing in dentistry and actionable, personalised feedback for clinicians may also be pertinent in improving prescribing patterns within dentistry, as they may help overcome the inertia many practitioners experience with regard to their current habits. Enhanced audit and personalised
How important are clinician and nurse attitudes to the delivery of clinical preventive services? J Fam Pract 1997;44:451-61. 25 Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations–a questionnaire study. BMJ 1997;315:520-3. 26 Coenen S, Francis N, Kelly M, Hood K, Nuttall K, Little P, et al. Are patient views about antibiotics related to clinician perceptions, management and outcome? A multi-country study in outpatients
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feedback strategies for dentists, such as those being investigated in the RAPiD trial, can deliver reinforcement to dental practitioners seeking to improve their prescribing profile and provide motivation to those who have not yet taken steps to rationalise their antibiotic use.30
Conclusions Prudent use of antibiotics plays a important role in minimising the impact of antimicrobial resistance on public health. Studies suggest that there is currently limited concordance between clinical guidelines on prescribing and antibiotic use in primary dental care in the UK. This may be due to a number of barriers that exist with regard to the integration of guidelines into clinical practice. These barriers may relate not only to the knowledge of practitioners but also to their attitudes and how much time they have to treat acute cases. Future interventions to optimise prescribing in both primary and secondary care environments should seek to identify the specific factors that most strongly influence antibiotic prescribing within that system, so that appropriate and effective interventions can be designed and implemented. Support for such interventions should be provided by national organisations such as NHS commissioning services and local and regional bodies such as local dental committees and postgraduate deaneries.
with acute cough. PLoS ONE. 2013;8:e76691. 27 Gilbert GH, Williams OD, Korelitz JJ, Fellows JL, Gordan VV, Makhija SK, et al. Purpose, structure, and function of the United States National Dental Practice-Based Research Network. J Dent. 2013;41:1051-9. 28 Palmer NA, Dailey YM, Martin MV. Can audit improve antibiotic prescribing in general dental practice? Br Dent J. 2001;191:253-5. 29 Löffler C, Böhmer F, Hornung A, Lang H, Burmeister U, Podbielski A, et al. Dental care resistance
prevention and antibiotic prescribing modification-the cluster-randomised controlled DREAM trial. Implement Sci. 2014;9:27. 30 Prior M, Elouafkaoui P, Elders A, Young L, Duncan EM, Newlands R, et al. Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): A partial factorial cluster randomised trial protocol. Implement Sci. 2014;9:50.
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