SPEAKER’S CORNER SUSAN O’CONNELL DENTAL CORE TRAINEE IN ORAL SURGERY, GUY’S HOSPITAL KATE YEATON DENTAL CORE TRAINEE IN ORAL SURGERY, GUY’S HOSPITAL JERRY KWOK CONSULTANT ORAL SURGEON, GUY’S HOSPITAL
AN AUDIT TO ASSESS COMPLIANCE WITH ANTIMICROBIAL PRESCRIBING IN THE MANAGEMENT OF ACUTE DENTOALVEOLAR INFECTIONS WITH ASSOCIATED FACIAL SWELLING Objective
Results
To determine whether or not antibiotics are being prescribed according to the FGDP(UK)’s guidelines for patients with acute dentoalveolar infection and associated facial swelling.
Fifty patients participated in this audit. Of these, 29 were prescribed the correct dose as per the FGDP(UK) guidelines; however, three different antibiotic regimes were prescribed. These included amoxicillin 250mg tds for five days (seven patients), metronidazole 200mg tds for five days (six patients), and a combination of amoxicillin 250mg and metronidazole 200mg tds for five days (16 patients).
Method Our criteria and standards were based on Antimicrobial Prescribing for General Dental Practitioners, published by the FGDP(UK).1 Our target was 100% compliance with the standards. A prospective audit was carried out in the acute dental care (ADC) department at Guy’s Hospital between October 2012 and January 2013. A sample size of 50 was set. Patients 16 years of age or older presenting with acute dentoalveolar infections with associated facial swelling were included. Patients were excluded if they were pregnant, suffered from any immunosuppressive disease, if systemic antibiotics had already been prescribed, or if systemic antibiotics were not necessary. Informed consent was obtained from all subjects. A pro forma was used to collect data from patients presenting with acute dentoalveolar infections and associated swelling. Information was recorded at presentation, day three and day five. Clinical features noted included the location and size of the swelling, lymph node involvement, body temperature, pulse and pain levels. Any medication taken prior to presentation was recorded, especially antibiotics. Treatment performed was also recorded, including antibiotic dose and duration prescribed. Treatment included drainage and removal of the source of infection (where possible) and the prescription of antibiotics.
V O L 3 N O 2 M AY 2 0 1 4
Incorrect doses were prescribed to 21 patients. Of these, two patients were prescribed amoxicillin 500mg tds for five days, one was prescribed metronidazole 400mg tds for five days, and 18 were prescribed amoxicillin 500mg and metronidazole 400mg tds for five days. A review was carried out in 36 cases, since 14 patients did not attend their review appointment. There was complete resolution of swelling by day three in all 29 patients who were prescribed the correct antibiotic dose, and no patient presented with worsening of symptoms.
Discussion and conclusion Antimicrobial guidelines only benefit patients if they are strictly adhered to by clinicians. The FGDP(UK) guidelines were used as the standard for this audit.
REFERENCES 1
2
Faculty of General Dental Practice (UK). Antimicrobial prescribing for general dental practitioners. 2nd ed. London: FGDP(UK); 2012 Ellison SJ. An outcome audit of three-day antimicrobial
3
Compliance with the guidelines was suboptimal, with 42% of prescriptions being of incorrect dose and/or duration. Interventions made to improve this included a poster demonstrating the appropriate antibiotic prescribing protocol in the ADC, and an email of the guidelines which was sent to all clinicians. Patients who were prescribed antibiotics as per the FGDP(UK) guidelines and who were reviewed on day three displayed no worsening of signs and symptoms. Furthermore, these patients had complete resolution of swelling by day three. This result is supported by other reports, which advocate the effectiveness of a three-day standard-dose antibiotic course.2 Since this audit, there has been a change to the protocol regarding antibiotic prescribing. Following review of the HPA’s consultation document3 and discussion with experts in relation to resistance to amoxicillin, the British National Formulary (BNF) has advised an increased dose of amoxicillin when managing infections in adults.4 A dose of 500mg every eight hours is now recommended in the BNF and FGDP(UK) guidelines where antimicrobials are indicated. In severe infections, the dose should be doubled.
prescribing for the acute dentoalveolar abscess, Br Dent J 2011;211:591-594. Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and Local Adaptation. November 2012, revised February
4
2013. Available at: http://www.hpa.org.uk/we bc/HPAwebFile/HPAweb_C /1279888711402 Joint Formulary Committee. British National Formulary. 66th ed. London: BMJ Group and Pharmaceutical Press; 2013.
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AN AUDIT TO ASSESS COMPLIANCE WITH ANTIMICROBIAL PRESCRIBING IN THE MANAGEMENT OF ACUTE DENTOALVEOLAR INFECTIONS WITH ASSOCIATED FACIAL SWELLING Objective
Results
To determine whether or not antibiotics are being prescribed according to the FGDP(UK)’s guidelines for patients with acute dentoalveolar infection and associated facial swelling.
Fifty patients participated in this audit. Of these, 29 were prescribed the correct dose as per the FGDP(UK) guidelines; however, three different antibiotic regimes were prescribed. These included amoxicillin 250mg tds for five days (seven patients), metronidazole 200mg tds for five days (six patients), and a combination of amoxicillin 250mg and metronidazole 200mg tds for five days (16 patients).
Method Our criteria and standards were based on Antimicrobial Prescribing for General Dental Practitioners, published by the FGDP(UK).1 Our target was 100% compliance with the standards. A prospective audit was carried out in the acute dental care (ADC) department at Guy’s Hospital between October 2012 and January 2013. A sample size of 50 was set. Patients 16 years of age or older presenting with acute dentoalveolar infections with associated facial swelling were included. Patients were excluded if they were pregnant, suffered from any immunosuppressive disease, if systemic antibiotics had already been prescribed, or if systemic antibiotics were not necessary. Informed consent was obtained from all subjects. A pro forma was used to collect data from patients presenting with acute dentoalveolar infections and associated swelling. Information was recorded at presentation, day three and day five. Clinical features noted included the location and size of the swelling, lymph node involvement, body temperature, pulse and pain levels. Any medication taken prior to presentation was recorded, especially antibiotics. Treatment performed was also recorded, including antibiotic dose and duration prescribed. Treatment included drainage and removal of the source of infection (where possible) and the prescription of antibiotics.
V O L 3 N O 2 M AY 2 0 1 4
Incorrect doses were prescribed to 21 patients. Of these, two patients were prescribed amoxicillin 500mg tds for five days, one was prescribed metronidazole 400mg tds for five days, and 18 were prescribed amoxicillin 500mg and metronidazole 400mg tds for five days. A review was carried out in 36 cases, since 14 patients did not attend their review appointment. There was complete resolution of swelling by day three in all 29 patients who were prescribed the correct antibiotic dose, and no patient presented with worsening of symptoms.
Discussion and conclusion Antimicrobial guidelines only benefit patients if they are strictly adhered to by clinicians. The FGDP(UK) guidelines were used as the standard for this audit.
REFERENCES 1
2
Faculty of General Dental Practice (UK). Antimicrobial prescribing for general dental practitioners. 2nd ed. London: FGDP(UK); 2012 Ellison SJ. An outcome audit of three-day antimicrobial
3
Compliance with the guidelines was suboptimal, with 42% of prescriptions being of incorrect dose and/or duration. Interventions made to improve this included a poster demonstrating the appropriate antibiotic prescribing protocol in the ADC, and an email of the guidelines which was sent to all clinicians. Patients who were prescribed antibiotics as per the FGDP(UK) guidelines and who were reviewed on day three displayed no worsening of signs and symptoms. Furthermore, these patients had complete resolution of swelling by day three. This result is supported by other reports, which advocate the effectiveness of a three-day standard-dose antibiotic course.2 Since this audit, there has been a change to the protocol regarding antibiotic prescribing. Following review of the HPA’s consultation document3 and discussion with experts in relation to resistance to amoxicillin, the British National Formulary (BNF) has advised an increased dose of amoxicillin when managing infections in adults.4 A dose of 500mg every eight hours is now recommended in the BNF and FGDP(UK) guidelines where antimicrobials are indicated. In severe infections, the dose should be doubled.
prescribing for the acute dentoalveolar abscess, Br Dent J 2011;211:591-594. Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and Local Adaptation. November 2012, revised February
4
2013. Available at: http://www.hpa.org.uk/we bc/HPAwebFile/HPAweb_C /1279888711402 Joint Formulary Committee. British National Formulary. 66th ed. London: BMJ Group and Pharmaceutical Press; 2013.
21
