Antibiotic stewardship programs designed to preserve drug efficacy and stem the tide of multidrug-resistant bacteria are being emphasized in hospitals, nursing homes, and other care delivery points across the continuum. However, dental offices are slipping under the radar in many areas. Dentists prescribe a surprising amount of antibiotics, and this can lead to adverse patient consequences in the community.

Minnesota investigators recently underscored this finding in San Diego at the annual IDWeek meeting. They found that many otherwise unexplained Clostridium difficile infections in the community were in patients who had a recent dental visit. The Minnesota Department of Health tracked community-associated C. diff infections — meaning those in patients who did not have an overnight stay in a hospital or nursing home — in five counties in the state, the investigators reported. During a six-year period, they found that 15% of people with C. diff had taken antibiotics prescribed for dental procedures.

The investigators found 2,176 presumptive community-acquired C. diff cases in reviewing records from 2009 to 2015.¹ Of those, 1,626 (75%) were interviewed. Overall, 926 (57%) were prescribed antibiotics and 136 (15%) were for dental procedures.

“[Overall], 46 (34%) had no mention of antibiotics in their medical chart, illustrating the disconnect between dental and medical facilities,” said Stacy Holzbauer, DVM, MPH, lead author of the study and career epidemiology field officer for the CDC and the Minnesota Department of Health.

“The primary reasons for receiving these antibiotics were either to treat an oral infection or prophylaxis for oral surgery,” she said.

Speaking at an IDWeek press conference, Holzbauer emphasized that dentists should be educated about the adverse effects of antibiotic prescriptions, including selecting out drug-resistant bacterial strains and killing off commensal gut bacteria that keep C. diff at bay. Dentists write some 25 million prescriptions for antibiotics annually, she added.

While it may be appropriate to prescribe antibiotics for infections like an abscessed tooth, many drugs are being prescribed as prophylaxis prior to dental work under guidelines that have been revised. For example, the American Dental Association no longer recommends that dental patients with prosthetic joints take antibiotics prophylactically before a dental procedure. The risk-benefit equation has shifted, and it is now considered that spurring a C. diff infection by prescribing antibiotics is a potentially greater harm than the unlikely event of getting a prosthetic joint infection through routine dental care.

“In many cases, the best treatment for an oral infection may not actually include an antibiotic at all,” Holzbauer said.

Communication and education are needed, she said, urging patients to tell their primary care physicians if they have been prescribed an antibiotic related to dental care.

“We found that 15% of our community-associated C. diff cases had taken antibiotics for dental reasons prior to the infection,” she said. “Dentists need to be included in antibiotic stewardship programs. They are often overlooked and it is absolutely critical that they are included to improve prescribing.”

REFERENCE

1. Bye M, Whitten T, Holzbauer S, et al. Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009-2015. Abstract 78. IDWeek Oct. 4-8. San Diego, CA.