Antibiotic prescription for endodontic infections among Italian dental practitioners: what is the extent of over-prescription?

Antibiotic Over-Prescription by Dentists in the Treatment of Apical Periodontitis: A Systematic Review and Meta-Analysis

After pulp infection and necrosis, the passage of microbial antigens into the periapical space causes apical periodontitis (AP). Most of the clinical forms of AP can be managed without prescribing antibiotics, only with root canal treatment and abscess drainage or, where appropriate, tooth extraction. However, the scientific literature provides evidence of inappropriate antibiotic prescriptions by dentists in the management of apical disease.

OBJECTIVES

The aim of this systematic review and meta-analysis was to analyze the global pattern of antibiotic prescription in the treatment of apical disease.

METHODS

PRISMA Guidelines were followed to carry out this systematic review. The research question was as follows: What is the pattern of antibiotic prescription by dentists in the treatment of the different clinical forms of apical periodontitis? A systematic search was conducted on MEDLINE/PubMed, Wiley Online Database, Web of Science and Scopus. All studies reporting data about the pattern of antibiotic prescription by dentists in the treatment of apical disease were included. The meta-analyses were calculated using the Open Meta Analyst version 10.10 software. Random-effects meta-analyses were performed. The risk of bias was assessed using the Newcastle-Ottawa Scale. The certainty of evidence was assessed using GRADE.

RESULTS

The search strategy identified 96 articles and thirty-nine cross-sectional studies fulfilled the inclusion criteria. The overall percentage of antibiotic prescriptions by dentists in cases of symptomatic AP was 25.8%, and 31.5% in cases of asymptomatic AP with sinus tract present. The percentage of dentists prescribing antibiotics in cases of acute apical abscess with no/mild symptoms was 47.7%, whereas, in cases of acute apical abscess with moderate/severe symptoms, 88.8% of dentists would prescribe antibiotics. Endodontists prescribe antibiotics at a lower rate than general practitioners. The total risk of bias was considered moderate, and the final rating for the certainty of the evidence was low.

CONCLUSIONS

Dentists worldwide are over-prescribing antibiotics in the management of apical disease. It is necessary to improve antibiotic prescribing habits in the treatment of endodontic infections, as well as educational initiatives to encourage the rational and appropriate prescription of antibiotics in periapical diseases.

Burden of delayed discharge on acute hospital medical wards: A retrospective ecological study in Rome, Italy

INTRODUCTION

Delayed discharge represents the difficulty in proceeding with discharge of patients who do not have any further benefit from prolonged stay. A quota of this problem is related to organizational issues. In the Lazio region in Italy, a macro service re-organization in on the way, with a network of hospital and territorial centers engaged in structuring in- and out- of hospital patient pathways, with a special focus on intermediate care structures. Purpose of this study is to quantify the burden of delayed discharge on a single hospital structure, in order to estimate costs and occurrence of potential resource misplacement.

MATERIAL AND METHODS

Observational Retrospective study conducted at the Santo Spirito Hospital in Rome, Italy. Observation period ranged from 1/09/2022, when the local database was instituted, to 1/03/2023 (6 months). Data from admissions records was anonymously collected. Data linkage with administrative local hospital database was performed in order to identify the date a discharge request was fired for each admission. Surgical discharges and Intensive Care Unit (ICU) discharges were excluded from this study. A Poisson hierarchical regression model was employed to investigate for the role of ward, Severity of Disease (SoD) and Risk of Mortality (RoM) on elongation of discharge time.

RESULTS

1222 medical ward admissions were recorded in the timeframe. 16% of them were considered as subject to potentially elongated stay, and a mean Delay in discharge of 6.3 days (SD 7.9) was observed.

DISCUSSION AND CONCLUSIONS

Delayed discharge may cause a "bottleneck" in admissions and result in overcrowded Emergency Department, overall poor performance, and increase in overall costs. A consisted proportion of available beds can get inappropriately occupied, and this inflates both direct and indirect costs. Clinical conditions on admission are not a good predictor of delay in discharge, and the root causes of this phenomenon likely lie in organizational issues (on structure\system level) and social issues (on patient's level).

Systemic Antibiotic Use in Acute Irreversible Pulpitis: Evaluating Clinical Practices and Molecular Insights

This scoping review systematically evaluates the use of systemic antibiotics in treating acute irreversible pulpitis, integrating clinical practice patterns with recent molecular insights. We analyzed clinical evidence on antibiotic prescription trends among dental professionals and examined molecular research advancements in relation to pulpitis. This review is intended to bridge the gap between clinical practice and molecular research, guiding more evidence-based approaches to treating acute irreversible pulpitis. Electronic databases were searched for relevant articles published in English based on the objective of the review. A second search using all identified keywords and index terms was undertaken across all the included databases. In addition, a reference list of identified articles was searched. Studies including original research, systematic reviews, meta-analyses, clinical trials, and observational and retrospective studies, all written in English and published from 2010 onwards, were included, and an analysis of the text words contained in the titles and abstracts of the retrieved papers and of the index terms used to describe the articles was performed. A total of N = 53 articles were selected. Altogether, N = 43 (76.79%) articles were cross-sectional studies, N = 4 (11.11%) were systematic reviews, and N = 3 (5.36%) were guidelines. The most frequent level of evidence was level VI (N = 43 (76.79%). The mean percentage of dentists who prescribed antibiotics to treat acute irreversible pulpitis was 23.89 ± 23.74% (range: 0.05-75.7). Similarly, for specialists, it was 22.41 ± 15.64 (range 2.2-50.4), and the percentage for undergraduates was 17.52 ± 20.59 (range 0-62.6). The significant developments in research models for pulpitis research and the characterisation of biomarkers have led to better management strategies. Concurrently, significant advancements in molecular research provide new understandings of pulpitis, suggesting alternative therapeutic approaches. Although there are guidelines available, increased rates of antibiotic prescription are still prevalent around the globe.

How decisions are made: Antibiotic stewardship in dentistry

BACKGROUND

We performed a preimplementation assessment of workflows, resources, needs, and antibiotic prescribing practices of trainees and practicing dentists to inform the development of an antibiotic-stewardship clinical decision-support tool (CDST) for dentists.

METHODS

We used a technology implementation framework to conduct the preimplementation assessment via surveys and focus groups of students, residents, and faculty members. Using Likert scales, the survey assessed baseline knowledge and confidence in dental providers' antibiotic prescribing. The focus groups gathered information on existing workflows, resources, and needs for end users for our CDST.

RESULTS

Of 355 dental providers recruited to take the survey, 213 (60%) responded: 151 students, 27 residents, and 35 faculty. The average confidence in antibiotic prescribing decisions was 3.2 ± 1.0 on a scale of 1 to 5 (ie, moderate). Dental students were less confident about prescribing antibiotics than residents and faculty (P < .01). However, antibiotic prescribing knowledge was no different between dental students, residents, and faculty. The mean likelihood of prescribing an antibiotic when it was not needed was 2.7 ± 0.6 on a scale of 1 to 5 (unlikely to maybe) and was not meaningfully different across subgroups (P = .10). We had 10 participants across 3 focus groups: 7 students, 2 residents, and 1 faculty member. Four major themes emerged, which indicated that dentists: (1) make antibiotic prescribing decisions based on anecdotal experiences; (2) defer to physicians' recommendations; (3) have limited access to evidence-based resources; and (4) want CDST for antibiotic prescribing.

CONCLUSIONS

Dentists' confidence in antibiotic prescribing increased by training level, but knowledge did not. Trainees and practicing dentists would benefit from a CDST to improve appropriateness of antibiotic prescribing.

Prevalence of Colonization with Multidrug-Resistant Bacteria: Results of a 5-Year Active Surveillance in Patients Attending a Teaching Hospital

Combating antimicrobial resistance (AMR) requires comprehensive efforts, such as screening to identify patients colonized by multidrug-resistant microorganisms (MDROs). The primary purpose of this study was to estimate the AMR pattern of methicillin-resistant Staphylococcus aureus (MRSA) isolated from nasal surveillance swabs and MDROs isolated from pharyngeal and rectal surveillance swabs in patients attending a teaching hospital. Data were sought retrospectively, from 1 January 2017 to 31 December 2021, from the records produced by the hospital microbiology laboratory. Duplicate isolates, defined as additional isolates of the same microorganism with identical antibiograms, were excluded. Among Staphylococcus aureus isolates from nasal swabs, 18.2% were oxacillin-resistant. Among Gram-negative bacteria, 39.8% of Klebsiella pneumoniae and 83.5% of Acinetobacter baumannii isolates were carbapenem-resistant. Resistance to three antibiotic categories was high among Acinetobacter baumannii (85.8%) and Klebsiella pneumoniae (42.4%). The present data highlight a high prevalence of MDRO colonization among patients admitted to the hospital and suggest that screening for MDROs could be an important tool for infection control purposes, especially in geographical areas where limiting the spread of MDROs is crucial. The results also underline the importance of active surveillance, especially for carbapenem-resistant, Gram-negative bacteria in reducing their transmission, especially in high-risk units.

Immunization during pregnancy: do healthcare workers recommend vaccination against influenza?

Background

A variety of circumstances can influence how widely vaccination during pregnancy is accepted. Healthcare workers (HCWs) are often seen as the main resource for recommending vaccination. The purpose of the current study was to determine whether Italian HCWs advise and recommend pregnant people to receive the influenza vaccinations, as well as what knowledge and attitudes affect their practices. A secondary aim of the study was to evaluate HCWs' knowledge and attitudes towards COVID-19 vaccination.

Methods

This cross-sectional study, took place between August 2021 and June 2022 in a randomly selected sample of HCWs in three Italian regions. The target population comprised obstetricians-gynecologists, midwives and primary care physicians, who provide medical care to pregnant people. The questionnaire consisted of 19 items divided into 5 parts gathered information about the participants' sociodemographic and professional characteristics, general knowledge about vaccinations during pregnancy, and vaccine-preventable diseases (VPDs), attitudes and practices towards immunization, and strategies to potentially increase vaccination uptake during pregnancy.

Results

Among the participants, 78.3% knew that pregnant people are at increased risk of severe complications from influenza, 57.8% that the influenza vaccine is not provided only in the 2nd/3rd trimester of pregnancy and 60% that pregnancy is a risk factor for severe COVID-19 infection. Of the enrolled HCWs, 10.8% believed that the potential risks of vaccines administered during pregnancy are greater than the benefits. An even higher proportion of the participants was unsure (24.3%) or did not deem (15.9%) that vaccinating against influenza during pregnancy reduces the risk of preterm birth and abortion. Moreover, 11.8% of the sample did not believe or was uncertain that COVID-19 vaccine must be offered to all pregnant people. Among HCWs, 71.8% advised women about influenza vaccination during pregnancy, and 68.8% recommended getting vaccinated against influenza during pregnancy. Results showed that good knowledge and positive attitudes were the strongest factors positively associated with advising women about influenza vaccination during pregnancy.

Conclusion

The gathered data showed that a sizable portion of the HCWs lacks up-to-date knowledge, underestimates the risks of contracting a VPD, and overestimates the risks of vaccine side effects during pregnancy. The findings shed light on such attributes useful to promote adherence to evidence-based recommendations among HCWs.

Antibiotics in Dentistry: A Narrative Review of the Evidence beyond the Myth

Antibiotics have undoubtedly revolutionized medicine and the health and survival of patients with life-threatening infections, being nonetheless free from potential adverse effects, and the risk of intestinal dysbiosis, antimicrobial resistance, and the resulting consequences for the patient's health and the public purse. The present study narratively reviewed the epidemiological data on worldwide antibiotic consumption and administration in dental practice, patients' adherence to prescriptions, the antimicrobial resistance phenomenon in dentistry, and the evidence supporting and recommending appropriate antibiotic use in dental care. Eligible systematic reviews and original studies in humans published in the English language from January 2000 to 26 January 2023 were considered. A total of 78 studies, 47 on the epidemiology of antibiotic use and prescription in dentistry, 6 on antibiotic therapy in dentistry, 12 on antibiotic prophylaxis in dentistry, 0 on adherence of dental patients to antibiotic prescription, and 13 on antimicrobial resistance in dentistry, were presently considered. Retrieved evidence revealed that antibiotics are frequently overused and misused in dental practice, dental patients frequently do not adhere to prescriptions, and antimicrobial resistance in dentistry is a still rising phenomenon also secondary to improper oral antiseptics use. The present findings highlighted the need to establish more evidence-based and accurate antibiotic prescriptions to sensitize dentists and dental patients to minimize and rationalize the use of antibiotics only when it is indicated and necessary, improve patients' adherence, and enhance knowledge and awareness of the antimicrobial resistance in dentistry.

Analysis of medicines returned to pharmacies for disposal and estimation of the cost due to medicine wasting

Background

Studies have shown that waste medicines generate a significant cost for the national health system (NHS) in many countries. No data are available on costs and therapeutic classes of unused medicines in Italy.Objective: Conduct a quantitative and qualitative analysis of unused medicines returned for disposal to selected pharmacies in Rome, Italy, as well as to estimate the related costs for the NHS.

Methods

Medicines returned to 4 pharmacies were collected for 8 months. Therapeutic class, number of remaining dosage units, remaining validity, and reimbursement by the NHS were analysed. The cost of reimbursed medicines was estimated on the prices provided by the Italian regulatory agency (AIFA).

Results

The study sample consisted of 3219 medicine packages containing remaining dosage units, of which 72.4% had expired while 27.6% had not. The average remaining validity of unexpired medicines was 13 months. Medicines reimbursed by the NHS accounted for 73% of the total. Cardiovascular drugs and anti-infectives were the main therapeutic classes (17.2% and 15.2% of total packages, respectively), followed by gastrointestinal drugs, central nervous system (CNS) drugs, non-steroidal anti-inflammatory drugs (NSAIDs), and corticosteroids. The average of remaining dosage units found in the examined packages was 68% of the initial number of units. In terms of cost, antibiotics were the most relevant therapeutic class, followed by cardiovascular drugs, analgesics, corticosteroids, and NSAIDs. The estimated cost for the Italian NHS was € 200,656,780 per year.

Conclusion

Waste medicines constitute a significant, but reducible cost for the NHS. The high prevalence of anti-infectives in the study sample appears to be a distinctive Italian characteristic and may be due to inappropriate prescribing. Policies aimed at reducing waste should improve prescriptive appropriateness and increase the variety of packaging size.