Dental care resistance prevention and antibiotic prescribing modification-the cluster-randomised controlled DREAM trial

Assessment of the Prescriptions of Systemic Antibiotics in Primary Dental Care in Germany from 2017 to 2021: A Longitudinal Drug Utilization Study

(1) Background: Due to increasing antibiotic resistance, the frequency of antibiotic use should be questioned in dentistry and attention paid to the choice of the best suited substance according to guidelines. In Germany, overprescribing of clindamycin was noteworthy in the past. Therefore, the aim of our study was to determine the trend of antibiotic prescriptions in primary dental care. (2) Methods: Prescriptions of antibiotics in German primary dental care from 2017 to 2021 were analysed using dispensing data from community pharmacies, claimed to the statutory health insurance (SHI) funds, and compared with all antibiotic prescriptions in primary care. Prescriptions were analysed based on defined daily doses per 1000 SHI-insured persons per day (DID). (3) Results: Amoxicillin was the most frequently prescribed antibiotic (0.505 DID in 2017, 0.627 in 2021, +24.2%) in primary dental care, followed by clindamycin (0.374 DID in 2017, 0.294 in 2021, -21.4%). Dental prescriptions still made up 56% of all clindamycin prescriptions in primary care in 2021. (4) Conclusions: Our study suggests that the problem of overuse of clindamycin in German dentistry has improved, but still persists.

Evaluation of antibiotic prescribing for ambulatory patients seeking primary dental care services in a public hospital in Ghana: a clinical audit study

Background

One in 10 of all antibiotic prescriptions globally are for dental conditions with 80% of them being inappropriate, making it a potential driver of antimicrobial resistance.

Objectives

To evaluate the appropriateness of antibiotic use among ambulatory patients seeking dental care services in a public hospital in Ghana.

Methods

A retrospective clinical audit was conducted by extracting the medical records of all patients seeking dental care at the ambulatory care clinic of Keta Municipal Hospital (KMH) from January 2020 to December 2020 using the hospital’s electronic database. Descriptive statistics, bivariate and multivariate analysis were performed on the data collected.

Results

Overall, 1433 patient medical records were extracted from the database within the study period. The mean age of the patients identified was 39.9 years with almost two-thirds being female. The majority (91.1%, n = 1306) of them were attended to by a dental nurse. In total, 88.6% (n = 1269) of the patients received antibiotics and 87.5% (n = 1254) of antibiotics prescribed were non-compliant with Ghana Standard Treatment Guidelines. Three-quarters of the dental conditions were managed with dual antibiotics comprising amoxicillin and metronidazole. Antibiotic prescription was associated with age, gender, type of prescriber and type of dental condition diagnosed.

Conclusions

There is a high usage of antibiotics for dental conditions managed at the outpatient section of the hospital and most are inappropriate. Development of local guidelines supported by education of dental clinicians on empirical use of antibiotics is a suitable target for the antimicrobial stewardship team to address in KMH.

Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review

OBJECTIVE

To identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection.DesignSystematic narrative review.

SETTING/PARTICIPANTS

Primary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded.

STUDY SELECTION

Seven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types.

OUTCOMES

Narrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries.

RESULTS

Searches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews.

DISCUSSION

A heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included.

CONCLUSIONS

A combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020210183.

Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada)

OBJECTIVE

Our objective was to compare patterns of dental antibiotic prescribing in Australia, England, and North America (United States and British Columbia, Canada).

DESIGN

Population-level analysis of antibiotic prescription.

SETTING

Outpatient prescribing by dentists in 2017.

PARTICIPANTS

Patients receiving an antibiotic dispensed by an outpatient pharmacy.

METHODS

Prescription-based rates adjusted by population were compared overall and by antibiotic class. Contingency tables assessed differences in the proportion of antibiotic class by country.

RESULTS

In 2017, dentists in the United States had the highest antibiotic prescribing rate per 1,000 population and Australia had the lowest rate. The penicillin class, particularly amoxicillin, was the most frequently prescribed for all countries. The second most common agents prescribed were clindamycin in the United States and British Columbia (Canada) and metronidazole in Australia and England. Broad-spectrum agents, amoxicillin-clavulanic acid, and azithromycin were the highest in Australia and the United States, respectively.

CONCLUSION

Extreme differences exist in antibiotics prescribed by dentists in Australia, England, the United States, and British Columbia. The United States had twice the antibiotic prescription rate of Australia and the most frequently prescribed antibiotic in the US was clindamycin. Significant opportunities exist for the global dental community to update their prescribing behavior relating to second-line agents for penicillin allergic patients and to contribute to international efforts addressing antibiotic resistance. Patient safety improvements will result from optimizing dental antibiotic prescribing, especially for antibiotics associated with resistance (broad-spectrum agents) or C. difficile (clindamycin). Dental antibiotic stewardship programs are urgently needed worldwide.

A comparative analysis of the efficacy of moxifloxacin and cefixime in the reduction of postoperative inflammatory sequelae after mandibular third molar surgery

Background/Aim. There is no scientific evidence that the prophylactic use of antibiotics as a part of the mandibular third molar surgery is effective in suppressing postoperative pain, edema, trismus, and dry socket. The aim of the study was to investigate the effects of antibiotics from the fluoroquinolone (moxifloxacin) and cephalosporin (cefixime) groups in reducing postoperative inflammatory sequelae (pain, edema, and trismus), as well as in possibly reducing the incidence of dry socket after mandibular third molar surgery. Methods. This double-blind study was completed by 157 subjects, comprising two study groups (who received the aforementioned antibiotics) and a control group, who received placebo tablets. Subjects were assessed on the first, second, and seventh day following surgery. In the postoperative course, patients were monitored for the occurrence, intensity, and duration of postoperative inflammatory sequelae and dry socket. Results. Both antibiotics, especially moxifloxacin, had a pronounced effect on reducing all inflammatory sequelae (pain, edema, and trismus) as the most common postoperative complaints following mandibular third molar surgery, and also contributed to reducing the incidence of dry socket. Conclusion. Antibiotic prophylaxis with cefixime and, especially moxifloxacin, reduced the occurrence of postoperative inflammatory sequelae and alleviated discomfort. It is interesting, that both antibiotics, especially moxifloxacin, also contributed to reducing the incidence of postoperative dry socket, which is not provoked by inflammation. Therefore, further research into the underlying mechanisms behind such an effect is warranted.

Co-Developing an Antibiotic Stewardship Tool for Dentistry: Shared Decision-Making for Adults with Toothache or Infection

Dentistry is responsible for around 10% of antibiotic prescribing across global healthcare, with up to 80% representing inappropriate use. Facilitating shared decision-making has been shown to optimise antibiotic prescribing (antibiotic stewardship) in primary medical care. Our aim was to co-develop a shared decision-making antibiotic stewardship tool for dentistry. Dentists, patients and other stakeholders prioritised factors to include in the new tool, based on previous research (a systematic review and ethnographic study) about dentists’ decision-making during urgent appointments. Candidate behaviour-change techniques were identified using the Behaviour Change Wheel and selected based on suitability for a shared decision-making approach. A ‘think aloud’ study helped fine-tune the tool design and Crystal Marking ensured clarity of messaging. The resulting paper-based worksheet for use at point-of-care incorporated various behaviour change techniques, such as: ’information about (and salience of) health consequences’, ‘prompts and cues’, ‘restructuring the physical (and social) environment’ and ‘credible sources’. The think aloud study confirmed the tool’s acceptability to dentists and patients, and resulted in the title: ‘Step-by-step guide to fixing your toothache.’ Further testing will be necessary to evaluate its efficacy at safely reducing dental antibiotic prescribing during urgent dental appointments in England and, with translation, to other dental contexts globally.

Antibiotic stewardship program in dentistry: Challenges and opportunities

Antimicrobial resistance (AMR) is assigned as a menace by the WHO (World Health Organization) where diseases resulting from multidrug-resistant bacteria are refractory to treatment as a result of a scarcity of new antibiotics in the queue. Antibiotic stewardship program is one of the worldwide strategies to advertise responsible use of antibiotics to halt AMR. The world has started facing a postantibiotic era without immediate and integrated action. Common infections which were treatable for decades can once again kill. The dentistry contributions towards antibiotic resistance are substantial. Approximately 10% of all common antibiotics are prescribed by dentists. Antimicrobial stewardship is a policy that can assist us in addressing the problems of antibiotic resistance. It is a framework that promotes the truly sustainable use of antimicrobials in dentistry. It refers to the approach which is multifaceted and incorporates policies, and guidelines along with surveillance, reports of prevalence and education, and audit of practice for reducing prescribing, adopted by health care organizations. The prime strategy is to improve clinical results while mitigating unintended consequences such as toxicity, pathogenic organism selection, and resistance emergence. Such issues should be centralized and the ongoing need to identify and convert "responsible usage" into context-specific and time-specific behavior. The importance of the antibiotic stewardship program, its team, and their action has become a challenge for the dental hospital but along with it, there are numerous opportunities to achieve the goal.

Antibiotics and toothache: a social media review

OBJECTIVES

Antibiotics are inappropriate for the treatment of toothache, yet many seek them. Social media allows users to express their opinions, share experiences and offer support. This study used social media to investigate the public's experiences of, and attitudes towards, antibiotics for toothache.

METHODS

A systematic search of posts on Facebook and Twitter was undertaken. Eligibility criteria were applied to select relevant social media posts for thematic analysis of word content. An inductive descriptive coding system was developed from the data and exemplary quotes were identified to illustrate the themes and subthemes identified. Key findings Searches identified 174 posts, of which 144 were selected for analysis. Five themes were identified: experience and expectations, self-care and professional treatment, access to dental care, quality of life and coping strategies. The belief that antibiotics are an appropriate treatment for a toothache was widespread. Antibiotic-seeking behaviour was related to access to professional dental care, including avoiding dental appointments due to dental anxiety and the perceived affordability of dentistry. A range of strategies to cope with the severe impact toothache was having on people's quality of life were identified, from prayer to antibiotics.

CONCLUSIONS

Social media is used extensively to seek antibiotics, avoid dental treatment and provide support to people with toothache. A general belief that antibiotics are an appropriate and necessary treatment for toothache exists. This improved understanding about the factors driving antibiotic-seeking behaviour provides new targets for the development of approaches to tackling antibiotic resistance, by reducing unnecessary antibiotic use in dental clinics and beyond.

[Antibiotic prophylaxis for infective endocarditis: current approaches]

This review addresses current views on prevention of infectious endocarditis (IE). History of establishing the concept of antibacterial prophylaxis (ABP), major approaches, and substantiation of changes in ABP in recent years are described. Recent international and national guidelines are highlighted, specifically, guidelines of the European Society of Cardiologists, American Heart Association/American College of Cardiology, and the Japanese Circulation Society. The review presents critical evaluation of previously approved international guidelines, including analysis of the effect of partial or complete ABP restriction on IE morbidity and incidence of complications. Special attention is paid to awareness of practitioners, particularly dentists, about ABP issues in their practice. Aspects of validity and key features of preventive approaches in implanting cardiac electronic devices and transcatheter aortic valve implantation are discussed.

Observación e intervención educativa para modificar la prescripción de antibióticos en un instituto social de la ciudad de Corrientes, Argentina

Objetivo: analizar y mejorar las prescripciones de antibióticos por parte de odontólogos, a través de una intervención educativa. Método: se realizó un estudio analizando las recetas de prescripción de medicamentos antes y después de la intervención educativa, en el Instituto de Servicios Sociales de la Universidad Nacional del Nordeste. El estudio comprendió tres etapas; en la etapa A se identificaron problemas de prescripción, que fueron socializados con los profesionales durante la intervención educativa como parte de la etapa B, cuya modalidad consistió en dos entrevistas presenciales, con talleres de discusión y debate. En esta se trabajó, además, con el informe de los resultados obtenidos en el análisis de situación de la etapa A. En la etapa C se analizó el impacto de la intervención educativa. Resultados: en la etapa A se observaron 417 recetas con 202 prescripciones de antibióticos, los más indicados fueron azitromicina (31%), amoxicilina con clavulánico (10%) y amoxicilina (8%). La adecuación de prescripción en relación a la indicación fue del 26%. En la etapa C, de un total de 191 recetas, se analizaron 107 recetas con prescripción de antibióticos. La amoxicilina fue el medicamento más prescripto (37%); la prescripción de azitromicina disminuyó a 14% y su adecuación fue del 46%. Ello evidenció una mejoría del 20%, la cual fue validada a través del test chi2 (p=0,00). Conclusión: por medio de la intervención educativa presencial es posible mejorar las prescripciones de antibióticos, no obstante se desconoce si el cambio de conducta prescriptiva se mantiene en el tiempo.El estudio comprendió tres etapas, la primera para identificar problemas de prescripción a fin de ser socializado con los profesionales durante la intervención educativa, que incluía procedimientos educativos presenciales. En la última etapa se analizó el impacto de la intervención educativa. Resultados: Etapa A: se observaron 417 recetas con 202 prescripciones de antibióticos, los más indicados fueron azitromicina (31%); amoxicilina con clavulánico (10%) y amoxicilina (8%).  La adecuación de prescripción en relación a la indicación fue del 26%; la etapa B correspondió a la intervención educativa, a través de discusión y análisis de la situación. En la etapa C se analizaron 107 recetas con prescripción de antibióticos, se observó que el más prescrito fue amoxicilina (37%) y la prescripción de azitromicina disminuyó a 14%. La adecuación fue del 46%, evidenciándose una mejoría del 20%, validado a través del test chi2 (p=0,00). En conclusión se observó que a través de una intervención educativa con los profesionales prescriptores, se pudo mejorar las prescripciones de antibióticos, no obstante se desconoce si el cambio de conducta prescriptiva se mantiene en el tiempo.

The Effectiveness of Online Course Intervention to Improve Knowledge of Antimicrobial Resistance among Dental Students, in Comparison to Reference Group Using a Randomized Controlled Trial

AIM

This study aimed to assess the effectiveness of a recognised antimicrobial resistance (AMR) online module on knowledge and perception among dental students, using a randomised controlled trial study design.

METHODS

Dental students (n = 64, aged 21-25 years) in clinical years agreed to participate in this triple-blinded, parallel, randomised controlled trial. There were 34 students in the study group and 30 students in the control group. The study group participated in an online course covering information about AMR, while students in the control group received another online course about microorganisms in dentistry. Both groups were assessed three times using online questionnaires: before the intervention (T1), after the intervention (T2), and two months later (T3). Each one of T1, T2 and T3 had 22 questions. The questions were repeated each time in T1, T2, and T3 asking about AMR but with different question format, to avoid the possibility of students to memorise the answers.

RESULTS

The mean (m) of correct answers for all students on T1 was 12.56, with standard deviation (SD) of 3.2. On T2, m = 14.03 and SD = 3.85, and on T3, m = 14.36 and SD = 3.71. Scores ranged from 0 to 22. The participants in the study and control groups showed significant score improvements from T1 to T2, immediately after the intervention, but there was no significant difference between T2 and T3. The study group students' scores did not improve significantly from T1 to T3, in contrast to the control group students' scores. More importantly, there was no significant difference in improvement from T1 to T2 when comparing the study and control groups.

CONCLUSION

Online courses might not be reliable learning methods for ensuring the optimal levels of AMR knowledge that are needed by dental practitioners.

[Antibiotic resistance : A challenge for society]

Without doubt, drug resistance is now one of the greatest health threats of our time. Not even 100 years after the discovery of the first antibiotics that saved human lives, we find ourselves threatened by the thought of a post-antibiotic era. Currently it is estimated that around 700,000 people die annually as a consequence of drug-resistant infections. Antibiotic resistance is a natural phenomenon with bacteria having devised several ways of combating the antibiotic attack. Rather than being a spontaneous event, resistance becomes an integral part of the microbe's genetic make-up, spreading further between and across species. However, the misuse and overuse of antibiotics over the years has in fact allowed for resistant bacteria to thrive, while slowly wiping out sensitive bacteria. Spreading awareness and proper information in the community about the risks and consequences of a rapidly developing antibiotic resistance is essential in tackling this global problem. In working together as an entire community, we can find long-lasting solutions. The One Health concept includes human and veterinary medical sectors, the environmental sector, as well as various decision-making bodies that include individual action as well as national and international policymakers. The role of stakeholders like pharmaceutical companies and agriculturists must be given importance, too, thinking all the while in a global context. Only this way will we find solutions for sustainable healthcare and together help slow down the process of antibiotic resistance.

Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015

Importance

Antibiotics are recommended before certain dental procedures in patients with select comorbidities to prevent serious distant site infections.

Objective

To assess the appropriateness of antibiotic prophylaxis before dental procedures using Truven, a national integrated health claims database.

Design, Setting, and Participants

Retrospective cohort study. Dental visits from 2011 to 2015 were linked to medical and prescription claims from 2009 to 2015. The dates of analysis were August 2018 to January 2019. Participants were US patients with commercial dental insurance without a hospitalization or extraoral infection 14 days before antibiotic prophylaxis (defined as a prescription with ≤2 days' supply dispensed within 7 days before a dental visit).

Exposures

Presence or absence of cardiac diagnoses and dental procedures that manipulated the gingiva or tooth periapex.

Main Outcomes and Measures

Appropriate antibiotic prophylaxis was defined as a prescription dispensed before a dental visit with a procedure that manipulated the gingiva or tooth periapex in patients with an appropriate cardiac diagnosis. To assess associations between patient or dental visit characteristics and appropriate antibiotic prophylaxis, multivariable logistic regression was used. A priori hypothesis tests were performed with an α level of .05.

Results

From 2011 to 2015, antibiotic prophylaxis was prescribed for 168 420 dental visits for 91 438 patients (median age, 63 years; interquartile range, 55-72 years; 57.2% female). Overall, these 168 420 dental visits were associated with 287 029 dental procedure codes (range, 1-14 per visit). Most dental visits were classified as diagnostic (70.2%) and/or preventive (58.8%). In 90.7% of dental visits, a procedure was performed that would necessitate antibiotic prophylaxis in high-risk cardiac patients. Prevalent comorbidities include prosthetic joint devices (42.5%) and cardiac conditions at the highest risk of adverse outcome from infective endocarditis (20.9%). Per guidelines, 80.9% of antibiotic prophylaxis prescriptions before dental visits were unnecessary. Clindamycin was more likely to be unnecessary relative to amoxicillin (odds ratio [OR], 1.10; 95% CI, 1.05-1.15). Prosthetic joint devices (OR, 2.31; 95% CI, 2.22-2.41), tooth implant procedures (OR, 1.66; 95% CI, 1.45-1.89), female sex (OR, 1.21; 95% CI, 1.17-1.25), and visits occurring in the western United States (OR, 1.15; 95% CI, 1.06-1.25) were associated with unnecessary antibiotic prophylaxis.

Conclusion and Relevance

More than 80% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary. Implementation of antimicrobial stewardship in dental practices is an opportunity to improve antibiotic prescribing for infection prophylaxis.

Use of Antibiotic Prophylaxis for Tooth Extractions, Dental Implants, and Periodontal Surgical Procedures

Background

Guidelines for antibiotics prior to dental procedures for patients with specific cardiac conditions and prosthetic joints have changed, reducing indications for antibiotic prophylaxis. In addition to guidelines focused on patient comorbidities, systematic reviews specific to dental extractions and implants support preprocedure antibiotics for all patients. However, data on dentist adherence to these recommendations are scarce.

Methods

This was a cross-sectional study of veterans undergoing tooth extractions, dental implants, and periodontal procedures. Patients receiving antibiotics for oral or nonoral infections were excluded. Data were collected through manual review of the health record.

Results

Of 183 veterans (mean age, 62 years; 94.5% male) undergoing the included procedures, 82.5% received antibiotic prophylaxis (mean duration, 7.1 ± 1.6 days). Amoxicillin (71.3% of antibiotics) and clindamycin (23.8%) were prescribed most frequently; 44.7% of patients prescribed clindamycin were not labeled as penicillin allergic. Of those who received prophylaxis, 92.1% received postprocedure antibiotics only, 2.6% received preprocedural antibiotics only, and 5.3% received pre- and postprocedure antibiotics. When prophylaxis was indicated, 87.3% of patients received an antibiotic. However, 84.9% received postprocedure antibiotics when preprocedure administration was indicated. While the majority of antibiotics were indicated, only 8.2% of patients received antibiotics appropriately. The primary reason was secondary to prolonged duration. Three months postprocedure, there were no occurrences of Clostridium difficile infection, infective endocarditis, prosthetic joint infections, or postprocedure oral infections.

Conclusion

The majority of patients undergoing a dental procedure received antibiotic prophylaxis as indicated. Although patients for whom antibiotic prophylaxis was indicated should have received a single preprocedure dose, most antibiotics were prescribed postprocedure. Dental stewardship efforts should ensure appropriate antibiotic timing, indication, and duration.

The effect of interventions aiming to optimise the prescription of antibiotics in dental care-A systematic review

BACKGROUND

Abundant evidence in dentistry suggests that antibiotics are prescribed despite the existence of guidelines aiming to reduce the development of antibiotic resistance. This review investigated (1) which type of interventions aiming to optimise prescription of antibiotics exist in dentistry, (2) the effect of these interventions and (3) the specific strengths and limitations of the studies reporting on these interventions.

METHOD

Literature search was based on Medline, Embase, Global Health, Cochrane CENTRAL, ClinicalTrials.gov and Current Controlled Trials. Studies with one of the two primary outcomes were included: (1) The number of antibiotics prescribed and/or (2) the accuracy of the prescription, commonly measured as a percentage of adherence to local clinical guidelines.

RESULTS

Nine studies met these inclusion criteria. Five studies reported on the prescription of antibiotics in primary dental care and four studies focused on outpatient dental care. Interventions used in primary dental care included a combination of audit, feedback, education, local consensus, dissemination of guidelines and/or academic detailing. Trials in the outpatient setting made use of expert panel discussions, educational feedback on previous acts of prescribing, the dissemination of guidelines and the establishment of internal guidelines. All studies successfully reduced the number of antibiotics prescribed and/or increased the accuracy of the prescription. However, most studies were confounded by a high risk of selection bias, selective outcome reporting and high variance across study groups. In particular, information relating to study design and methodology was insufficient. Only three studies related the prescriptions to the number of patients treated with antibiotics.

CONCLUSIONS

This systematic review was able to offer conclusions which took the limitations of the investigated studies into account. Unfortunately, few studies could be included and many of these studies were confounded by a low quality of scientific reporting and lack of information regarding study methodology. High-quality research with objective and standardised outcome reporting, longer periods of follow-up, rigorous methodology and adequate standard of study reporting is urgently needed.

An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial

BACKGROUND

Dentists prescribe approximately 10% of antibiotics dispensed in UK community pharmacies. Despite clear clinical guidance, dentists often prescribe antibiotics inappropriately. This cluster-randomised controlled trial used routinely collected National Health Service (NHS) dental prescribing and treatment claim data to compare the impact of individualised audit and feedback (A&F) interventions on dentists' antibiotic prescribing rates.

METHODS AND FINDINGS

All 795 antibiotic prescribing NHS general dental practices in Scotland were included. Practices were randomised to the control (practices = 163; dentists = 567) or A&F intervention group (practices = 632; dentists = 1,999). A&F intervention practices were allocated to one of two A&F groups: (1) individualised graphical A&F comprising a line graph plotting an individual dentist's monthly antibiotic prescribing rate (practices = 316; dentists = 1,001); or (2) individualised graphical A&F plus a written behaviour change message synthesising and reiterating national guidance recommendations for dental antibiotic prescribing (practices = 316; dentists = 998). Intervention practices were also simultaneously randomised to receive A&F: (i) with or without a health board comparator comprising the addition of a line to the graphical A&F plotting the monthly antibiotic prescribing rate of all dentists in the health board; and (ii) delivered at 0 and 6 mo or at 0, 6, and 9 mo, giving a total of eight intervention groups. The primary outcome, measured by the trial statistician who was blinded to allocation, was the total number of antibiotic items dispensed per 100 NHS treatment claims over the 12 mo post-delivery of the baseline A&F. Primary outcome data was available for 152 control practices (dentists = 438) and 609 intervention practices (dentists = 1,550). At baseline, the number of antibiotic items prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. At follow-up, antibiotic prescribing had decreased by 0.4 antibiotic items per 100 NHS treatment claims in control practices and by 1.0 in intervention practices. This represents a significant reduction (-5.7%; 95% CI -10.2% to -1.1%; p = 0.01) in dentists' prescribing rate in the intervention group relative to the control group. Intervention subgroup analyses found a 6.1% reduction in the antibiotic prescribing rate of dentists who had received the written behaviour change message relative to dentists who had not (95% CI -10.4% to -1.9%; p = 0.01). There was no significant between-group difference in the prescribing rate of dentists who received a health board comparator relative to those who did not (-4.3%; 95% CI -8.6% to 0.1%; p = 0.06), nor between dentists who received A&F at 0 and 6 mo relative to those who received A&F at 0, 6, and 9 mo (0.02%; 95% CI -4.2% to 4.2%; p = 0.99). The key limitations relate to the use of routinely collected datasets which did not allow evaluation of any effects on inappropriate prescribing.

CONCLUSIONS

A&F derived from routinely collected datasets led to a significant reduction in the antibiotic prescribing rate of dentists.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49204710.

Barriers and facilitators of evidence-based management of patients with bacterial infections among general dental practitioners: a theory-informed interview study

Background

General dental practitioners (GDPs) regularly prescribe antibiotics to manage dental infections although most infections can be treated successfully by local measures. Published guidance to support GDPs to make appropriate prescribing decisions exists but there continues to be wide variation in dental antibiotic prescribing. An interview study was conducted as part of the Reducing Antibiotic Prescribing in Dentistry (RAPiD) trial to understand the barriers and facilitators of using local measures instead of prescribing antibiotics to manage bacterial infections.

Methods

Thirty semi-structured one-to-one telephone interviews were conducted using the Theoretical Domains Framework (TDF). Responses were coded into domains of the TDF and sub-themes. Priority domains (high frequency: ≥50 % interviewees discussed) relevant to behaviour change were identified as targets for future intervention efforts and mapped onto ‘intervention functions’ of the Behaviour Change Wheel system.

Results

Five domains (behavioural regulation, social influences, reinforcement, environmental context and resources, and beliefs about consequences) with seven sub-themes were identified as targets for future intervention. All participants had knowledge about the evidence-based management of bacterial infections, but they reported difficulties in following this due to patient factors and time management. Lack of time was found to significantly influence their decision processes with regard to performing local measures. Beliefs about their capabilities to overcome patient influence, beliefs that performing local measures would impact on subsequent appointment times as well as there being no incentives for performing local measures were also featured. Though no knowledge or basic skills issues were identified, the participants suggested some continuous professional development programmes (e.g. time management, an overview of published guidance) to address some of the barriers. The domain results suggest a number of intervention functions through which future interventions could change GDPs’ antibiotic prescribing for bacterial infections: imparting skills through training, providing an example for GDPs to imitate (i.e. modelling) or creating the expectation of a reward (i.e. incentivisation).

Conclusions

This is the first theoretically informed study to identify barriers and facilitators of evidence-based management of patients with bacterial infections among GDPs. A pragmatic approach is needed to address the modifiable barriers in future interventions intended to change dentists’ inappropriate prescribing behaviour.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0372-z) contains supplementary material, which is available to authorized users.

Inappropriate prescribing of antibiotics in primary dental care: reasons and resolutions

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.

Awareness of antibiotic prescribing and resistance in primary dental care

Dentists in primary care account for approximately one in ten of all therapeutic antibiotic prescriptions, but many of these prescriptions may be unnecessary and will contribute to the critically important problem of bacterial resistance. Emerging guidance on antimicrobial stewardship is discussed and the annual European Antibiotic Awareness Day (EAAD), which takes place on 18 November, is highlighted.