Antibiotic Stewardship

The U.S. Centers for Disease Control and Prevention’s (CDC’s) Division of Oral Health defines antibiotic stewardship as “the effort to measure antibiotic prescribing; to improve antibiotic prescribing by clinicians and use by patients so that antibiotics are only prescribed and used when needed; to minimize misdiagnoses or delayed diagnoses leading to underuse of antibiotics; and to ensure that the right drug, dose, and duration are selected when an antibiotic is needed."¹ The ADA has adopted an evidence-based approach to guideline development in the area of dental antibiotic use, which has resulted in recommendations for decreased indications for and use of prophylactic antibiotics in people with heart conditions and those who have had joint replacements, as well as recommendations for antibiotic use in the urgent management of dental pain and intra-oral swelling. A 2018 systematic review² in JADA found dentists regularly prescribing antibiotics for inappropriate purposes (e.g., administering prophylactic doses in healthy patients and treating oral infections with systemic antibiotics when localized treatment would suffice), and that “…it is reasonable to believe that a well-implemented antibiotic stewardship initiative can change dentists’ antibiotic prescription practices.” Additionally, a 2013 survey³ of antibiotic prescribing by dentists found considerable geographic variability in prescribing practices and called for additional study to “better understand the reasons for this variability and identify areas of possible intervention and improvement.”

Antibiotic resistance—when bacteria no longer respond to antibiotics—is a growing problem.  According to the Centers for Disease Control and Prevention, more than 2.8 million people in the U.S. become infected with bacteria that are resistant to antibiotics and at least 35,000 people die each year as a direct result of these infections.⁴

Improving understanding of how antibiotics work will be helpful in preventing the spread of antibiotic-resistant bacteria.  Education regarding the responsible use of antibiotics will help practitioners to identify the circumstances when antibiotics are indicated, to choose the right antibiotic, and to prescribe it at the right dose for the right duration.

In addition to problems associated with antibiotic resistance, antibiotics are a major cause of adverse effects from systemically administered medications. A 2018 study found over 145,000 emergency hospital visits for systemically administered antibiotic adverse events in adults between 2011 and 2015 in the United States.⁵ More than half of the visits were from adults aged 20 to 50 years, and approximately 75% of the cases involved allergic reactions to antibiotics. Oral sulfonamides were the most frequent cause of adverse events, followed closely by penicillins, and, lastly, fluoroquinolones.⁵ These results were similar to a 2008 study that stated, “[m]inimizing unnecessary antibiotic use by even a small percentage could significantly reduce the immediate and direct risks of drug-related adverse events.”⁶ The development of adverse events may also depend on the length of the antibiotic regimen. A 2019 systematic review⁷ in JAMA found that extended course (i.e., ≥72 hours) antibiotic prophylaxis may increase the risk of developing adverse events (e.g., diarrhea, nausea, rash, gastric pain, and fever) by 140% compared to short course (i.e., ≤24 hours) antibiotic prophylaxis.

Clostridioides (formerly Clostridium) difficile is a spore-forming, Gram-positive anaerobic bacillus that is a cause of 15 to 25% of all episodes of antibiotic-associated diarrhea.⁸  It is commonly found at low levels within the commensal microbiota of the human gut.⁹  Among those organisms, it is considered to be pathobiont, meaning that within its indigenous community, it is benign; however, when homeostasis is disrupted, it acts as a pathogen.⁹ Factors that can alter this homeostatic balance include antibiotic treatment, tissue damage, changes to diet, and immune deficiencies.¹⁰

C. difficile infection (CDI) is increasing in both prevalence and severity. While the majority (56%) of reported cases are associated with a stay in a healthcare facility, the remaining (44%) cases, numbering 65.8 cases/1000 individuals, are considered community-associated CDI.¹¹ Of these, it has been estimated that 65% of the community associated CDI occurred after the use of antibiotics.¹² Manifestations of CDI range from mild to life-threatening sequelae. CDI can result in pseudomembranous colitis, toxic megacolon, colon perforations, sepsis, and, rarely, death.⁸

Clinical factors associated with increased risk of CDI include age older than 65 years, the presence of underlying disease, and recent courses of antibiotics.¹² Dentists are estimated to prescribe 10% of outpatient antibiotics, so while they are not the sole source of these drugs in the community, they make a measurable contribution to it.³ There is some overlap among the antibiotics commonly prescribed by dentists and those reported to carry higher risk for CDI. Antibiotics associated with higher risk of CDI include clindamycin, the cephalosporins, and the fluoroquinolones,¹² which are reported to account for 14%, 5%, and less than 1% of the antibiotics prescribed by dentists, respectively.³

Some clinicians prescribe probiotics during a course of antibiotics for the prevention of CDI. According to the Infectious Diseases Society of America (IDSA), there are insufficient data supporting the effectiveness of probiotics in preventing CDI, and the administration of probiotics for this purpose is therefore not recommended by the IDSA at this time.¹³

As part of antibiotic stewardship, antibiotic prophylaxis prior to dental procedures should be reserved for patients who are at the greatest risk of post-treatment bacterial-related complications. The following are ADA resources related to antibiotic prophylaxis:

• An evidence-based clinical practice guideline for dental practitioners about antibiotics prior to dental work in patients who have joint replacements, published in the Journal of the American Dental Association (JADA), states that, in general, antibiotics are not recommended prior to dental procedures for patients with prosthetic joint implants.¹⁴
• A 2017 commentary¹⁵ published in the February 2017 issue of JADA written by ADA-appointed experts, offers guidance for using appropriate use criteria published by the American Academy of Orthopaedic Surgeons in January 2017¹⁶ that address managing care for patients with orthopedic implants undergoing dental procedures. The JADA editorial calls the appropriate use criteria "a decision-support tool to supplement clinicians in their judgment" and it emphasizes discussion of available treatment options between the patient, dentist and orthopedic surgeon, weighing the potential risks and benefits. The commentary encourages dentists to continue to use the 2015 guideline,¹⁴ consult the appropriate use criteria as needed, and respect the patient's specific needs and preferences when considering antibiotic prophylaxis before dental treatment. According to the ADA Chairside Guide(PDF), in cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription.
• Guidelines¹⁷ from the American Heart Association (AHA) about the prevention of infective endocarditis (PDF) approved by the ADA Council on Scientific Affairs as they relate to dentistry, were published in JADA and clarify the conditions for which prophylaxis should be considered, as well as the regimens that should be used, if indicated. These guidelines were updated in 2021 with a scientific statement¹⁸ from the AHA that recommended no changes to the findings of the earlier guideline; however, the 2021 AHA scientific statement no longer recommends use of clindamycin as an oral or parenteral alternative to amoxicillin or ampicillin in individuals with allergies to these drugs because clindamycin “may cause more frequent and severe reactions than other antibiotics used for [antibiotic prophylaxis]” (including C. difficile infection).¹⁸

Antibiotic stewardship also involves the responsible use of therapeutic antibiotics to treat existing infections, as it is common for clinicians to inappropriately prescribe antibiotic treatment. Some of the reasons that dentists may misuse antibiotics include inadequate knowledge about management of infections, pressure from patients requesting antibiotics, failure to consider treatments other than systemic antibiotics (e.g., surgery), belief that broad-spectrum antibiotics are the most effective treatment, and the demands of running a busy practice.¹⁹  Raising awareness about the risks of unnecessary use of antibiotics should be included as part of a dental antimicrobial stewardship strategy.²⁰

According to the CDC,²¹ “appropriate antibiotic prescribing means antibiotics are only prescribed when needed, and when needed, the right antibiotic is selected and prescribed at the right dose and for the right duration” and “appropriate antibiotic prescribing should be in accordance with evidence-based national and local clinical practice guidelines, when available.

The treatment of endodontic infections is one area where dentists can exercise responsible antibiotic administration. An ADA ACE Panel Report on antibiotic use in endodontic infections²² suggests that the management of endodontic infections is best achieved through proper root canal debridement, disinfection, and drainage of the abscess and discourages the use of systemic antibiotics due to their inability to reach necrotic tissue and their contribution to antibiotic resistance and CDI. The same report found that of 391 member dentists surveyed, 51% had decreased their antibiotic prescribing patterns from 5 years ago, 43% remained similar, 2% increased their prescribing patterns, and 4% were unable to prescribe.

Dentists may want to consider the following when deciding whether or not to prescribe antibiotic treatment:²

• The overall health and immunity of the patient
• Preexisting conditions of the patient
• The type and location of the infection
• Whether the infection shows signs of spreading
• If the condition can be treated with surgical treatment
• If the patient has symptoms other than localized pain

The ADA Center for Evidence-Based Dentistry has developed a clinical practice guideline²³ on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intra-oral swelling. The guideline, based on a systematic review and meta-analysis,^{24, 25} came to the following recommendations:

• The guideline recommends against using antibiotics for most pulpal and periapical conditions and instead recommends only the use of dental treatment and, if needed, over-the-counter pain relievers such as acetaminophen and ibuprofen.
• Instead of prescribing antibiotics, dentists should prioritize dental treatments such as pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage for symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess in adult patients with a normal immune response.
• If a patient’s condition progresses to systemic involvement, showing signs of fever or malaise, then dentists should prescribe antibiotics.

1. U.S. Centers for Disease Control and Prevention Division of Oral Health. Antibiotic Stewardship. https://www.cdc.gov/oralhealth/infectioncontrol/faqs/antibiotic-stewardship.html. Accessed December 21, 2022.
2. Stein K, Farmer J, Singhal S, et al. The use and misuse of antibiotics in dentistry: A scoping review. J Am Dent Assoc 2018;149(10):869-84 e5.
3. Roberts RM, Bartoces M, Thompson SE, Hicks LA. Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc 2017;148(3):172-78.e1.
4. U.S. Centers for Disease Control and Prevention. About Antimicrobial Resistance. https://www.cdc.gov/drugresistance/about.html. Accessed December 21, 2022.
5. Geller AI, Lovegrove MC, Shehab N, et al. National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015. J Gen Intern Med 2018;33(7):1060-68.
6. Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis 2008;47(6):735-43.
7. Oppelaar MC, Zijtveld C, Kuipers S, et al. Evaluation of Prolonged vs Short Courses of Antibiotic Prophylaxis Following Ear, Nose, Throat, and Oral and Maxillofacial Surgery: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2019;145(7):610-16.
8. US Centers for Disease Control and Prevention. https://www.cdc.gov/cdiff/clinicians/faq.html U.S. Department of Health and Human Services. Accessed December 21, 2022.
9. Kamada N, Chen GY, Inohara N, Nunez G. Control of pathogens and pathobionts by the gut microbiota. Nat Immunol 2013;14(7):685-90. Accessed February 26, 2019.
10. Hajishengallis G, Lamont RJ. Dancing with the Stars: How Choreographed Bacterial Interactions Dictate Nososymbiocity and Give Rise to Keystone Pathogens, Accessory Pathogens, and Pathobionts. Trends Microbiol 2016;24(6):477-89.
11. U.S. Centers for Disease Control and Prevention. 2015 Annual Report for the Emerging Infections Program for Clostridium difficile Infection. National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) 2017. https://www.cdc.gov/hai/eip/Annual-CDI-Report-2015.html. Accessed December 21, 2022.
12. Rupnik M, Wilcox MH, Gerding DN. Clostridium difficile infection: new developments in epidemiology and pathogenesis. Nat Rev Microbiol 2009;7(7):526-36.
13. McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018;66(7):987-94.
14. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(1):11-16 e8.
15. American Dental Association-Appointed Members of the Expert Writing and Voting Panels Contributing to the Development of American Academy of Orthopedic Surgeons Appropriate Use Criteria. American Dental Association guidance for utilizing appropriate use criteria in the management of the care of patients with orthopedic implants undergoing dental procedures. J Am Dent Assoc 2017;148(2):57-59.
16. Quinn RH, Murray JN, Pezold R, Sevarino KS. The American Academy of Orthopaedic Surgeons Appropriate Use Criteria for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures. J Bone Joint Surg Am 2017;99(2):161-63.
17. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2008;139 Suppl:3S-24S.
18. Wilson WR, Gewitz M, Lockhart PB, et al. Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. Circulation 2021;143(20):e963-e78.
19. Dana R, Azarpazhooh A, Laghapour N, Suda KJ, Okunseri C. Role of Dentists in Prescribing Opioid Analgesics and Antibiotics: An Overview. Dent Clin North Am 2018;62(2):279-94.
20. Teoh L, Thompson W, Suda K. Antimicrobial stewardship in dental practice. J Am Dent Assoc 2020;151(8):589-95.
21. U.S. Centers for Disease Control and Prevention (CDC). https://www.cdc.gov/antibiotic-use/community/programs-measurement/measuring-antibiotic-prescribing.html. U.S. Department of Health and Human Services. Accessed December 21, 2022.
22. American Dental Association. ACE Panel Report: Antibiotic Use in Endodontic Infections. 2019. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ace/ace-panel-report_antibiotic-use-in-endodontic-infections_final.pdf. Accessed December 21, 2022.
23. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc 2019;150(11):906-21.e12.
24. Tampi MP, Pilcher L, Urquhart O, et al. Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: Systematic review and meta-analysis—a report of the American Dental Association. J Am Dent Assoc 2019;150(12):e179-e216.
25. Tampi MP, Pilcher L, Urquhart O, et al. Plain language summary for "Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: systematic review and meta-analysis-a report of the American Dental Association". J Am Dent Assoc 2019;150(12):1048-50
    

For Professionals:

• Antibiotic Use for the Urgent Management of Dental Pain and Intra-oral Swelling Clinical Practice Guideline (2019) 
• ACE Panel Report: Antibiotic Use in Endodontic Infections (PDF)
• ADA Oral Health Topic: Antibiotic Prophylaxis Prior to Dental Procedures
• Search JADA for articles related to antibiotic stewardship
• ADA Store: ADA Dental Drug Handbook: A Quick Reference (Item #J05921BT)
• ADA Library Services: DynaMedPlus Online Drug Reference (ADA member login required)

For Patients:

• For the Patient: Using antibiotics wisely
• MouthHealthy: Will antibiotics help treat my dental pain?

Centers for Disease Control and Prevention:

• Antimicrobial Resistance
• Antibiotic Stewardship
• Antibiotic Use for a Safe Dental Visit Patient Brochure (PDF)
• Antibiotic Use in the United States, 2017: Progress and Opportunities (PDF)
• CDC Checklist for Antibiotic Prescribing in Dentistry (PDF)
• Dentists: Be Antibiotics Aware – Treating Patients with Dental Pain and Swelling Fact Sheet (PDF)