Antibiotic Blindspot: Don’t Forget About the Dentist

At the dentist

 

Clostridium difficile infection, the most common cause of hospital-acquired diarrhea, is serious business. There were nearly half a million C difficile infections in the US in 2011 – the last year numbers were available – and 29,000 patients died within a month of diagnosis. The two most important risk factors for developing C. diff infection are antibiotic exposure and age > 65 years old.

We tend to equate antibiotic exposure with the prescription from our doctor. But a new study reported in Medscape Medical News says that “Antibiotics prescribed by dentists could be contributing to cases of potentially deadly C. diff.”

Centers for Disease Control researchers looked at 1626 cases of C diff across Minnesota and found that 136 patients (15%) had been prescribed an antibiotic by a dentist in the prior 12 weeks. Moreover, just over a third (34%) of those prescribed antibiotics by a dentist had no mention of the dental antibiotics in their medical chart.

Lead researcher Stacy Holzbauer, DVM, MPH, an epidemiology field officer with the CDC, says we’re overlooking antibiotics that we get from the dentist, and identifies the factors contributing to this blindspot:

I think the biggest issue is that dentists have been left out of the conversation, because no one really recognized how large the dental prescribing was in the greater scheme of things, especially when it comes to outpatient prescribing ….

Physicians are not always asking about dental antibiotics specifically when they take a medical history, dentists are not necessarily focused on the possible harms of antibiotics and are not warning patients of the potential risks or reminding them to report the antibiotic use to their primary care physicians, and patients are not making sure all their providers know about antibiotics from different sources.

 

But the problem is especially acute for the elderly. Dr. Holzbauer explains:

People who were prescribed antibiotics for dental procedures tended to be older than those prescribed antibiotics for other indications (57 years old vs 45 years)….

From 1996 to 2013, physician prescribing declined by 18.2%. However, at the same time, dental prescribing increased by 62.2%…. The rate of prescribing increased most for dental patients aged 60 years or older….

[The elderly are] more likely to receive clindamycin, an antibiotic that causes diarrhea and has been more closely linked to C difficile infection, compared with other antibiotics (50% vs 10%)….

[S]ometimes patients come in to dentists saying their surgeon told them years ago when they got their hip replacement that they would need to take antibiotics before a dental cleaning.

 

Holzbauer notes that in 2015, the American Dental Association issued a practice guideline that said no antibiotic prophylaxis is needed for people with joint replacements. Yet she thinks “that change may not have reached all dentists.”

Observing that doctors have been warned about the inappropriate use of antibiotics “for at least 20 years, and they’re still struggling,” Holzbauer concludes: “I think dentists are at the place primary care physicians were 20 years ago.”

 

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