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Sir, antimicrobial resistance is an increasingly important consideration when managing systemic or localised infections. Individuals prescribed an antibiotic develop bacterial resistance to that antibiotic,1 so unnecessary use should always be avoided. Research has suggested that up to 80% of antibiotic use in general dental practice may be inappropriate.2 In 2015, a statutory duty on healthcare providers in England was introduced to ensure appropriate antimicrobial use.3
With this in mind, Health Education South West now requires its foundation dentists to conduct an antibiotic prescribing audit. Prescribing data from the 80 foundation training practices were collected over a 3-week period during 2016/17. Over three-quarters of the 1,127 antibiotic prescriptions were associated with four clinical diagnoses: acute apical infection (n = 518), pericoronitis (n = 171), acute periodontal abscess (n = 166) and irreversible pulpitis (n = 36).
Pain and/or localised infection were the reason for 46% of all prescriptions; notably neither is an indication for antibiotics in FGDP(UK) guidance.4 Similarly, antibiotic-only treatment plans are rarely indicated, yet accounted for nearly half (48%) of the prescriptions in this audit. So while prescribing quality was found to be somewhat better than that published by Cope et al.,2 most (60%) were still found to be inappropriate in terms of clinical indication, antibiotic type, dose, frequency or duration when assessed against FGDP(UK) guidance.
That many clinicians don't follow published clinical guidelines is well known. One of the reasons, according to Gabbay and LeMay, is that clinicians rely instead on own personal 'mindlines': internalised, tacit guidelines, collectively reinforced mainly by experience, interactions with each other and with opinion leaders.5 Foundation dentists are at a crucial point in the development of their own mindlines and training in an environment which supports use of published clinical guidelines during their first year in clinical practice is essential.
This audit shows that more work is required to ensure the foundation training environment is appropriate in relation to antibiotic use. To address this, we suggest that each foundation trainer should task his/her foundation dentist(s) with leading a practice-wide annual clinical audit of antibiotic prescribing. An online dental antimicrobial stewardship toolkit is available to assist with this and can be accessed via the British Dental Association, FGDP(UK) and Public Health England websites.6
References
Costelloe C, Metcalfe C, Lovering A, Mant D, Hay A D . Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010; 340: c2096; 10.1136/bmj.c2096.
Cope A L, Francis N A, Wood F, Chestnutt I G . Antibiotic prescribing in UK general dental practice: a cross-sectional study. Community Dent Oral Epidemiol 2016; 44: 145–153.
The Health and Social Care Act 2008. Code of Practice on the prevention and control of infections and related guidance. 2015. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/449049/Code_of_practice_280715_acc.pdf (accessed 21 April 2018).
Faculty of General Dental Practice. Antimicrobial prescribing for GDP. Available at https://www.fgdp.org.uk/antimicrobial-prescribing (accessed 21 April 2018).
Gabbay J, le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ 2004; 329: 1013.
Dental Antimicrobial Stewardship Toolkit. Available at https://www.gov.uk/guidance/dental-antimicrobial-stewardship-toolkit (accessed 21 April 2018).
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Ihimekpen, A., Thompson, W. Antimicrobial resistance: Antimicrobial prescribing: the work continues.... Br Dent J 225, 3–4 (2018). https://doi.org/10.1038/sj.bdj.2018.554
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DOI: https://doi.org/10.1038/sj.bdj.2018.554
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