May 9, 2019
One of the most serious health threats clinicians are facing is antimicrobial resistance, which occurs when infectious organisms have adapted themselves in order to become resistant to certain medicines. “Every year, over two million people in the US have an infection caused by a resistant organism,” said Dr. Katie Suda, Associate Professor of Pharmacy Systems, Outcomes and Policy, UIC College of Pharmacy. “Most of these infections caused by resistant organisms are in the community.” “Not only are these resistant infections more difficult to treat, but we are running out of antibiotics due to limited drug development by the pharmaceutical companies.”
These organisms — such as bacteria — can cause serious harm when not properly treated. Every time an antibiotic is prescribed, there is a chance it may not work for the patient and/or the patient may develop an allergy to it, which is why determining solutions to prevent antimicrobial resistance is so important.
“It has become apparent in recent years that the resistance to antibiotics has become a significant issue. The national and international medical communities are seeing that there are conditions now that are essentially untreatable with antibiotics or any other type of medications because of resistance that has developed. As an example, the development of C. difficile infection, a potentially life threatening disease has been attributed to dentist prescribing in up to 15 percent of the 23,000 annual deaths associated with the condition,” said Dr. Susan Rowan, Associate Dean for Clinical Affairs and Executive Associate Dean at the University of Illinois at Chicago (UIC) College of Dentistry.
Every year, over two million people in the US have an infection caused by a resistant organism.
Because antibiotics are one of the most commonly prescribed drugs in human medicine, Antibiotic Stewardship Programs (ASPs) have become a requirement for inpatient settings, such as hospitals. However, antimicrobial stewardship is expanding to outpatient health care settings. ASPs work toward a goal of limiting inappropriate antimicrobial use, optimize antimicrobial selection and limit any unintended consequences. ASPs are a vital component to fighting antimicrobial resistance, but they require leadership collaboration and commitment in order to be successful.
UIC College of Dentistry, in collaboration with UI Health is the first to document the development of a comprehensive ASP in a dental practice.
Making Changes in the Dental Community Would Have Significant, Positive Effects
In the past, a majority of ASPs have concentrated on the inpatient setting, although the majority of antibiotic use takes place in outpatient settings, such as the dentist’s office. “Over 80 percent of human antibiotic use is in outpatient settings,” said Suda.
Recent research has demonstrated that the dental community prescribes 1 in 10 prescriptions in the outpatient setting, and the effort to determine whether the prescription patterns are within current evidence-based standards is important. The Centers for Disease Control and Prevention (CDC) estimates that 30 percent of outpatient prescribing is inappropriate in terms of need, selection or dosage.
One in ten antibiotic prescriptions are given by dentists.
Antibiotics are prescribed by dentists, for uses such as:
- Before a dental procedure to prevent infection (prophylaxis)
- To prevent surgical site infections after oral surgery
- To treat oral infections
One example is clindamycin, an antibiotic medicine used to treat a wide variety of bacterial infections. Dentists prescribe a significant amount of clindamycin for patients with penicillin allergies. “Dentists are the top prescriber of clindamycin in the US” said Suda. “This is important because clindamycin, which is often an alternative prescribed by dentists, has significant toxicity such C. difficile infection.”
“There is a major opportunity for dentists to help assess beta-lactam allergies, educate patients, and avoid clindamycin prescribing when it is not needed,” said Alan E. Gross, Clinical Assistant Professor of Pharmacy Practice, UIC College of Pharmacy. “We know from studies in other settings that most of these patients actually do not have an allergy or one that warrants avoiding beta-lactams altogether.”
Despite this opportunity, there are no consensus guidelines in the US for treating oral infections, which makes standardizing care across dentistry difficult.
“Recognizing that the risk associated with antibiotic prescribing can be so grave is something that we need to share with the dental community who may not have had the awareness efforts brought to them,” Rowan said.
Suda said she was surprised at how little information was disseminated to dentistry on antimicrobial stewardship.
“Dr. Rowan and Dr. Hanna acknowledged the importance of the problem and were willing to look into the antibiotic prescribing practices at the UIC College of Dentistry,” Suda said. “They were also committed to change to improve patient care.”
The CDC has Core Elements for outpatient ASPs that include:
Commitment: Making a commitment to optimizing antibiotic use
Action: Implementing a policy or practice to improve prescribing
Tracking: Tracking prescribing and related outcomes of the intervention(s) and feeding this information back to clinicians
Education: Providing education to prescribers and patients
Expertise: Ensuring access to expertise needed to improve antibiotic prescribing
Collaborative Effort to Initiate Antibiotic Stewardship
There are several reasons why UIC is an ideal setting to develop a comprehensive ASP for the dental community.
First, UI Health, the health care enterprise at UIC, brings together seven UIC health science colleges along with a 465-bed hospital, 21 outpatient clinics, and 11 Federally Qualified Health Centers throughout the Chicago area.
As part of UI Health, UIC College of Dentistry is the largest oral health provider in IL, including Medicaid recipients. Approximately half of the college’s graduates go on to practice in IL. In addition, dentists in IL prescribe antibiotics to nearly 8 percent of their patients, which is higher than the national average.
“We are in a perfect environment to make meaningful changes.”
-- Dr. Susan Rowan, Associate Dean for Clinical Affairs and Executive Associate Dean, UIC College of Dentistry
As one of the nation’s top federally funded public research universities, UIC is a leader in health science and other research areas that improve the well-being of Chicago residents and others around the world. Scientists and clinicians at UIC work closely across many disciplines to investigate and deploy life changing scientific advances for patients and other care providers.
In late 2016, the UIC College of Dentistry partnered with an existing ASP at UI Health, which is working toward empowering frontline providers to use anti-infectives appropriately and optimize patient outcomes. The Colleges of Dentistry and Pharmacy were collaborating on research led by Dr. Suda to assess antibiotic prescribing by dentists nationally. The collaboration of Drs. Suda and Rowan led to implementing antibiotic stewardship in the UIC dental clinics.
In forming the dental ASP, UI Health and the College of Dentistry looked at:
- The perceptions about the use of prophylactic antibiotics and antibiotics used for acute oral infections
- The choice of antibiotics, dosage and duration
- Areas for improvement in antibiotic use related to third molar extraction, bone or soft tissue grafting and surgical implants
In late 2017, Hanna and Rowan reviewed baseline data from September of that year for antibiotic prescriptions and identified two areas for improvement. First was the prescribing rate for patients with acute dentoalveolar conditions (often pain and swelling associated with a toothache) in the urgent care clinic. And second, was patients undergoing surgical placements of dental implants
They decided the first intervention of the ASP would be to standardize antibiotic use for acute dentoalveolar criteria. Educational interventions were also implemented including weekly educational emails with updates regarding clinical guidelines, safety measures and general reminders along with a continuing education presentation posted on the College of Dentistry faculty website.
Educational signs with ways to prevent antimicrobial resistance were displayed throughout the college and clinics, while educational posters on antibiotics were placed in patient areas, including exam rooms.
“Part of this is a change in practice and philosophy,” Hanna said. “Twenty years ago, it was more routine to prescribe antibiotics and now we know that wasn’t necessarily appropriate.”
Equipping Dentists with Decision Support Tools
The team created a clinical decision support tool that can be used by dental students and dentists around the world to help determine if antibiotics are appropriate in just minutes. The tool applies to most cases presented in the urgent-care setting.
“It is a tool that helps prescribers weigh several factors to ensure that decisions are evidence based and appropriate to the individual patient’s needs,” Rowan said.
The tool is used in the clinic, but also in educational settings where dental students learn about treatment considerations from the biomedical and pharmacological perspective in the College’s integrated pre-patient care curriculum. Students are often given scenarios, shown resources, and asked questions before they work in teams to come up with answers for various situations.
“I was surprised — in developing this tool, it changed my own prescribing habits,” Hanna said. “Now I need a compounding factor to consider writing an antibiotic and that’s really been a change in the philosophy.”
Reviewing the First Round of Results From the Antibiotic Stewardship Program
After approximately eight months of utilizing the decision tool and implementing comprehensive educational efforts, the group looked at the antibiotic prescribing rates and compared them with their initial baseline data from September 2017.
The collaborative effort between the College of Dentistry, College of Pharmacy, and UI Health has resulted in a significant reduction in the amount of antibiotics prescribed at the College of Dentistry. Among all providers, the antibiotic prescribing rate per urgent care clinic visit had decreased by 73 percent. Clinical providers also reported that they had become more conscious of appropriate prescribing since implementation of the educational guidelines.
“Our faculty and residents heard the message, took it under advisement, and we saw a significant reduction in the amount of prescribing,” Rowan said. “We are proud of that, and to be one of the first dental schools in the country that has initiated an antibiotic stewardship program."
A 73 percent reduction in urgent care antibiotic prescriptions in the initial round.
“We focused our assessment in just one clinic, but this clinic is responsible for significant amount of the overall antibiotic prescribing. After diving in, I think there are opportunities in many areas,” Gross said.
Expanding the ASP for Maximum Results
UIC College of Dentistry is the first to document the development of a comprehensive ASP in a dental practice, and there are already plans to expand the ASP into other areas, including:
- Mandating indications when prescribing antibiotics
- Integrating clinical decision tools into computerized medication order entry to further facilitate appropriate antibiotic use
Rowan said they are already starting on the next level of the ASP, which would be prophylactic antibiotic prescribing for patients with heart valve issues and replacement joints.
Suda added that they will continue to assess the impact of the ASP strategies already implemented, spread the intervention across the other UIC dental clinics and dentistry in general, and to start educating students, residents, and fellows on the important of prescribing antibiotics only when they are needed per clinical guidelines.
The ultimate goal is to work with professional societies to provide prescribing resources tailored to dentists and to engage patients in the prescribing process.
“We are in a perfect environment to make meaningful changes,” Rowan said. “We are in an institution where graduates of our dental and specialty programs will be able to take this awareness with them and make a consequential difference in the communities they serve”.
The team reported its results in February 2019 in the journal Open Forum Infectious Diseases.
Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice: Alan E Gross, Danny Hanna, Susan A Rowan, Susan C Bleasdale, Katie J Suda, Open Forum Infectious Diseases, Volume 6, Issue 3, March 2019, ofz067