Antibiotic prescribing
Exam Pass Notes

Key Takeaways

• Follow principles of antibiotic stewardship - right drug, dose, duration.
• Reserve antibiotics for infections not manageable by local measures alone.
• Use narrow spectrum agents first line where possible.
• Short 3-5 day courses are recommended, review at 3 days, and stop if improved.
• If 3 day review not possible, advise patient to stop when improved.
• Prophylaxis generally not supported by evidence and has risks.
• Informed consent weighing risks and benefits is essential.

Overview

• Over-prescription of antimicrobials is creating resistant organisms.
• According to the CGDent, UK dentists prescribe 8% of all antibiotic prescriptions in NHS primary care.
• 73% of antibiotics globally go to farm animals as feed additives to increase meat production.
• Antibiotic stewardship aims to limit antimicrobial prescription through education about resistance dangers.
• Drug companies rely on excessive antibiotic use for profit and promote this through advertising, "education", and lobbying.

How to Write a Prescription

• Prescriptions should have patient's full name and address, date, be in ink, signed by prescriber.
• Patient's age does not need to be included.
• Avoid decimals. Write units in full.
• Avoid brand names, use generic names. Pharmacists can substitute generics.
• In the UK, dentists prescribe from the Dental Practitioner's Formulary for NHS.

Antimicrobial Stewardship

• Aims to improve antimicrobial use to enhance outcomes, reduce resistance, and decrease costs.
• Decreasing overuse serves goals like reducing adverse effects, protecting microbiome, decreasing resistance.
• Also reduces environmental damage from antibiotic waste.
• Follow principles like right drug, right dose, right duration.

When to Prescribe Antibiotics

• For some acute/chronic infections unmanageable by local measures alone.
• As temporary relief if treatment is deferred and infection could worsen.
• Consider sepsis risk when infections present.
• Use sepsis protocol to identify and manage sepsis.
• Refer immediately if severe infection, dangerous swelling, high fever.
• Use short course of 3-5 days. Review at day 3.
• Resistance occurs through mutation and selection pressure.

What to Prescribe

• No access to sensitivity testing so choose empirically.
• Most oral infections still respond to a range of antibiotics.
• Follow stewardship rules: narrow spectrum first, then broad if needed.
• First Line
  • Phenoxymethylpenicillin (Penicillin V/VK) - narrow spectrum.
  • Amoxicillin - broad spectrum, use if Pen V unsuitable.
• Second Line (allergy, or recent penicillin)
  • Metronidazole - narrow spectrum, effective.
  • Azithromycin - broad spectrum, once daily dose.
  • Clarithromycin - broad spectrum, twice daily dose.
  • Erythromycin - broad spectrum, poorly tolerated.
• Third Line (Hospital Prescribing Only)
  • Clindamycin, Cephalosporins, Tetracyclines.
  • Avoid combinations except specialist periodontal cases.

Dento-Alveolar Infections

• Chronic infections often well localised, not painful. Can flare up.
• Antibiotics generally not indicated for localised chronic infections.
• Acute infections can spread with serious consequences.
• Antibiotics indicated if signs of spreading infection or systemic involvement.
• Refer immediately if severe infection, high fever, swelling, difficulty breathing/swallowing.
• Use short 3-5 day course. Review on day 3.
• Stop course if improvement.
• Resistance occurs through mutation and selection pressure.

Acute Sinusitis

• Sinusitis often presents as toothache of upper posterior teeth.
• Usually viral and self-limiting. Antibiotics not indicated.
• Palliative treatments include decongestants, saline irrigation, pain medication.
• Refer to medical practitioner if severe or high-risk patient.

The 3-Day Antibiotic Review

• Reviewing patient 3 days after starting antibiotics is critical for stewardship.
• Allows assessment of response and change therapy if poor response.
• Identify any adverse reactions and make drug changes if needed.
• Reassess need for antibiotics and discontinue if not needed.
• Promotes patient engagement and adherence.
• Minimises unnecessary antibiotic duration.

Antibiotic Prophylaxis

• Prophylaxis aims to prevent infection from dental procedures.
• No clear benefit proven and significant risks including resistance.
• Generally not indicated for dental procedures in healthy patients.
• Individual higher risk cases should be discussed with medical specialist.
• Must differentiate evidence vs opinion when obtaining consent.
• If used, single dose at procedure is as effective as full course.

Implants and Antibiotic Prophylaxis

• Evidence does not support prophylaxis for simple implant placement.
• Benefits do not outweigh risks for healthy patients.
• Prophylaxis may be justified for complex cases and augmentation.
• Patients must give informed consent weighing all risks and benefits.
• If used, single pre-op dose as effective as full course.

What's in the Dental Practitioner's Formulary

• Formulary lists drugs UK dentists can prescribe under NHS.
• Main antibiotics:
  1. Phenoxymethylpenicillin (Penicillin V/VK)
  2. Amoxicillin
  3. Metronidazole
  4. Azithromycin
  5. Clarithromycin
• Also includes tetracyclines, co-amoxiclav, clindamycin but these have limited indications.

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