|Year : 2021 | Volume
| Issue : 1 | Page : 80-86
Antimicrobial Stewardship – Implementation and Improvements in Antibiotic-Prescribing Practices in a Dental School
Lahari Ajay Telang1, Jayashri Tamanna Nerali2, Pishipati Vinayak Kalyan Chakravarthy3, Fawaz Shamim Siddiqui4, Ajay Telang5
1 Department of Oral Medicine and Radiology, Penang International Dental College, Butterworth, Penang, Malaysia
2 Department of General Dentistry, Penang International Dental College, Butterworth, Penang, Malaysia
3 Department of Conservative Dentistry and Endodontics, Penang International Dental College, Butterworth, Penang, Malaysia
4 Department of Pediatric Dentistry, Penang International Dental College, Butterworth, Penang, Malaysia
5 Department of Oral Pathology, Penang International Dental College, Butterworth, Penang, Malaysia
|Date of Submission||19-Jan-2021|
|Date of Decision||03-Mar-2021|
|Date of Acceptance||04-Mar-2021|
|Date of Web Publication||26-Jun-2021|
Dr. Lahari Ajay Telang
Department of Oral Medicine and Radiology, Penang International Dental College, 5050, Jalan Bagan Luar, 12000, Butterworth, Penang
Source of Support: None, Conflict of Interest: None
Background and Aim: Antimicrobial stewardship (AMS) is a coordinated systematic approach aimed at educating prescribers to follow evidence-based prescription practice to reduce misuse of antimicrobials and thus antimicrobial resistance (AMR). We aimed to improve the standards of antimicrobial prescribing in a dental school by implementing AMS. Materials and Methods: A retrospective (first) clinical audit of antibiotic prescriptions (n = 200) over a 6 months' period was analyzed for the following parameters: type of antibiotic, clinical condition, compliance to national guidelines, and errors in prescriptions. In response to the results of this audit, an educational intervention workshop was conducted for clinical faculty. A validated self-administered questionnaire on perception and practice of antimicrobial prescribing was given to participants (n = 31) before and after the workshop and t-test was used to compare the mean scores of responses. Prospective clinical audits were conducted 6 months (second) and 1 year (third) after the workshop assessing the same parameters. A Strengths, Weaknesses, Opportunities, and Threats analysis of the AMS program was also done. Results: The total number of prescriptions issued was 943 in the first audit, which reduced to 552 in the second audit and further to 435 in the third audit. The most commonly prescribed antibiotic was a combination of amoxicillin and metronidazole. The percentage of prescriptions in accordance with national guidelines improved from 19% during the first audit to 54% and 79% in the subsequent audits. The percentage of erroneous prescriptions was 23% in the first audit, which reduced to 12% in the second audit and 9% in the third audit. The pre- and posttest mean values of the questionnaire when compared suggested that there is a need for uniformity in prescribing antimicrobials. Conclusions: Clinical audits with educational workshops on appropriate use of antibiotics have a positive impact on conforming with prescription guidelines. This will encourage the rational prescription of antibiotics based on clinical needs of patients, thus contributing to the fight against AMR.
Keywords: Antibiotics, antimicrobial resistance, antimicrobial stewardship, clinical audit, dentistry
|How to cite this article:|
Telang LA, Nerali JT, Kalyan Chakravarthy PV, Siddiqui FS, Telang A. Antimicrobial Stewardship – Implementation and Improvements in Antibiotic-Prescribing Practices in a Dental School. Arch Med Health Sci 2021;9:80-6
|How to cite this URL:|
Telang LA, Nerali JT, Kalyan Chakravarthy PV, Siddiqui FS, Telang A. Antimicrobial Stewardship – Implementation and Improvements in Antibiotic-Prescribing Practices in a Dental School. Arch Med Health Sci [serial online] 2021 [cited 2021 Dec 6];9:80-6. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/80/319382
| Introduction|| |
Antimicrobial resistance (AMR) as outlined by the WHO is caused by multiple factors such as overprescribing of antibiotics, patients not finishing their treatments, overuse of antibiotics in livestock and fish farming, poor infection control in hospitals and clinics, lack of hygiene and poor sanitation, and lack of new antibiotics being developed. This leads to problems which are multifold. First, resistance to first-line drugs leads to the use of second- or third-line drugs which may be less effective, more toxic, and/or more expensive. Second, the pace of development of new antibiotics has slowed down tremendously leaving the medical world with few options of therapy, and finally, there may be potential negative impacts to patient outcomes in terms of patient safety, loss of treatment options for common infections, and increase in expenditure. As a response to these issues, antimicrobial management or stewardship programs have been developed. Antimicrobial Stewardship (AMS) is a coordinated systematic approach to improve the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen along with right choice of antimicrobial, right route of administration, right dose, right time and right duration in order to minimize harm to the patient and future patients.
Antimicrobials are routinely prescribed in clinical dental practice for prevention and treatment of bacterial infection although most of these infections can be treated with local measures. Literature from the UK states that dentists are responsible for nearly 7%–10% of all antibiotic prescriptions in National Health Service primary care., Wide variations are known to exist in dental antibiotic prescribing in spite of availability of published guidelines to support decision-making. Prescribing antimicrobials as opposed to performing local measures was done due to barriers such as “patient factors,” “time management,” “lack of incentives to perform local measures,” and “impact of subsequent appointments.” Clinical audits, as part of a AMS program, have been proven to be valuable in evaluating and improving the quality of care provided to patients and in the health policy planning and financing.
In Malaysia, the second edition of National Antibiotic Guidelines (2014) was developed in line with the protocol on AMS program in health-care facilities, which contains clear guidelines on antibiotic prescribing for all diseases including those affecting the oral/dental region. The third edition was introduced in 2019, with no notable changes to prescription guidelines for oral/dental infections. Information on the compliance to these national antibiotic guidelines by general dental practitioners is, however, sparse in literature.
With the intention of introducing AMS in a dental teaching institute, a clinical audit to evaluate the current practices of antimicrobial prescribing was planned as an initial step. The current practices would be compared with the recommended national guidelines and, if deemed necessary, educational interventions planned to meet these requirements.
| Materials and Methods|| |
A proposal was drafted and a team of four members was designated as the AMS committee. The AMS program was conducted in two stages to ensure maximum impact of the proposed intention. First, a retrospective review was done using clinical audit of antibiotic prescriptions over a period of 6 months (n = 200) by simple random sampling. A modified clinical audit pro forma was designed based on FDGP (UK) Antimicrobial Prescribing Self-Auditing Tool and National Antibiotic Guidelines, Malaysia. The prescriptions (n = 200) were analyzed for the following: (1) type of antibiotic, (2) clinical condition/(reason for prescription of antibiotic), (3) compliance to national guidelines, and (4) errors in prescriptions.
Second, based on the results of the first audit, an educational intervention was planned. This consisted of a workshop on AMR for all clinicians and distribution of a validated self-administered questionnaire to all the participating faculties (n = 31) before (pretest) and after (posttest) the workshop. The questionnaire consisted of two parts: Part A consisted of five statements assessing the perception of participants regarding antibiotic-prescribing practices of dentists. The perception was assessed using a five-point Likert scale (strongly disagree, disagree, neutral, agree, and disagree), and the mean score of responses was calculated. t-test was used to compare the mean scores of participants before and after the workshop. Part B consisted of simulated case scenarios that were specially created and required the participants to respond “yes” or “no” based on the requirement of antibiotics prescription for the case.
During the workshop, the results of the clinical audit were shared and a discussion on AMS was facilitated. Suggestions and recommendations to improve the rational use of antibiotics were evaluated. A checklist was indigenously developed and its usage was made mandatory for any antibiotic prescription written [Figure 1].
A prospective clinical audit of antibiotic prescriptions (n = 200) was conducted 6 months later assessing the same parameters and followed by another audit 1 year later. Based on the results of the audits, a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was done and feedback was provided as part of implementation of AMS.
| Results|| |
The number of clinicians who were part of the study was 31. In the 6 months' period of the first audit, the total number of prescriptions that were issued was 943, which was reduced to 552 in the next 6 months (second audit) and further to 435 in the third audit, that is, within 1 year of the retrospective audit. A total of 200 prescriptions were reviewed on each audit. During each audit, the most commonly prescribed antibiotic in the dental clinic was a combination of amoxicillin and metronidazole, followed by amoxicillin alone. It was noticed that the number of prescriptions of amoxicillin alone increased in comparison to combination of amoxicillin plus metronidazole [Table 1].
With respect to the clinical condition for which the antibiotics were prescribed, it was noticed that the percentage of prescriptions given for postsurgical conditions and pericoronitis increased in comparison to other conditions such as necrotic pulp and irreversible pulpitis [Table 2].
|Table 2: Clinical conditions for which antimicrobials have been prescribed (%)|
Click here to view
The percentage of prescriptions in accordance with the national guidelines is shown in [Table 3]. It was noticed that during the first audit, only 19% of the 200 prescriptions audited were in accordance with national guidelines. This percentage improved to 54% in the second audit 6 months later and to 79% in the third audit 1 year later. A prescription was termed erroneous if errors were recorded in any one of its components, i.e., dose, frequency, or others, e.g., penicillin being prescribed for a person allergic to penicillin. The percentage of errors in the prescription also showed improvement over the 1-year period, as shown in [Table 4]. In the first audit, the percentage of errors was 23%, which reduced to 12% errors in the second audit and finally 9% in the third audit.
The pre- and posttest mean values of the perception questionnaire were compared, and the results showed a significant difference with the statement ”There is a lack of uniformity among dental surgeons in prescribing antibiotics” [Table 5]. In Part B of the questionnaire, significant differences in the results were noticed in 9 out of the 12 case scenarios. This suggests that as a result of the educational workshop, participants changed their opinion about the need for antibiotics in the given case scenarios [Table 6].
Following the third audit, after 1 year, a SWOT analysis was done to highlight possible barriers and enablers to the implementation of the AMS program and also its future direction [Table 7]. The results of the SWOT analysis showed that the AMS achieved so far had strengths that would enable its future advancement and weaknesses that needed to be overcome.
|Table 7: Strengths, Weaknesses, Opportunities, and Threats analysis of antimicrobial stewardship achieved|
Click here to view
| Discussion|| |
Antibiotic use in dentistry
There is increasing evidence of inappropriate use of antimicrobials by dentists which in turn may lead to AMR., Among the wide range of antibiotics prescribed for treatment of orofacial infections by dentists Amoxicillin is the most commonly preferred antibiotic followed by a combination of Amoxicillin and Metronidazole.,,, These were similar to results seen in our study. In a systematic review, on antibiotic-prescribing pattern among dentists for endodontic infections, amoxicillin was again reported as the drug of choice for endodontic infections in most countries, and clindamycin and erythromycin were the choices for patients allergic to penicillin. Dentists worldwide are known to prescribe antibiotics for routine endodontic infections such as pulpitis even though the pathophysiology of pulpal diseases suggests that antibiotics may be ineffective and most of these infections can be treated successfully by local measures.,,,
In our study during the first audit, a total of 943 prescriptions were issued in the 6-month period, whereas in the second audit 6 months later after the educational workshop, the number of prescriptions reduced to 553 prescriptions indicating a reduction of 41.3%, and in third audit, it further reduced to 435. The results of our study showed that the awareness about antibiotic resistance and attitude of clinical faculty toward prescribing antibiotics improved significantly. This effect was further verified by the results of prospective clinical audits, which most importantly showed a decrease in the number of antibiotic prescriptions. The checklist developed proved to be useful in assessing prescriptions by an individual clinician and reducing errors. The pharmacist verified the checklist before dispensing the drugs and was also made accountable in the AMS process.
Compliance to prescribed guidelines
In this study, only 19% of the dentists complied with national guidelines, in the first audit which improved to 54% in the second audit and 79% in the third audit. This is in line with evidence from other studies which recommend the need for educational initiatives to promote rational use of antibiotics whenever a discrepancy is noticed between observed and recommended practice of antibiotic prescription. However, the best method to slow the spread of resistant bacteria is by improved stewardship of antibiotics and using them more carefully and reducing the number of prescriptions.
Local antimicrobial resistance and antimicrobial stewardship
In Malaysia, the antibiotic-prescribing rates have been found to be high (21.1%) in both public and private primary care settings, with evidence of excessive and inappropriate prescribing for self-limiting conditions. Some of the reasons which explain higher antibiotic prescribing, particularly in the private primary care clinics, are that private practitioners are generally more responsive to patients' expectations of antibiotics, the financial incentives of medication overuse as well as suboptimal knowledge about the harm of AMR. Moreover, effective and successful intervention plans to combat these issues in the private sector have not yet been identified., There is a dearth of similar comparative information in the dental sector however, and more studies in this field are imperative to understand it better.
Implementing and sustaining antimicrobial stewardship
The hurdles to the success of AMS interventions identified in countries with emerging economies are multifactorial. However, factors that complicate this could be a combination of lack of effective surveillance, inadequately trained personnel, hampered infection control, lack of clinical data, and absence of regulatory frameworks to effectively check prescribing and dispensing. Added to this is a low level of public awareness.,,
Implementing and sustaining evidence-based AMS requires that the change has to be implemented in the “prescribing behavior” of health-care providers as well as the organization. Internal factors which have been identified to contribute are (1) lack of awareness of AMR, (2) belief that broad-spectrum antibiotics are very effective and carry low risk, (3) influence of senior's preference on a junior's prescribing, and (4) physician's autonomy in prescribing what he or she thinks is best. The sustenance of AMS program requires the intervention to be tailored to the needs of our dental teaching institution. The steps that were implemented were (1) regular audit and feedback, (2) access to E-learning resources, and (3) discussion on AMS as an agenda on clinical meetings.
In the present study, the results of the SWOT analysis of implementation of AMS program had its strengths in having a positive framework and weaknesses mainly revolve around the clinicians who are involved and the challenges faced by new clinicians who have to adapt to the existing system. The opportunities in sustaining the program are increased awareness through continuing education and threats in having limited funding and less priority given to the program itself. The positive outcome of this study also has a direct impact on student learning, as this has been done in a dental school setting and modification of clinician's behavior will impact learner's behavior as well. A study assessing this impact could be interesting as its implications on health economics would be significant.
| Conclusion|| |
This study was aimed at implementing AMS by rationalizing and improving the standards of antimicrobial prescribing in a dental teaching institution. The consequences of AMR are serious, far reaching, and leading to an impending global health crisis. Dentists like all other health-care workers have a role to play in keeping antibiotics working by prescribing them only when needed as well as educating patients to use them responsibly. Clinical audit with educational workshops on appropriate use of antibiotics, conforming with prescription guidelines, will encourage the rational prescription of antibiotics based on clinical needs of patients.
The authors would like to thank all the clinical faculty of Penang International Dental College who participated in the study and Mr. Muhamad Faizal, junior pharmacist, for pharmacy records.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Poveda Roda R, Bagan JV, Sanchis Bielsa JM, Carbonell Pastor E. Antibiotic use in dental practice. A review. Med Oral Patol Oral Cir Bucal 2007;12:E186-92.
Chate RA, White S, Hale LR, Howat AP, Bottomley J, Barnet-Lamb J, et al
. The impact of clinical audit on antibiotic prescribing in general dental practice. Br Dent J 2006;201:635-41.
Palmer NO, Longman L, Randall C, Pankhurst CL. Antimicrobial Prescribing for General Dental Practitioners. UK: Faculty of General Dental Practitioners (FGDP); 2012.
Newlands R, Duncan EM, Prior M, Elouafkaoui P, Elders A, Young L, et al
. Barriers and facilitators of evidence-based management of patients with bacterial infections among general dental practitioners: A theory-informed interview study. Implement Sci 2016;11:11.
National Antimicrobial Guideline (NAG) 2019. 3rd ed. Pharmaceutical services program. Ministry of health. Malaysia ISBN 978-967-5570-78-0. Available f r o m : h t t p s : / / www.pharmacy.gov.my/v2/en/documents/ national antimicrobial guideline nag 2019 3rd
edition.html. [Last accessed on 14 Dec 2019].
Palmer NA, Pealing R, Ireland RS, Martin MV. A study of prophylactic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J 2000;189:43-6.
Tulip DE, Palmer NO. A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract. Br Dent J 2008;205:659-64.
Durkin MJ, Hsueh K, Sallah YH, Feng Q, Jafarzadeh SR, Munshi KD, et al
. An evaluation of dental antibiotic prescribing practices in the United States. J Am Dent Assoc 2017;148:878-860.
Cope AL, Francis NA, Wood F, Chestnutt IG. Antibiotic prescribing in UK general dental practice: A cross-sectional study. Community Dent Oral Epidemiol 2016;44:145-53.
Vasudavan S, Grunes B, Mcgeachie J, Sonis AL. Antibiotic Prescribing Patterns Among Dental Professionals In Massachusetts. Pediatr Dent 2019;41:25-30.
Kaul R, Angrish P, Jain P, Saha S, V Sengupta A, Mukherjee S. A survey on the use of antibiotics among the dentists of Kolkata, West Bengal, India. Int J Clin Pediatr Dent 2018;11:122-7.
Segura-Egea JJ, Martín-González J, Jiménez-Sánchez MD, Crespo-Gallardo I, Saúco-Márquez JJ, Velasco-Ortega E. Worldwide pattern of antibiotic prescription in endodontic infections. Int Dent J 2017;67:197-205.
Yingling NM, Byrne BE, Hartwell GR. Antibiotic use by members of the American Association of Endodontists in the year 2002: Report of a national survey. J Endod 2002;28:396-404.
Rodriguez-Núñez A, Cisneros-Cabello R, Velasco-Ortega E, Llamas-Carreras JM, Tórres-Lagares D, Segura-Egea JJ. Antibiotic use by members of the Spanish Endodontic Society. J Endod 2009;35:1198-203.
Sukumar S, Martin FE, Hughes TE, Adler CJ. Think before you prescribe: How dentistry contributes to antibiotic resistance. Aust Dent J 2020;65:21-9.
Mainjot A, D'Hoore W, Vanheusden A, Van Nieuwenhuysen JP. Antibiotic prescribing in dental practice in Belgium. Int Endod J 2009;42:1112-7.
Thompson W, Tonkin-Crine S, Pavitt SH, McEachan RRC, Douglas GVA, Aggarwal VR, et al
. Factors associated with antibiotic prescribing for adults with acute conditions: An umbrella review across primary care and a systematic review focusing on primary dental care. J Antimicrob Chemother 2019;74:2139-52.
Ab Rahman N, Teng CL, Sivasampu S. Antibiotic prescribing in public and private practice: A cross-sectional study in primary care clinics in Malaysia. BMC Infect Dis 2016;16:208.
Hassali MA, Kamil TK, Md Yusof FA, Alrasheedy AA, Yusoff ZM, Saleem F, et al
. General practitioners' knowledge, attitude and prescribing of antibiotics for upper respiratory tract infections in Selangor, Malaysia: Findings and implications. Expert Rev Anti Infect Ther 2015;13:511-20.
Oh AL, Hassali MA, Al-Haddad MS, Syed Sulaiman SA, Shafie AA, Awaisu A. Public knowledge and attitudes towards antibiotic usage: A cross-sectional study among the general . Public knowledge and attitudes towards antibiotic usage: A cross-sectional study among the general public in the state of Penang, Malaysia. J Infect Dev Ctries 2011;5:338-47.
Tiong JJ, Loo JS, Mai CW. Global antimicrobial stewardship: A closer look at the formidable implementation challenges. Front Microbiol 2016;7:1860.
Tiong JJ, Mai CW, Gan PW, Johnson J, Mak VS. Separation of prescribing and dispensing in Malaysia: The history and challenges. Int J Pharm Pract 2016;24:302-5.
Rodrigues AT, Roque F, Falcão A, Figueiras A, Herdeiro MT. Understanding physician antibiotic prescribing behaviour: A systematic review of qualitative studies. Int J Antimicrob Agents 2013;41:203-12.
Krockow EM, Colman AM, Chattoe-Brown E, Jenkins DR, Perera N, Mehtar S, et al
. Balancing the risks to individual and society: A systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals. J Hosp Infect 2019;101:428-39.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]