The superbug crisis

The problem of antimicrobial resistance is getting worse, largely due to the over-prescribing of antibiotics. The good news is dentists can play a role in minimising their use. By Harry Pearl

The discovery of antibiotics is recognised as one of the greatest advances in medicine. But today, talk of a doomsday-like, post-antibiotic era is gaining serious attention.

Antibiotics like penicillin that proved stunningly successful in treating bacterial infections in the 1940s and 1950s are becoming increasingly ineffective as antimicrobial resistance grows due to use and misuse of the drugs.

Nearly 500,000 people each year develop multi-drug resistance to tuberculosis, according to the World Health Organization (WHO). Numerous other diseases, ranging from common hospital infections like Acinetobacter, to malaria and HIV, are becoming harder to treat. Public health experts warn that, if left unchecked, medical procedures such as caesarean sections and hip replacements will become more dangerous and the cost of healthcare will rise.

So what role do dentists play in both the problem and solution?

“It concerns a lot of dentists that we’re prescribing too many antibiotics. We probably do prescribe too often and often when it is not needed,” says Dr Michael Foley, vice-chair of the Australian Dental Association (ADA) Oral Health Committee.

While dentists account for a relatively small proportion of antibiotic prescriptions compared to other health professionals, their contribution can often be overlooked.

About 11 per cent of all antibiotic prescriptions made in the US in 2013 came from dentists, according to the American Dental Association. Similar rates have been recorded in the UK. Although the figure is lower in Australia (three per cent according to Department of Health data), there are signs misuse may be increasing.

A study published in the Australian Dental Journal this year found a “concerning increase” in the prescription of antibiotics by dentists in Australia between 2001 and 2012.

Drawing on subsidised dispensing data from the Pharmaceutical Benefits Scheme, researchers from the University of Queensland found the use of antibiotics increased 50 per cent over the study period.

“It concerns a lot of dentists that we’re prescribing too many antibiotics. We probably do prescribe too often and often when it is not needed.”—Dr Michael Foley, vice-chair, ADA Oral Health Committee

Amoxicillin plus clavulanic acid use increased nearly 200 per cent over 12 years, and the use of clindamycin increased threefold. Moreover, the use of amoxicillin, which accounted for two thirds of all prescriptions among dentists, did not appear to meet therapeutic guidelines for the sector, the researchers said.

They suggested that regular and continuous education about the guidelines for antibiotic prescriptions should be made mandatory. “Other mechanisms to inform, regulate and monitor dental prescribing practices should also be considered,” they advised.

Antibiotic guidelines in Australia state active dental treatment is the best solution for problems. When drugs are necessary, they should be the narrowest spectrum possible and their duration limited.

Dr Foley says in many cases dentists are simply misusing antibiotics, often prescribing them following procedures like dental implants and extractions, or to treat abscesses.

“Antibiotics are designed for systemic infections where you are getting an infection that is spreading away from the tooth, and it is raising your temperature and causing swelling,” Dr Foley says.

“If you’ve got a really, really sore, painful tooth, but it’s a localised infection, antibiotics won’t help that. You need your tooth extracted or the nerves taken out of the tooth, maybe some painkillers as well.”

The threat of antimicrobial resistance in therapeutic use was known as far back as the 1940s, at the dawn of the antibiotic age, but only in the past couple of decades has the threat become well understood, according to Dr Foley.

“When I was at dental school in the ‘70s and ‘80s, we didn’t talk much about antibiotic resistance,” he says. “We’ve been a lot more aware of it in recent years because people are becoming resistant.”

The term ‘superbug’, which refers to microbes that have mutated multiple times to become drug-resistant, has entered the common lexicon and health organisations, including WHO, are undertaking major drives to raise awareness about the public health risk.

“When you’ve been practising this way for decades, it’s often difficult to change mindsets, especially when you’ve got a patient who insists on getting an antibiotic. [But] if health practitioners don’t take the lead on this issue, who will?”—Dr Michael Foley, vice-chair, ADA Oral Health Committee

During Antibiotic Awareness Week earlier this year, the ADA urged patients and health practitioners to commit all year-round to only using antibiotics as recommended, including to treat dental problems.

Misuse of drugs by medical practitioners is not the only contributing factor to antimicrobial resistance. The use of antibiotics in food and animal production has also been linked to resistant infections in humans. Health professionals are also worried the supply of new antibiotics is drying up. Drug companies are producing fewer antibiotics now than they were four or five decades ago because they have a poor return on investment. But dentists and other health professionals have an important role to play and can start by being firm with patients who ask for antibiotics, Dr Foley says. “It behoves all of us, particularly health professionals, to say ‘hang on, I know you’ve had antibiotics before, but you don’t actually need that’.”

Common preventative measures will also go a long way.

“Using gloves, using masks, washing our hands thoroughly, ensuring our surgeries are scrupulously clean; those sort of measures do reduce disease transmission,” Dr Foley says. “That’s no secret, we’ve known that for the last 200 years.”

The impact of antimicrobial resistance in Australia is hard to determine, but the country’s above average consumption when compared to other OECD countries is of concern, according to the Department of Health.

Results from the 2013 National Antimicrobial Prescribing Survey found 30 per cent of prescriptions were considered inappropriate, and for about one third of all prescriptions no reason was given in the medical notes.

It appears the issue is being taken more and more seriously, though. In 2015, Australia developed its first national antimicrobial resistance strategy, and an increasing amount of effort is being put into changing prescribing and consumption habits.

Dr Foley notes there is still, however, some way to go.

“When you’ve been practising this way for decades, it’s often difficult to change mindsets, especially when you’ve got a patient who insists on getting an antibiotic. [But] if health practitioners don’t take the lead on this issue, who will?”

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