Antibiotic Use by Members of the Spanish Endodontic Societ

Elsevier Editorial System(tm) for Journal of Endodontics Manuscript Draft Manuscript Number: Title: Antibiotic Use by Members of the Spanish Endodontic Society Article Type: Clinical Research Keywords: antibiotic therapy; prescribing habits; apical periodontitis; endodontist. Corresponding Author: Prof. JUAN JOSE SEGURA-EGEA, Ph.D., M.D., D.D.S. Corresponding Author's Institution: University of Seville, School of Dentistry First Author: ANTONIO RODRIGUEZ-NUÑEZ, DDS Order of Authors: ANTONIO RODRIGUEZ-NUÑEZ, DDS; RAFAEL CISNEROS-CABELLO, MD, DDS, PhD; EUGENIO VELASCO-ORTEGA, MD, DDS, PhD; DANIEL TORRES-LAGARES, DDS, PhD; JUAN JOSE SEGURA-EGEA, Ph.D., M.D., D.D.S. Manuscript Region of Origin: Europe & Central Asia Abstract: The purpose of this study was to determine the prescribing habits of active members of the Spanish Endodontic Society (AEDE) with regard to antibiotics. A one-page questionnaire was sent to the active members of the AEDE. Of the 508 surveys mailed, 158 surveys were returned, and 140 were found to be usable. The overall response rate was 31.1%. The data were analyzed using descriptive statistics and chi-square tests of independence. The average duration of antibiotic therapy was 6.8  1.8 days. In patients with no medical allergies most of responders (86.1%) selected amoxicillin as first-choice antibiotic, alone (44.3%) or associated to clavulanate (41.8%); metronidazole-spiramycin and clindamycin were prescribed by 7.6% and 3.7% of the respondents. The first drug of choice for patients with an allergy to penicillins was clindamycin 300 mgr (63.2%), followed by metronidazole-spiramycin (23.7%). For cases of irreversible pulpitis, 40.0 % of respondents prescribed antibiotics. For the scenario of a necrotic pulp, acute apical periodontitis, and no swelling, 52.9% prescribed antibiotics. Almost 21.5% prescribed antibiotics for necrotic pulps with chronic apical periodontitis and a sinus tract. We conclude that, for the most part, the majority of the members of the AEDE were selecting the appropriate antibiotic for use in orofacial infections, but there are still many who are prescribing antibiotics inappropriately. The use of antibiotics for minor infections, or in some cases in patients without infections, could be a major contributor to the world problem of antimicrobial resistance. Antibiotic Use by Members of the Spanish Endodontic Society Antonio Rodriguez-Núñez, DDS1, Rafael Cisneros-Cabello, PhD, MD, DDS2, Eugenio Velasco-Ortega, PhD, MD, DDS3, Daniel Tórres-Lagares, PhD, MD, DDS4, and Juan José Segura-Egea, PhD, MD, DDS4. 1Doctoral fellow, Department of Odontology, School of Health Sciences, European University of Madrid, C/Tajo s/n, Urb. El Bosque, Villaviciosa de Odón, 28670Madrid, Spain. 2Professor, Department of Odontology, School of Health Sciences, European University of Madrid, C/Tajo s/n, Urb. El Bosque, Villaviciosa de Odón, 28670Madrid, Spain. 3Professor, Department of Stomatology, School of Dentistry, University of Seville, C/ Avicena s/n, 41009-Seville, Spain. 4Associate Professor, Department of Stomatology, School of Dentistry, University of Seville, C/ Avicena s/n, 41009-Seville, Spain. .Title Page (Only file with author names) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 ABSTRACT The purpose of this study was to determine the prescribing habits of active members of the Spanish Endodontic Society (AEDE) with regard to antibiotics. A one-page questionnaire was sent to the active members of the AEDE. Of the 508 surveys mailed, 158 surveys were returned, and 140 were found to be usable. The overall response rate was 31.1%. The data were analyzed using descriptive statistics and chi-square tests of independence. The average duration of antibiotic therapy was 6.8 1.8 days. In patients with no medical allergies most of responders (86.1%) selected amoxicillin as first-choice antibiotic, alone (44.3%) or associated to clavulanate (41.8%); metronidazolespiramycin and clindamycin were prescribed by 7.6% and 3.7% of the respondents. The first drug of choice for patients with an allergy to penicillins was clindamycin 300 mgr (63.2%), followed by metronidazole-spiramycin (23.7%). For cases of irreversible pulpitis, 40.0 % of respondents prescribed antibiotics. For the scenario of a necrotic pulp, acute apical periodontitis, and no swelling, 52.9% prescribed antibiotics. Almost 21.5% prescribed antibiotics for necrotic pulps with chronic apical periodontitis and a sinus tract. We conclude that, for the most part, the majority of the members of the AEDE were selecting the appropriate antibiotic for use in orofacial infections, but there are still many who are prescribing antibiotics inappropriately. The use of antibiotics for minor infections, or in some cases in patients without infections, could be a major contributor to the world problem of antimicrobial resistance. KEY WORDS: antibiotic therapy, prescribing habits, apical periodontitis, endodontist. * Manuscript 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 INTRODUCTION The first antibiotic, penicillin, was discovered by Alexander Fleming in 1928. Florey, in 1940, introduced the use of antibiotics to clinical practice. Since then, antibiotics have been used extensively in dentistry. However, while many bacterial species were initially found to be sensitive to different types of antibiotics, there has been a gradual and sustained emergence of resistant strains (1). Antibiotic resistance is the ability of a microorganism to withstand the effects of antibiotics. We have now entered an era where some bacterial species, including those involved in endodontic infections (2), are resistant to the full range of antibiotics presently available. Dentistry’s contributions to the problem of antibiotic resistance can be substantial because dentists prescribe approximately 10% of all common antibiotics (3). Odontogenic infections and, especially, endodontic infections, are polymicrobial involving a combination of Gram-positive, Gram-negative, facultative anaerobes and strict anaerobic bacteria (4, 5). Thus, antibiotics, with analgesics, account for the vast majority of medicines prescribed by dentists. In 2004, a survey of over 6,000 general dental practitioners in the UK revealed that 40% of dentists were prescribing antibiotics on at least three occasions every week. The research also revealed that 15% of the dentists prescribed antibiotics on a daily basis. However, it is increasingly being accepted that such prescribing habits are often either inappropriate or unnecessary (1). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 In USA, several surveys have analyzed the use of antibiotic by diplomates of the American Board of Endodontics in the treatment of endodontic infections (6, 7, 8). Yingling et al. (2002) determined the prescribing habits of active members of the American Association of Endodontists (AAE) with regard to antibiotics concluding that the majority of the members of the AAE were selecting the appropriate antibiotic for use in orofacial infections, but there were still many who are prescribing antibiotics inappropriately. However, in Spain no study has analyzed the prescribing habits with regard to antibiotics between endodontists. The purpose of this study was to investigate the antibiotic prescribing habits of the members of the Spanish Endodontic Society (Asociación Española de Endodoncia, AEDE). MATERIALS AND METHODS A one-page questionnaire was sent to the members of the AEDE (Fig. 1). A cover letter and postage-paid return envelope were also included. The 2007 mailing list of members was obtained from the AAE. Some questions were based on those asked in the previous surveys developed in USA (6-9), and the questionnaire was reviewed by dental researchers and endodontic faculty for appropriateness and clarity. The data were analyzed using descriptive statistics and groups were compared by using a chi square test of independence. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 RESULTS Of the 508 surveys mailed, 158 surveys were returned. A total of 18 were returned as undeliverable, and the others (n: 140) were found to be usable. The overall response rate was 31.1%. The demographics of the respondents are described in Table 1. Male respondents accounted for 63% and females 37% of the total. Fifty seven percent of the respondents were less than 35 years old and 36% more than 45 years old. The mean age of the respondents was 34 6 yr of age. The most frequent academic degree was DDS (62.9%). Stomatologist, medical doctor specialised in stomatology, represented 28.5% of total. Only 8.6% of the respondents were both MD and DDS. In relation with the percentage of time assigned to endodontic practice, the majority of respondents were in part-time, and only 21.4% declared themselves to be in full-time endodontic practice. However, 56% of the respondents dedicated to endodontics more than a half of their dental practice. The nation-wide proportion of respondents by region of Spain was evenly distributed (Fig. 2). The average duration of antibiotic therapy was 6.8 1.8 days (Fig. 3). The standard deviation in this response indicated that majority prescribe for between 6 and 8 days. There were no significant differences between respondents in relation with age, gender, academic degree, region, nor time dedicated to endodontics (p > 0.05). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 Most of responders (86.1%) chosen amoxicillin in patients with no medical allergies (Table 2), alone (44.3%) or associated to clavulanic acid (41.8%). Metronidazole-spiramycin and clindamycin were prescribed as first-choice antibiotic by 7.6% and 3.7% of the respondents. The first drug of choice for patients with an allergy to penicillin was clindamycin 300 mgr (63.2%), followed by metronidazole-spiramycin (23.7%) (Table 3). Table 4 lists the percentage of respondents who prescribed antibiotics for various pulpal and periapical diagnoses. For cases of irreversible pulpits with moderate/severe symptoms and irreversible pulpitis with acute apical periodontitis and moderate/severe symptoms, 11.4% and 28.6% of respondents, respectively, prescribed antibiotics. In cases of a necrotic pulp, chronic apical periodontitis, no swelling, and no other symptoms, antibiotics were prescribed by 14.3%. In the scenario of necrotic pulp, acute apical periodontitis, moderate/severe symptoms but no swelling, 52.9% prescribed antibiotics. For a case of necrotic pulp, chronic apical periodontitis, asymptomatic but with a sinus tract, 21.4% prescribe antibiotics. In the case of a necrotic pulp, acute apical periodontitis, swelling, and other moderate/severe symptoms, 94.3% of respondents prescribed antibiotics. There were no significant differences between respondents in prescribing habits in relation with age, gender, academic degree, region, nor time dedicated to endodontics (p > 0.05). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 DISCUSSION The survey instrument has historically been successful in obtaining pertinent information on the practice of endodontics. The population sampled in this study was large, 508 members of the AEDE. A large percentage of this target population was practicing endodontists, and it should be noted that no attempt was made to survey practicing endodontists who were not members of the AEDE. The overall response rate of 31.1% can be considered to be an acceptable rate of return for surveys. Other similar surveys published recently have reported response rates of 35% and 41% (10, 11). Questions were designed to collect a variety of information relative to the types of antibiotics used and the prescribing habits of endodontists as determined by age, gender, academic degree, area of the country, and percentage of time assigned to endodontics in their whole private dental practice. In relation with antibiotic therapy, an infection must be persistent or systemic to justify the need for antibiotics: i.e. fever, swelling, lymphadenopathy, trismus, or malaise in a healthy patient. Antibiotics are also more likely to be needed in an immunocompromised patient or a patient in poor health. The decision to prescribe antibiotics should not be influenced by patient demand, expectation of referring dentists, “just in case” situations, or because it is the day before a weekend or holiday. These reasons constitute inappropriate use of antibiotics. As it has been previously reported by Yingling et al. (9), some respondents submitted comments that patients and referring general practitioners often “demand” antibiotics be prescribed for every endodontic scenario. These 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 because of insufficient training or fear of litigation, then this is clearly an inappropriate use of antibiotics (9). Nonsurgical root canal therapy without antibiotics is usually adequate to treat cases of irreversible pulpitis, acute and chronic apical periodontitis, draining sinus tracts, and localized swellings (16). The pulpal circulation is compromised in these cases, and systemic antibiotics will not reach therapeutic concentrations in the pulp. Removing the source of the infection by performing nonsurgical root canal therapy will usually allow healing of any periradicular lesion or inflammation to occur. Analgesics are indicated for pulpitis pain and pain from periapical inflammation, not antibiotics (9, 16). Antibiotic therapy is an art and a science (9). There are so many confounding variables, such as suspected pathogen, ability to establish drainage, pharmacokinetic properties of the drug, mechanism of action of the antibiotic, virulence of the infection, the current health status of the host, and host defense mechanisms, that it is not possible to make antibiotic therapy into a mechanistic technological science (24). The most important decision for the dental practitioner to make is not which antibiotic to use but whether to use one at all. The prevalence of teeth with apical periodontitis amongst the Spanish population is high (25). Nonsurgical root canal treatment is the treatment of choice. Moreover, most of endodontic situations are resolved by nonsurgical endodontics and accompanying incision and drainage procedures when indicated (9). Spanish endodontists must take into account that, when the decision is made to use an antibiotic, it is important to adhere to basic principles 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 of antibiotic dosing: (a) use high doses for short durations; (b) use an oral antibiotic loading dose; (c) achieve blood levels of the antibiotic at 2 to 8 times the minimum inhibitory concentration; (d) use frequent dosing intervals; and (e) determine duration of therapy by remission of disease (12). However, it is important that not only the dental profession but the general public understand the importance of restricting the use of antibiotics to those true cases of severe infection that require them (1). The use of antibiotics for minor infections, or in some cases in patients without infections, could be a major contributor to the world problem of antimicrobial resistance. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 FIGURE LEGENDS Figure 1. Antibiotic survey sent to members of the AEDE. Figure 2. Distribution of respondents by Spain’s regions. Figure 3. Distribution of respondents by treatment duration. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 REFERENCES 1. Lewis MA. Why we must reduce dental prescription of antibiotics: European Union Antibiotic Awareness Day. Br Dent J. 2008; 205:537-8. 2. Sedgley CM, Lee EH, Martin MJ, Flannagan SE. 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Antibiotic prescribing over the last 16 years: fewer antibiotics but the spectrum is broadening. Eur J Clin Microbiol Infect Dis 2009; Feb 20. [Epub ahead of print]. 18. 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; discussion 648. 19. Whitten BH, Gardiner DL, Jeannsonne BG, Lemon RR. Current trends in endodontic treatment: report of a national survey. J Am Dent Assoc 1996; 127:1333–41. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 20. Wynn RL, Meiller TF, Crossley HL. Drug information handbook for dentistry. 6th ed. Hudson: Lexi-Comp, Inc., 2001. 21. Jaimes EC. Lincocinamides and the incidence of antibiotic-associated colitis. Clin Ther 1991;13:270–80. 22. Bahal N, Nahata MC. The new macrolide antibiotics: azithromycin, clarithromycin, dirithromycin, and roxithromycin. Ann Pharmacother 1992;26: 46–55. 23. Roche Y, Yoshimori RN. In-vitro activity of spiramycin and metronidazole alone or in combination against clinical isolates from odontogenic abscesses. J Antimicrob Chemother 1997; 40:353-7. 24. Pallasch TJ. Antibiotic myths and reality. J Cal Dent Assoc 1986; 14: 40–5. 25. Jiménez-Pinzón A, Segura-Egea JJ, Poyato M, Velasco E, Ríos JV . Prevalence of apical periodontitis and frequency of root-filled teeth in an adult Spanish population. Int Endod J 2004; 37:167-73. Table 1. Description of respondents Gender Male 62.9 % Female 37.1 % Age (yr) 25 - 35 57.1 % 35 - 45 7.2 % > 45 35.7 % Mean age (yr) 34 6 Academic degree DDS 62.9% MD (stomatologist) 28.5% MD+DDS 8.6% Time assigned to endodontics Full-time 21.4% Part-time (75-95%) 10.0% Part-time (50-75%) 24.3% Part-time (< 50%) 44.3% Table Table 2. Antibiotic preference in patients with no medical allergies. Antibiotic % Amoxicillin 500 mgr 20.3 750 mgr 15.2 1000 mgr 8.8 Amoxicillin / Clavulanic acid 500 / 125 mgr 15.2 875 / 125 mgr 26.6 Metronidazole / Spiramicyn 125 mgr / 750.000 UI 7.6 Clindamicyn 300 mgr 3.7 Azithromicyn 500 mgr 1.3 Other 1.3 Table Table 3. Antibiotic preference in patients with medical allergies. Antibiotic % Clindamicyn 300 mgr 63.2 Metronidazole / Spiramicyn 125 mgr / 750.000 UI 23.7 Erythromicyn 500 mgr 3.9 Lincomicyn 500 mgr 3.9 Azithromicyn 500 mgr 2.6 Other 2.6 Table