To premedicate or not to premedicate? The next chapter

I published an article in RDH magazine in 2014 that examined the science and research related to the correlation between the use of antibiotics as a preventive premedication and the occurrence of Clostridium difficile (C. diff).1 We learned a lot from the studies that were going on at that time:

• 94% of all C. diff is related to health care in some way, and that includes dental care.



• A majority of those at risk from this possibly deadly diarrheal infection have taken antibiotics and have received medical care in any setting.



• C. diff is linked to about 15,000 American deaths annually.2



• The risk of patients getting C. diff is increased seven- to tenfold while they’re taking antibiotics, and during the month following discontinuation. Even after two months, the risk continues to be two- to threefold.3

According to the Centers for Disease Control and Prevention (CDC), Clostridium difficile is a spore-forming, gram-positive, anaerobic bacillus. This big boy produces exotoxins toxin A and toxin B. It is found to be associated with antibiotics 15% to 25% of the time, so it is called antibiotic-associated diarrhea (AAD). It accounts for 15% to 25% of all episodes of AAD.1 This impacts the gastrointestinal flora, wiping out both good and bad bacteria. This allows the overgrowth of C. diff when the bacteria that fights it off is no longer present. This can lead to severe diarrhea and eventual death.

Dentistry is not static, and it is vital for all of us to stay up-to-date on the latest research. I can hardly wait every year to see what is happening at the annual meeting of the Infectious Diseases Society of America (IDSA). At this year’s meeting we received further confirmation on C. diff and its relationship to antibiotic stewardship.

Researchers presented findings confirming the role dentistry plays in the prevalence of Clostridium difficile. The continued unnecessary prescription of antibiotics by dentists has had strong correlations to C. diff. It was reported at the meeting that dental professionals are prescribing a lot of antibiotics and it has not slowed. Stacy Holzbauer, DVM, MPH, lead author of the study and career epidemiology field officer for the CDC and MDH, said in a statement, “It’s important to educate dentists about the potential complications, including C. diff, of antibiotic prescribing.” She continued, “Dentists have written more than 24.5 million prescrip tions for antibiotics a year. That’s a staggering number!”

‘Dentists have written more than 24.5 million prescriptions for antibiotics a year. That’s a staggering number!’

The meeting reported that studies have continued. Tracking by the Minnesota Department of Health (MDH) looked to see what factors beyond hospital or nursing home stays were connected with acquiring C. diff. They tracked community-associated C. diff infections in 1,626 people between 2009 and 2015. They followed five counties in Minnesota over a six-year period. The common factor in 15% of the cases was that they had been given premedication antibiotics for dental procedures.

Four other important findings from the study were:

• 926 (57%) of the respondents reported they had been prescribed antibiotics. Of those, 136 (15%) were for dental treatment.



• 34% of the medical charts of these patients included no mention of premedication being used for dental procedures.



• 36% of dentists were prescribing unnecessary premedication. Their patients did not fall within the recommendations from the American Dental Association (ADA) or the American Heart Association (AHA). The report revealed that many professionals are challenged or confused about the need to premedicate. (For updated recommendations, see AAPD.org, and ADA.org.) These documents state that premedication for many medical conditions is no longer recommended.



• Patients who were prescribed antibiotics for dental procedures tended to be older and more likely to receive clindamycin, an antibiotic that is associated with C. diff.

The ADA made a strong statement about the use of antibiotics in its guidelines. There is a place for antibiotics in dentistry. It is appropriate to use them when treating an infection such as a root or periodontal abscess. Based on a very careful review of scientific findings and literature:

• Dental procedures are not associated with prosthetic joint implant infections, and antibiotics given before dental procedures do not prevent such infections.



• For most people, the known risks of taking antibiotics may outweigh the uncertain benefits. Risks related to antibiotic use include nausea, upset stomach, and allergic reactions, including anaphylactic shock. Other risks include developing antibiotic resistance in bacteria, which can complicate treatment of infections such as strep throat, pink eye, and meningitis, as well as increasing the risk of C. diff.4



• Patients over 70 years of age are at an increased risk of experiencing adverse reactions to some antibiotics.

It is clear that reducing antibiotic use for outpatients such as dental patients can impact the rate of community-acquired C. diff, creating a major impact on patients. Here are three things you can do as a health-care provider:

• Prescribe medications only when needed.



• Stay up-to-date on the guidelines regarding the need for premedication.



• Communicate with other health-care providers regarding the need for and use of premedication for your patients. Make patients’ health-care providers aware if antibiotic premedication is being used.

NOEL BRANDON KELSCH, RDH, RDHAP, MS, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists’ Association.

References

1. Kelsch N. Clostridium difficile and dentistry. January 15, 2014. RDHmag website.http://www.rdhmag.com/articles/print/volume-34/issue-1/columns/clostridium-difficile-and-dentistry.html. Accessed November 12, 2017.

2. Clostridium difficile infection. CDC website. http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html. Accessed November 12, 2017.

3. Frequently asked questions about Clostridium difficile for health-care providers. CDC website. http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a1. Accessed November 12, 2107.

4. Antibiotic prophylaxis prior to dental procedures. ADA website. http://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis. Accessed November 12, 2017.