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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 109-113

Antibiotic prescription pattern among dentists in Imphal city of North East India: A cross-sectional survey study


1 Department of Periodontology, Dental College, JNIMS, Imphal, Manipur, India
2 Department of Oral Medicine and Radiology, Dental College, JNIMS, Imphal, Manipur, India
3 Department of Periodontology, Sri Rajiv Gandhi College of Dental Science and Hospital, RGUHS, Bengaluru, Karnataka, India
4 Department of ENT, Shija Academy Of Health Science, Imphal, Manipur, India

Date of Submission06-Sep-2021
Date of Decision21-Oct-2021
Date of Web Publication11-Feb-2022

Correspondence Address:
Dr. Bebika Devi Thoudam
Department of Periodontology, Dental College, JNIMS, Imphal East - 795 005, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_24_21

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  Abstract 


Background: Antibiotics are a subject of intensive abuse due to overprescription and also administration for inappropriate reasons. In India, some studies have reported the use and abuse of antibiotic therapy and their consequential impact on antibiotic resistance. However, there has been no study yet on the use of antibiotics among dentists in North East India.
Objective: To determine the rationale and prescription pattern of antibiotics among dentists of Imphal city in North East India.
Materials and Methods: A self-administered questionnaire was used. The questionnaire consisted of demographic data and comprised questions related to the use of antibiotics for various dental procedures and in certain clinical situations.
Results: The results of this survey indicate that there is wide spectrum of antibiotics prescribed by dentists in Imphal city. Amoxicillin was clearly the choice of antibiotic among dentists. Although the dentists handpicked antibiotics based on its efficacy and side effects, at certain places these drugs were overtly used. Majority of the respondents thought that antibiotic sensitivity tests would help them choose the right antibiotic.
Conclusion: The prescription pattern for antibiotics was inconsistent and at times inappropriate. A standard guideline needs to be formulated according to the population for prescribing antibiotics; because when used judiciously antibiotics are lifesaving.

Keywords: Antibiotics, dental practice, prescription pattern


How to cite this article:
Thoudam BD, Santosh H N, Bose A, Singh MN. Antibiotic prescription pattern among dentists in Imphal city of North East India: A cross-sectional survey study. Int J Oral Health Sci 2021;11:109-13

How to cite this URL:
Thoudam BD, Santosh H N, Bose A, Singh MN. Antibiotic prescription pattern among dentists in Imphal city of North East India: A cross-sectional survey study. Int J Oral Health Sci [serial online] 2021 [cited 2022 May 24];11:109-13. Available from: https://www.ijohsjournal.org/text.asp?2021/11/2/109/337498




  Introduction Top


Antibiotics are used extensively in dentistry for two main reasons: To prevent infection (chemoprophylaxis) and in the treatment of an infection. However, they are also the subject of intensive abuse, both overprescription and also injudicious use in certain conditions. This has contributed to the worldwide problem of bacterial resistance. Dentists prescribe between 7% and 11% of all common antibiotics (beta-lactams, macrolides, tetracycline, clindamycin, and metronidazole). The National Center for Disease Control and Prevention estimates that approximately one-third of all outpatient antibiotic prescriptions are unnecessary.[1] Dentistry's impact on the development of antimicrobial resistance is not known at present, but researchers are beginning to look at this question. Our contribution is difficult to determine, as there are currently no accurate data available in India on the number of prescriptions for antibiotics being written by dentists. However, it is already recognized that dentists must use antibiotics judiciously. Orofacial infections must be treated with local drainage whenever possible. Antibiotics should be considered adjuncts to treatment when there are signs of systemic involvement such as extraoral, neck, or intraoral airway swelling, or fever. Antimicrobials are not the primary treatment for dental infections, except in the case of primary spreading cellulitis.[2]

In India, some studies have reported the use and abuse of antibiotic therapy and their consequential impact on antibiotic resistance. However, no such information is available on the use of antibiotics among the dental practitioners in North East India. There could be many reasons for this lack of data in this part of India. First, the availability of dentists in this region to date, second, a system to collect data in a structured manner. Imphal is one of the largest cities of North East India with a population of around 4–5 lakhs. The number of practicing dentists is significantly high in this region with an average of 300 registered dentists.

The present study was an effort to know the prescription pattern of antibiotics for various dental procedures by dental practitioners in Imphal city. Besides, the study explored possible variations in prescription patterns due to academic qualifications. The study also probed various issues related to antibiotic allergy, dental conditions which require antibiotic coverage, preferences while choosing the Antibiotics, and nonclinical factors governing the use of antibiotics.


  Materials and Methods Top


The present study is a cross-sectional survey, study to determine the antibiotic prescribing practices among dentists in Imphal city. All the dentists included in the study were personally interviewed at their workplace and were asked to fill a questionnaire. A detailed questionnaire was drafted, recording all relevant general information, and specific information related to antibiotic prescribing patterns. The sampling methodology adopted was the convenience sampling.

A self-administered questionnaire was used. The questionnaire consisted of demographic data i.e., name, age, gender, and qualification. The second part comprised questions related to the use of antibiotics for various dental procedures and certain clinical situations, use of antibiotics in inflammatory lesions, antibiotic usage during the presence of certain clinical signs, commonly used antibiotics, preference for monotherapy, or combination therapy. Questions were asked pertaining to dosage of antibiotics (for adults and children), when and why to change antibiotic, nonclinical parameters affecting antibiotic prescription, and antibiotic allergy. The questions covered the use of culture and sensitivity tests and follow-up of patients on antibiotics. The statistical analysis was done by calculating the percentages with help of MS Office 2007.


  Results Top


[Table 1] clearly shows that majority of them preferred to prescribe antibiotic as preprocedural prophylaxis in cardiac and other medical conditions followed by root canal treatment (RCT) in adults. Although there was a high predilection on prescribing antibiotics for pulp and periapical pathology and periodontal diseases. However, there was lack of enthusiasm to prescribe antibiotics for dry socket and cellulitis.
Table 1: Prescription pattern at different clinical procedures expressed as percentage of dentists preferring to prescribe antibiotics

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On being asked the question about the absolute necessity of prescribing antibiotics, majority believed antibiotics are prescribed in an event of extraoral swelling, fever, and trismus. [Table 2] depicts the instances where antibiotics are deemed necessary pain and infection was the second major reason to prescribe antibiotics.
Table 2: Percentage of antibiotic prescription in various clinical conditions

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On being asked the question if monotherapy was preferred or combination therapy, majority of the respondents preferred combination therapy. [Table 3] shows that amoxicillin is the most preferred antibiotic followed by a combination of amoxicillin and metronidazole and amoxicillin and cloxacillin. Long-term regimen of antibiotic prescription was opted by majority of the respondents i.e., a dose of 500 mg TID for 5 days and a second majority of respondents preferred 400 mg TID dose 5 days for metronidazole.
Table 3: Preferred choice of anitbiotics

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For the antibiotic prescription for pediatric patients, respondents preferred the 250 mg TID 5 days dose regimen for amoxicillin and 200 mg BD 5 days for metronidazole. Some of respondents preferred the short-term regimen of 250 mg TID 3 days for amoxicillin and 200 mg BD 5 days for metronidazole. Doxycycline was not preferred by respondents. The most common reason for the dentist to shift to parenteral route of administration was when the infection did not subside. The most common cause for changing the antibiotic was cited to be when infection did not subside and only attributed the change to patient noncompliance.

[Table 4] shows the most common parameter kept in view before prescribing antibiotic was efficacy followed by side effects. The most common nonclinical factor influencing antibiotic therapy was when treatment had to be postponed. This was followed by uncertainty of diagnosis. In the event of antibiotic allergy, respondents preferred to stop the medication. However, only a few respondents preferred to stop the medication and refer to a physician as compared. On being asked the question of whether the respondents were able to choose the appropriate antibiotic after culture and sensitivity test, a vast majority agreed that culture, and sensitivity helped them choose the antibiotic. Majority of the dentists rated the follow-up of patients after administering antibiotic to be moderate i.e., patients who returned on second episode of pain.
Table 4: Parameters affecting choice of antibiotics

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  Discussion Top


In our study, a total of 90 dentists in Imphal city were interviewed. The results of this survey indicate that there is wide spectrum of antibiotics prescribed by dentists in Imphal. The results of this study would be relevant as a large population of the dentists has been covered for the first time in a North Eastern state of India.

This study showed that most of the dentists prescribed antibiotics after extractions in adults. However, antibiotic prescription after RCT was also a common situation.

The common practice of prescribing antibiotics postextraction has minimal effect, as bacteremia would have occurred as a result of extraction and the defense mechanism can cope with healing process.[3] Antibiotic prophylaxis for the prevention of surgical infections is only effective if the drug is in the system before the procedure begins and then only in clean surgery, where the drug is discontinued shortly after the surgery is completed.[4]

Most of the dentists preferred performing RCT under antibiotic cover.[5] This result corroborates with our results where a majority of respondents preferred to perform RCT under antibiotics. However, the fact of the matter remains that antibiotic prescription should only be adjunctive and not a substitute for root canal debridement.[6]

Facial cellulitis that may or may not be associated with dysphagia, is a serious disease that should be treated by antibiotics promptly because of the possibility of infection spread through lymph and blood circulation, with development of septicemia.[7] Pulp and periapical pathologies do not warrant for an antibiotic course unless there is evidence of gross local spread or inability to establish drainage.[7] However, in our study, majority of the BDS respondents were prescribed antibiotics.

Surprisingly, 80% of the patients with dry sockets are on antibiotic cover.[3] However, the respondents in our study were not enthusiastic in prescribing antibiotics for a clinical situation like dry socket. The antibiotics were prescribed keeping in view that postextraction healing would be uneventful. A clinical situation of reimplantation of teeth attracted some of the respondents. Local application of an antibiotic to the root surface of an avulsed tooth with an open apex and Less than 6 minutes extraoral dry time is recommended.

Systemic antibiotics have been recommended as adjunctive therapy for avulsed permanent incisors. Tetracycline is the drug of choice. However, keeping in view the risk of tooth discoloration, penicillin V is administered.[8] Although the empirical use of some antibacterial agents in various inflammatory diseases has proved beneficial in the past, it is only recently that the therapeutic anti-inflammatory potential of cyclines and macrolides has received attention worldwide.[9] A similar view echoed in our study where a majority felt antibiotics have anti-inflammatory effects. Most practitioners preferred to give antibiotics in case of spreading infections, malaise, elevation of temperature, and lymphadenitis.[10] A similar view echoed in our study where majority preferred to give antibiotics during similar clinical features. An overwhelming combination of amoxicillin and metronidazole is being prescribed as per our study. This is in contrast to the guidelines published by the Commission of the Federation Dentaire Internationale which recommends to avoid combination therapy.[11]

This recommendation was prompted by the wide variation in frequency and duration of antibiotic course and dose, with only 8.2% of prescriptions for penicillin V as recommended by Dental Practitioner's Formulary for most infections. Amoxicillin is the preferred drug.[10],[12] The most commonly used antibiotic in dental practice. Penicillin in general was most commonly prescribed. Penicillin is still the gold standard in treating dental infections. Among the group of penicillin, penicillin V, and amoxicillin with clavulinic acid have been advocated for use in odontogenic infections. However, there are no differences in clinical outcome between penicillin V or amoxicillin.[7] A two dose of 3 g regimen of amoxicillin has been shown to be effective. Oral antibiotic use for 2–3 days has been advocated for the treatment of acute dentoalveolar infections and in dose recommended by the British National Formulary. Short antibiotic therapy requires antibiotics to have rapid onset of action, easy penetrability into tissues, and survival at low temperatures.[12] However, contrastingly majority of the respondents in our study preferred a long-term regimen for prescribing antibiotics. The prescription pattern for the pediatric population was the same as that of adults except for the dose and that tetracycline was not preferred by anyone. Tetracyclines are of limited use and can cause alteration of tooth color and must not be used in children below 8 years, pregnant, or nursing mothers. As per the basic principles of antibiotic administration, a switch from oral to parenteral is considered when the infection does not subside. A similar opinion was reflected in our study. Certain serious infections such as bacterial meningitis and neutropenic sepsis require IV antibiotics for the full period of treatment. Patient noncompliance is the greatest impediment in practicing good antibiotic prescription patterns. In a study conducted in 11 countries among 4514 adults, 22.3% (912/4088) admitted noncompliance.[12] Nonclinical factors influencing antibiotic prescription include patients' expectation of an antibiotic prescription, convenience, and demand necessitated by the social background of the patients.[12] Although these are unscientific reasons, yet followed.

Eastern Mediterranean region has shown tendency to prescribe on patient's demand, especially when short of time.[7] There are other nonclinical factors influencing antibiotic prescription, like some doctors practice prescribing antibiotics to any patient with fever presuming it to be a bacterial infection. Furthermore, incentives for the pharmacist to make profit from drug sales and lack of knowledge among the public contributes to these. According to the WHO recommendation in 2001 (antibiotic resistance: Synthesis of recommendations by expert policy groups Alliance for Prudent Use of Antibiotics), culture and sensitivity tests are surveillance tools which can be used to treat patients, to update treatment guidelines and to observe, monitor, as well as contain local spread of resistant strains.

A similar opinion was reflected in our study, where 88% of the respondents believed antibiotic sensitivity test helped them in choosing the appropriate antibiotic. In an event of antibiotic allergy, definitive treatment involves cessation of the suspected antibiotic.[12] A similar opinion is reflected in our study. In certain instances, where antibiotic is required because there are no alternatives (e.g., infection with multiresistant organisms or when alternative drugs are costly) drug desensitization can be carried out. Desensitization is a method of reintroducing antibiotics into highly sensitized patients to induce tolerance.


  Conclusion Top


The results of the present study have demonstrated a lack of uniformity in the rational use of antibiotics among the dentists in Imphal city. The key outcomes from this survey study are as follows:

  1. Amoxicillin was the antibiotic of choice
  2. Although dentists handpicked antibiotics based on its efficacy and side effects, at certain places these drugs were overtly used, for example, after extractions and endodontic treatment. This adds to the menace of antibiotic resistance
  3. Majority of the respondents believed that culture and sensitivity tests would help them choose the appropriate antibiotic
  4. Although the nonclinical factors should not have any binding on the prescription pattern, still, a majority was influenced by it.


Appropriate and correct use of antibiotics is essential to ensure that effective and safe treatment is available. To improve standards of care, dentists need to be up to date in their knowledge of pharmacology and should lay stress on evidence-based practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cleveland JI, Kohn WC, Antimicrobial resistance and dental care: A CDC perspective. Dent Abstr 1998;108.  Back to cited text no. 1
    
2.
Swift JQ, Gulden WS. Antibiotic therapy – Managing odontogenic infections. Dent Clin North Am 2002;46:623-33, vii.  Back to cited text no. 2
    
3.
Murali R. Controlled Clinical Trial to understand the need for antibiotics during routine dental extractions. E J Dent 2011; 82:13-6.  Back to cited text no. 3
    
4.
Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontol 2000 1996;10:107-38.  Back to cited text no. 4
    
5.
Goud SR, Nagesh L, Fernandes S. Are we eliminating cures with antibiotic abuse? A study among dentists. Niger J Clin Pract 2012;15:151-5.  Back to cited text no. 5
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6.
European Society of Endodontology. Quality Guidelines For Endodontic Treatment: Consensus Report of The European Society of Endodontology. Int Endod J 2006;39:921-30. doi:10.1111/j.1365-2591.2006.01180.x.PMID:17180780.  Back to cited text no. 6
    
7.
Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. Antibiotic prescribing practices by dentists: A review. Ther Clin Risk Manag 2010;6:301-6.  Back to cited text no. 7
    
8.
Peedikayil FC. Antibiotics: Use and misuse in pediatric dentistry. J Indian Soc Pedod Prev Dent 2011;29:282-7.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Labro MT. Antibiotics as anti-inflammatory agents. Curr Opin Investig Drugs 2002;3:61-8.  Back to cited text no. 9
    
10.
Palmer NO, Martin MV, Pealing R, Ireland RS, Roy K, Smith A, et al. Antibiotic prescribing knowledge of National Health Service general dental practitioners in England and Scotland. J Antimicrob Chemother 2001;47:233-7.  Back to cited text no. 10
    
11.
Samaranayake LP, Johnson NW. Guidelines for the use of antimicrobial agents to minimise development of resistance. Int Dent J 1999;49:189-95.  Back to cited text no. 11
    
12.
Palmer NA, Pealing R, Ireland RS, Martin MV. A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J 2000;188:554-8.  Back to cited text no. 12
    



 
 
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