Antimicrobial the situations where antibiotics are prescribed, the

Antimicrobial
Resistance: Is it in the mind of Health Professionals? – A Cross Sectional
Study.

INTRODUCTION

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Antibiotics are widely
used, and they form an indispensible part of both prophylactic and treatment
modalities in documented as well as suspected infections.1 Dentists
prescribe medications for the management of a number of oral conditions, mainly
orofacial infections.2

Antibiotics should only
be prescribed on the basis of a defined need otherwise their use may present
more of a risk to the patient than the infection being treated or prevented.3

Rates of antimicrobial
resistance are growing worldwide, which is threatening public health and
increasing the morbidity, mortality and healthcare costs.4 The
principal factor behind the increase in resistance at a population and
individual level is antibiotic misuse and abuse.5 The results of
ecological studies have shown that the overuse of antibiotics at the population
leads to resistance.6 It is the stark reality across the globe,
including India. The challenges associated with controlling antibiotic
resistance, particularly in India, are many and multifaceted.12

However resistance to
antibiotics has been a rising global problem and modalities for preventing
resistance are being undertaken. The WHO theme on world Health Day 2011 has stated
“Combat Antimicrobial Resistance: No Action Today, No Cure Tomorrow.1

The WHO Global Strategy
defines ‘the appropriate use of antimicrobials as the cost-effective use of
antimicrobials which maximizes clinical therapeutic effect while minimizing
both drug-related toxicity and the development of antimicrobial resistance’.13

It is the duty of every
dentist to arrive at the correct diagnosis in order to avoid indispensible use
of antibiotics.1 With the increasing worldwide problem of
antimicrobial resistance and the threat to public health, there is a need to
rationalize the prescribing of antibiotics.7 Hence, this study
sought to assess the practice, attitude and knowledge of antimicrobial drugs
use amongst the prescribing dentists.

MATERIALS
AND METHODS

A cross sectional
survey using a structured validated questionnaire was done to
assess the knowledge, attitude, and practice. All the dental practitioners who
were willing to participate in the study were included and were asked not to
disclose their identity. The study was conducted after obtaining approval from
the Institutional Ethics Committee.

A total of 325
participants which included practicing dentists, postgraduate students and
interns participated in the study. The questionnaire included 9 questions to
assess the practice of antimicrobial drug use and 18 questions to assess the
attitude and knowledge of antimicrobial drug use. The questionnaire used a
simple format of multiple choice questions and the participants were requested
to tick the relevant choices.

The first part of the questionnaire
investigated the practice to assess the situations where
antibiotics are prescribed, the second part assessed in which clinical
conditions / situations antibiotics are prescribed and the third part assessed
the pharmacological and clinical knowledge of antibiotics and their use .The
questions on the knowledge and practice about antibiotics, in general, were
asked.

Statistical analysis
was done by using SPSS

RESULTS

Most of the
participants were prescribing antibiotics when patient did not want or could
not afford a test. Out of the three groups the 74.3% of post graduates were
doing antibiotic abuse by prescribing antibiotics in these conditions.

Similarly, 86.5% of
post graduates, 73.6% of interns and 64.2% of practitioners were prescribing
antibiotics just for speedy recovery of their patients.

Practitioners (97.6%), post
graduates (93.6%) and interns (84.7%) were not prescribing antibiotics when
patients insist on it. There was variation in results when the participants
were asked whether they were prescribing an antibiotic in situations in which
it is impossible for them to conduct a systematic follow-up of the patient as
more than 50% of interns and graduates were prescribing antibiotic in such
situations.

In case of doubt as to
whether a disease is of bacterial etiology; 55.65% interns, 47.4% post
graduates and 34.1% practitioners, thought that it is preferable to prescribe
an antibiotic.

73.6% of interns and 81.9%
of postgraduates think that is preferable to use a wide spectrum antibiotic to
ensure that the patient is cured of an infection. Most common antibiotic
prescribed by the participants was Amoxicillin followed by Metronidazole and
Augmentin.

78.2% of participants believed
that self-medication is the main cause of appearance of antibiotic resistance
whereas 28.8% of all the participants thought misuse by the clinicians to be
the main cause of antimicrobial resistance. Almost all the
participants strongly agreed that dispensing antibiotics without a prescription
should be more closely controlled.

The results in three
groups regarding prescription of antibiotics for different clinical entities
were also observed. 87.8% of practitioners, 86.1% of interns and 87.1% of post
graduates were prescribing antibiotics for acute periapical abscess; 70.7% of
practitioners, 87.5% of interns and 83.0% of post graduates were prescribing
antibiotics for chronic periapical abscess; practitioners (81.7% and 63.4%),
interns (79.2% and 80.6%) and post graduates (88.3% and 77.1%) were prescribing
antibiotics for acute periodontal abscess and chronic periodontal abscess respectively.

52.4% of practitioners
were not prescribing antibiotics for extraction whereas on the contrary, 87.5%
of interns and 82.5% of post graduates were prescribing antibiotics for
extraction; practitioners (91.5%), interns (95.8%) and post graduates (95.9%)
were prescribing antibiotics for surgical extraction.

68.9 % of participants were
not prescribing antibiotics for chronic generalized periodontitis.
Practitioners (79.3%), Interns and post graduates (88.9%) were prescribing
antibiotics for aggressive periodontitis.

Around 58.5% of
practitioners, 79.2% of interns and 78.9% of post graduates were prescribing
antibiotics for dental trauma. Practitioners (98.8%), interns (91.7%) and post
graduates (94.7%) strongly agreed in prescribing antibiotics for cellulitis.

When the knowledge was
evaluated 63.4% of participants believed that the methicillin resistant staphylococcus
aureus is also resistant to cephalosporins (practitioners- 72%, post graduates-
62.6% and interns- 55.6%).

84.6% of participants
said that the metronidazole is indicated for anaerobes and 61.5% of
participants were not prescribing gentamycin to patients with renal failure.

91.4% of participants
believed that combination therapy is more effective in treating infections.
54.8% of the participants were prescribing antibiotics for 3 days, 32.6% for 5
days followed by 11.4% for 7 days and 1.2% for more than 7 days.

The percentage mean
error in the practice of dental professional, interns and post graduates was
30.09 ± 2.02, 47.92 ± 2.79 and 47.14 ± 1.49 respectively. The percentage mean
error in the attitude of dental professional, interns and post graduates was
44.02 ± 1.90, 53.47 ± 2.79 and 47.14 ± 1.49 respectively.  The percentage mean error in the knowledge of
dental professional, interns and post graduates was 50.60 ± 2.71, 49.53 ± 1.77
and 44.73 ± 1.21 respectively.

When the results were
compared it was found that the P-value was statistically significant when the
practice and attitude of the dental professionals was compared whereas it was
statistically not significant for the knowledge of dental professionals.

                                         

                                            

              

DISCUSSION

Antibiotic resistance
has become a threat to public health and has posed a worldwide problem.
Evidence suggest that inappropriate prescribing practices by the dental
practitioners has been on the rise since few years and this could lead to the
issue of antibiotic resistance.8

Assessing knowledge and
attitude that guide antibiotic prescribing is an essential step when it comes
to keep a check on the worldwide growing problem of antimicrobial resistance.
Several scales have been developed to measure the factors associated with antibiotic
misuse worldwide but most of them have not been fully validated.4

Our results indicate
that fear of complications, complacency with patients, and insufficient
knowledge are the factors related with the prescribing of antibiotics by
general practitioners. In a recent study by Palmer et al in 2000, lack of time
and uncertainties of diagnosis were cited as reasons for antibiotic
prescribing.19

A study was conducted
by Rodrigues AT et al in 2016, to assess physicians’ attitudes and knowledge
of  antibiotic prescribing, antibiotic
use and antibiotic resistance, and the usefulness of different sources of
knowledge used in clinical practice and Intraclass correlation coefficients
(ICCs) for primary-care and hospital-care physicians were evaluated. The p- value
was < 0.001 amongst the two groups when they were asked whether in case of doubt, it is preferable to use a wide-spectrum antibiotic to ensure that the patient is cured of an infection. The similar results were found by Gonzalez C.G et al in 2015. 5 In the present study, majority of the participants believed self-medication to be the main cause of antibiotic resistance. According to Grigoryan et al in 2006,  self-medication was the main  factor involved in the development of antibiotic resistance.21 A study in Puducherry showed the prevalence as high as 71% (Balamurugan E et al in 2011) and  a study in urban Delhi showed that prevalence of self-medication among those who had suffered some illness episode in the last 1 month was 31.3% (Lal V et al in 2007).22 In a study by Vessal et al. in 2011, more than 40% of dentists responding to a questionnaire would inappropriately prescribe antibiotics for conditions for which antibiotics are not required according to good practice guidelines, and in which treatment via local measures would be adequate. The present study evaluated the knowledge and the attitude in prescribing the antibiotics for odontogenic infections. A considerable percentage of dental pain originates from acute and chronic infections of pulpal origin, which necessitates operative intervention, rather than antibiotics.2 The indications for antibiotics in acute dentoalveolar infections are well defined as signs of spreading infection, patient malaise, temperature elevation and lymphadenitis.9 There is no indication for prescribing antibiotics for acute pulpitis9 but in our study 87.1 % of the participants were prescribing antibiotics in the patients having acute periapical abscess. In 2013, Fedorowicz et al. conducted a systematic review and meta-analysis concluded that periapical abscess should be drained through a pulpectomy or incision and drainage and that the use of antibiotics was of no additional benefit in terms of the outcomes of pain or infection.6 Antibiotics may be required for patients presenting with acute necrotising ulcerative gingivitis; severe pericoronitis, rapidly progressing diffuse swelling involving fascial spaces, severe trismus (<20mm) and jaw osteomyelitis.14 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 via lymph and blood circulation with development of septicemia.2 Another aspect of antibiotic over prescribing is prescribing based on non-clinical factors. Patient's expectation of an antibiotic prescription convenience and demand necessitated by the social background of the patients are considered as the main unscientific reasons for antibiotic prescription.2 In our study, 63.4% dental professionals knew that methicillin resistant Staphylococcus aureus is also resistant to cephalosporins. In a study by Jacobson, J. J. et al in 1997, staphylococci from the oral cavity were all found to be susceptible to cephalosporins, although an older study reported the presence of methicillin-resistant S. aureus in the oral cavity (Rossi, T et aal in 1995).20 In our study, Amoxicillin was most commonly prescribed antibiotic followed by Metronidazole and Augmentin.  This explains that the majority of the participants used particular antibiotics to treat specific infections. Although 91.4% of the participants preferred broad spectrum antibiotics instead of narrow spectrum which is in contraindication to the above mentioned result which stated Amoxicillin was most commonly prescribed. This is similar to the results of a previous study by Palmer et al. and shows that amoxicillin and metronidazole are the antibiotics of choice as the majority (78%) of the prescriptions issued by a large population of National Health Service GDPs in England were for these two antibiotics.17 Lewis et al have shown that only 5% of the main isolates from dental abscesses are resistant to amoxicillin/clavulinic acid. 2 The duration of prescribing antibiotics has never been described precisely. In our study, 54.8% of dental professionals were prescribing antibiotics for 3 days, followed by 32.6% for 7 days and 11.45% for 5 days. A survey in Canada found that the average duration of antibiotic use prescribed by dentists is 6.92 days.2 Another survey in the USA found that endodontists prescribe antibiotic use for an average of 7.58 days.2 Recent studies on the attitudes of dentists in the Eastern Mediterranean region showed that dentists preferred to prescribe a lower dosage of an antibiotic over a longer period.2 The most effective use of prophylactic antibiotics is in short term, high dosage regimens that are active against the common pathogens.3 There is no evidence that continuing prophylactic antibiotics beyond surgery (operative intervention) reduces the risk of infection.16 However, in recent years, more attention has been given to short courses. As explained by Rubenstein short-course antibiotic therapy requires those antibiotics which have certain characteristics, such as: rapid onset of action, bactericidal activity, lack of propensity to induce resistant mutants, easy penetrability into tissues, activity against non-dividing bacteria, not being affected by adverse infection conditions (low pH, anaerobiasis, presence of pus, etc.), administration at an optimal dose, and optimal dosing regimen.10 WHO guidelines state that antibiotics such as amoxicillin 500 mg should be prescribed twice daily for at least 5 days and metronidazole 500-750 mg three times daily for 7 days (WHO, 1979). According to the British National Formulary (Ahmed-Jushuf et al., 2009), co-amoxiclav 250 mg every 8 hours should be prescribed, which is doubled for severe dental infections or dental infection not responding to ?rst-line antibacterial treatment and 125 mg every 8 hours for children up to 10 years which is doubled in severe infections.18 The relatively relaxed regulation on antibiotics without prescription worsens the scenario.1 In addition to the proper dosing regimens and professionally responsible prescribing practice, the general public needs to be educated about the importance of restricting the use of antibiotics to only cases of severe infection.8  Indian Network for Surveillance of AMR started in 2009 which included Policy makers and planners, Pharma industry, Pharmacists and dispensers, Physicians and prescribers, Public patient/civil society and media.15 Dental patients not only pressurize their dentists to get an antibiotic prescription, they also self-medicate, which is found alarmingly high in some developing countries.8 CONCLUSION In conclusion, we found poor attitude, knowledge and practice regarding antimicrobial use in dentistry thereby increasing the risk of antimicrobial resistance. Prescribing antibiotics should be done with caution and care. A fundamentally changed view of antibiotics is required. The prescribing practices of dentists can be improved by increasing awareness among dental practitioners of the recommended guidelines.