Open Forum Infectious Diseases MAJOR ARTICLE Use of Antibiotic Prophylaxis for Tooth Extractions, Dental Implants, and Periodontal Surgical Procedures 1,2 3 3 1,4 1,5 Katie J. Suda, Heather Henschel, Ursula Patel, Margaret A. Fitzpatrick, and Charlesnika T. Evans 1 2 Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. Veterans Affairs Hospital, Illinois; Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at 3 4 5 Chicago; Pharmacy Service, Edward Hines, Jr. Veterans Affairs Hospital, Illinois; Department of Medicine, Loyola University Stritch School of Medicine, Maywood, Illinois; and Department of Preventive Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois Background. Guidelines for antibiotics prior to dental procedures for patients with specific cardiac conditions and prosthetic joints have changed, reducing indications for antibiotic prophylaxis. In addition to guidelines focused on patient comorbidities, sys- tematic reviews specific to dental extractions and implants support preprocedure antibiotics for all patients. However, data on dentist adherence to these recommendations are scarce. Methods. This was a cross-sectional study of veterans undergoing tooth extractions, dental implants, and periodontal procedures. Patients receiving antibiotics for oral or nonoral infections were excluded. Data were collected through manual review of the health record. Results. Of 183 veterans (mean age, 62 years; 94.5% male) undergoing the included procedures, 82.5% received antibiotic prophylaxis (mean duration, 7.1 ± 1.6 days). Amoxicillin (71.3% of antibiotics) and clindamycin (23.8%) were pre- scribed most frequently; 44.7% of patients prescribed clindamycin were not labeled as penicillin allergic. Of those who received prophylaxis, 92.1% received postprocedure antibiotics only, 2.6% received preprocedural antibiotics only, and 5.3% received pre- and postprocedure antibiotics. When prophylaxis was indicated, 87.3% of patients received an antibiotic. However, 84.9% received postprocedure antibiotics when preprocedure administration was indicated. While the majority of antibiotics were indicated, only 8.2% of patients received antibiotics appropriately. The primary reason was secondary to prolonged duration. Three months postprocedure, there were no occurrences of Clostridium difficile infection, infective endocarditis, prosthetic joint infections, or postprocedure oral infections. Conclusion. e m Th ajority of patients undergoing a dental procedure received antibiotic prophylaxis as indicated. Although patients for whom antibiotic prophylaxis was indicated should have received a single preprocedure dose, most antibiotics were pre- scribed postprocedure. Dental stewardship efforts should ensure appropriate antibiotic timing, indication, and duration. Keywords. antibiotic prophylaxis; dental implant; dentist; periodontal surgery; tooth extraction. Antibiotic resistance, driven by antibiotic prescribing, is one of . In fact, transient bacteremia from dental procedures has the most serious health threats facing the world today , and been estimated to occur at rates similar to those of daily oral approximately 30% of antibiotics prescribed in primary care health activities [8–11]. In addition, unnecessary use of anti- settings are considered unnecessary [2, 3]. Dentists prescribe biotics can have serious adverse drug events, including allergic 10% of all antibiotics in the community, ranking fourth aer ft reactions, bacterial resistance, and Clostridium difficile infection family practitioners, pediatricians, and internists [4, 5]. While (CDI). Use of antibiotics for short durations for dental infec- the indication for the majority of dental antibiotics is for infec- tion prophylaxis has been associated with CDI . In a popula- tion prophylaxis , appropriateness of dental prescribing of tion-based study of the epidemiology of community-associated antibiotics for prophylaxis prior to a dental procedure has not CDI, dental antibiotic prophylaxis was one of the most common been determined in the United States. indications for antibiotics, second only to upper respiratory Current evidence indicates that antibiotics administered tract infections . prior to most dental procedures lack a clear benefit and that Guidelines from the American Heart Association (AHA) and the American Academy of Orthopaedic Surgeons (AAOS) for when antibiotics are not given, the risk of infection is minimal antibiotic prophylaxis prior to dental procedures were changed in 2007 and 2013, respectively, secondary to a lack of evidence Received 24 July 2017; editorial decision 7 November 2017; accepted 13 November 2017. to support the utility of antibiotic prophylaxis in preventing Correspondence: K. J. Suda, PharmD, MS, Center of Innovation for Complex Chronic infective endocarditis or prosthetic joint infections [8, 13–16]. Healthcare, Edward Hines, Jr. Veterans Affairs Hospital, 5000 South 5th Avenue, Hines, IL uTh s, the AHA and AAOS guidelines significantly revised 60141 (email@example.com). Open Forum Infectious Diseases their recommendations for preprocedure infection prophy- Published by Oxford University Press on behalf of Infectious Diseases Society of America 2017. laxis. Guidelines for the use of antibiotics for infective endo- This work is written by (a) US Government employee(s) and is in the public domain in the US. carditis prophylaxis prior to dental procedures recommend the DOI: 10.1093/ofid/ofx250 Dental Antibiotic Prophylaxis • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/1/ofx250/4633784 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Definitions of Appropriateness of Infection Prophylaxis use of antibiotics in patients with specific cardiac conditions Appropriate infection prophylaxis prescribing was defined using undergoing certain dental procedures . Cardiac conditions various recommendations. First, appropriate infective endocar- for which prophylaxis is indicated include a prosthetic cardiac ditis and prosthetic joint infection prophylaxis were based on valve, prosthetic material used for a cardiac valve repair, his- recommendations from the AHA/ADA (for cardiac conditions) tory of infective endocarditis, specific congenital heart defects, and AAOS/ADA (for prosthetic joints) [8, 13]. Infective endo- and cardiac transplant patients who develop cardiac valvulopa- carditis prophylaxis was considered appropriate if the patient thy . Prophylaxis should be recommended in these patients met the criteria as defined in the AHA guidelines. These crite- undergoing dental procedures that involve manipulation of gin- ria include the patient having an appropriate cardiac condition, gival tissue or the periapical region of teeth or perforation of dental procedure, and a single dose of an antibiotic adminis- the oral mucosa (such as extractions and implants). Following tered 1 hour before the procedure (“preprocedure”) without a the AHA/ADA guidelines, in 2013 and 2016, the AAOS/ADA postprocedure antibiotic . Appropriate cardiac conditions recommended discontinuing the practice of routinely prescrib- comprise diagnoses prior to a dental procedure including in- ing antibiotics for patients with hip and knee prosthetic joint fective endocarditis, congenital heart disease, prosthetic cardiac implants undergoing any dental procedure [13, 14]. valve/material, and cardiac transplant with cardiac valvulopa- However, data on the appropriateness of prescribing since thy . In patients with the aforementioned cardiac conditions, these updated guidelines were published are scarce. Thus, the appropriate dental procedures include those that involve gin- primary objective was to determine if dental antimicrobial gival manipulation or mucosal incision (which included tooth prophylaxis at a VA dental clinic was in accordance with guide- extractions, dental implants, bone and gum grafting, scaling, lines. Secondary objectives were to evaluate the use of post- and root planing). Antibiotic prescribing for prosthetic joint procedure antibiotics and to identify any adverse effects that infection prophylaxis was defined as inappropriate (in the ab- may be associated with the antibiotics 3 months postprocedure. sence of another indication) [13, 14]. METHODS Second, a subset of dental procedures potentially at high risk for infection (tooth extractions, dental implants) was con- Study Design, Setting, and Population sidered separately from patient comorbidities. In the absence This study was a cross-sectional study of antibiotic use in of national guidelines, systematic reviews by the Cochrane patients 18 years of age and older receiving dental procedures at Collaboration were used to formulate the definition for appro- a Department of Veterans Affairs (VA) dental clinic located in a priateness of antibiotic prescribing for tooth extraction and im- VA medical center from January 1, 2015, through December 31, plant placement [17, 18]. Regardless of the patient’s history of 2015. The dental procedures evaluated included tooth extrac- cardiac conditions or prosthetic joint implant, preprocedural tions, dental implants, and periodontal procedures (bone and antibiotic prophylaxis was considered appropriate adminis- gum grafting; scaling and root planing). These procedures tered 1 hour prior to tooth extraction and implant placement were selected because they are the most common procedures (without postprocedure antibiotic prophylaxis) . Antibiotic performed in the study clinic and entail manipulation of the prophylaxis for bone grafting, gum grafting, scaling, and root gingival tissue or the periapical region of the teeth or perforate planing was considered inappropriate. the oral mucosa, as stated in the AHA/ADA guidelines . In Secondary outcomes include serious antibiotic-related ad- the case of a patient receiving multiple procedures at different verse effects (allergic reactions, CDI), infective endocarditis, visits, only the first dental procedure meeting the inclusion prosthetic joint infections, and postprocedural infections. criteria that occurred during the study period was assessed. Secondary outcomes were evaluated three months postproce- Postoperative follow-up visits and preventative visits (eg, rou- dure by review of laboratory results, inpatient notes, medical tine dental cleanings) were not included. Patients were excluded clinic notes, and dental clinic notes. if they were receiving antibiotics for a separate indication (eg, urinary tract infection or extra-oral infection). Statistical Analyses e den Th tal clinic provided a list of patients who received SAS 9.3 (SAS, Inc; Cary, NC) was used for statistical analyses. tooth extractions, dental implants, and periodontal procedures. For categorical data, a chi-square or Fisher exact test was applied This list was screened for inclusion and exclusion criteria and as appropriate. The Student’s t test was used for continuous data. proceeded to full review of the electronic health record where A P value ≤0.05 was considered statistically significant. appropriate. The systematic chart review involved the use of a RESULTS standardized data collection tool. Variables collected include patient characteristics, past medical history, pharmacy records, Over the 1-year study period, a total of 183 unique veterans laboratory information, and hospital, medical clinic, and dental met the inclusion criteria and were included in the analysis. Of clinic encounter data. Data were entered into a secure relational the excluded patients (n = 24), 58.3% did not undergo a pro- database for analysis. cedure, 25.0% had an oral infection, 12.5% had an extra-oral 2 • OFID • Suda et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/1/ofx250/4633784 by Ed 'DeepDyve' Gillespie user on 16 March 2018 infection, and 4.2% had a follow-up appointment. The average some type of antimicrobial prophylaxis (preprocedure and/or age of the patients was 62.0 years, 94.5% of the patients were postprocedure). However, 84.9% (n = 141) received postproce- male, and 71.0% were white (Table 1). The most common den- dure antibiotics for a mean of 7.2 days when only preprocedure tal procedure was tooth extraction, followed by periodontal administration was indicated. Only 8.2% of the 183 patients surgeries (Table 1). received antibiotics appropriately based on administration time, The majority (82.5%, n = 151) of patients undergoing procedure, and comorbidities; 6.0% (n = 11) did not receive dental procedures received 160 antibiotic prescriptions for antibiotics when none were indicated, and 2.2% (n = 4) received prophylaxis. Amoxicillin and clindamycin were prescribed preprocedure antibiotics appropriately without postprocedure most frequently for infection prophylaxis (71.3% and 23.8% antibiotics. of antibiotic prescriptions, respectively). The other antibi- Of the 12 patients who received preprocedure antibiotics otics prescribed for dental procedures included amoxicil- (alone and/or in combination with postprocedure antibiotics), lin-clavulanate (3.1%), azithromycin, metronidazole, and all received a tooth extraction or dental implant, appropriate trimethoprim-sulfamethoxazole (each <1%). Almost half of indications for antibiotics. Five (41.7%) of the preprocedure patients (44.7%) prescribed clindamycin did not have a pen- antibiotic patients also had a cardiac indication for preproce- icillin allergy noted. The mean duration of antibiotics was dure infective endocarditis prophylaxis; all were appropriately 7.1 ± 1.6 days (1–14 days), where the majority of patients prescribed an antibiotic prior to the dental procedure. All received a 7-day supply (82.5%). patients with a prosthetic joint in the cohort (n = 9) also under- Of the 151 patients who received antibiotic prophylaxis, went an implant/extraction procedure; 66.7% (n = 6) appropri- 92.1% (n = 139) received postprocedure antibiotics only, 2.6% ately received an antibiotic secondary to the dental procedure. (n = 4) were prescribed preprocedure antibiotics only, and e p Th rimary reason for inappropriate prescribing was post- 5.3% (n = 8) were prescribed both pre- and postprocedure procedure antibiotics when 1 dose preprocedure was indicated. antibiotics. Appropriate prescribing of antibiotics for infection prophylaxis Of the 183 veterans in the sample, 17 were not indicated to was not found to be associated with any patient characteristic or receive antibiotic prophylaxis, and the majority (64.7%, n = 11) dental procedure (Table 3). did not receive antibiotics (Table 2). Ninety percent (n = 166) of Three months postprocedure, there were no occurrences of patients had an indication (procedure and/or cardiac condition) CDI, infective endocarditis, prosthetic joint infections, oral to receive antibiotics. Of these patients, 87.3% (n = 145) received infections, or allergic reactions to antibiotics. Table 1. Baseline Demographics of Cohort Undergoing Dental Procedures Table 2. Antibiotic Indication, Timing, and Appropriateness of the Included Patients Prescription Characteristic (n = 183) Age, mean ± SD (range) 62.0 ± 12.7 (24–91) Frequency (%) Male sex, n (%) 173 (94.5) Indication, Timing, and Appropriateness (n = 183) Race, n (%) Indicated to receive antibiotics (procedure/cardiac) 166 (90.7) Asian 1 (0.5) Received pre- and/or postprocedure antibiotics 145 (87.3) Black 36 (19.7) (denominator = 166) Hispanic 7 (3.8) Not indicated to receive antibiotics 17 (9.3) Other 2 (1.0) Did not receive antibiotic prophylaxis (denominator = 17) 11 (64.7) White 130 (71.0) Antibiotic prescribing consistent with study definitions 15 (8.2) Unknown 8 (4.4) No antibiotics prescribed; no antibiotics were indicated 11 (6.0) Penicillin allergic, n (%) 27 (14.8) Preprocedure antibiotics were prescribed; preprocedure 4 (2.2) Dental procedure antibiotics were indicated Extraction, n (%) 119 (65.0) Antibiotic prescribing inconsistent with study definitions 168 (91.8) Periodontal surgery, n (%) 94 (51.4) No antibiotics prescribed; preprocedure antibiotics were 21 (11.5) Dental implant placement, n (%) 63 (34.4) indicated Cardiac condition included in AHA guidelines, n (%) 5 (2.7) Postprocedure antibiotics were prescribed; no antibiot- 6 (3.3) ics were indicated History of infective endocarditis 0 Postprocedure antibiotics were prescribed; preproce- 141 (77.0) Congenital heart defect 0 dure antibiotics were indicated Cardiac transplant with valvulopathy 0 Preprocedure and postprocedure antibiotics were 8 (5.7) Prosthetic cardiac valve/material 5 (2.7) prescribed; preprocedure antibiotics were indicated Orthopedic joint replacement, n (%) 9 (4.9) (denominator = 141) History of a prosthetic joint infection, n (%) 1 (0.6) Unless otherwise indicated, the denominator for percentages equals 183. a b Some patients underwent multiple dental procedures at 1 visit (eg, tooth extraction and Of those patients who had an indication to receive antibiotics (n = 166), 84.9% (141/166) implant replacement). received postprocedure antibiotics when only preprocedure administration was indicated. Dental Antibiotic Prophylaxis • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/1/ofx250/4633784 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 3. Covariates Assessed for an Association With Prescribing of Antimicrobial Prophylaxis (n = 183) Antibiotic Prophylaxis Indication Consistent With Antibiotic Prophylaxis Indication Characteristics Guidelines (n = 156) Inconsistent With Guidelines (n = 27) P Value Age, mean 62.2 ± 12.0 60.7 ± 16.6 .6580 Male sex, n (%) 148 (94.9) 25 (92.6) .6439 Nonwhite, n (%) 48 (30.8) 5 (18.5) .1951 White, n (%) 108 (69.2) 22 (81.5) Extraction, n (%) 105 (67.3) 14 (51.9) .1200 Dental implant placement, n (%) 54 (34.6) 9 (33.3) .8970 Periodontal surgery, n (%) 79 (50.6) 15 (55.6) .3344 Penicillin allergic, n (%) 23 (14.7) 3 (11.1) .7714 Indication based on AHA guidelines, n (%) 5 (3.2) 0 (n/a) 1.0 Orthopedic joint replacement, n (%) 8 (5.1) 1 (3.7) 1.0 DISCUSSION may have also been missed if patients sought care from non-VA providers/facilities. Finally, national guidelines for To our knowledge, this is the first US report of the appropriateness dental procedure antibiotic prophylaxis are lacking in the of antibiotic prophylaxis prescribing prior to dental procedures absence of comorbidities (ie, cardiac conditions, prosthetic in adults. Evidence from other countries has demonstrated that joints). However, a systematic review by the Cochrane 58%–81% of dental antibiotic prescribing for infection prophy- Collaboration on the use of antibiotics for infection proph- laxis is inconsistent with guidelines [19–26]. Our results in a VA ylaxis following tooth extractions found that antibiotics clinic identified that while 87.3% of antibiotics were indicated, reduced the risk of infection, but also increased the risk 91.8% of antibiotics prescribed for infection prophylaxis were of adverse events . The authors concluded that due to inconsistent with recommendations. In our study, postproce- the risk of adverse events and resistant bacteria, clinicians dure antibiotic prophylaxis was administered for the majority of should carefully consider treating healthy patients with patients undergoing tooth extraction or implant surgery despite postprocedural prophylactic antibiotics . A second evidence supporting administering antibiotics preprocedure only Cochrane review evaluating the role of antibiotics at the [8, 13, 17, 18]. Postprocedure antibiotics used in this setting were time of dental implant placement in preventing complica- prescribed for an extended duration (mean, 7.2 days for an excess tions found that participants receiving antibiotics were less of 824 days in the cohort), for which evidence is lacking. likely to experience implant failure compared with partic- In the clinical notes, dental providers were occasionally una- ipants not receiving antibiotics, with a number needed to ware of the oral health and procedures to be completed prior to treat of 25 . The authors concluded that antibiotics are the appointment and, thus, the need for preprocedure antibiotic beneficial for reducing failure of dental implants, specifi- prophylaxis. This may explain the high frequency of postproce- cally amoxicillin 2 or 3 grams by mouth as a single dose 1 dure antibiotics when a preprocedure antibiotic was indicated. hour before the procedure, but it is still unknown whether While patients with cardiac conditions listed in the AHA guide- postoperative antibiotics are beneficial . lines were limited, preprocedure antibiotic prophylaxis prescribing was consistent with these guidelines for the prevention of infective CONCLUSION endocarditis. In a larger cohort of 1351 patients over 10 years, only 8.6% of visits received antibiotic prophylaxis inconsistent with the The majority of patients who underwent a dental procedure were infective endocarditis guidelines . However, adherence with administered antibiotic prophylaxis as indicated. However, only these guidelines in a larger cohort should be assessed. 8.2% of antibiotic prescribing for infection prophylaxis was appro- Limitations to this study include the retrospective design, priate based on currently available evidence, the majority receiving small sample size, and use of a single dental clinic. In add- antibiotics post-procedure. Modifying postprocedure antibiotic ition, providers may choose to administer prophylactic prescribing for implants and extractions to only 1 dose prior to the antibiotics to patients with poor oral health or uncontrolled procedure could significantly decrease overprescribing in dentis- co-morbidities; however, this was infrequently documented try. Guidelines beyond the prevention of infective endocarditis and in the dental notes, thus making it difficult to take this prosthetic joint infections should be developed to provide guidance factor into consideration. Another limitation is that con- in the prescribing of antibiotics for prophylaxis. Implementing genital heart disease will always be limited in VA studies antimicrobial stewardship efforts, including documentation of the as these persons are typically excluded from military ser- medication indication, in dental clinics may be an opportunity to vice. Adverse drug events and postprocedure infections improve antibiotic prescribing for infection prophylaxis. 4 • OFID • Suda et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/1/ofx250/4633784 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Acknowledgments 12. Chitnis AS, Holzbauer SM, Belflower RM, et al. Epidemiology of community-as- sociated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med Disclosure. e v Th iews expressed in this article are those of the authors 2013; 173:1359–67. and do not necessarily reflect the position or policy of the Department of 13. Watters W 3rd, Rethman MP, Hanson NB, et al. Prevention of orthopaedic Veterans Affairs of the United States government. implant infection in patients undergoing dental procedures. J Am Acad Orthop Financial support. This material is the result of work supported with Surg 2013; 21:180–9. resources from and the use of facilities at the Hines VA Hospital (Hines, IL). 14. Quinn RH, Murray JN, Pezold R, Sevarino KS, et al. The American Academy of Potential conifl cts of interest. All authors: no reported conflicts of Orthopaedic Surgeons appropriate use criteria for the management of patients interest. All authors have submitted the ICMJE Form for Disclosure of with orthopaedic implants undergoing dental procedures. J Bone Joint Surg Am 2017; 99:161–3. Potential Conflicts of Interest. Conflicts that the editors consider relevant to 15. Sollectio TP, Lockhart PB, Truelove E, et al. 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