Introduction
The World Health Organization (WHO) has identified antimicrobial resistance (AMR) as one of the top 10 global public health threats facing humanity due to the inappropriate and unnecessary use of antibiotics, which makes bacteria, viruses, fungi and parasites become resistant to existing drugs. This phenomenon leads to infections harder to treat and increases the risk of disease spread, severe illness and death. The Antimicrobial Resistance Collaborators group reported in 2022 that 1.27 million deaths per year are directly caused by bacterial AMR, and almost 5 million are associated with bacterial AMR (ANTIMICROBIAL RESISTANCE COLLABORATORS 2022). The annual epidemiological report for 2021 established by the European Centre for Disease Prevention and Control has stated that the prescription of antibiotics varies from country to country, with higher consumption observed in the southern countries and a constantly reducing prescription in the northern countries. As a result, a decrease in AMR was observed between 2012 and 2021(EUROPEAN CENTRE FOR DISEASE PREVENTION AND CONTROL 2018). Further opportunities exist for antimicrobial stewardship of broad-spectrum and last-line antibiotics.
In 2017, the Swiss government published a list of action items aimed at limiting the development and spread of AMR in the environment (ZUMBRUNN 2017) and today Switzerland has one of the lowest rates of antibiotic consumption in Europe, although wide variations exist between cantons (FILIPPINI ET AL 2006). Worldwide, dentists are responsible for about 10% of all prescribed antibiotics, significantly contributing to global antibiotic use (TEOH ET AL 2020). Dental practitioners prescribe antibiotics for either prophylactic or therapeutic reasons. Antibiotic prophylaxis is mostly administered to prevent endocarditis or prosthetic joint infection in high-risk patients; while antibiotic treatment is mainly prescribed to manage orofacial infections or to minimize the risk of complications after a specific, often invasive dental procedure. However, antibiotic prescription by dentists is often empirical, leading to inappropriate use (BIANCO ET AL 2021; KOYUNCUOGLU ET AL 2017).
While a decrease in prescribing antibiotics among other health practitioners has been observed in several countries, dental prescribing of antibiotics has remained unchanged (DURKIN ET AL 2018) or even increased (KJOME ET AL 2022). Discrepancies between countries are observed not only on the number of dental prescriptions but also on the class of the prescribed antibiotics. For example, fewer antibiotic prescriptions are issued by dentists in Norway and Sweden compared to England and Scotland, with phenoxymethyl penicillin dominating prescriptions in Sweden/Norway, while Amoxicillin and Metronidazole are more frequently used in England/Scotland (SMITH ET AL 2020). Several surveys addressed to dentists found that antibiotic prescription, in terms of choice, duration, and dose, was inappropriate in 14% of cases (DURKIN ET AL 2018; KOPPEN ET AL 2018). The study of Cope et al. 2018 reported that 80% of antibiotics for treating acute dental conditions were unnecessary, as dental infections are generally amenable to treatment by a dental procedure without the need for adjunctive antibiotics (COPE ET AL 2018). Similarly, Suda et al. (2019) reported that 81% of antibiotic prophylaxis prescription before dental visits was unnecessary (SUDA ET AL 2019).
The U.S. Centers for Disease Control and Prevention defines appropriate antibiotic prescribing as only prescribing antibiotics when needed, selecting the right antibiotic at the right dose and duration, and following evidence-based national and local clinical practice guidelines. The aim of the present survey was to assess self-reported practices towards systemic antibiotic prescription among Swiss dentists in Romandy,
Methods
Sample and data collection
The present cross-sectional survey involved 331 dentists practicing in the French part of Switzerland. An electronic version of the questionnaire, along with an information sheet, was emailed to registered dentists working in private or public clinics, including both general and specialist practitioners. The questionnaire was sent out again three months later to maximize the number of responses. The study was exempt from the Swiss legislation regulating research on human subjects, as it was deemed to fall outside of its scope. The questionnaire consisted of seven main sections and was adapted from existing questionnaires used in similar studies (AGOSSA ET AL 2021; BAUDET ET AL 2020; CHOUDHURY ET AL 2001;
FALKENSTEIN ET AL 2016; KÖHLER ET AL 2013). The first section collected general and demographic data, such as age, sex, practice location, years since graduation, university of graduation, and the number of working hours per week. The second and third sections contained questions related to antibiotic prescription in various situations and procedures, using common clinical vignettes. In the fourth section, participants were asked which antibiotic they most frequently prescribed, as well as their first alternative in case of penicillin allergy. The fifth and sixth sections concerned the prophylactic use of antibiotics, such as the type of patients who require antibiotic prophylaxis, and the procedures in which prophylactic antibiotics are prescribed before the procedure. This section solely focused on the healthy population, without any immunocompromised individuals or patients at risk of infective endocarditis. The last part consisted of questions about dentists' education during pre-graduate studies and/or continuous education on the use of antibiotics in dentistry. The final question of this section asked about the practitioner's willingness and need for specific guidelines on this topic. Items were answered using a three-point Likert scale. A pilot questionnaire was created and pre-tested on a small group of general practitioners (N=6).
Statistical analysis
We utilized descriptive statistics, including frequency and percentages, to analyze the various items addressed to the dentists. For questions that required participants to rank different items simultaneously (from most often to least often), a ranking design was used. The weightings were applied in reverse order; the answer most frequently set to the first place by the participants received the highest weighting, while the answer least frequently set to the first position received the lowest weighting. Specifically, the answer set to position 1 received a weight of 7, the answer set to position 2 received a weight of 6, and so on.
Results
Demographics
A total of 331 questionnaires was distributed electronically to dentists practicing in Romandy between April 2022 and October 2022. The response rate was approximately 28%, with 92 completed questionnaires being included in the analysis. Of the respondents, 65.2% (N=60) were male and 34.8% (N=32) were female. Nearly half of the participants were over 50 years old. As indicated in Table I, the years of experience since graduation ranged widely, with 50% reporting more than 20 years of experience. 77.2% of the participants had obtained their degree from a Swiss university, while 22.8% had graduated from other universities. 84.8% of the participants reported working 5-6 days per week, with 15.2% reporting working between 3-4 days per week. Almost all practitioners (89.1%) had their own private practice, while 27.2% reported also having an academic position. More than half of the dentists (54.4%) reported seeing 40-60 patients per week and 89% of them prescribing antibiotics between 1 to 5 times per week. (Table I).
Table II presents self-reported antibiotic prescription by the participants for various situations and procedures in the healthy population. The most common reasons for antibiotic prescription were abscess with systemic symptoms (89%), cellulitis (81.5%), oral-sinus communication (62%), acute maxillary sinusitis of dental origin (62%), and necrotizing periodontal disease (52.2%). Procedures that led to antibiotic prescription by the practitioners were mainly implant surgery (60.9%), sinus floor elevation (59.8%), surgery for peri-implantitis (44.6%), and extraction of impacted wisdom teeth (42.4%). The only procedures for which antibiotics were not prescribed were endodontic treatment of vital teeth (95.6%) and of teeth with necrotic pulp (59.8%) (Table III).
Using a scale from 1 to 7, participants were asked which antibiotic they prescribe most often. As shown in Figure Ia, amoxicillin was the most frequently prescribed antibiotic (weight of 6.67), followed by clindamycin (weight of 5.67), amoxicillin+ clavulanic acid (weight of 5.18), and amoxicillin+ metronidazole (weight of 4.45). For patients allergic to penicillin, clindamycin was by far the most frequently prescribed antibiotic by the participants (87%) (Figure Ib).
Procedures for prophylactic antibiotic prescription
The results regarding antibiotic prophylaxis are presented in Table IV and Table V. Most dentists prescribed prophylactic antibiotics for patients with a high risk of endocarditis (86.9%), followed by those with immunodeficiency/immunosuppression (50%), patients with joint replacement in the past year (47.8%), and those receiving IV bisphosphonate treatment (40.2%). Among the dentists who prescribe prophylactic antibiotics, most of them (82.6%) used a dose of 2g of amoxicillin administered one hour before the procedure.
Concerning antibiotic prophylaxis for individuals without any underlying health condition, about 50% of dentists prescribed it before implant surgery, 40.2% before sinus floor elevation, and 32.6% before extraction of impacted wisdom teeth. Only 24% of dentists prescribed prophylactic antibiotics before surgical treatment of peri-implantitis, as shown in Table V.
Dentists’ education on the use of antibiotics in dentistry
Courses and /or recommendations on this topic during pre-graduate and continuous education curricula are rare, as reported by most of the practitioners (68.5% and 65.2%, respectively). The need for specific guidelines was highlighted by the participants (76.1%) (Table VI).
Discussion
In Switzerland, there has been a noteworthy 19% reduction in total antibiotic consumption since 2019, which may be attributed to COVID-19 measures. The Swiss Antibiotic Resistance Report reveals that Switzerland has one of the lowest levels of antibiotic use in Europe, especially for antibiotics that contribute to antibiotic resistance. Outpatient settings account for most of the antibiotic use (85%) compared to hospitals (15%). Usage varies regionally, with higher consumption in French- and Italian-speaking areas and lower usage in German-speaking regions. The report focuses primarily on antibiotic consumption and resistance in human and veterinary medicine, and no data on antibiotic consumption in dental medicine is provided (FEDERAL OFFICE OF PUBLIC HEALTH AND FEDERAL FOOD SAFETY AND VETERINARY OFFICE 2022). Based on the European Medicines Agency's 2021 report, in the field of veterinary medicine there has been a significant reduction in the sale of antibiotics as veterinary antimicrobial agents across 31 European Union/European Economic Area countries. The total amount sold in 2021 was reported to be 5,219.6 tons (EUROPEAN MEDICINES AGENCY 2022), which is noticeably lower compared to the 8,421 tons sold in 2011, as indicated by a previous study (EUROPEAN MEDICINES AGENCY 2013).
Considering these findings, a question arises regarding the extent to which dentists contribute to antibiotic resistance when treating infections. Mombelli et al. (2016) reported that the total amount of penicillin, approximately 1,947 tons, administered to food-producing animals in a year is equivalent to the dosage needed to treat 247 million human cases of periodontitis. This calculation assumes a dosage of 375mg of amoxicillin taken three times a day for seven days. Although it seems minimal compared to veterinary prescriptions, dental health professionals should not underestimate their role in contributing to antibiotic resistance (MOMBELLI ET AL 2016).
The primary objective of this cross-sectional survey was to examine the antibiotic prescribing patterns among a group of Swiss dentists practicing in the French-speaking region of Switzerland, primarily in the cantons of Geneva and Vaud. According to the Federal Statistical Office, there were a total of 259 and 390 dental offices in these cantons in 2020, respectively. Hence, our survey encompassed nearly half of the dental workforce in these regions (FEDERATION OF SWISS DOCTORS, FEDERAL STATISTICAL OFFICE 2022).The survey obtained a response rate of 28%, which is higher than that reported in a study targeting German-speaking dentists (response rate of 20%) (KÖHLER ET AL 2013) but significantly lower than those reported in surveys conducted in France (BAUDET ET AL 2020) or Italy (BIANCO ET AL 2021), in which the response rates were 58.75% and 52.6%, respectively. Given that the estimated number of dentists practicing in Switzerland is around 3500, it can be calculated that our study included approximately 2.62% of the dentists (n=92 participants). Notably, almost one third of the participants reported having an academic position, suggesting that this sample may be less representative of the general population. These points are addressed as limitations of the study.
Interestingly, in this study, it was found that a high proportion of participants (89.1%) prescribe antibiotics 1-5 times per week. Systemic antibiotics were most prescribed as first-line therapy in cases of abscess with systemic symptoms (89.1%), cellulitis (81.5%), oral-sinus communication (62%), and acute maxillary sinusitis of dental origin (62%). For certain procedures, such as implant surgery and sinus floor elevation, antibiotics were prescribed by 60% of the participants. These findings are consistent with a systematic review of survey-based studies on antibiotic prophylaxis for dental implant surgery in healthy patients, which reported that three-quarters of dentists routinely prescribe prophylaxis for implant surgery, mainly perioperative, followed by postoperative and preoperative (in decreasing order of frequency) (BERNABEU-MIRA ET AL 2021). In 2015, the European Association of Osteointegration consensus report stated that antibiotic prophylaxis has not been shown to be beneficial for straightforward implant placement but may be beneficial for complex cases with grafting or immediate implant placement and/or patients with systemic comorbidities (KLINGE ET AL 2015).
For complex tooth extractions or extractions of impacted teeth, 17% and 42.4% of the participants responded prescribing antibiotics, respectively. Antibiotic use after tooth extraction, especially those of broad-spectrum, increased over a period of 17 years (CHOI & LEE 2021). In a retrospective cohort study, the only factor influencing the prescription of antibiotics was the number of extracted teeth (SHEIKH REZAEI ET AL 2022).
Apparent uncertainty was observed for situations such as aggressive periodontitis (34.8% prescription) and necrotizing periodontal disease (52.2% prescription) as well as for several periodontitis/periimplantitis treatment procedures (periapical surgery, resective periodontal surgery, regenerative periodontal surgery, or surgical treatment of peri-implantitis). In the management of aggressive periodontitis, the addition of Metronidazole or Amoxicillin and Metronidazole to mechanical treatment was reported to improve clinical parameters (RABELO ET AL 2015). Herreira et al. (2014) recommended the use of systemic antimicrobials adjunctively to mechanical cleaning only in severe cases or in non-responsive conditions for the treatment of periodontitis (HERREIRA ET AL 2014). Furthermore, the EFP S3 level clinical practice guideline for the treatment of Stage I-III periodontitis indicated that the adjunctive use of specific antibiotics may be considered for generalized periodontitis Stage III in young adults (SANZ ET AL 2020). For peri-implantitis treatment, no specific drug prescription recommendation exists (ROCUZZO ET AL 2018), resulting in heterogeneity observed for surgical management, with 56.7% of dentists sometimes prescribing antibiotics.
The current results showed that amoxicillin was the most prescribed antibiotic, followed by clindamycin and amoxicillin and clavulanic acid. This trend is consistent with previous studies conducted in other European countries and the United States (BAUDET ET AL 2020, GERMACK ET AL 2017, PALMER ET AL 2000, RODRIGUEZ-NUNEZ ET AL 2009). For patients with penicillin allergies, clindamycin was the preferred alternative antibiotic, prescribed by most participants (85.9%), followed by azithromycin (4.3%), which is also consistent with findings from similar studies in other countries (GERMACK ET AL 2017, RODRIGUEZ-NUNEZ ET AL 2009).
Antibiotic prophylaxis was primarily prescribed for patients at high risk of endocarditis (86.9%), followed by those who have undergone joint replacement less than one year ago (47.8%), patients with immunodeficiency/immunosuppression (50%), and those receiving bisphosphonate treatment (40.2%). The participants agreed on the appropriate dosage of prophylactic antibiotics.
According to a study conducted by WALSH ET AL (2021), there was a significant rise in the prescription of broad-spectrum antibiotics among Australian dentists between 2005 and 2016 (WALSH ET AL 2021). Most of the increase occurred between 2011 and 2016, which contrasts with the national antimicrobial stewardship initiatives and guidelines. However, it is worth noting that Australia had the lowest antibiotic prescription rate compared to England, the United States, and Canada. In fact, the United States had a prescription rate that was twice as high as Australia's, with clindamycin being the most prescribed antibiotic (THOMPSON ET AL 2021). Limited available data exists regarding the prescription of antibiotics by dentists in Switzerland. The only similar survey to ours was conducted in the German-speaking part of Switzerland (KÖHLER ET AL 2013) and various uncertainties regarding accurate diagnosis and treatment were discovered. However, when comparing the two surveys, only minor differences were observed in antibiotic prescription patterns for different clinical conditions. The most notable contrast was observed in the treatment of aggressive periodontitis, where 65.8% of dentists in the German-speaking part of Switzerland prescribed antibiotics as an adjunct to mechanical treatment, compared to only 34.8% of the dentists of the French-speaking part. Furthermore, 67% of the responders in the survey of KÖHLER ET AL (2013) had expressed the need for specific guidelines on the prescription of antibiotics which was slightly less than the 76% reported in the present survey.
It is important to note that in dentistry, there are currently no control mechanisms in place for monitoring antibiotic prescriptions. This differs from the veterinary field, where veterinarians are required to register all prescriptions for livestock in the Information System for Antibiotics in Veterinary Medicine (IS ABV). This stringent control system has contributed to a consistent decline in the sales of antibiotics in veterinary medicine over the past decade (FEDERAL OFFICE OF PUBLIC HEALTH AND FEDERAL FOOD SAFETY AND VETERINARY OFFICE 2022).
In a recent development, the Swiss Dental Journal published guidelines on the use of antibiotics in various dental specialties, including periodontology and endodontology (MOMBEELLI &WALTER 2019, NEUHAUS ET AL 2020). These guidelines serve as a valuable resource for dental professionals, promoting responsible and evidence-based antibiotic use.
In conclusion, the use of antibiotics in Romandy appears to be cautious among dentists. However, there is a clear need for specific guidelines on the prescription of antibiotics in their daily practice. Obtaining an accurate diagnosis is a crucial step in limiting the prescription of antibiotics. In addition, there is a pressing need for high-level evidence to inform clear guidelines on antibiotic prescribing in dental infections. This will be crucial in reducing the inappropriate use of antibiotics in dentistry and ultimately mitigating the development of antimicrobial resistance.
Acknowledgments
The authors wish to thank all the participants who took the time to fill out the questionnaire.
Conflict of interest
The authors declare no conflict of interest.
Zusammenfassung
Einleitung
Die Antibiotikaresistenz (AMR) ist eine erhebliche globale Gesundheitsbedrohung, die aus dem übermäßigen und falschen Einsatz von Antibiotika resultiert. Weltweit sind Zahnärzte für etwa 10 % aller verschriebenen Antibiotika verantwortlich. Da sie eine Schlüsselrolle bei der Entwicklung der Antibiotikaresistenz spielen, werden sie in ihrer täglichen Praxis häufig zu ihren Indikationen für die Verschreibung von Antibiotika befragt.
Mehrere an Zahnärzte gerichtete Umfragen ergaben, dass die Verschreibung von Antibiotika in Bezug auf Auswahl, Dauer und Dosis in 14 % der Fälle unangemessen war, dass 80 % der Antibiotika zur Behandlung akuter Zahnerkrankungen unnötig waren und dass 81 % der Antibiotikaprophylaxe-Verordnungen vor Zahnarztbesuchen unnötig waren. Ziel der vorliegenden Umfrage war es, die selbstberichteten Praktiken der Schweizer Zahnärzte bei der Verschreibung systemischer Antibiotika zu bewerten.
Material und Methode
Ein elektronischer Fragebogen wurde an 331 Zahnärzte in der Westschweiz verschickt, und die Antworten wurden anhand einer dreistufigen Likert-Skala ausgewertet.
Resultate
Die Rücklaufquote betrug 28 %. Die Ergebnisse zeigten, dass die Hauptindikationen für den Einsatz von Antibiotika Abszesse mit systemischen Symptomen (89%), Zellulitis (81,5%), akute Sinusitis (62%) und nekrotisierende Parodontitis (52%) waren. Die am häufigsten mit Antibiotika kombinierten chirurgischen Eingriffe waren die Sinusbodenelevation (59,8 %) und die Implantation (60,9 %). Amoxicillin war das Antibiotikum der ersten Wahl, und Clindamycin wurde am häufigsten für Patienten mit einer Penicillinallergie verschrieben (87 %). Die meisten Zahnärzte empfahlen eine Prophylaxe mit 2 g Amoxicillin eine Stunde vor dem Eingriff für Patienten mit einem hohen Endokarditisrisiko (82,6 %), Immunschwäche/Immunsuppression (50 %) oder Gelenkersatz im letzten Jahr (47,8 %). Die meisten Teilnehmer (76,1 %) äußerten den Wunsch nach spezifischen Leitlinien für den Einsatz von Antibiotika in der Zahnmedizin. Die Studie kam zu dem Schluss, dass die Teilnehmer Antibiotika zwar mit Bedacht verschreiben, die Verschreibung von Antibiotika in verschiedenen Situationen jedoch aleatorisch ist.
Diskussion
Daher besteht ein eindeutiger Bedarf an spezifischen Leitlinien für die geeigneten Bedingungen und Verfahren, bei denen Antibiotika indiziert sind, und für die Auswahl eines geeigneten Behandlungsregimes, wenn dies erforderlich ist. Dies wird entscheidend dazu beitragen, den unangemessenen Einsatz von Antibiotika in der Zahnmedizin zu verringern und letztlich die Entwicklung von Antibiotikaresistenzen einzudämmen.
Résumée
Introduction
La résistance aux antibiotiques est une menace sanitaire importante qui résulte de l'utilisation excessive et incorrecte des antibiotiques. Au niveau mondial, les dentistes sont responsables d'environ 10 % de l'ensemble des prescriptions. En tant qu'acteurs clés de l'évolution de la résistance, ils sont souvent interrogés sur leurs indications de prescription au cours de leur pratique quotidienne.
Plusieurs enquêtes adressées aux dentistes ont montré que la prescription d'antibiotiques, en termes de choix, de durée et de dose, était inappropriée dans 14 % des cas, que 80 % des antibiotiques utilisés pour traiter des affections dentaires aiguës étaient inutiles et que 81 % des antibiotiques prophylactiques prescrits avant une visite chez le dentiste étaient inutiles. La présente enquête visait à évaluer les pratiques déclarées par les dentistes suisses en matière de prescription d'antibiotiques systémiques.
Matériels et méthodes
Un questionnaire électronique a été envoyé à 331 dentistes de Suisse romande et les réponses ont été analysées sur une échelle de Likert en trois points.
Résultats
Le taux de réponse a été de 28%. Les résultats ont montré que les principales indications pour l'utilisation d'antibiotiques étaient les abcès avec symptômes systémiques (89%), la cellulite (81,5%), la sinusite aiguë (62%) et la parodontite nécrosante (52%). Les interventions chirurgicales les plus fréquemment associées à des antibiotiques étaient l'élévation du plancher sinusal (59,8 %) et la pose d'implants (60,9 %). L'amoxicilline était l'antibiotique de premier choix, et la clindamycine était surtout prescrite aux patients allergiques à la pénicilline (87 %). La plupart des dentistes ont recommandé une prophylaxie avec 2 g d'amoxicilline, une heure avant l'intervention, pour les patients présentant un risque élevé d'endocardite (82,6 %), une immunodéficience/immunosuppression (50 %) ou un remplacement articulaire au cours de l'année précédente (47,8 %). La plupart des participants (76,1 %) ont exprimé le besoin de lignes directrices spécifiques sur l'utilisation des antibiotiques en médecine dentaire. L'étude a conclu que, bien que la prescription d'antibiotiques par les participants semble être prudente, dans plusieurs situations, la prescription d'antibiotiques est aléatoire.
Discussion
Il existe donc un besoin évident de lignes directrices spécifiques sur les conditions et procédures appropriées pour lesquelles les antibiotiques sont indiqués et pour choisir le régime approprié lorsque c'est nécessaire. Cela sera crucial pour réduire l'utilisation inappropriée des antibiotiques en médecine dentaire et, en fin de compte, pour atténuer le développement de la résistance aux antibiotiques.