The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#93 Antibiotic Stewardship: What dental teams need to know
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Antibiotic prescription writing has become a concern throughout all of healthcare. According an article in the JADA, dentists prescribe 10% of all outpatient antibiotics.
- CDC Core Elements of Antibiotic Stewardship https://www.cdc.gov/antibiotic-use/core-elements/index.html
- The Core Elements of Outpatient Antibiotic Stewardship Checklist https://www.cdc.gov/antibiotic-use/community/pdfs/16_268900-A_CoreElementsOutpatient_check_2_508.pdf
- The Core Elements of Outpatient Antibiotic Stewardship https://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm?s_cid=rr6506a1_e
- CDC Training on Antibiotic Stewardship https://www.cdc.gov/antibiotic-use/training/continuing-education.html
- ADA Evidence-based Clinical Practice Guideline on Antibiotic Use for the Urgent Management of Pulpal- and Periapical-related Dental Pain and Intraoral Swelling https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/antibiotic-prophylaxis
- ADA Antibiotic Prophylaxis Prior to Dental Procedures https://jada.ada.org/article/S0002-8177(19)30617-8/fulltext?dgcid=PromoSpots_EBDsite_ABX
Welcome. I'm Leslie Kannon. I'm Mary Gavoni. I'm Linda Harvey.
SPEAKER_02I'm Olivia Wan. And together we are the Compliance Divas.
SPEAKER_03Welcome to the Compliance Divas Podcast. I'm Mary Gavoni and I'll be the moderator for this episode. We bring clarity and simplicity to compliance by navigating the regulatory world to keep you on course. You can subscribe to the Compliance Divas podcast through your favorite podcast channel or on our website, thecompliancedeivas.com. All the resources we mentioned during this episode can be found on our website, thecompliancedivas.com, and you can always submit questions and feedback to support at thecompliancedivas.com. The topic for this episode is antibiotic stewardship. And you may have heard this term or read some news feeds about it. It's becoming a very hot topic in dentistry and all of healthcare. And antibiotic stewardship, if you're not familiar with it, is a concept that's gaining a great deal of attention because of the increase in antibiotic resistance, but also an increase in the number of cases of C. diff or Clostridium difficile, which can actually be fatal to some patients. So the principles of antibiotic stewardship seek to improve how antibiotics are prescribed by clinicians and how they're used by patients. According to the American Dental Association, dentists prescribe about 10% of the antibiotics that are prescribed in outpatient settings. So that's a fairly large number. Dentistry is being tapped to help be a part of this movement. So, Olivia, I'd like to start with you. And can you give us some background on antibiotic stewardship and why there's a need for improving prescribing in outpatient settings, which dentistry is, and in particular in dentistry?
SPEAKER_02Well, I think you brought up some really good points, Mary, that most of the antibiotic prescribing is coming from outpatient facilities. And as you indicated, dentists account for at least 10% of that. And so with the increase of antibiotic resistance and this digestive infection that could occur using antibiotics, we have to re-evaluate our prescribing and whether dental practices are practicing this stewardship of antibiotics. We realize that the antibiotics, when prescribed, can result in complications. And the side effects could be something as simple as a rash or diarrhea, but could be very severe, such as a severe allergic reaction or some of these other infections that we talked about. So with dentists accounting for outpatient facilities as well that are prescribing, they really need to adhere to this uh antibiotic stewardship program and get up to date and not just prescribe. I know we've talked about this in other episodes, that it's almost like the patients expect to be given an antibiotic and a pain prescription. And there's been so much information over the years about opioids, but now it's time to step up to the plate with antibiotics and get away from that attitude when patients come in thinking that just because they had a tooth extracted or just because they had some type of procedure, that that does not automatically warrant the dentist prescribing an antibiotic and opioid. So that's some of my thoughts, Mary, that I'm really glad that this topic is getting more attention and more ground. And I think I have fallen into that same category over the years, thinking that, well, if if I get a little cold, I think if I go to my doctor, they should give me an antibiotic or some kind of prescription to make my copay worth it. But that's not the case at all because of this antibiotic resistance. We might find ourselves in a precarious situation if those antibiotics are no longer effective.
SPEAKER_03You are absolutely right, Olivia, and thank you for for that information. It's you know, it is something that has developed over the years that there is that expectation. Um, andor the doctors in many cases are concerned that their patients may have some post-op infection. So, in the normal course of doing a procedure, a surgical procedure in particular, antibiotics are prescribed. And of course, we've we'll we'll talk in a in a bit about the whole issue of um prophylactic antibiotics and how much of that has changed. Um, the CDC has a tremendous amount of resources about antibiotic stewardship in all kinds of settings, including um outpatient settings. Linda, can you go over with us the four core elements of outpatient antibiotic stewardship?
SPEAKER_01Sure, Mary. These are so applicable to any outpatient setting. And I know you and Olivia have done a great job of mentioning how what percentage of the prescriptions dentists write and how we are we do need to be accountable for our prescription writing. And I think it's also a matter of resetting my patients' expectations. So I love what you said, Olivia, about the patients expecting to get their money's worth for their copay, and it doesn't necessarily equal to an antibiotic. So these four core elements, the first one is commit, commitment, and that is to demonstrate your dedication to an accountability for optimizing antibiotic prescribing and patient safety. And you know, dentists and all of all of our dental teams are so in tune to patient safety and strive to have a safe patient visit every time. It's just a matter of looking at it a little differently and now beginning to reset the patient's expectations and verbalizing this to the patient as part of your commitment. Next is action for policy and practice. This involves implementing at least one policy or practice to improve antibiotic prescribing and assessing whether it's working, and then of course, modify as needed. And to me, that this may not be each of us may not have a written policy, Mary, although that's not a bad idea, but they could at least have a protocol outline of what patients they feel they're going to be needing to use an antibiotic and have an algorithm of decision questions so that way they have an idea of how they're going to move forward when they do need to prescribe antibiotics. And it reminds me of OSHA's post-exposure prophylactic procedure and the follow-up for that, you know, if this happens, follow this. If this, if it's not contaminated, then you do that. Was not a contaminated sharp. Let me be a little clearer on that. So third is tracking and reporting. Monitor your antibiotic prescribing practices and give feedback to one another within the group. If you're in a group practice or CSO or whatever the setting is, and there's more than one doctor, then assess help each other to assess your practices and seek you know input from one another. And I'm wondering could a report be run on those prescriptions that have been given to patients over a certain period of time. Another way is perhaps keeping a tracking log. And with a tracking log, I liken that, Mary, to the implant logs that a practice implements. And by doing so, you could add you maybe add prescriptions written with your tracking log. And so you're also tracking implants at the same time and those serial numbers, which is important because if there's a device recall or there's an infection, then you need to notify, notify the manufacturer under the Safe Medical Devices Act. And it's important, just kind of ties it all together so it doesn't create one more thing for the authors to do, it just is a value add. And I also parallel this to controlled substances with all the tracking that's being done in that world. How can you do something even minimal within your own practice to track and monitor and help to support one another for maintaining antibiotic stewardship? And last but not least is education and experience, Mary. That's providing educational resources to clinicians and even to patients on antibiotic prescribing. So I'm going to be thinking about here the fact that I've seen many of our medical providers and the in our area have little signs at the check-in on what their you know control substance policy is. How do we notify patients? Maybe we don't need one more sign in the reception area, but how do we notify patients that of our antibiotic prescribing practices? Maybe that's in the literature that you give the patient when they're getting ready for dental surgeries and they understand what the protocol is. I think that it would be incumbent for doctors and even team members to take a CE course on this topic, read scientific articles, stay abreast of what our peers are doing and what the research shows, so they can be on the cutting edge with that information. So where it comes back to these four things commitment, action for policy and practice, tracking and reporting, education and experience. Because when I think about stewardship, I think about the definition that I read in the online Merriam-Webster dictionary. It's careful and responsible management of something entrusted to one's care. And our patients have been entrusted to us because they've chosen to come to us and chosen to have trust in us for their care. And they know we have their best interest at heart.
SPEAKER_03Well said, Linda. And I love the fact that you brought up the concept of the team participating in an education program about antibiotic stewardship. And the CDC just happens to have several available online. We will make those resources available, the links to those resources available on our website and in the show notes, so that any practice that would like to participate in that particular training program, what is antibiotic stewardship? And I believe you can also get continuing education credit for that. So that's always a plus. So, Linda, you did a great job of summarizing the core elements of outpatient antibiotic stewardship. And part of that is really setting priorities for when we need to prescribe. So, Leslie, can you walk us through the information that's provided to us from the CDC about prescribing antibiotics?
SPEAKER_00Well, Mary, you know, sometimes there are high-priority conditions for intervention with antibiotics. And high priority conditions are conditions for which clinicians commonly deviate from the best practices for antibiotic prescribing. And that includes conditions for which antibiotics are either over-prescribed, under-prescribed, misprescribed, with the wrong antibiotic agent, dose, or duration. So sometimes when we talk about these conditions, uh, we might want to think about how we may recognize these in our own practice, because sometimes it's barriers where we deviate from the best practices because of outside influences. And that that, in addition to, let's say, a knowledge gap about a best practice and clinical guidelines, um, the clinician's perception of patient expectation for antibiotics, like Olivia was talking about, I don't feel well, so an antibiotic is going to cure me. Or a perceived pressure to see patients quickly. And as we all know, when a patient feels like they have an emergency, they want to be seen now. Or clinician concerns about decreased patient satisfaction with clinical visits when antibiotics are not prescribed. So you can see how there are other pressures, you know, scheduling, patient pressure, patient expectations, and feeling like we might be letting the patient down. Um, there's also sometimes examples of high priority conditions for improving antibiotic prescribing. And so we do need to be cautious, as uh, and again, the prescribers, the dentists and doctors who make the decisions of the conditions for which the antibiotics are over-prescribed. Um, and then the conditions for which antibiotics might be appropriate but are over-diagnosed. Um, and then conditions for which antibiotics might be indicated, but then the wrong agent dose or duration is selected, such as selecting an antibiotic that is not necessarily recommended for that particular condition. And then conditions for which watchful waiting or delayed prescribing is appropriate but underused. And again, that may tee up with patient pressure to expecting to have care and relief from pain be immediate. And then finally, um, conditions for which antibiotics are underused or the need for timely antibiotics is not recognized. Now, um, you know, I think I just want to add one more thing in there is that uh so many times, I myself included, we feel better after being prescribed an antibiotics, so we stop taking it. And while the clinicians don't have control over that, the control is in the communication to make sure that patients fully understand what the directions are for use and to continue to use the whole uh prescribed dosage and amount and number of pills until gone, not just until pain has uh uh been eliminated or they feel better. Mary.
SPEAKER_03Excellent job, Leslie. Um, and what I want to do now is kind of pull it all back together and focus it on what do we do in dentistry? Because I'm sure that's many of our listeners are thinking, okay, so now what? So I cannot emphasize enough how important it is for our listeners to go to the show notes, go to our website, and look at the resources there and access those resources. Because, in addition to the CDC guidelines on antibiotic stewardship, the ADA has issued recommendations and results of a lot of research on managing pulpal and periac-related dental pain and intraoral swelling. They have very specific parameters for prescribing antibiotics and what to prescribe, what drugs to prescribe. And the ADA has recommendations based on American Heart Association, based on the um American Um Orthopedic Association on antibiotic prophylaxis. And those again are included as resources. So the recommendations, just to sort of summarize for patients described in the ADA document for um prophylactic antibiotics, are for all dental patient procedures that involve manipulation of gingival tissue or the periapical region of the tooth or teeth, and perforation of the oral mucosa. So, this is a lot of information for everybody to sort of digest. And I'm going to go back again to Linda's comment about having a training session on this so that everyone is up to date. I get questions all the time, I'm sure the other divas do as well, about do I need to pre-medicate my patient or not anymore? And we really need to have the most updated information. So I'll call on the divas for any final comments or any other thoughts on today's podcast. Olivia.
SPEAKER_02Just to dovetail off of what you had just said, Mary, dental practices may find it helpful if the dentist actually writes a simple position statement in layman terminology of why or why not antibiotics would be prescribed so that if a patient tries to debate with the dentist, they're not bombarding them with medical literature, but rather putting it in a format that they could understand and hopefully educate that patient.
SPEAKER_03Oh, that's an excellent suggestion, Olivia. And I also like the idea of having that perhaps even on the practice website so that if someone calls, you know, if you have an emergency, here's the protocol. And by the way, here is our policy on antibiotics and pain medication. I know my own personal physician has signs in all of their um exam rooms that say, you know, we will not do this, this, this. And it is uh the conditions for not prescribing antibiotics. So, as I'm sure our listeners can appreciate, this is a pretty meaty topic here to um do some follow-up research on, do some training, um, read through the current guidance, and we hope that you will. We thank you for your participation. Remember that the compliance divas brings clarity and simplicity to regulatory compliance by navigating that regulatory world to keep you on course. Please submit any questions or feedback to support at thecompliancedivas.com. The resources from today's podcast will be in the show notes and on the compliancedevas.com website. Thank you for joining us.