Exploring oral antibiotic prescription patterns for the management of dental conditions at two public health institutions in Pietermaritzburg, KwaZulu-Natal.
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Introduction: Oral antibiotics are typically prescribed for the management of dental conditions such as acute odontogenic and non-odontogenic infections, and as prophylaxis for patients such as those with infective endocarditis or placement of joint prosthesis. While these measures are intended to limit the spread of possible infection that could occur as a result of oral surgical procedures, very little is known about antibiotic prescription practices and trends for dental purposes, specifically in the public sector in KwaZulu-Natal. Study Aim and Objectives: The aim of this study was to determine patterns of oral antibiotic prescription for the management of dental conditions at public health facilities in the Pietermaritzburg complex so as to create practitioner awareness of the need for the judicious use of antibiotics. The study objectives were to determine patterns of oral antibiotic prescription for dental patients at the identified public health institutions; understand dental and medical practitioners‘ knowledge, attitudes and practices related to antibiotic prescription for dental conditions; and ascertain public health pharmacists‘ perspectives on these patterns of oral antibiotic prescription. Method: This study was divided into 3 phases and a combination of quantitative and qualitative data was collected. The research sites comprised two purposively selected public sector hospitals located in the Pietermaritzburg complex of UMgungundlovu district (Institution A and B respectively). In Phase 1, data collection comprised a retrospective clinical record review to determine oral antibiotic prescription patterns for dental purposes (n=720) at the two identified research sites during the period March 2012- July 2018. For Phase 2, a cross sectional study design was used. Purposive sampling was used to select the study sample comprising medical and dental practitioners (Group 1, n=123) and pharmacists (Group 2, n=25). A separate self-administered questionnaire was developed for each group. The questionnaires comprised open and closed ended questions that were designed to assess the identified health care workers‘ knowledge, attitudes and practices related to oral antibiotic prescriptions or dispensing for dental use; perceptions of therapeutic duplication of antibiotics, availability of laboratory information and recommendations for the improvement of oral antibiotic prescriptions. A Likert scale format was used to elicit responses such as 1 (Strongly agree), 2 (Agree), 3 (Not sure), 4 (Disagree), 5 (Strongly Disagree). For Phase 3, the qualitative data was derived from focus group discussions held with purposively selected health care practitioners at each institution (Institutions A and B). The study sample included health care practitioners (medical and dental practitioners) and pharmacists, involved in prescribing or dispensing oral antibiotics for dental purposes. Two focus-group discussions (FGDs) comprising six people per group at each research site, were set up. The quantitative data was analyzed using the Statistical Package for Social Sciences software (SPSS Version 25 R). Univariate descriptive statistics such as frequency and mean distribution and inferential techniques such as Pearson‘s Chi-Square test were conducted to determine a possible relationship between the independent and dependent variables. A p-value of 0.05 was established as being significant. The internal consistency of the questionnaire, according to the Cronbach alpha score, was 0.68. Validity of the questionnaire was maintained. The qualitative data (obtained from the focus group discussions) were analyzed using thematic analysis. All emergent themes were further analyzed to gain a better understanding of participants‘ perspectives related to oral antibiotic prescriptions for dental conditions. Credibility, conformability, transferability and dependability of the collected data were maintained to enhance rigor and trustworthiness in the qualitative component of the study. Results: The results of the retrospective chart review indicated that dental abscesses (n=479; 66%) were the most common dental condition for which oral antibiotic therapy was prescribed. There were inconsistencies in the pattern of oral antibiotic prescription for dental conditions between the two public health care institutions. At Institution A, antibiotic therapy was prescribed for dental conditions such as trismus (n=13; 6%), soft palate swelling (n=9; 4%), fibrous epulis (n=6; 3%) and acute herpes (n=2; 1%). Interestingly, oral antibiotics were not prescribed at Institution B for the same dental conditions. Antibiotic therapy was prescribed for eruption pain (n=4; 1%) and in cases where patients did not bring their inhaler for asthma treatment (pump) (n=3; 1%) at Institution B. For the self-administered questionnaire, the response rate for Group 1 (medical and dental practitioners was 77.5% (n=93). The response rate for Group 2 (pharmacists) was 92% (n=23). The majority of participants in this study (n=72, 77.4%) indicated awareness of an Antibiotic Stewardship Programme in their respective institutions yet 42 participants (45%) were not sure on whether the programme was active. More than half of the study participants (n=60, 64.5%) indicated referring to the Standard Treatment Guidelines „some times‟ when prescribing antibiotics. The majority of participants (n=72, 77.4%) indicated that they would prescribe antibiotics for orofacial swellings. Almost 33 participants (35.4%) stated that they would prescribe antibiotics for irreversible pulpitis. Almost 31 participants (88.9%) from Institution A and 40 (75%) from Institution B indicated prescription of antibiotics for pericoronitis. Similarly, 27 participants (76.9%) Institution A and 14 (72.1%) from Institution B would prescribe antibiotics for periodontitis. The majority of participants (n=80, 86%) agreed that there was need to improve antibiotic prescription processes. With regards to the prescription of oral antibiotics as prophylaxis for the prevention of infections such as infective endocarditis, the following responses were obtained. Almost 13% of respondents from Institution A reported prescribing PEN VK 250mg daily followed by Penicillins, Augmentin, Benzyl Penicillin, Clindamycin and Kefazol while 23% of respondents from Institution B indicated prescribing Amoxicillin 2g stat dose one hour before a dental procedure followed by Pen VK, Penicillin, Clindamycin, Benzyl Penicillin oral and intravenous, Benzatime Penicillin, Penicillin G and Vancomycin. More than two thirds of study participants in Group 2 (n=18; 78%) perceived a correlation between the dental condition and the antibiotic prescribed thereof. Participants (n=17; 73.9%) also believed that oral antibiotics were sometimes prescribed without any clinical indication. The following themes emerged from qualitative data analysis (focus group discussions): inconsistencies in antibiotic coverage for dental-related clinical management between the two sites. There was no consensus among research participants on the need for diagnosis laboratory testing to improve antibiotics prescription. However, all participants agreed that there is a need to improve antibiotic prescription in their various hospitals. Discussion: Overall the results of the study indicated inconsistencies in antibiotic prescriptions for dental conditions. This suggests that over and under prescribing may be occurring in the identified clinical settings. The most common dental infection in this study, requiring antibiotic therapy was dental abscesses (66%). While the recommended treatment of choice for the management of periapical abscess, periodontitis abscess and localized dentoalveolar abscess is incision and drainage (Kuriyama et al. 2005), Lalloo et al. suggested that practitioners might be following some personal or ad-hoc criteria in selecting when to prescribe antibiotics or not (Lalloo et al. 2017). Peric et al. also reported that antibiotics were prescribed as a precaution because of ‗uncertainty concerning the diagnosis, patient‘s expectations, unavailability of dental services and in short- term cases where there is insufficient time for doing any treatment‘ (Peric et al. 2015:111). Participants in this study also prescribed antibiotics for the treatment of alveolitis (dry socket) (15%). This finding is supported by a previous study done in England, Kuwait and Turkey where almost half of the study population (dentists) reported that they would prescribe antibiotics for dry socket treatment (Dar-odeh et al. 2010). Antibiotics were also prescribed for systemic conditions (10%) in this study. This finding is consistent with previous reviews that concluded patients with low immunity may be at higher risk of infection (Sidana et al. 2017). Interestingly, a pattern of antibiotic prescription emerged based on the clinical site where the respondent was located. According to Standard Treatment Guidelines 2018, the prescribed regimen should be as follows: Amoxil, oral, 2g one hour before the procedure. Respondents from Institution B appeared to adhere to the Standard Treatment Guidelines. This difference in prescription pattern for the same health condition, which was dependent on the clinical site, was an interesting observation. Additionally, only 65% of respondents referred to the Standard Treatment Guidelines. In contrast, a previous study reported that only 45% of practitioners adhered to the Standard Treatment Guidelines and Essential Medicines List in Primary Health Care settings in South Africa (Gasson 2018). In a recent South African study, it was also reported that dentists were aware of the treatment guidelines but few followed the recommendations for antibiotic prophylaxis (Mthethwa et al. 2018). More research is thus required to further understand these differences across clinical settings. On the other hand 78% of pharmacists perceived a correlation between the dental condition and the antibiotic prescribed for the dental condition. This is a significant finding as a previous study has shown that when the treatment guidelines are adhered to, the resistant micro-organisms reduce in numbers (Ntsekhe et al. 2011). Gutierrez et al. therefore, highlight the need for professional agreement and consensus building with regards to the conditions for antibiotic prescriptions (Gutierrez et al. 2006). Such efforts are also needed in a South African context to facilitate practitioner consensus building and ensure consistency in antibiotic prescription. Antimicrobial Stewardship and infection and prevention control teams could provide opportunities to augment prescribing practices and streamline this process (South African National Department of Health 2015). Additionally, there is need for continuing professional development so as to better equip health practitioners with updated knowledge on antibiotic prescription for dental conditions (Rocha-Periera, Lafferty, Nathwani 2015; Lee et al. 2015). Conclusion: The results indicated that health care practitioners reported inconsistent knowledge, attitudes and practices related to antibiotic prescription patterns. The study showed that there was inconsistency in antibiotic therapy prescription for dental conditions at the two public health institutions. There is a need for consensus building among health professionals and better guidance for antibiotic prescription in the management of dental conditions.