ALLERGY STATUS
Many patients report an allergic history to certain antibiotics, which may limit the treatment options in managing oral infections. The prudent practitioner should first validate the allergic status by inquiring into the circumstances and the allergic response reported by the patient. In every case in which the patient reports a reaction that has affected breathing (e.g., the tongue or throat swelled, acutely compromising the airway), or if a patient has ever been taken to the hospital because of an allergic reaction to an antibiotic, then this type of immediate, Type I IgE-mediated anaphylactic reaction may be considered a true allergy and future exposure to this medicine should be avoided. In patients who report more of an intolerance or delayed-type reaction, re-exposure to the medicine may not necessarily be life threatening and may in fact be considered if the benefit of treatment outweighs the potential risk of the reaction (e.g., diarrhea, itchiness, other mild cutaneous reactions). However, when any doubt exists, it is always prudent to contact the patient’s physician for consultation. Penicillin-induced anaphylaxis is uncommon, occurring with an incidence of between one and four episodes per 10,000 administrations (Idsoe, Guthe, Willcox, & de Weck, 1968; International Rheumatic Fever Study Group, 1991; Macy, 2014). Still, amoxicillin and penicillin were the leading cause of severe antibiotic-induced anaphylaxis in one report, probably because these drugs are so commonly administered (Renaudin, Beaudouin, Ponvert, Demoly, & Moneret-Vautrin, 2013). There is cross-reactivity between the penicillins and cephalosporins (due to the shared β -lactam-containing structure) in patients with a true allergic history. Therefore, a reported allergy to an antibiotic in either drug class would cause the prescribing of an antibiotic from the other class to be contraindicated. These patients should be treated more appropriately with a macrolide antibiotic (erythromycin, clarithromycin, or azithromycin) or a lincosamide antibiotic such as clindamycin. Among patients who report penicillin reactions (but do not undergo confirmatory testing), between 0.17% and 8.4% will also react if given a cephalosporin such as cephalexin (Lee, 2014; Petz, 1978; Pichichero & Zagursky, 2014). If patients report more of an intolerance or delayed- type reaction to an antibiotic in
either drug class, prescribing of an antibiotic from the other class would not necessarily be contraindicated based on this relatively low rate of cross-reactivity. Macrolides, the tetracyclines, clindamycin, and metronidazole infrequently cause hypersensitivity reactions, compared with penicillins, cephalosporins, sulfonamides, and other classes of antimicrobials. Macrolides can cause delayed- onset maculopapular exanthems (a type of widespread rash characterized by flat, red areas on the skin covered with small confluent bumps) in about 1% of treated patients, which is close to the rate in placebo-treated patients in many drug studies (Lee, 2014). Anaphylaxis and serious non-IgE-mediated reactions are rare. Patients who have reacted to one macrolide (e.g., erythromycin) in the past may tolerate other macrolides (e.g., clarithromycin or azithromycin; Naldi et al., 1999). IgE- mediated reactions with the tetracyclines are rare, with only a few published reports of reactions in single patients (Jang et al., 2010; Ogita, Takada, & Kawana, 2011; Okano & Imai, 1996). Allergic reactions to clindamycin are uncommon, although clindamycin is a frequent cause of gastrointestinal side effects and is one of the more common causes of Clostridium difficile colitis. Frequently, patients may report these types of side effects as allergies, although they are not immunologic reactions. Hypersensitivity reactions to metronidazole are rare, with only a small number of case reports in the published literature (Asensio Sánchez et al., 2008; García-Rubio, Martínez-Cócera, Santos Magadán, Rodríguez-Jiménez, & Vázquez-Cortés, 2006; Knowles, Choudhury, & Shear, 1994; Kurohara, Kwong, Lebherz, & Klaustermeyer, 1991; Maize & Tomecki, 1977; Naik & Singh, 1977; Shelley & Shelley, 1987; Short, Fuller, & Salisbury, 2002; Weart & Hyman, 1983). Practitioners should also be cautious that despite the ubiquity of chlorhexidine, dental products containing this agent can cause various hypersensitivity reactions that range in severity from type IV, delayed hypersensitivity (usually manifesting as urticaria and dermatitis or fixed drug eruptions), to type I, which has serious and life-threatening consequences (immediate hypersensitivity and anaphylaxis) (Donaldson & Goodchild, 2019).
ANTIBIOTIC STEWARDSHIP
Antibiotic stewardship refers to activities that aim to promote the appropriate use of antibiotics, lower costs, reduce antibiotic resistance, decrease the spread of infections caused by multidrug-resistant organisms and improve patient outcomes (Centers for Disease Control and Prevention, 2018). An antibiotic stewardship program works to ensure that patients receive antibiotic therapy only when it is indicated and that the right drug is prescribed at the right dose for the right patient and the right duration. Recent reviews demonstrate that, in dentistry, it is possible to minimize the use of antibiotics, thoroughly assessing patient's conditions and type of intervention, thus improving their efficacy and reducing the adverse effects and enhancing the modern concept of personalized medicine (Buonavoglia, et al., 2021). In June 2015, during a White House Forum on Antibiotic Stewardship, more than 100 organizations made commitments to improve antibiotic prescribing over the next 5 years (Centers for Disease Control and Prevention, 2021). These strategic activities were submitted to the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention [2], 2021). The American Dental Association (ADA) pledged to provide appropriate clinical and scientific expertise to assess fully and respond to antibiotic health care issues, offer continuing education courses at professional meetings, and provide systematic reviews and up-to-date scientific information on the proper use of antibiotics in online resources (Fluent, Jacobsen, & Hicks,, 2016; ADA, 2021b).
The following are suggested initial steps to take to develop, understand, and support antibiotic stewardship better in dentistry: ● Identify data sources that can be used to understand better and characterize antibiotic prescribing by dentists. ● Develop and update national prescribing recommendations for the treatment of dental infections. ● Encourage ADA and dental specialty organizations to work together to develop and adopt antibiotic stewardship policies that are relevant to dentistry. ● Incorporate national prescribing recommendations within dental software management prescription templates. ● Develop educational tools, resources, and messages for dentists and patients about the importance of antibiotic stewardship in dentistry. ● Foster collaboration among the ADA, dental specialty organizations, and other relevant stakeholders to provide consistent messaging regarding antibiotic use in dentistry. Until national prescribing guidelines are endorsed by dental specialty organizations and the ADA, dentists must continue to use their judgment to optimize antibiotic prescribing and should consider this module an important resource for this education.
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