These guidelines were developed by the Dental Antibiotic Stewardship Working Group, which is a subgroup of the Primary Care Antimicrobial Guideline Expert Advisory Committee associated with the HSE Antimicrobial Resistance and Infection Control Team.
One of the key principles of Antimicrobial Stewardship is to limit unintended consequences of antibiotic use. The guidelines facilitate antimicrobial prescription for oral infections to minimise patient adverse events (including development of Clostridioides difficile infection) and minimise development of antimicrobial resistance.
The guidelines provide advice, taking account of best available evidence, on prescribing for oral infections including BNF, BNF-C and the SDCEP Guidelines on Drug Prescribing in Dentistry. The guidelines have been developed after review of national and international guidelines and current practice, expert opinion, clinical consensus and published evidence where it exists.
The treatment options outlined are meant as guidelines for prescribers, they do not replace clinical judgement but augment it. While the guidelines are primarily for use by dentists they may also be of benefit to GP’s where a patient presents with an oral infection.
Before prescribing antimicrobials clinicians should also consider the following:
- Previous antimicrobial treatment which has been prescribed for the current and previous infections
- The allergy status of the patient
- Patient’s medical history
- Concurrent medication that the patient is taking:
- There is emerging evidence of significant interactions between certain antibiotics, antifungals, and statins. Caution is advised when prescribing macrolides such as clarithromycin or erythromycin, metronidazole, fusidic acid and miconazole oral gel as they have shown adverse reactions with statins, such as a risk of myopathy.
- There are also emerging concerns about increased risk of bleeding where miconazole oral gel or metronidazole are prescribed for patients on Warfarin.
- Co-amoxiclav, is not recommended for use in oral infections and has recently been associated with increased incidence of liver toxicity.
- See table on adverse drug interactions for current best guidance.
- It is important to recognise that antibiotics should be administered at the correct dose i.e., avoid under-dosing or overdosing.
- Under-dosing has been shown to be associated with increasing resistance. This is especially true of the Macrolides classes e.g. erythromycin.
- Overdosing may lead to toxicity issues and increase risk of adverse drug reactions.
Principles of Antimicrobial Treatment
- This guidance is based on the best available evidence, but its application must be tailored by professional judgement.
- A dose and duration of treatment is suggested.
- Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
- The prescribing of clindamycin, cephalosporins or co-amoxiclav offers no advantage over a penicillin, metronidazole or a macrolide and is not recommended for the routine management of oral infections. The inappropriate use of these drugs can increase the risk of resistant strains and limit the future usefulness of these important agents.
- Caution in prescribing practices is advised for patients who are pregnant, diabetic, with kidney disease or liver disease, who are on statins, warfarin and for very young children and the elderly or infirm.
- Antimicrobials prescription is only indicated as:
- An adjunct to the management of acute infection.
- Where definitive treatment has to be delayed due to referral to a specialist/hospital
- There is no indication for antimicrobials in acute pulpitis where treatment with analgesics is more appropriate.
- Antimicrobials are not indicated in endodontics unless there is evidence of significant local spread of infection or systemic infection. Antimicrobials should not be routinely prescribed post-operatively as research indicates that it does not reduce pain, swelling or the need for analgesics in symptomatic root filled teeth
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Reviewed March 2021