Patients Should Never Be “Stuck in the Middle”
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Debra Goff, PharmD, FCCP, is an associate professor and infectious diseases clinical pharmacist at The Ohio State University Wexner Medical Center
Julie E. Mangino, MD, FSHEA, FIDSA, is a professor of infectious diseases at The Ohio State University Wexner Medical Center
In June 2018, The Ohio State University Infectious Diseases Institute hosted “Dental Antibiotic Stewardship in Orthopedic Patients,” a workshop for private practice dentists and orthopedic surgeons.
We came up with the idea when Doug Goff, DDS (Debra’s husband), encountered a patient whose orthopedic surgeon had told her that she needed to take prophylactic antibiotics before any dental procedure for the rest of her life. (The American Dental Association (ADA) does not recommend prophylactic antibiotics before dental procedures in patients with prosthetic joint implants, but the American Academy of Orthopedic Surgeons does recommend them in very limited situations.) Dr. Doug Goff shared the ADA guidelines with his patient and told her about the risk of developing a Clostridioides difficile (C. difficile) infection or a “superbug” infection from unnecessary antibiotics. The patient was confused and canceled the dental appointment. Debra told her husband, “the patient should NEVER be stuck in the middle, and we need to do something about it.” So, we created a community forum to bring together both parties and discuss the recommendations and communication difficulties between dentists and surgeons. Here are some of the items that were discussed:
We came up with the idea when Doug Goff, DDS (Debra’s husband), encountered a patient whose orthopedic surgeon had told her that she needed to take prophylactic antibiotics before any dental procedure for the rest of her life. (The American Dental Association (ADA) does not recommend prophylactic antibiotics before dental procedures in patients with prosthetic joint implants, but the American Academy of Orthopedic Surgeons does recommend them in very limited situations.) Dr. Doug Goff shared the ADA guidelines with his patient and told her about the risk of developing a Clostridioides difficile (C. difficile) infection or a “superbug” infection from unnecessary antibiotics. The patient was confused and canceled the dental appointment. Debra told her husband, “the patient should NEVER be stuck in the middle, and we need to do something about it.” So, we created a community forum to bring together both parties and discuss the recommendations and communication difficulties between dentists and surgeons. Here are some of the items that were discussed:
Primary care dentists prescribe approximately 10 percent of all antibiotic prescriptions filled in outpatient pharmacies each year. That equates to nearly 26 million prescriptions.
- Drs. Goff and Mangino gave an overview on antimicrobial resistance, adverse effects of antibiotics, and Clostridioides difficile in our community.
- An orthopedic surgeon and an oral surgeon gave presentations on their communication difficulties between dentists and surgeons.
- CDC physicians shared information about antibiotic prescribing rates and interventions on the national and global level to improve antibiotic use.
- In small groups, patient cases were discussed with next steps to engage more private practice dentists and orthopedic surgeons.
- Hospital lawyers answered questions about prescribing prophylactic antibiotics as “defensive medicine” for fear of lawsuits.
Here’s what we learned from the forum:
- One size does not fit all. Lifetime antibiotic prophylaxis for a routine primary total hip replacement in a healthy patient is unnecessary, but it is recommended for a patient with osteosarcoma and a total femoral replacement, where an infection may mean limb amputation.
- Eighty-six percent of attendees stated that the new information they learned regarding risk of C. difficile, superbugs, and antibiotic adverse events changed their perspectives on the safety of antibiotic prophylaxis.
- One hundred percent of attendees reported this type of forum was effective. They felt that similar workshops should be held at the local level throughout the United States to bring dentists and orthopedic surgeons together.
There was much respect and great collegial interactions between the surgeons and dentists, which allowed for identification of misconceptions on both sides. In the end, there was a consensus to use fewer antibiotics for joint implant patients receiving dental treatment. We encourage other antibiotic stewardship programs to reach out to private practice dentists to start the discussion of dental stewardship in joint implant patients.
Debra Goff PharmD, FCCP is a founding member of The Ohio State University Wexner Medical Center Antimicrobial Stewardship Program (ASP). She works with OSU One Health ASP and leads the OSU-South Africa “train-the-trainer” ASP mentoring program for South African pharmacists. Dr. Goff works in hospitals across six continents helping them to implement ASP in resource limited countries. Follow her on Twitter @idpharmd to learn, engage, and connect with people interested in antibiotic stewardship.
Julie Mangino MD, FSHEA, FIDSA is an active Emeritus Professor of Medicine at the Ohio State University in the Division of Infectious Diseases, where she sees patients and teaches Infectious Diseases Fellows and medical students. She remains a supporter of ASP principles with the “right drug at the right time and at the correct dose.” In her role as the Medical Director of Clinical Epidemiology at The Ohio State University Wexner Medical Center, she focused on teaching and preventing healthcare associated infections among patients, staff, and visitors.
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