Bugs & Drugs: The Controversy Surrounding Prophylaxis

Episode #350 with Dr. Tom Viola, R.Ph., C.C.P.

Imagine causing an accident while trying to prevent said accident. That is where prophylaxis stands in dentistry. By prescribing them unnecessarily to prevent infections, it can actually create resistance and increase infection risk. But there are ways to prevent this! And Dr. Tom Viola returns with Kirk Behrendt to teach you everything you need to know about prophylaxis to help you prescribe them appropriately and effectively. For the best practices on being a steward for antibiotics, listen to Episode 350 of The Best Practices Show!

Main Takeaways:

Dentists are overprescribing unnecessary antibiotics.

Overuse of antibiotics can lead to resistance.

Antibiotics and antibacterials can have adverse effects.

Overusing clindamycin can increase the risk of C. diff infection.

For the average patient, there is no evidence that prophylaxis is necessary.

Guidelines for antibiotic prophylaxis are constantly evolving. 

Quotes:

“[Why prophylaxis is controversial] boils down to two main points. And the first one is, is antibiotic prophylaxis even necessary? If I have to ask that question, I have to ask a preview question to that. What the heck is prophylaxis and why is it necessary? Well, we know that there are certain vectors under which bacteria that normally reside in the mouth can end up causing trouble in other parts of the body. Obviously, one of the issues is infective endocarditis. That is where bacteria from the mouth have found a way into the endocardium and may cause issues that can ultimately lead to bad outcomes for our patients.” (3:20—4:03)

“Bacteria in the mouth can find a way to where we’ve had replacement joints, plates, knee replacements, hip replacements, and so on. And that can lead to joint replacement failure. These are pretty significant events in people’s lives and, certainly, we want to try everything we can in dentistry to avoid that from happening. So, one of the ways we avoid bacteria that normally resides in the mouth to find other places or other ways into the body cavities is to prophylax with antibiotics, to kill them before they have a chance to establish residence elsewhere. But it’s controversial because everybody knows that when you overuse an antibiotic, it increases the risk of infection.” (4:05—4:47)

“There is that whole aspect of antibiotic stewardship, which is, we should be the stewards. We should be the lookouts for making sure that antibiotics are used both effectively and efficiently, but also appropriately so we’re not overusing them and therefore causing resistance to occur.” (4:47—5:04)

“I can run down the list pretty easily, of antibiotics, that we normally use in dentistry. And that's the problem, in and of itself, is that we have a great arsenal of antibiotics that we use in dentistry, but unfortunately, it’s a very small arsenal. And they're not really all antibiotics. We use the term colloquially but, really, they're antibacterials.” (5:14—5:33)

“Penicillins are our favorite antibacterials. That would include penicillin VK and amoxicillin, specifically, in dentistry. And I'd be hard-pressed to find a general dentist and any dental specialist as well that hasn't prescribed amoxicillin at some point in their practice. And the reason for that is because it works, because it has great efficacy and great coverage against the bugs we find in the mouth. Now, the penicillins are bactericidal, which means that they destroy the cell wall and, therefore, they kill the bacteria. Which would sound great if you're treating virulent bacteria that you want to get rid of. But remember, they don't just kill the bad guys; they also kill the good guys. And that can lead to problems with things like opportunistic infections and...