Combating antibiotic resistance
ADA COUNCIL ON SCIENTIFIC AFFAIRS
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ABSTRACT
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Background. The ADA Council on Scientific Affairs developed this report to provide dental professionals with current information on antibiotic resistance and related considerations about the clinical use of antibiotics that are unique to the practice of dentistry.
Overview. This report addresses the association between the overuse of antibiotics and the development of resistant bacteria. The Council also presents a set of clinical guidelines that urges dentists to consider using narrow-spectrum antibacterial drugs in simple infections to minimize disturbance of the normal microflora, and to preserve the use of broad-spectrum drugs for more complex infections.
Conclusions and Practice Implications. The Council recommends the prudent and appropriate use of antibacterial drugs to prolong their efficacy and promotes reserving their use for the management of active infectious disease and the prevention of hematogenously spread infection, such as infective endocarditis or total joint infection, in high-risk patients.
For the past 70 years, antibiotic therapy has been a mainstay in the treatment of bacterial infectious diseases. However, widespread use of these drugs by the health professions and the livestock industry has resulted in an alarming increase in the prevalence of drug-resistant bacterial infections.
Worldwide, many strains of Staphylococcus aureus exhibit resistance to all medically important antibacterial drugs, including vancomycin,1,2 and methicillin-resistant S. aureus is one of the most frequent nosocomial pathogens.3 In the United States, the proportion of Streptococcus pneumoniae isolates with clinically significant reductions in susceptibility to ß lactam antimicrobial agents has increased more than threefold.4,5 Even more alarming is the rate at which bacteria develop resistance; microorganisms exhibiting resistance to new drugs often are isolated soon after the drugs have been introduced.6 This growing problem has contributed significantly to the morbidity and mortality of infectious diseases, with death rates for communicable diseases such as tuberculosis rising again.7,8
Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity, allergy and the development, selection and transmission of microbial resistance.
Disease etiologies also are changing. In recent studies, staphylococci, particularly S. aureus, have surpassed viridans streptococci as the most common cause of infective endocarditis.9 Resistance among bacteria of the oral microflora is increasing as well. During the past decade, retrospective analyses of clinical isolates have clearly documented an increase in resistance in the viridans streptococci.10 Further, strains of virtually every oral microorganism tested exhibit varying degrees of resistance to various antibacterial agents.11
This increase in antibacterial resistance has been attributed primarily to two different processes. First, reduced susceptibility may develop via genetic mutations that spontaneously confer a newly resistant phenotype.12 Alternatively, the exchange of resistant determinants between sensitive and resistant microorganisms (of the same or different species) may occur.13 Regardless of the genetic basis of resistance, the selective pressure exerted by widespread use of antibacterial drugs is the driving force behind this public health problem. It is only through the prudent and appropriate use of antibacterial drugs that their efficacy may be prolonged.
Antibacterial drugs should be reserved for the management of active infectious disease and considered for the prevention of hematogenously spread infection, such as infective endocarditis or total joint infection, in high-risk patients (as defined by the American Heart Association14 and the American Dental Association and the American Academy of Orthopedic Surgeons15). One example of their use in managing infectious disease is in the treatment of aggressive periodontal disease, which use has become well-accepted for optimal control of the disease process.16 The Council encourages further research on the appropriate use of antibacterial therapy in the management of oral diseases.
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GUIDELINES FOR PRESCRIBING ANTIBIOTICS
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The following guidelines should be observed when prescribing antibacterial drugs:
- make an accurate diagnosis;
- use appropriate antibiotics and dosing schedules;
- consider using narrow-spectrum antibacterial drugs (Table 1
) in simple infections to minimize disturbance of the normal microflora, and preserve the use of broad-spectrum drugs (Table 2) for more complex infections17;
- avoid unnecessary use of antibacterial drugs in treating viral infections;
- if treating empirically, revise treatment regimen based on patient progress or test results;
- obtain thorough knowledge of the side effects and drug interactions of an antibacterial drug before prescribing it;
- educate the patient regarding proper use of the drug and stress the importance of completing the full course of therapy (that is, taking all doses for the prescribed treatment time).
Furthermore, the diagnosis and antibiotic selection should be based on a thorough history (medical and dental) to reveal or avoid adverse reactions, such as allergies and drug interactions. Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity, allergy and the development, selection and transmission of microbial resistance.15
It remains incumbent on dental practitioners, as health care providers, to use antibacterial drugs in a prudent and appropriate manner. Adherence to the principles outlined here will aid in extending the efficacy of the antibacterial drugs that form the treatment foundation for many infectious diseases.
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FOOTNOTES
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Address reprint requests to ADA Council on Scientific Affairs, 211 E. Chicago Ave., Chicago, Ill. 60611.
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REFERENCES
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- Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in Staphylococcus aureus. Glycopeptide-Intermediate Staphylococcus aureus Working Group. N Engl J Med 1999;340:493–501.[Abstract/Free Full Text]
- Fridkin SK. Vancomycin-intermediate and -resistant Staphylococcus aureus: what the infectious disease specialist needs to know. Clin Infect Dis 2001;32(1):108–15.[Medline]
- Flournoy DJ. Methicillin-resistant Staphylococcus aureus at a Veterans Affairs Medical Center (1986–96). J Okla State Med Assoc 1997;90(6):228–35.[Medline]
- Istre GR, Tarpay M, Anderson M, Pryor A, Welch D. Pneumococcus Study Group. Invasive disease due to Streptococcus pneumoniae in an area with a high rate of relative penicillin resistance. J Infect Dis 1987;156:732–5.[Medline]
- Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP. Pneumococcal bacteremia in Charleston County, South Carolina: a decade later. Arch Intern Med 1990;150:1401–5.[Abstract]
- Stratton CW. Dead bugs don’t mutate: susceptibility issues in the emergence of bacterial resistance. Emerg Infect Dis 2003;9(1):10–6.[Medline]
- Khan K, Muennig P, Behta M, Zivin JG. Global drug-resistance patterns and the management of latent tuberculosis infection in immigrants to the United States. N Engl J Med 2002;347(23):1850–9.[Abstract/Free Full Text]
- Musoke RN, Revathi G. Emergence of multidrug-resistant gram-negative organisms in a neonatal unit and the therapeutic implications. J Trop Pediatr 2000;46(2):86–91.[Abstract/Free Full Text]
- Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med 2001;345(18):1318–30.[Free Full Text]
- Doern GV, Ferraro MJ, Brueggemann AB, Ruoff KL. Emergence of high rates of antimicrobial resistance among viridans group streptococci in the United States. Antimicrob Agents Chemother 1996;40: 891–4.[Abstract]
- Jorgensen MG, Slots J. The ins and outs of periodontal antimicrobial therapy. J Calif Dent Assoc 2002;30(4):297–305.
- Normark BH, Normark S. Evolution and spread of antibiotic resistance. J Inter Med 2002;252(2):91–106.
- Kozlova EV, Pivovarenko TV, Malinovskaia IV, Aminov RI, Kovalenko NK, Voronin AM. Antibiotic resistance of Lactobacillus strains [in Russian]. Antibiot Khimioter 1992;37(6):12–5.
- Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JADA 1997;128:1142–51.
- American Dental Association; American Academy of Orthopedic Surgeons. Antibiotic prophylaxis for dental patients with total joint replacements. JADA 2003;134:895–9.
- Herrera D, Sanz M, Jepsen S, Needleman I, Roldan S. A systematic review on the effect of systemic antimicrobials as an adjunct to scaling and root planing in periodontitis patients. J Clin Periodontol 2002;29(supplement 3):136–59.
- Ciancio SG, ed. ADA guide to dental therapeutics. 3rd ed. Chicago: ADA Publishing; 2003:136–72.
- Physicians’ desk reference. 58th ed. Montvale, N.J.: Medical Economics; 2004:1321.
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J. Antimicrob. Chemother.,
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1161 - 1166.
[Abstract]
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