padiatric antibiotic prescribing by general dental practitioners in england by ale Stela

Paper 280 Disc International Journal of Paediatric Dentistry 2001; 11: 242±248

Paediatric antibiotic prescribing by general dental practitioners in England N. O. A. PALMER, M. V. MARTIN, R. PEALING & R. S. IRELAND Department of Clinical Dental Sciences, University of Liverpool, Liverpool, U.K.

Summary. Objectives. The inappropriate use of antibiotics is known to be a major contributory factor to the problem of antimicrobial resistance. No information is available on how practitioners prescribe antibiotics for children. This study investigated the prescribing of liquid-based antibiotics for children by general dental practitioners in England. Design. Analysis of National Health Service liquid-based prescriptions issued by general dental practitioners in England. Sample and methods. All prescriptions issued by practitioners in 10 Health Authorities in England for February 1999 were collected. All the liquid-based antibiotic prescriptions for children were selected and we investigated the type of antibiotic prescribed, whether sugar free, the dose, frequency and duration. Results. A total of 18614 prescriptions were issued for antibiotics. Of the 1609 liquidbased paediatric prescriptions 88.3% were for generic and 11.7% for proprietary antibiotics, of which 75.5% were for amoxicillin, 15.2% for phenoxymethylpenicillin, 6.6% for erythromycin, 1.7% for metronidazole. Cephalexin, ampicillin, cephadrine and combinations of two antibiotics were also prescribed. There was a wide variation in dosages for all the antibiotics prescribed. A significant proportion of practitioners prescribed at frequencies inconsistent with manufacturers' recommendations and for prolonged periods, with some practitioners prescribing for periods up to 10 days. Only 29.1% of all the prescriptions issued were sugar free. Conclusions. The results of this study show that some practitioners prescribe liquidbased antibiotics inappropriately for children. This may contribute to the problem of antimicrobial resistance. Clear guidelines on the choice of antibiotic, dose, frequency and duration along with educational initiatives for GDPs might reverse this trend.

Introduction General dental practitioners (GDPs) prescribe antibiotics for children, both therapeutically and prophylactically, to manage oral and dental infections. The bene®ts of prescribing antibiotics are limited by a number of problems associated with their use, e.g. side-e ects, allergic reactions, toxicity and the development of resistant strains of microbes. The emergence of resistant bacterial strains due to the inappropriate use of antibiotics is a cause for Correspondence: Nikolaus O. A. Palmer, Department of Clinical Dental Sciences, University of Liverpool, Liverpool L69 3BX, UK

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worldwide concern [1±3]. The Dental Practitioners Formulary (DPF), a section of the British National Formulary (BNF), gives advice on how and what should be prescribed for dental infections and prophylaxis [4]. However, it only provides nonspeci®c recommendations on therapeutic dose and frequency of antibiotics for children, stating that age and weight should be considered when prescribing, with no recommendations for the treatment duration. The management of abscessed teeth is in¯uenced by the severity of the infection. The important principle should be to establish and maintain drainage by incision of the soft tissue abscess, by opening up the pulp chamber or # 2001 BSPD and IAPD

Ahed Bhed Ched Dhed Ref marker

Fig marker Table marker Ref end Ref start

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extracting the tooth [5]. Inappropriate prescribing of antibiotics by GDPs has not been perceived as a problem but in 1998, GDPs issued 3.56 million antibiotic prescriptions, equating to 7.5% of all antibiotics prescribed by general medical and dental practitioners in the community [6]. There is evidence in general dental practice of overuse of antibiotics [7±9] but there is no information on dental practitioner paediatric prescribing apart from a survey of paedodontists [10] and an examination of children attending a casualty department with dental pain [11]. Both these investigations showed antibiotics were prescribed in some cases inappropriately, with antibiotics prescribed for pain where there was no swelling and for infection and trauma with no swelling. Other limited studies have shown a wide variation in what is prescribed therapeutically and dosages employed [12±14]. The aim of the present study was to investigate the prescribing of antibiotics for children, by analysis of prescriptions issued by a large population of GDPs in England. Method The Regional Prescription Pricing Authorities (RPPAs) for the nine Health Authorities selected, collected all dental prescriptions for the month of February 1999. The nine Health Authorities were Liverpool, Wirral, Oxfordshire, Buckinghamshire, North Tyneside and Newcastle, Northumberland, Nottingham, North Nottinghamshire and Shef®eld. The RPPAs photocopied the prescriptions with the patient and dentist information removed in order to maintain con®dentiality. Paediatric prescriptions for antibiotics were then selected from those received from the RPPAs. The selection was based on whether a liquid preparation was prescribed. The prescriptions were given an individual identi®cation number and were grouped into Health Authority areas. The information collected from the prescriptions was the antibiotic prescribed, dose, frequency and duration in days and whether the preparation was dispensed sugar free. This information was numerically coded and entered into a Statistical Package for Social Science (SPSS) database [15]. From this database frequencies were used to describe the sample and examine the distribution of variables.

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Results A total of 18614 prescriptions were issued for antibiotics. Of these, 1609 paediatric prescriptions were analysed and the antibiotics prescribed are shown in Table 1. The majority (88.3%) of these were generic prescriptions but 11.7% were for proprietary antibiotics. The most prescribed antibiotic was amoxicillin (75.5%) followed by phenoxymethylpenicillin (15.2%) and erythromycin (6.6%). No prescriptions were written for clindamycin. Only 29.1% of the prescriptions were in sugar free form, with the dispensing pharmacist changing a further 3.8% of the prescriptions to sugar free form. Detailed analysis of the commonest antibiotics prescribed, shown in Tables 2, 3, 4 and 5 demonstrated a wide variation in the doses employed, frequency and duration of the course. A signi®cant number of practitioners prescribed at frequencies inconsistent with manufacturers' recommendations and for prolonged duration of treatment with some prescribing for up to 10 days. Table 6 shows the distribution of prescriptions for each Health Authority area, the number of GDPs practising in each of the areas and the number of prescriptions for each GDP. Discussion There are approximately 15800 dentists (excluding assistants and vocational trainees practising within the NHS General Dental Services in England, 72% are male and 28% are female [16]. The geographically distributed areas chosen for this study included rural and urban areas with approximately 10% of all dentists practising in the GDS in England. In order to preserve con®dentiality the patient and dentist details, along with the age of the patient, were removed from the prescriptions. The prescripTable 1. Prescriptions for liquid oral antibiotics written by GDPs in nine Health Authorities in England during a one month period. Antibiotic Amoxicillin Metronidazole Penicillin V Erythromycin Amoxicillin + Metronidazole Cephalexin Cephradine Ampicillin Total

Frequency

Percentage

1219 28 244 106 2 5 1 4 1609

75.7 1.7 15.2 6.6 0.1 0.3 0.1 0.2 100

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Table 2. Distribution of prescriptions for amoxicillin showing dosage, frequency of dose and duration in days. Number of days

1 3 5 6 7

8 10

Dosage prescribed (mg)

1 dose

1500 750 125 250 125 250 500 125 75 125 250 500 125 125

4 2

3x daily

Frequency of dose 4x daily 1 dose + 1 dose 8 h later

193 38

Number of days Dosage prescribed (mg) Frequency of dose 3 6 daily 4 6 daily

7 8

1 dose + 1 dose 8 hrs later then 3x daily

1 8 2

87 35 1 1 2

125 125 100 125 175 250 500 125 250 125

2 x daily

10 2 710 104 1 5

Table 3. Distribution of prescriptions for Penicillin showing dosage, frequency of dose and duration in days.

3 4 5

2 doses followed by 1 dose 3x daily

29 8

1 1 1 129 1 54 1 16 2

tions were taken for one month (February), as there is little seasonal, or monthly variation in the number of antibiotic prescriptions issued (Prescription Pricing Authority, data on ®le) Only prescriptions containing antibiotics prescribed in liquid form were included in this study. It was assumed that these would be mainly for younger children, although it is acknowledged that some children may have been prescribed tablets and some liquid prescription may have been for elderly adults. The majority of prescriptions issued were for amoxicillin (75.5%), followed by phenoxymethylpenicillin (15.2%) and erythromycin (6.6%). The majority of prescriptions were generic, which are known to be as e cacious as brand name equivalents but also produce cost savings [17]. For most therapeutic prescribing the antibiotic of choice recommended by the DPF is phenoxymethylpeni-

cillin at a dose for children below 5 years of age of 125 mg every six hours. This is increased to 250 mg for children aged 6±12 years. The BNF section is more speci®c and it suggests that children's doses should be calculated from adult doses by using age (in age ranges), body weight, or body surface area [4]. There was a wide variation in doses in this study perhaps mirroring these recommendations. As the age of the patient for whom the antibiotic was prescribed was unavailable, it was not possible to see if there was a relationship between the age of the patient and the dosage prescribed. Further investigations of this aspect would be of bene®t. The recommended use of phenoxymethylpenicillin is based on studies that had isolated mainly streptococci and staphylococci from dental abscesses [18±20]. More recent studies have shown that isolates from dental abscesses are a complex mixture of facultative and anaerobic bacteria, some of which are resistant to penicillin [21±23]. The use of amoxicillin by the majority of GDPs within this study can therefore be supported by some microbiological and clinical ®ndings [24,25]. The use of erythromycin in the treatment of dental infections has been shown to be ine ective as a ®rst choice due to poor absorption and rapid emergence of resistant strains [26]. It is however, recommended as the choice for patients allergic to penicillin, along with metronidazole [4]. Within this study, 6.6% of GDPs prescribed erythromycin and 1.7% metronidazole. Table 6 showed that although very few prescriptions for antibiotics were pre-

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Table 4. Distribution of prescriptions for metronidazole showing dose, frequency of dose and duration in days. Number of days

Dosage prescribed (mg)

Frequency of dose 3 6 daily 4 6 daily

100 200 100 125 200 100 200

2 2 4 1 13

5 7

2 6 daily 1 1

1 1 1

Table 5. Distribution of prescriptions for erythromycin showing dose, frequency of dose and duration in days. Number of days

0 1 5

7 10

Dosage prescribed

2 g+1 g 1.5 g + 0.5 g 1g 125 mg 250 mg 750 mg + 125 mg 125 mg 250 mg 125 mg

Frequency of dose ÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐ± 36 46 1 dose 2 doses 1 dose 26 1 dose daily daily +1 +3 +3 daily +2 8 hrs 6 daily 6 daily 6 daily later 1 7 6

40 35

5 2

1 1

Table 6. Distribution of liquid based prescriptions, number of GDPs for each Health Authority and the number of prescriptions issued for each GDP. Health Authority

Number of GDPs

Number of prescriptions

Number of prescriptions / GDP

Liverpool Wirral Oxfordshire Buckinghamshire North Tyneside Northumberland Newcastle North Notts Nottingham Sheffield Total

162 122 219 250 55 86 124 208 113 205 1544

309 125 147 183 57 111 96 225 214 142 1609

1.9 1.0 0.7 0.7 1.0 1.3 0.8 1.1 1.9 0.7 1.0

scribed over the month there were wide variations in frequency of dosage with over 19% failing to prescribe the antibiotics used at the frequencies recommended in the DPF. No indication is given within the DPF or BNF on the duration of the course other than a recommendation that treatment should not be unduly prolonged [4]. It has been shown that compliance by children to complete a conventional course of antibiotics is poor [27]. Within this study there was evidence of prolonged

duration of treatment with antibiotics prescribed up to 10 days. There is evidence that short courses of antibiotics, with appropriate treatment, are adequate for resolution of dental infections [24,28,29]. The British Society for Antimicrobial Chemotherapy recommends for prophylaxis a single dose of amoxicillin (750 mg for children under 5 years of age and 1.5 g for children aged 5±10 years) for patients not allergic to penicillin, and clindamycin (150 mg for the under 5 years and 300 mg for children aged

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5±10 years) for patients allergic to penicillin. Clindamycin has replaced erythromycin as the choice for patients allergic to penicillin for prophylaxis [4,30,31]. It would appear from the analysis within this study that the antibiotics of choice for prophylaxis were amoxicillin and erythromycin. It was disappointing to note that only 29% of the prescriptions were speci®ed as sugar free, with a further 3.8% prescriptions altered by pharmacists to be dispensed in this form. There is evidence that liquid medicines, many of which contain sugar, can cause decay and so sugar free preparations should be used whenever possible [32,33]. DPF products marked `sugar free' do not contain glucose, fructose or sucrose but may contain hydrogenated glucose syrup, mannitol or sorbitol which have all been shown not to be cariogenic [4]. Pharamacists cannot dispense sugar-free generic prescriptions without contacting the prescriber and marking the prescription accordingly, so the proportion of antibiotics without fermentable carbohydrates was unlikely to have been higher than the 29% and 3.8% recorded in the study. There is obviously a need to educate practitioners to prescribe sugar-free liquid preparations of antibiotics whenever possible. The number of paediatric liquid prescriptions in this study amounted to approximately 9% of all prescriptions issued [7,8], and there is anecdotal evidence that antibiotic prescriptions for children are increasing. One reason for this increase in antibiotic prescribing may be the removal of general anaesthetics from general dental practice. There may be a delay in extracting abscessed teeth under general anaesthetic due to waiting lists and the need for patient pre-anaesthetic assessment. Antibiotics may therefore be prescribed until de®nitive treatment can be provided. Recent research has shown that GDPs prescribe antibiotics when treatment has to be delayed [7]. This is an area of prescribing that requires investigation. It is accepted that antibiotics should only be used as an adjunct to surgical treatment in the management of acute or chronic infection, where there is evidence of spreading infections, for the de®nitive management of active infectious disease and for the prevention of metastatic infection such as infective endocarditis [34]. In order to prevent the further development of antimicrobial resistance and to optimise the care to patients, general dental practitioners need clear guidelines on antibiotic prescribing for children.

Acknowledgements We would like to thank the Central Prescription Pricing Authority and the Regional Prescription Pricing Authorities for organising and providing the prescriptions, the nine Health Authorities for their support and the NHS National Primary Dental Care Research and Development Programme for funding this study. ReÂsumeÂ. Objectifs. L'utilisation inapproprieÂe d'antibiotiques est connue pour eÃtre un facteur majeur contribuant au probleÁme de la reÂsistance microbienne. Aucune information n'est disponible concernant les habitudes des praticiens de prescription des antibiotiques pour enfants. Cette a eu pour objet la prescription d'antibiotiques aÁ base liquide pour enfants par les omnipraticiens d'Angleterre. Protocole. Analyse des prescriptions aÁ base liquide du National Health Service par les omnipraticiens d'Angleterre. Echantillon et MeÂthode. Toutes les prescriptions e ectueÂes par les praticiens de dix Services de SanteÂ en Angleterre, depuis FeÂvrier 1999 ont eÂteÂ recueillies. Toutes les prescriptions d'antibiotiques pour enfants aÁ base liquide ont eÂteÂ seÂlectionneÂes, et le type d'antibiotique prescrit, l'absence de sucre, la dose, la freÂquence et la dureÂe ont eÂteÂ eÂtudieÂs. ReÂsultats. Un total de 18614 prescriptions ont porteÂ sur les antibiotiques. Sur les 1609 prescriptions peÂdiatriques aÁ base liquide, 88,3% l'ont eÂteÂ pour des geÂneÂriques et 17,3% pour des antibiotiques de marques. De ceux-laÁ, 75,5% ont concerneÂ l'amoxicilline, 15,2% la phenoxymeÂthympeÂnicilline, 6,6% l'eÂrythromycine, 1,7% le meÂtronidazole. La ceÂphalexine, l'ampicilline, la ceÂphadrine, et des combinaisons de deux antibiotiques ont eÂgalement eÂteÂ prescrits. Il y avait une grande variation dans les dosages pour tous les antibiotiques prescrits. Une partie signi®cative des praticiens a prescrit aÁ des freÂquences sans lien avec les recommandations des fabriquants et pour des peÂriodes prolongeÂes, certains praticiens prescrivant pour des peÂriodes allant jusqu'aÁ dix jours. Seulement 29,1% de toutes les prescriptions eÂtaient sans sucre. Conclusions. Les reÂsultants de cette eÂtude montrent que certains praticiens prescrivent les antibiotiques aÁ base-liquide de facËon inapproprieÂe pour les enfants. Ceci peut contribuer au probleÁme de la reÂsistance microbienne. Des reÁgles claires sur le choix d'un antibiotique, la dose, la freÂquence et la

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dureÂe associeÂes aÁ des initiatives d'instruction pour omnipraticiens pourraient inverser cette tendance. Zusammenfassung. Ziele. UnsachgemaÈûe Antibiotikaverwendung ist bekanntermaûen die Hauptursache fuÈr Antibiotikaresistenz. Es sind keine Informationen verfuÈgbar wie AllgemeinzahnaÈrzte Antibiotika fuÈr Kinder verordnen. Die vorliegende Studie untersuchte die Verornung von AntibiotikasaÈfte fuÈr Kinder durch AllgemeinzahnaÈrzte in England. Studienanlage. Analyse von National Health Service Verordnungen von AntibiotikasaÈften ausgestellt von AllgemeinzahnaÈrzten in England. Stichprobe und Methodik. Alle Verordnungen von Praktikern in zehn Gesundheitsbezirken in England im Februar 1999 wurden gesammelt. Alle Verordnungen von AntibiotikasaÈften wurden herausgesucht, die Art des Antibiotikums, Zuckergehalt, Dosierung, HaÈu®gkeit der Einnahme und die Dauer wurden untersucht. Ergebnisse. Insgesamt 18614 Verordnungen fuÈr Antibiotika wurden ausgestellt. Von 1609 Verordnungen von AntibiotikasaÈften fuÈr Kinder waren 88,3% Generika und 11,7% OriginalpraÈparate, dabei waren 75,5% Amoxicillin, 15,2% fuÈr Penicillin V, 6,6% fuÈr Erythromycin und 1,7% fuÈr Metronidazol. Cephalexin, Ampicillin, Cephadrin und Kombinationen wurden ebenfalls verordnet. Es lag eine groûe Spannbreite an verordneten Dosierungen vor. Ein betraÈchtlicher Teil der Praktiker verordnete Frequenzen, welche nicht mit den Herstellerempfehlungen uÈbereinstimmten, sowie fuÈr verlaÈngerte Perioden bis zu 10 Tagen. Nur 29,1% der Verordnungen waren zuckerfrei. Schluûfolgerungen. Die Ergebnisse dieser Studie zeigen, daû manche Praktiker AntibiotikasaÈfte ungeeignet fuÈr Kinder verordnen. Die kann zur Entstehung von Resistenzen beitragen. Klare Richtlinien fuÈr die Auswahl, Dosierung, Einnahmefrequenz und Verordnungsdauer koÈnnten in Verbindung mit Fortbildungsinitiativen fuÈr die AllgemeinzahnaÈrzte diesen Trend umkehren. Resumen. Objetivos. El uso inapropiado de antibioÂticos se conoce como el factor maÂs importante que contribuye al problema de la resistencia antimicrobiana. No existe informacioÂn disponible de coÂmo los profesionales prescriben antibioÂticos en ninÄos. Este estudio investigoÂ la prescripcioÂn de antibioÂticos en forma lõÂ quida para ninÄos por OdontoÂlogos generales en Inglaterra.

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DisenÄo. AnaÂlisis de las prescripciones de antibioÂticos lõÂ quidos en el Servicio Nacional de Salud realizado por OdontoÂlogos generales en Inglaterra Muestra y meÂtodos. Se registraron todas las prescripciones realizadas por los odontoÂlogos de 10 Centros de Salud de Inglaterra durante Febrero de 1999. Se seleccionaron todas las prescripciones de antibioÂticos en forma lõÂ quida para ninÄos y se investigoÂ el tipo de antibioÂtico prescrito, si eÂste no contenõÂ a azuÂcar, la dosis, la frecuencia y la duracioÂn. Resultados. Se realizaron un total de 18614 prescripciones de antibioÂticos. De las 1609 prescripciones pediaÂtricas de antibioÂticos en forma lõÂ quida, 83,3% fueron geneÂricos y un 11,7% con nombre comercial, de los cuales un 75,5% fueron Amoxicilina, un 15,2% Fenoximetilpenicilina, 6,6% Eritromicina y un 1,7% Metronidazol. TambieÂn se prescribieron Cefalexina, Ampicilina, Cefadrina y combinaciones de dos antibioÂticos. Se evidencioÂ una amplia variacioÂn de las dosis para todos los antibioÂticos prescritos. Una proporcioÂn signi®cativa de odontoÂlogos prescribõÂ oÂ unas frecuencias que no se relacionaban con las indicaciones del fabricante y durante periodos prolongados, algunos de ellos prescribõÂ an por periodos de maÂs de diez dõÂ as. Solo un 29,1% de todas las prescripciones realizadas eran de productos sin azuÂcar. Conclusiones. Los resultados de este estudio muestran que algunos profesionales prescriben antibioÂticos en forma lõÂ quida inapropiados para los ninÄos. Esto podrõÂ a contribuir con el problema de la resistencia antimicrobiana. Con unas buenas referencias para la eleccioÂn del antibioÂtico, dosis, frecuencia y duracioÂn junto con iniciativas educacionales para la GDPS se podrõÂ a invertir esta tendencia. References 1 The World Health Organisation. Monitoring and management of bacterial resistance to antimicrobial agents. A World Health Organisation symposium. Clinical Infectious Diseases 1997; 24 (Suppl. 1): S1±176. 2 Standing Medical Advisory Committee. The Path of Least Resistance. London: Department of Health; 1998. 3 Wise R, Hart T, Cars O, Streulens M, Helmuth R, Huovinen P et al. Antimicrobial resistance is a major threat to public health [editorial]. British Medical Journal 1998; 317: 609±610. 4 The Royal Pharmaceutical Society of Great Britain and the British Medical Association. Dental Practitioners Formulary 1998±2000 British National Formulary No 36. London; 1998. 5 Barker GR, Qualtrough AJ. An investigation into antibiotic prescribing at a dental teaching hospital. British Dental Journal 1987; 162: 303±306. 6 Department of Health Statistics Division 1E. Prescription

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