Antimicrobial practice

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1 Journal of Antimicrobial Chemotherapy (2001) 47, JAC Antimicrobial practice Antibiotic prescribing knowledge of National Health Service general dental practitioners in England and Scotland N. O. A. Palmer a *, M. V. Martin a, R. Pealing a, R. S. Ireland a, K. Roy b, A. Smith b and J. Bagg b a Department of Clinical Dental Sciences, University of Liverpool, Liverpool L69 3BX; b Infection Research Group, University of Glasgow, Glasgow G2 3JZ, UK The inappropriate use of antibiotics has contributed to the worldwide problem of antimicrobial resistance. Information on the knowledge, understanding and training of dental practitioners in the use of antibiotics in clinical practice is scarce. This study assessed the level of knowledge of general dental practitioners and the need for educational initiatives. An anonymous postal questionnaire was sent to National Health Service dental practitioners working in 10 Health Authorities in England (1544) and four Health Boards in Scotland (672). Each correct answer to the questionnaire was given a score of one mark; there were 84 questions. The scores for each section of the questionnaire were compared. Responses were received from 1338 (60.4%) of practitioners, of whom 22.1% had attended postgraduate courses in the previous 2 years on antibiotic prescribing. Practitioners who had attended courses had a significantly greater knowledge of antibiotic use (P < 0.05) than those who had not. There was no significant difference in knowledge between all age groups under 60 years of age. There were significant differences in knowledge between dentists practising in English Health Authorities and Scottish Health Boards (P < 0.01). Knowledge was good for clinical signs that are indicators for prescribing antibiotics and for a number of non-clinical factors, e.g. patient expectation. Knowledge of therapeutic prescribing for commonly presenting clinical conditions and prophylactic prescribing for medically compromised patients, however, was generally poor. This study has shown that an urgent review of dental undergraduate and postgraduate education in antibiotic prescribing is required. Provision of prescribing guidelines may improve knowledge and encourage the appropriate use of antibiotics in clinical dental practice. Introduction The increasing problem of antimicrobial resistance has emphasized the need for rationalization of antibiotic use in the treatment of infections. 1,2 Very little information is available on the knowledge and understanding of general dental practitioners concerning the use of antibiotics in everyday clinical practice. Previous studies have investigated the prescribing of antibiotics in acute dentoalveolar infections 3,4 and for prophylaxis for endocarditis. 5 More recent studies have shown that general dental practitioners prescribe inappropriately both therapeutically and prophylactically, and that a number of non-clinical factors can affect prescribing. 6,7 The aim of this study was to assess the level of knowledge of the use of antibiotics by a large population of general dental practitioners from England and Scotland, and to assess whether there is a need to investigate current undergraduate and postgraduate teaching. Materials and methods A questionnaire was designed to investigate general practitioners knowledge of prescribing of antibiotics, both therapeutically and prophylactically. The questionnaire was first evaluated in a pilot study, and following modifications was sent to a sample of general dental practitioners (GDPs) in England and Scotland. 8 *Correspondence address. 5 Springfield Close, Formby, Merseyside L37 2LL, UK. Tel: ; Fax: ; NikolausPalmer@compuserve.com 2001 The British Society for Antimicrobial Chemotherapy 233

2 N. O. A. Palmer et al. The questionnaire first sought information on the place and year of qualification, gender, age (banded in decades from years) and whether any postgraduate courses had been attended on antibiotics in the previous 2 years. The questionnaire investigated practitioners knowledge of the indications for prescribing antibiotics for a number of clinical signs that may be associated with a dental infection. The clinical signs chosen were elevated temperature, evidence of systemic spread, localized fluctuant swelling, gross diffuse swelling, difficulty in swallowing and closure of the eye due to infection. GDPs were asked to indicate their chosen antibiotic regimen for an acute infection in a patient not allergic to penicillin and for patients allergic to penicillin. GDPs were also asked whether a number of clinically presenting conditions required antibiotics and, if so, their choice of agent. The clinical conditions were acute pulpitis, acute periapical infection (before, with and after drainage), chronic apical infection, pericoronitis, cellulitis, periodontal abscess, acute ulcerative gingivitis, chronic marginal gingivitis, sinusitis, chronic periodontitis, dry socket, trismus and re-implantation of teeth. A number of non-clinical factors that can influence prescribing were investigated. The questionnaire asked whether patient expectation of a prescription, pressure of time or workload in the surgery, the patient s social history, uncertainty of diagnosis or where treatment had to be delayed might be a reason for prescribing antibiotics. GDPs were asked if prophylactic antibiotics were required for dental treatment or oral surgery in non-medically compromised patients. They were asked specifically whether antibiotics were required for surgical extractions, apicectomies and before or after root-canal treatment. If antibiotics were indicated, practitioners were asked to state their choice of antibiotic. The next part of the questionnaire sought knowledge on the medical conditions and dental procedures that may require prophylactic antibiotics. The dental procedures were scaling and polishing, subgingival restorations, rootcanal therapy, extractions and impressions. The medical conditions included patients with cardiac and immunological problems, renal pathology and transplantation, prosthetic joints and radiotherapy-treated head and neck cancer together with diabetes, Hodgkin s disease and AIDS. A copy of the questionnaire can be obtained from the corresponding author. services were included with the exception of specialist orthodontic practitioners. A total of 1544 questionnaires were sent in England and 672 in Scotland. The questionnaires contained a Health Authority/Health Board identifier, but no individual respondent could be identified. The responses were analysed using a Statistical Package for Social Science (SPSS) database. 9 The total response rate and scores for each question were calculated, correct answers were given a score of 1, with a maximum correct score for the questionnaire of 84. The correct answers were based on a review of the clinical literature, expert opinion where there is a lack of good evidence and the recommendations of specialist societies, e.g. the British Society for Antimicrobial Chemotherapy. The knowledge of GDPs was equated to their total score for the questionnaire. Mean scores were compared using gender, age band, attendance at postgraduate courses, Health Authority/Board and University of qualification as grouping variables. Results A total of 1338 replies were received, giving a response rate of 60.4%; 63 questionnaires were returned incomplete, resulting in 1275 useable replies (891 from England and 384 from Scotland). Only 22.1% of respondents had attended postgraduate courses on antibiotic usage in the previous 2 years. Table I shows the breakdown of responses and postgraduate attendance of courses on antibiotic prescribing in the previous 2 years. All dental schools within the UK were represented, alongside a number of overseas graduates. There was a normal distribution of age groups, of which 70% were males and 30% were females, as shown in the Figure. The maximum possible score for the questionnaire was 84, with respondents achieving a range of (mean 57.28, S.D. 6.73). Table II shows the range of scores, means Subjects and data handling Ten Health Authorities in England and four Health Boards in Scotland were chosen for sampling. These were Liverpool, Wirral, Oxfordshire, Buckinghamshire, North Tyneside, Northumberland, Newcastle, Nottingham, North Nottinghamshire, Sheffield, Lothian, Argyle and Clyde, Grampian, and Dumfries and Galloway. All GDPs contracted to provide National Health Service (NHS) general dental Figure. Questionnaire responses by age group and gender., information missing;, female;, male. 234

3 Antibiotic prescribing knowledge of dental practitioners and standard deviations for the subject areas. The total mean scores for gender, age groups and attendance at postgraduate courses were compared. t-tests showed no significant difference between genders (t 1.906; P 0.05), with a female mean score of (S.D. 7.15) and male mean score of (S.D. 6.98). A separate t-test, however, showed a small but significant difference between those who had attended a postgraduate course on antibiotic prescribing in the last 2 years and those who had not (t 4.68; P 0.05), with a mean score of (S.D. 7.09) for nonattenders and (S.D. 6.88) for attenders. A one-way analysis of variance (ANOVA) using age Table I. Number of GDPs by Health Authority/Board who had attended a postgraduate course on antibiotics in the previous 2 years Postgraduate course attendance Health Authority no yes Liverpool Wirral Oxfordshire Buckinghamshire North Tyneside Northumberland 45 6 Newcastle Nottingham North Notts Sheffield Grampian Lothian Argyle and Clyde Dumfries and Galloway 16 6 Total bands as the grouping variable showed there were significant differences [F(4,1269) 5.305; P 0.01] between age bands and knowledge. A Tukey honestly significant difference (HSD) post hoc statistical test revealed that the significant differences (P 0.05) were between age bands over 61 years of age (mean total score 49.2) and those under 61 years (mean total score 56.53), with no significant differences between the four age groupings under 61 years of age. A t-test (t 6.582; P 0.01) showed that there was a significant difference in total scores between English Health Authorities (mean total score 57.28, S.D. 6.73) and Scottish Health Boards (mean total score 54.47, S.D. 7.56). When comparisons were made between individual Health Authorities/Boards of mean total scores (shown in Table III) using a one-way ANOVA, significant differences in scores were evident [F(13,1273) 4.527; P 0.01]. Table IV shows small but non-significant differences between the mean total scores for the respondents university of qualification. Discussion There are approximately dentists practising (excluding assistants and vocational trainees) within the NHS General Dental Services in England, of whom 72% are male and 28% female. 10 Approximately 1912 dentists practise in Scotland, of whom 69% are male and 31% female. This study sampled c. 10% of GDPs in England and 30% in Scotland. The geographical areas covered included inner city and rural areas, and 2216 dentists were surveyed in total. This study represents one of the largest studies reported on antibiotic prescribing in the UK. When the sample was analysed, the 60.4% response rate had a gender distribution of 72% male and 28% female, reflecting the distribution in NHS practice in England and Scotland. Table II. Maximum score, range of scores, means and standard deviations for subject areas Range of scores Maximum Standard Subject area possible score minimum maximum mean deviation Clinical signs Antibiotic for acute infections Non-clinical factors Antibiotic for pt allergic to Pen Clinical conditions Prophylactic use in non medically compromised patients Medical conditions Prophylactic regimen Regimen for patients allergic to penicillin 235

4 N. O. A. Palmer et al. Table III. Mean scores of GDPs by Health Authority/Board Mean Standard Health Authority/Board n score deviation Liverpool Wirral Oxfordshire Buckinghamshire North Tyneside Northumberland Newcastle Nottingham North Notts Sheffield Grampian Lothian Argyle and Clyde Dumfries and Galloway Table IV. Mean scores of GDPs by university of qualification Mean Standard Dental school n score deviation Belfast/Cork/Dublin Birmingham Bristol London Overseas Cardiff Dundee Edinburgh Glasgow Leeds Liverpool Manchester Sheffield Newcastle There was a normal distribution of age groups and graduates representing all the English and Scottish dental schools. It had been hoped to achieve a higher response rate, but research in medical practice has suggested that the reasons for non-response to postal surveys is that questionnaires are lost in other paperwork or are routinely thrown away, or practitioners are too busy. 11 There was a significant difference in knowledge of the use of antibiotics amongst those who had attended postgraduate courses in the previous 2 years, although only 22% of all respondents had received education in this area. This may be because very few courses had been organized, or that the majority of practitioners felt that they were up to date with current opinion. Most practitioners scored well on the clinical signs indicating the need for prescribing antibiotics (spreading infection, patient malaise, temperature elevation, lymphadentitis), 12 but about a third felt that there was a need for antibiotics where there was only localized swelling. Generally, practitioners scored well on the non-clinical factors that should not influence prescribing. A number did feel, however, that it was acceptable to prescribe when short of time, if a definitive diagnosis could not be made or if treatment had to be delayed. As can be seen from Table II, there were low scores for the questions on the common clinical conditions presenting in everyday practice. This may be due to practitioners thinking that antibiotics are required for conditions that are easily dealt with by routine operative dental treatment. Low scores were also evident for questions on prophylactic prescribing for medical conditions. The total mean score of 56 out of a possible 84 indicates a poor understanding of the use of antibiotics in dental practice. There was no significant difference in scores relating to age bands, with the recently qualified scoring little better than those who had been qualified for 30 years. This perhaps calls into question the efficacy of present undergraduate teaching and the retention of knowledge. Graduates of some dental schools scored more poorly than others, although this was not statistically significant. The Standing Medical Advisory Committee (SMAC) recommended that greater emphasis should be placed on education of clinical students and qualified clinicians about antimicrobial prescribing. The SMAC also recommended that teaching about antimicrobials should be better integrated with teaching about the infections against which they are used. 2 There is a clear need to re-evaluate the teaching of antibiotic usage to undergraduates to see if these recommendations have been put into practice. Practitioners working in some Health Authorities/Boards showed less knowledge than others, though this may be linked to the place of qualification. There is therefore a need to standardize the teaching of antibiotics to all undergraduates. It would appear from this study that dental practitioners knowledge about the use of antibiotics in general practice is far from ideal. This mirrors general medical practice, where studies have shown that decision making in antibiotic therapy requires improvement. 13 Rational prescribing based on a thorough knowledge is an important objective. Effective communication between microbiologists and practitioners, and the publication of prescribing guidelines and protocols could help to achieve this. 13 A study in medical practice has shown the effectiveness of educational intervention, using guidelines, in attaining the appropriate prescribing of antibiotics within a specific clinical situation. 14 An audit of antibiotic prescribing in dental practice showed that there was a reduction in the 236

5 Antibiotic prescribing knowledge of dental practitioners number of prescriptions following the introduction of guidelines. 15 The use of clinical audit as a tool to increase knowledge of antibiotic prescribing and improve patient care should not be underestimated. Computers as a tool for education and behaviour change, along with direct mail interventions have been shown to be effective in medical prescribing. 16,17 This study supports the conclusion that there is a lack of knowledge of the use of antibiotics in practice and that GDPs need clear advice on when and what to prescribe, for how long and in what dosage. The Faculty of General Dental Practitioners of the Royal College of Surgeons of England has recently published recommended standards for antimicrobial prescribing for dental practitioners, which may improve knowledge. 18 There is also a need to improve undergraduate education and to increase the provision of postgraduate courses and other educational initiatives on antibiotic prescribing. Acknowledgements The authors would like to thank the general dental practitioners for their time in answering the questionnaires, the Health Authorities and Health Boards for providing current lists of NHS practitioners, and the NHS National Primary Dental Care Research and Development Programme for funding. References 1. Anonymous. (1997). Monitoring and management of bacterial resistance to antimicrobial agents: a World Health Organisation symposium. Geneva, Switzerland, 29 November 2 December Clinical Infectious Diseases 24, Suppl. 1, S Standing Medical Advisory Committee. (1998). The Path of Least Resistance. Department of Health. London. 3. Lewis, M. A., Meechan, C., MacFarlane, T. W., Lamey, P. J. & Kay, E. (1989). Presentation and antimicrobial treatment of acute orofacial infections in general dental practice. British Dental Journal 166, Thomas, D. W., Satterthwaite, J., Absi, E. G., Lewis, M. A. & Shepherd, J. P. (1996). Antibiotic prescription for acute dental conditions in the primary care setting. British Dental Journal 181, Barker, G. R. & Qualtrough, A. J. (1987). An investigation into antibiotic prescribing at a dental teaching hospital. British Dental Journal 162, Palmer, N. A., Pealing, R., Ireland, R. S. & Martin, M. V. (2000). A study of prophylactic antibiotic prescribing in National Health Service general dental practice in England. British Dental Journal 189, Palmer, N. A., Pealing, R., Ireland, R. S. & Martin, M. V. (2000). A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England. British Dental Journal 188, Palmer, N. A., Ireland, R. S. & Palmer, S. E. (1998). Antibiotic prescribing patterns of a group of general dental practitioners: results of a pilot survey. Primary Dental Care 5, SPSS for Windows Base Version. (1998) version. SPSS Inc., Chigaco, IL. 10. Dental Practice Board. (1999). Manpower tables. Eastbourne, UK. 11. Kaner, E. F., Haighton, C. A. & McAvoy, B. R. (1998). So much post, so busy with practice so, no time! : a telephone survey of general practitioners reasons for not participating in postal questionnaire surveys. British Journal of General Practice 48, Pogrel, M. A. (1994). Antibiotics in general practice. Dental Update 21, Swann, R. A. & Clark, J. (1994). Antibiotic policies relevance to general practitioner prescribing. Family Health Services Authority, Great Britain. Journal of Antimicrobial Chemotherapy 33, Suppl. A, De Santis, G., Harvey, K. J., Howard, D., Mashford, M. L. & Moulds, R. F. (1994). Improving the quality of antibiotic prescription patterns in general practice.the role of educational intervention. Medical Journal of Australia 160, Steed, M. & Gibson, J. (1997). An audit of antibiotic prescribing in general dental practice. Primary Dental Care 4, Bates, D. W., Soldin, S. J., Rainey, P. M. & Micelli, J. N. (1998). Strategies for physician education in therapeutic drug monitoring. Clinical Chemistry 44, Sadowsky, D. & Kunzel, C. (1991). The use of direct mail to increase clinician knowledge: an intervention study. American Journal of Public Health 81, Faculty of General Dental Practitioners, Royal College of Surgeons, England. (2000). Antimicrobial Prescribing in Primary Dental Care for General Dental Practitioners. Received 14 March 2000; returned 31 July 2000; revised 12 September 2000; accepted 13 October

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