Article
Antibiotics represent arguably one of the greatest achievements of modern medicine. Alexander Fleming not only had the insight to recognize that the mould contaminating his agar plate was producing a potent antibiotic, he also warned in his Nobel Prize acceptance speech of the risk of bacteria developing resistance due to sub-optimal doses of antibiotics.1 In a little over 70 years since the introduction of penicillin, we are now faced with the prospect of a world without effective antibiotics, where patient outcomes in specialties such as oncology, transplant and complex surgery could worsen as minor infections become untreatable.
The convergence of the rapid spread of antimicrobial resistant organisms and the lack of new antibiotics to treat the resulting infections is of global concern.2 The increasing incidence of Gram-negative multi-drug resistant (MDR) pathogens, such as those producing extended-spectrum β-lactamases (ESBLs), has led to a reliance on carbapenems as antibiotics of ‘last-resort’. As a consequence, we have witnessed the emergence of carbapenemase-producing bacteria, resistant not only to carbapenems and other β-lactam antibiotics, but also to aminoglycosides and fluoroquinolones. The situation is exacerbated by the fact that no new classes of antibiotics active against Gram-negative bacteria have been discovered in the last 25 years.
The use of antibiotics is acknowledged as the single most important factor leading to the development of antibiotic resistance.3 The majority of antibiotics prescribed in the community can alter the flora in the oral cavity, with the selection of resistant strains.4 In community settings, dental practitioners in England prescribe almost 8% of all antibiotics.5 Research shows that antibiotic prescribing by dentists is often sub-optimal, with antibiotics prescribed when surgical intervention is more appropriate, or the incorrect dose, duration and frequency are applied.6,7 Variation in local prescribing practice is poorly understood and the implementation of electronic dental prescribing systems will help narrow this knowledge gap. Data on NHS dental prescriptions, 2010–2013, does show an increase in prescriptions for broad spectrum agents, especially co-amoxiclav.5,8
In response to the problem, the Chief Medical Officer for England, in her first annual report,9 and the subsequent UK five-year antimicrobial resistance strategy,10 made a series of recommendations aimed at conserving the effectiveness of existing treatments, improving the antimicrobial development pipeline, increasing knowledge and awareness. The Department of Health has made available resources for promoting responsible antibiotic use11,12 as part of the European Antibiotic Awareness Day (EAAD) on November 18th. The Faculty of General Dental Practice (FGDP) has also supported the EAAD13 and promotes a responsible approach to antimicrobial prescribing through the publication of evidence-based prescribing guidance.14 It has been shown that clinical audit, in conjunction with prescribing guidelines and education (CPD) can favourably change antibiotic prescribing amongst dental prescribers.15
As part of multi-faceted interventions aimed at mitigating against a future where untreatable infections caused by MDR pathogens are rife, collective action is required now to ensure that antibiotics are used wisely and sparingly. Increasing awareness amongst the public and professionals of the impact of inappropriate antibiotic use in all aspects of clinical care, including dentistry, will be central to slowing the emergence and spread of antimicrobial resistance.