Antibiotic Stewardship a Peer-Reviewed Article Written by Amber Auger, MPH, RDH, and Erinne Kennedy, DMD, Mmsc, MPH

EARN This course was written for dentists, 3 CE dental hygienists, CREDITS and dental assistants.

Antibiotic Stewardship A peer-reviewed article written by Amber Auger, MPH, RDH, and Erinne Kennedy, DMD, MMSc, MPH

PUBLICATION DATE: JANUARY 2020

EXPIRATION DATE: DECEMBER 2022

SUPPLEMENT TO ENDEAVOR PUBLICATIONS EARN 3 CE CREDITS

This continuing education (CE) activity was developed by the PennWell dental group, an operating unit of Endeavor Business Media, with no commercial support. This course was written for dentists, dental hygienists, and dental assistants, from novice to skilled. Educational methods: This course is a self-instructional journal and web activity. Provider disclosure: Endeavor Business Media neither has a leadership position nor a commercial interest in any products or services discussed or shared in this educational activity, nor with the commercial supporter. No manufacturer or third party had any input in the development of the course content. Antibiotic stewardship Requirements for successful completion: To obtain three CE credits for this educational activity, you must pay the required fee, review the material, complete the course evaluation, and obtain a score Abstract of at least 70%. The inappropriate use of antibiotics has been associated with adverse events CE planner disclosure: Laura Winfield, Endeavor Business Media dental group CE coordinator, neither has a leadership nor commercial that have short- and long-term effects on the patient and society. These interest with the products or services discussed in this educational adverse events have the potential to burden the health-care system and neg- activity. Ms. Winfield can be reached at [email protected]. Educational disclaimer: Completing a single continuing education atively impact current and future generations. Dentists contribute to more course does not provide enough information to result in the participant than 10% of all antibiotic prescriptions. Antibiotic stewardship is defined being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that as “the optimal selection, dosage, and duration of antimicrobial treatment allows the participant to develop skills and expertise. that results in the best clinical outcome for the treatment or prevention of Image authenticity statement: The images in this educational activity have not been altered. infection, with minimal toxicity to the patient and minimal impact on sub- Scientific integrity statement: Information shared in this CE course sequent resistance.”1 The practice of antibiotic stewardship will help dentists is developed from clinical research and represents the most current information available from evidence-based dentistry. prescribe the appropriate antibiotic with correct dose, duration, and timing Known benefits and limitations of the data: The information for the patient diagnosis. Dentists and dental offices nationwide will benefit presented in this educational activity is derived from the data and information contained in reference section. The research data is from the practice of antibiotic stewardship, and the implementation of these extensive and provides a direct benefit to the patient and improvements practices will likely improve patient outcomes. This continuing education pro- in oral health. Registration: The cost of this CE course is $59 for 3 CE credits. gram will provide an understanding of antibiotic stewardship, direct dental Cancellation and refund policy: Any participant who is not 100% teams to the information they need to evaluate their current protocols, and satisfied with this course can request a full refund by contacting Endeavor Business Media in writing. inspire dental teams to practice antibiotic stewardship.

Endeavor Business Media Nationally Approved PACE Program Educational objectives Provider for FAGD/MAGD credit. At the conclusion of this educational activity, participants will be able to: Approval does not imply acceptance by any regulatory authority or AGD 1. Review the current status of public health problems that result from the endorsement. 11/1/2019 to 10/31/2022. Provider ID# 320452 inappropriate use of antibiotics

2. Define and explore the concept of antibiotic stewardship Endeavor designates this activity for 3 continuing educational credits. Dental Board of California: Provider 4527, course registration number 3. Explore existing national trainings, state toolkits, and practice guidelines CA code: 03-4527-15403 in general dentistry “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” 4. Apply and evaluate the practice of stewardship to their private practices

Endeavor Business Media is designated as an approved Provider by the American Academy of Dental Hygiene Inc. # AADHPNW (January 1, 2019–December 31, 2020). Approval does not imply acceptance by a state or provincial Board of Dentistry. Licensee should maintain this document in the event of an audit.

Endeavor Business Media is an ADA CERP–recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp.

Go online to take this course. DentalAcademyofCE.com QUICK ACCESS code 15403 DENTAL ACADEMY OF CONTINUING EDUCATION

Public health problem state can last for years.5 Some of the gut clindamycin, penicillins (including ampicil- As unfavorable patient outcomes continue microbiota functions include influencing lin and amoxicillin), and cephalosporins.9,10 to climb in the United States, the demand the function of other cells, signaling and It is important to note that C. diff is found for antibiotic stewardship in inpatient and systems, biosynthesis, and metabolism.6 at low levels among normal flora, but anti- outpatient settings increases. Some adverse Disruption of the microbiota can alter these biotics are associated with disruption of patient outcomes associated with inappro- functions and/or result in disease. this flora, often leading to antibiotic-resis- priate antibiotic use include allergic reac- A long-term complication of inappropri- tant organisms and the potential for CDI.11 tions, antibiotic resistance, Clostridioides ate antibiotic use is the rise and spread of difficile infections (CDI), and disruption antibiotic-resistant infections. According to Antibiotic prescribing patterns of normal flora. As clinicians practicing the Centers for Disease Control and Preven- Short-term and long-term adverse events evidence-based dentistry (EBD), we are tion (CDC), antibiotic resistance is a national can result from clinical scenarios in which called to evaluate each case with the lat- urgent public health threat causing at least antibiotics are used inappropriately. Antibi- est evidence and our own personal exper- 2,049,442 illnesses per year and claiming at otic stewardship has the ability to reduce, tise, while accounting for patient needs, least 23,000 lives.7 Antimicrobial-resistant not eliminate, the patient risks for these desires, and values. Understanding the risks strains of bacteria or fungi arise when anti- adverse events. In 2017, Durkin et al. exam- and benefits associated with the use of antibiotics kill some of the good bacteria along ined outpatient antibiotic claims data for biotics will help our practice of EBD for pre- with most of the organisms causing an infec- the 2015 calendar year.4 All dentists, includ- venting and treating oral infections.1 tion or illness. However, the antibiotics may ing specialists, were ranked third by count An example of a short-term adverse not kill all the bacteria or fungi, leaving dan- of antibiotics prescribed. General dentists event associated with systemic antibi- gerous drug-resistant organisms to grow and ranked first when ranked by count of pre- otic use is an allergic reaction. Data from multiply. This gives rise to strains of bacteria scriptions. Dentists accounted for 17.93% of 2011–2015 demonstrated adults age 20 and or fungi that are less susceptible or no longer all prescribers, and 13.17% of all prescrip- older had an estimated 145,490 emergency susceptible to current therapies. tions during this one-year period. Antibi- department visits for adverse events associ- Health-care facilities often administer otics were typically prescribed for seven ated with antibiotic use.2 Studies estimate antibiotics to treat infections that can result to 10 days, with few prescriptions shorter 74–78% of antibiotic-associated adverse in resistant and infectious organisms. These than five days. The number of prescriptions events are allergic reactions.2,3 The most resistant organisms can spread through written to treat infections was highest in common antibiotic classes that resulted contaminated objects or unclean hands in the Southern and Northeastern regions in adverse events included sulfonamides, a hospital environment. Those who come of the United States. Although antibiotics penicillins, and quinolones.2 Among gen- into contact with the microbes can then are frequently needed to prevent and treat eral dentists, these three antibiotic classes transfer them to patients in the commu- oral infections, often antibiotics are used account for the majority of commonly pre- nity. Patients who are most at risk of anti- inappropriately. scribed antibiotics for prevention and treat- biotic resistance include those who receive ment of oral infections.4 treatment for end-stage renal disease, trans- Practical implementation In addition to allergic drug reactions, plants, chemotherapy, complex surgery, or Outpatient settings, including dental aspects of the microbiome that are benefi- patients with inflammatory arthritis.7 offices, are the sites for the majority of cial to the body’s homeostasis can be altered A costly adverse outcome associated antibiotic prescribing. The CDC shares and by antibiotics. Antibiotics benefit the host with the use of antibiotics is Clostridioi- explains the common reasons for the inap- by treating the infection and benefit the des difficile (C. diff) infection. C. diff is an propriate use of antibiotics.12 community by preventing the spread of anaerobic, gram-positive, spore-forming • Unnecessary antibiotic use is a situation infection. However, one of the consequences bacillus that induces pseudomembranous in which a provider prescribes an antibi- associated with antibiotics is the disruption colitis. Strains of C. diff can become drug otic when it is not indicated. A possible of normal flora.5 The human microbiome resistant, and they are increasing in preva- example of unnecessary antibiotic use in encompasses the organisms, genes, metabo- lence and severity. Complications from C. dentistry is prescribing a systemic antibi- lites, and the host, as well as their intimate diff infection (CDI) are costly and range in otic for a healthy patient presenting with and collective interactions. Alteration of severity from diarrhea to severe complica- irreversible pulpitis.13 In this case, defini- the human microbiome or normal flora tions such as toxic megacolon, sepsis, colec- tive dental treatment is recommended. can compromise our individual health in tomy, and death.8 In 2015, over a half million • Improper antibiotic selection is when many ways, such as antibiotic-resistant and cases of CDI occurred among patients in the wrong antibiotic is prescribed for a opportunistic infections. Once the antibi- the United States, and an estimated 15,000 specific diagnostic condition. otic treatment has stopped, the microbiota of these infections resulted in death.7 Like • Errors in antibiotic dosing occur when experiences a degree of resilience, mean- antibiotic resistance, the CDC has classified the proper antibiotic is selected for the ing they work to return to their preexpo- C. diff as an urgent public health threat.7 correct duration, but the dosing is too sure state. However, the microbiota often Antibiotics commonly used in dentistry frequent, or infrequent, or the individ- does not fully recover, and the compromised and frequently associated with CDI include ual doses are too high or too low. An

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example would be prescribing a pediat- In order to combat these effects, the CDC commitment, schedule trainings and/or ric dose of amoxicillin for an adult with encourages antibiotic stewardship to reduce train team members on antibiotic steward- pericoronitis. adverse patient outcomes (including the ones ship, conduct and summarize audit reports, • Errors in antibiotic duration result in described previously), and decrease the cost and promote provider, staff, and patient inappropriate dosing. For example, if burden on the health-care system.17 Antimi- education throughout the office and social a patient with dental cellulitis is given crobial stewardship is defined by the Asso- media platforms. Additionally, it’s impor- only one dose of amoxicillin, 2 g would ciation for Professionals in Infection Control tant that auxiliary staff be trained to ade- be incorrect. That dosage is used for pro- and Epidemiology (APIC) as “a coordinated quately communicate with patients about phylaxis when needed. A longer duration program that promotes the appropriate use the office protocol and clinicians’ practice of antibiotics based on the case-specific of antimicrobials (including antibiotics), standards of antibiotic use. details would be recommended to treat improves patient outcomes, reduces micro- the condition adequately. bial resistance, and decreases the spread of IMPLEMENT NEW POLICIES OR PRACTICES In dentistry, there are challenges in infections caused by multidrug-resistant Tools exist to help you as a practitioner quantifying the inappropriate use of antibi- organisms.”18 The CDC has created a frame- prescribe responsibly. The CDC has devel- otics. Specifically, we do not have diagnostic work to help providers, such as dentists, to oped a checklist for prescribing antibiotics codes that are associated with dental visits implement these principles, called the Core specifically for dentists. It addresses deci- or prescriptions; therefore, we are unable to Elements of Outpatient Antibiotic Steward- sions that a dentist makes while prescrib- track and link a diagnosis to the drug, dose, ship.19 The four core elements include a com- ing and educating the patient.21 Hanging duration, and timing on the prescription, mitment to judicious prescribing and patient this checklist in your operatories or office making assessment of appropriateness of safety; implementing at least one policy or where you frequently write your prescrip- use unclear.14 Despite these challenges, over new clinical practice to improve antibiotic tions will help you develop a protocol and a three-year period, Durkin et al. estimated stewardship; tracking and reporting pre- resource for safe prescribing. As noted on 14% of antibiotics prescribed by dentists scribing practices; and offering education the checklist, one of the keys to responsible were inappropriate. Lack of awareness and for patients, staff, and clinicians.19 Follow- prescribing is accurate diagnosis. slow adoption of current guidelines for car- ing are practical ways to implement the four It is important to remember that the diovascular and prosthetic joint prophylaxis core elements. dentist doesn’t have to prescribe alone. Not have been indicated as reasons for nonad- only is it important to have a stewardship herence and altered prescribing patterns Tips for antibiotic stewardship champion, but it is also important to work among dentists.15,16 A survey among Cana- implementation in private collaboratively with health-care providers dian dentists also reported explanations practice dental offices in the community. Interdisciplinary care for unnecessary antibiotic prescriptions MAKE A COMMITMENT centered on the patient can help the den- that included: unnecessary treatment for Practicing antibiotic stewardship starts tist practice evidenced-based dentistry. A periapical abscess and irreversible pulpi- with the clinician’s commitment to safe report published by the Veterans Associa- tis; prescribing patterns associated with and responsible prescribing. Making a com- tion (VA) demonstrated a 12% decrease in dental implant surgery and further compli- mitment may be different for each provider. inpatient prescribing of antibiotics over cations; and palliative care for uninsured The CDC recommends that a “stewardship the course of seven years when primary patients seeking a substitute for definitive champion” is identified in the office to coor- care providers, pharmacists, and dentists care, among others.15 Additionally, it has dinate and execute stewardship protocol.19 worked together to provide interdisciplin- been noted that diagnostic uncertainty, the One of the best ways that you can support ary care.22 In addition to interdisciplinary fear of adverse outcomes and medicolegal the role of a stewardship champion in your care, it is important to support antibiotic liability, pressure for patient satisfaction, practice is to include these responsibili- stewardship within our discipline or pro- and decision fatigue have been associated ties in job descriptions. For example, you fession. Once you make a commitment to with the unnecessary use of antibiotics by may choose to have your lead assistant, antibiotic stewardship, it may be helpful medical and dental providers.12 hygienist, office manager, or associate den- to share this with your local study club or Patients may find it difficult to under- tist hold the role of stewardship champion. other dentists within your community. You stand why they no longer need prophylactic Expectations and duties should be clear. can use some of your study club time to dis- antibiotics when they have been previously In the Antibiotic Stewardship Toolkit in cuss cases, share stories about the impact told that it was necessary. It is essential to Massachusetts, you will see sample job in your community, or help one another an evidence-based practice and protocols descriptions.20 make better clinical decisions. to ensure providers properly educate and The antibiotic stewardship champion communicate with patients on their risks. can have a few roles that will help imple- TRACK AND REPORT Adhering to the new guidelines will assist ment the CDC Core Elements of Outpatient Each oral health professional must remain in reducing the risk of an adverse event Antibiotic Stewardship. The steward- accountable for his or her own prescrib- as a result of inappropriate antibiotic use. ship champion can help others make a ing patterns. One way to stay accountable

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is conducting a self-audit. An example frequency of the antibiotic prescription is antibiotics for years prior to preventive pro- of an audit tool that you can use in your in alignment with the diagnosis, evidence, cedures no longer need them. These patients office is located in the Massachusetts State and treatment plan. The review offers an are often hesitant when informed they no Toolkit. 20 This toolkit is a comprehensive opportunity for a prescriber to adjust how longer need to take premedication. It is resource that is easy to follow and divided he or she will treat a case in the future. our job to communicate our commitment into five indicator factors that help clini- We recommend training all team mem- to antibiotic stewardship and prevent the cians identify how they are prescribing. bers on how to use the Antibiotic Stew- inappropriate use of antibiotics. Through the use of the Antibiotic Steward- ardship Chart Audit Tool and to review The impact of providing patient mate- ship Chart Audit Tool,20 the clinician can as a team quarterly. Each team member rials is often underestimated. Meeker et determine his or her own prescribing pat- assists in the collection of data; therefore, al. explored the relationship of a low-cost terns and determine what changes need it is essential to train staff on essential behavioral intervention (a personalized to be implemented to be a more effective chart information for evaluating antibiotic poster) that demonstrated a public com- steward of antibiotics. stewardship practices. Broadly, a quarterly mitment to stewardship concerning acute The first section is the informed consent report of all prescriptions—including the respiratory infections. They found that a and medical history. This section prompts name of the antibiotic, dosage, and dura- commitment poster with clinician photo- the prescriber to obtain a thorough, up-to- tion of each prescription that was written by graphs and signatures, when displayed in date medical history and review if there was each practitioner in the practice—should be the examination room for 12 weeks, showed a recent medical or dental treatment that recorded. Regularly reviewing these reports a significant decrease in unnecessary anti- required antibiotics. can help your team identify any prescribing biotic prescribing for those with the poster Second is the diagnostic indicator, which patterns that can be improved. compared to the control with no poster.24 helps the prescriber collect all the informa- It is important to note that the study men- tion necessary to make a proper assessment PATIENT AND STAFF EDUCATION tions that unnecessary prescribing patterns of the patient’s presenting condition. For Prescribers are accountable to the patient were still high, greater than 30%, even after example, this segment looks at intraoral and the community at large to practice anti- the poster intervention. This supports the and extraoral findings, radiographic evalu- biotic stewardship. One way to help your idea that continual education and imple- ation, and the pulpal and periapical diag- office be accountable is to provide patients mentation of a stewardship program is still noses of symptomatic teeth. This diagnosis and clinicians with educational resources needed. segment reinforces the need for diagnostic on current antibiotic guidelines. Each den- Hanging posters throughout the office testing such as percussion, palpation, prob- tist, dental assistant, and dental hygienist in locations such as treatment rooms, rest- ing depths, hot and cold testing, and the should have access to the American Dental rooms, and waiting rooms is another way for electronic pulp testing for accurate diag- Association Chairside Clinical Guide, an the dental team to demonstrate that they nosis prior to prescribing. example of effective education materials.23 are making a commitment to antibiotic The third element of the assessment tool This guide reviews the protocol for patients stewardship. Signage and educational mate- reviews the indications for antibiotic use. with prosthetic joints in relation to the use rials can supplement and reinforce infor- These symptoms include, but are not lim- of antibiotics prior to a prophylaxis. mation offered by dental team members. ited to, prophylaxis procedures, localized The American Dental Association’s Sharing informational content through fluctuant swelling, elevated temperature, Center for Evidence-based Dentistry social media accounts prior to the appoint- inability to remove the drain or source of also released a new clinical practice ment prepares the patient to better under- infection, and delayed treatment or spe- guideline titled “Evidence-based clinical stand dental team members during their cialty referral. Additionally, patient expecta- practice guideline on the antibiotic use appointment. Informational content is tion is listed under this indication. Although for the urgent management of pulpal- and easy to implement through social media evidence-based practice is ideal, if you find periapical-related dental pain and intraoral accounts. Offering written content is also that patients are influencing your practice, swelling.”26 Accompanying this guideline important so caretakers are informed. Sim- you can use this data to create specific role are two additional chairside guides that ple, yet influential, studies conducted by plays to train staff or to create office poli- help clinicians make decisions for the Moerenhout et al. found that “ . . . 94% of cies concerning antibiotic prescribing to use of antibiotics to treat tooth pain and respondents stated they read [posters and guide your patient base. intraoral swelling when dental care is leaflets provided in medical and dental The fourth indicator on the Antibiotic and is not available in adults who are not offices], 45% took the leaflets home, and Stewardship Chart Audit Tool is the stew- immunocompromised.27 78% indicated they understood the content ardship review. The review assesses each Printing these guides and laminating of the leaflets. Nineteen percent of respon- case, stewardship guidelines, and drugs the document for chairside use is an effec- dents reportedly discussed the content of prescribed within the current recommen- tive communication tool and will help sup- the leaflets with their physician and 26% dations. This stewardship review aims port the commitment that the prescribers indicated that leaflets allowed them to to determine if the dosage, duration, and have made. Many patients who have taken ask fewer questions of their physician.”25

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Educational infographics can enhance the A key aspect to clear communication dental organizations and reach out to your patient’s knowledge and reinforce the infor- is unified messaging among team mem- state’s department of public health. This mation shared by the dental team. bers. Team meetings allow for all members network will help you identify resources Suggestions for using patient educational to present questions and review the office with regard to antibiotic stewardship for material on social media platforms in dental policy concerning antibiotic stewardship. dental health-care workers and help you offices can be found in the Massachusetts Empowering each team member to repre- start your own journey in stewardship. State Toolkit for Antibiotic Stewardship for sent the commitment will increase their Oral Health Clinicians.20 Additionally, using credibility with patients and will reinforce REFERENCES technology to provide patients with infor- the importance of antibiotic stewardship for 1. Gerding DN. The search for good antimicrobial mation in person, or using visual aids or vid- the patient and the community. stewardship. Jt Comm J Qual Improv. eos, can assist in their comprehension of the There are multiple resources that can 2001;27(8):403-404. theory of antibiotic stewardship. Audio and be reviewed during team meetings. The 2. Geller AI, Lovegrove MC, Shehab N, et al. National video content can be highlighted through CDC provides valuable online CE courses. estimates of emergency department visits for antibiotic office newsletters, emails, patient reminder The online antibiotic stewardship course adverse events among adults—United States, 2011– 2015. J Gen Intern Med. 2018 Jul;33(7):1060–8. systems, and social media accounts. The CDC reviews the history of antibiotic use, the pro- http://link.springer.com/10.1007/s11606-018-4430-x. and some state toolkits provide audio and cess of antibiotic resistance, and practical Accessed Jan. 21, 2019. video resources to assist the dental team in steps to implement to encourage responsible 3. Shehab N, Patel PR, Srinivasan A, Budnitz DS. 12 educating patients on the risks and benefits prescribing. This course includes four sec- Emergency department visits for antibiotic-associated of taking antibiotics, the expectations for use, tions that inform health-care professionals adverse events. Clin Infect Dis. 2018;47(6):735-743. 12 and the role of stewardship in good practice. about proper prescribing and aims to pro- 4. Durkin MJ, Hsueh K, Sallah YH, et al. An evaluation In order to effectively achieve antibiotic mote conversations between clinicians and of dental antibiotic prescribing practices in the United stewardship, it is essential to conduct regu- patients. As a dental team, it may be useful States. J Am Dent Assoc. 2017 Dec;148(12):878- lar team meetings. This allows the team to to work through these online resources at 886.e1. https://linkinghub.elsevier.com/retrieve/pii/ evaluate the current science, train staff on regular team meetings or attend training in S0002817717306542. Accessed Jan. 20, 2019. protocol, reinforce the practice’s steward- your state. When onboarding new employ- 5. Blaser MJ. Antibiotic use and its consequences ship commitment, and review patient cases. ees, providing training on the practice’s for the normal microbiome. Science. 2016 Apr Updates on antibiotic stewardship can be commitment to stewardship is essential 29;352(6285):544–5. http://www.sciencemag.org/ incorporated into the existing monthly or so that the team shares uniform informa- lookup/doi/10.1126/science.aad9358. Accessed Jan. biweekly meetings. The collaborative meet- tion with the patients. 22, 2019. ings become a valuable resource for the 6. Lynch SV, Pedersen O. The human intestinal entire team when conducted effectively. Conclusion microbiome in health and disease. N Engl J Med. 2016 All team members need to practice com- We hope that this course provided an intro- Dec;15;375(24):2369-2379. Accessed Jan. 23, 2019. municating with patients about the sci- duction to the impact you can make for 7. Centers for Disease Control and Prevention. Antibiotic ence and recommendations of antibiotic your patients and community by practic- resistance threats in the United States, 2013. https:// stewardship. Communication can be chal- ing antibiotic stewardship in your office. www.cdc.gov/drugresistance/threat-report-2013/pdf/ ar-threats-2013-508.pdf. Accessed Jan. 21, 2019. lenging, but when updating the science, We hope that you take the first step today phrases such as “we now know,” “current by committing to one aspect of steward- 8. Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N research demonstrates,” and “the benefits ship by writing it down and sharing it with Engl J Med. 2015 Feb 26;372(9):825–34. http://www. of the antibiotic do not outweigh the risks” your team. We encourage you to explore the nejm.org/doi/10.1056/NEJMoa1408913. Accessed can increase patient confidence. resources through the CDC and professional Jan. 18, 2019.

Notes

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9. ADA Council on Scientific Affairs. Combating antibiotic 18. Association for Professionals in Infection Control and Dental Pain and Intraoral Swelling. J Am Dent Assoc. resistance. J Am Dent Assoc. 2004 Apr;135(4):484–7. Epidemiology. Antimicrobial stewardship. https:// 2019;150(11). doi:10.1016/j.adaj.2019.08.020 https://linkinghub.elsevier.com/retrieve/pii/ apic.org/Professional-Practice/Practice-Resources/ 27. American Dental Association. Center for Evidence- S0002817714612344. Accessed Jan. 21, 2019. Antimicrobial-Stewardship. Accessed Jan. 21, 2019. Based Dentistry. Chairside guide: Dental treatment is 10. Leffler DA, Lamont JT. Clostridium difficile infection. N 19. Centers for Disease Control and Prevention. The immediately available. https://ebd.ada.org/~/media/EBD/ Engl J Med. 2015 Apr 16;372(16):1539–48. http:// core elements of outpatient antibiotic stewardship. Files/ADA_Chairside_Guide_Antibiotics_TA.pdf?la=en. www.nejm.org/doi/10.1056/NEJMra1403772. https://www.cdc.gov/antibiotic-use/community/ Accessed Jan. 22, 2019. pdfs/16_268900-A_CoreElementsOutpatient_508. AMBER AUGER, MPH, RDH, is a 11. Kamada N, Chen GY, Inohara N, Núñez G. Control of pdf. practicing dental hygienist in pathogens and pathobionts by the gut microbiota. Nat 20. Massachusetts Department of Public Health, Bureau of Boston, Massachusetts. She graduated from the University of Immunol. 2013 Jun 18;14(7):685-690. http://www. Infectious Disease and Laboratory Sciences. Antibiotic New Haven with a bachelor’s nature.com/doifinder/10.1038/ni.2608. Accessed Jan. Stewardship Toolkit Oral Health Clinicians. https:// degree in dental hygiene and 22, 2019. mdphgis.maps.arcgis.com/apps/Cascade/index.html?a from the University of New 12. Centers for Disease Control and Prevention. Antibiotic ppid=d719c2ecbe1149cfbc7c85fe373f2cd7. Accessed England with a master’s degree prescribing and use in doctor’s offices. https:// Mar. 29, 2019. in public health. Auger has www.cdc.gov/antibiotic-use/community/materials- 21. Centers for Disease Control and Prevention. Checklist experience teaching at multiple dental hygiene colleges references/video-audio.html. Accessed Mar. 9, 2019. for antibiotic prescribing in dentistry. https://www.cdc. and has provided preventive dental services in five different countries. She serves as the marketing manager 13. Nagle D, Reader A, Beck M, Weaver J. Effect of gov/antibiotic-use/community/downloads/dental-fact- for Hygienists for Humanity, a nonprofit organization that systemic penicillin on pain in untreated irreversible sheet-FINAL.pdf. Accessed Mar. 9, 2019. provides dental care locally and abroad. Auger provides CE pulpitis. Oral Surg Oral Med Oral Pathol Oral 22. Kelly AA, Jones MM, Echevarria KL, et al. A report courses throughout the nation, has published over 100 Radiol Endodontology. 2000 Nov;90(5):636- of the efforts of the Veterans Health Administration articles, and is editor of the RDH Graduate newsletter. She 640. http://linkinghub.elsevier.com/retrieve/pii/ National Antimicrobial Stewardship Initiative. Infect is passionate about creating protocols for chairside S1079210400544333. Accessed Feb. 4, 2019. Control Hosp Epidemiol. 2017 May;38(5):513-520. technologies to ensure they are implemented. 14. Fluent MT, Jacobsen PL, Hicks LA. Considerations for 23. American Dental Association. Center for Evidence- responsible antibiotic use in dentistry. J Am Dent Assoc. Based Dentistry. Chairside guide: Management of ERINNE KENNEDY, DMD, MMSc, graduated from Nova 2016 Aug;147(8):683-686. https://linkinghub.elsevier. patients with prosthetic joints undergoing dental MPH, Southeastern College of Dental com/retrieve/pii/S0002817716304093. Accessed procedures. https://www.ada.org/~/media/EBD/Files/ Medicine in 2015. She completed Jan. 22, 2019. ADA_Chairside_Guide_Prosthetics.pdf?la=en. a one-year general practice 15. Marra F, George D, Chong M, et al. Antibiotic 24. Meeker D, Knight TK, Friedberg MW, et al. Nudging residency at a Veterans Affairs prescribing by dentists has increased. J Am Dent guideline-concordant antibiotic prescribing: hospital in 2016, and her dental Assoc. 2016 May;147(5):320-327. https://linkinghub. a randomized clinical trial. JAMA Intern Med. public health residency in 2018. elsevier.com/retrieve/pii/S0002817715012131. 2014 Mar;174(3):425-431. doi:10.1001/ She graduated as an inaugural Accessed Jan. 20, 2019. jamainternmed.2013.14191 student in a master’s program in dental education at Harvard School of Dental Medicine in spring 2019 and 16. Roberts RM, Bartoces M, Thompson SE, Hicks LA. 25. Moerenhout T, Borgermans L, Schol S, et al. Patient serves in a local health center in Boston, Massachusetts. Antibiotic prescribing by general dentists in the United health information materials in waiting rooms of family She has a passion for antibiotic stewardship and has been a States, 2013. J Am Dent Assoc. 2017 Mar;148(3):172- physicians: do patients care? Patient Preference and member of the American Dental Association expert panel for 178.e1. https://linkinghub.elsevier.com/retrieve/pii/ Adherence. 2013 Jun;7:489-497. doi:10.2147/PPA. developing antibiotic stewardship guidelines. S0002817716309424. Accessed Jan. 22, 2019. S45777 17. Centers for Disease Control and Prevention. Antibiotic 26. Lockhart P, Tampi M, Abt E, et al. Evidence-Based use in the United States, 2017: progress and Clinical Practice Guideline on Antibiotic Use for the opportunities. Atlanta, GA: US Department of Health Urgent Management of Pulpal- and Periapical-Related and Human Services, CDC; 2017.

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QUESTIONS

1. Which of the following is not an 6. According to the CDC, antibiotic 12. According to a 2017 study by Durkin et adverse outcome of antibiotic use? resistance is classified as which al., of all prescriptions written during A. Allergic reaction level of public health threat? this one-year period, what estimated B. Antibiotic resistance A. Mild percentage was attributed to dentists? A. 10% C. Clostridioides difficile infections (CDI) B. Concerning D. Resolution of an infection C. Serious B. 11% D. Urgent C. 12% 2. Which best describes evidenced- D. 13% based dentistry (EBD)? 7. Which of the following conditions result in A. Personal expertise, patient an increased susceptibility of developing 13. Which of the following are reasons for needs, anecdotal evidence an antibiotic-resistant infection? the inappropriate use of antibiotics? B. Personal expertise, patient A. End-stage renal disease A. Improper antibiotic selection needs, latest evidence B. Chemotherapy B. Errors in dose C. Personal expertise, provider C. Inflammatory arthritis C. Errors in duration needs, anecdotal evidence D. All of the above D. All of the above D. None of the above 8. Which of the following classes of 14. An adult patient presents with a diffuse 3. Among emergency department antibiotics are commonly used in odontogenic infection associated visits for adults in the US, what dentistry and frequently associated with tooth No. 1. You prescribe a estimated percentage is associated with Clostridioides difficile infections? pediatric dose of amoxicillin. How with allergic reactions? A. Clindamycin would you classify this error? A. ~ 25% B. Vancomycin A. Unnecessary use B. ~ 50% C. Cephalosporins B. Improper antibiotic selection C. ~ 75% D. A and C C. Error in dose D. ~100% D. Error in duration 9. According to the CDC, Clostridioides 4. What are the top three antibiotics classes difficile is classified as which 15. In 2015, how many cases of that result in allergic reactions leading level of public health threat? Clostridioides difficile occurred among to emergency department visits? A. Mild patients in the United States? A. Macrolides, penicillins, and quinolones B. Concerning A. 100,000 B. Sulfonamides, macrolides, and quinolones C. Serious B. 200,000 C. Penicillins, macrolides, and quinolones D. Urgent C. 300,000 D. Sulfonamides, penicillins, and quinolones D. 500,000 10. According to a 2017 study by Durkin 5. Antibiotics are known to disrupt et al., how do general dentists rank by 16. In 2015, how many cases of Clostridioides the normal flora of the microbiome. count of prescriptions of all providers? difficile resulted in death among The compromised state of the gut A. First patients in the United States? microbiota can last for how long? B. Second A. 10,000 A. Minutes C. Third B. 13,000 B. Days D. Last C. 15,000 C. Months D. 22,000 D. Years 11. According to a 2017 study by Durkin et al., in which regions of the United States were the number of prescriptions written by dentists the highest? A. Northeast and South B. Northwest and Midwest C. Midwest and Southwest D. None of the above

68 DentalAcademyOfCE.com QUICK ACCESS code 15403 ONLINE COMPLETION Take this test online for immediate credit. Go to dentalacademyofce.com and log in. If you do not have an account, sign up using enrollment key DACE2019. Then, find this course by searching for the title or the quick access code. Next, select the course by clicking the “ENROLL” option. Continue by pressing “Start.” After you have read the course, you may take the exam. Search for the course again and place the exam in your cart. Check out, take the exam, and receive your credit!

QUESTIONS

17. In addition to patients with end-stage 22. The CDC has created a framework to help 26. What tool can help the dental team keep renal disease, transplants, chemotherapy, providers, such as dentists, implement track of cases in which antibiotics are used and complex surgery, which of the antibiotic stewardship. What is it called? so they can review and adapt practices? following conditions puts patients A. Core Elements of Outpatient A. Self-audit reports most at risk of antibiotic resistance? Antibiotic Stewardship B. Educational posters A. High blood pressure B. Elements of Outpatient C. Case review Antibiotic Stewardship B. Asthma D. All of the above C. Inflammatory arthritis C. Comprehensive Elements of Outpatient Stewardship D. All the above 27. According to a survey of Canadian dentists, D. Core Elements of Antimicrobial Stewardship in Outpatients what were possible explanations for 18. Prescribing a systemic antibiotic unnecessary antibiotic prescriptions? for a patient presenting with a 23. What are the four core elements of A. Unnecessary treatment for condition that does not warrant periapical abscess outpatient antibiotic stewardship? antibiotic use is an example of: B. Irreversible pulpitis A. Antibiotic stewardship A. Commitment; action for policy and practice; monitoring; C. Prescribing patterns associated B. Improper antibiotic selection education and expertise with dental implants C. Error in dosing B. Contribution; action for policy and D. All of the above D. Unnecessary antibiotics practice; tracking and reporting; education and expertise 28. What percentage of respondents stated 19. What is the term for prescribing C. Commitment; support for policy and they read posters and leaflets provided the wrong antibiotic for a specific practice; tracking and reporting; in medical and dental offices? diagnostic condition? education and expertise A. 87% A. Antibiotic stewardship D. Commitment; action for policy and B. 75% practice; tracking and reporting; B. Improper antibiotic selection education and expertise C. 68% C. Error in dosing D. 54% D. Unnecessary antibiotics 24. What does APIC stand for? A. Association for Professionals in 29. The CDC has developed a checklist 20. What is the term for prescribing a Infection Control and Epidemiology for prescribing antibiotics specifically pediatric dose of amoxicillin for an B. American Professionals in CDC for dentists. Where is the best place to place this checklist? adult with a dental infection? C. American Professors in CDC A. Top drawer of the treatment room cabinet A. Antibiotic stewardship D. Association of Professionals B. Improper antibiotic selection in Infection Cases B. Reception area C. Error in dosing C. Lunch room D. Unnecessary antibiotics 25. The CDC recommends that a person D. Where you prescribe antibiotics be responsible for helping other team most frequently 21. What percentage of inappropriate members be trained and evaluated on antibiotics was prescribed over the importance of antibiotic stewardship, 30. How can dental professionals a three-year period according organize reports, and organize provider, demonstrate their commitment to a study by Durkin et al.? staff, and patient education. What to antibiotic stewardship? is the role of this person called? A. 5 % A. Customized poster in the reception area A. Lead assistant B. 9 % B. Social media content B. Lead RDH C. 13% C. Patient pamphlets C. Office manager D. 25% D. All of the above D. Stewardship champion

DentalAcademyOfCE.com 69 PUBLICATION DATE: JANUARY 2020 ANSWER SHEET EXPIRATION DATE: DECEMBER 2022

Antibiotic stewardship

NAME: TITLE: SPECIALTY:

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REQUIREMENTS FOR OBTAINING CE CREDITS BY MAIL/FAX: 1) Read entire course. 2) Complete info above. 3) Complete test by marking one answer per question. 4) Complete course evaluation. 5) Complete credit card info or write check payable to Endeavor Business Media. 6) Mail/fax this page to DACE. A score of 70% is required for CE credit. FOR QUESTIONS, CALL (800) 633-1681. COURSE MAY ALSO BE COMPLETED AT DENTALACADEMYOFCE.COM.

Educational Objectives Mail/fax completed answer sheet to: 1. Review the current status of public health problems that result from the inappropriate use of antibiotics Endeavor Business Media Attn: Dental Division 2. Define and explore the concept of antibiotic stewardship 7666 E. 61st St. Suite 230, Tulsa, OK 74133 3. Explore existing national trainings, state toolkits, and practice guidelines in general dentistry Fax: (918) 831-9804 4. Apply and evaluate the practice of stewardship to their private practices Payment of $59 is enclosed. Course Evaluation Make check payable to Endeavor Business Media 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No If paying by credit card, please complete the following: Objective #2: Yes No Objective #4: Yes No MC Visa AmEx Discover

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Acct. number:______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. date: ______CVC #:______3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Billing address:______4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 ______5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 Charges on your statement will show up as Endeavor. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 7. Was the overall administration of the course effective? 5 4 3 2 1 0 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 1. 16. 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 2. 17. 10. Do you feel that the references were adequate? Yes No 3. 18. 11. Would you participate in a similar program on a different topic? Yes No 4. 19. 12. If any of the continuing education questions were unclear or ambiguous, please list them. 5. 20. 6. 21. 13. Was there any subject matter you found confusing? Please describe. 7. 22.

14. How long did it take you to complete this course? 8. 23. 9. 24. 15. What additional continuing dental education topics would you like to see? 10. 25. 11. 26. 12. 27. 13. 28. 14. 29. 15. 30. AGD Code 730

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INSTRUCTIONS PROVIDER INFORMATION EDUCATIONAL DISCLAIMER All questions have only one answer. Grading of this examination is done manually. Participants will receive Endeavor Business Media is an ADA CERP–recognized Provider. ADA CERP is a service of the American Dental Completing a single CE course should not provide enough information to give participants the feeling that they confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within Association to assist dental professionals in identifying quality providers of continuing dental education. ADA are experts in the field related to the course topic. It is a combination of many educational courses and clinical two weeks after taking an examination. CERP neither approves nor endorses individual courses or instructors, nor does it imply acceptance of credit experience that allows the participant to develop skills and expertise. hours by boards of dentistry. Concerns about a CE provider may be directed to the provider or to ADA CERP at COURSE EVALUATION AND FEEDBACK ada.org/gotocerp/. CANCELLATION AND REFUND POLICY We encourage participant feedback. Complete the survey above and e-mail feedback to Aileen Gunter Endeavor is designated as an approved PACE program provider by the Academy of General Dentistry. The Any participant who is not 100% satisfied with this course can request a full refund by contacting Endeavor ([email protected]) and Laura Winfield ([email protected]). formal continuing dental education programs of this program provider are accepted by the AGD for fellowship, in writing. mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial COURSE CREDITS AND COST board of dentistry or AGD endorsement. The current term of approval extends from 11/1/2015 to 10/31/2019. IMAGE AUTHENTICITY All participants scoring at least 70% on the examination will receive a verification form for three CE credits. Provider ID# 320452. The images provided and included in this course have not been altered. The formal CE program of this sponsor is accepted by the AGD for fellowship and mastership credit. Please © 2019 by the Academy of Dental Therapeutics and Stomatology, a division of Endeavor Business Media contact Endeavor for current term of acceptance. Participants are urged to contact their state dental boards for RECORD KEEPING continuing education requirements. Endeavor is a California CE provider. The California provider number is 4527. Endeavor maintains records of your successful completion of any exam for a minimum of six years. Please CUSTOMER SERVICE | CALL (800) 633-1681 The cost for courses ranges from $20 to $110. contact our offices for a copy of your CE credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.