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pdf7 Ways Dentists
Can Act Against
Antibiotic Resistance
Dentists are uniquely positioned to play a role in pre enting
the spread of antibiotic resistance. Here are se en simple
“how-tos” for safe, appropriate antibiotic prescribing and
use when treating dental infections.
1. MAKE an accurate diagnosis.
2. When prescribing an antibiotic,
CHOOSE the right drug for the right dose and duration.
3.
SE narrow-spectrum antibiotics for simple
infections and preser e broad-spectrum drugs
for more complex infections.
4. AVOID prescribing antibiotics for iral infections.
5. For empiric treatment, REVISE treatment regimen
based on patient progress and/or test results.
6. KNOW the side effects and drug interactions of an
antibiotic before prescribing.
7. TEACH your patients about appropriate antibiotic use
and emphasize the importance of taking antibiotics
exactly as prescribed.
www.cdc.gov/antibiotic-use
ANTIBIOTIC SAFETY
ANTIBIOTICS ARE RESPONSIBLE
FOR ALMOST
1 OUT OF 5
EMERGENCY DEPARTMENT VISITS
FOR ADVERSE DRUG EVENTS
ANTIBIOTICS ARE THE MOST
COMMON CAUSE OF EMERGENCY
DEPARTMENT VISITS FOR
ADVERSE DRUG EVENTS
IN CHILDREN UNDER
18 YEARS OF AGE.
www.cdc.gov antibiotic-use
HOSPITAL PHARMACISTS:
BE ANTIBIOTICS AWARE
Reassess
Antibiotic Therapy
SCENARIO
You are following up on a pharmacy
kinetic consult for a patient who has
received intravenous vancomycin
empirically for three days for the treatment
of hospital-acquired pneumonia.
Reassessment of antibiotic therapy evaluates the continued need for and choice of antibiotics
when the clinical picture is clearer and more diagnostic information is available.1 Anti-MRSA
coverage is a practical target for reassessment based on the patient’s microbiology results.1
Exceptions to de-escalating anti-MRSA coverage may include purulent skin and soft tissue
infections, prosthetic joint/orthopedic surgical infections, osteomyelitis, septic arthritis, and
abscesses.2
Pharmacists can help reassess antibiotic therapy by:
1. Reviewing the patient’s microbiology results, including rapid
diagnostic tests and clinically relevant cultures.1,2
2. Prompting the provider to consider discontinuation of
anti-MRSA therapy if there is no microbiological evidence
of MRSA, if appropriate.
The scenarios and recommendations discussed are applicable to most immunocompetent adult patients. Prior to making interventions,
always assess the individual patient and use your clinical judgment. Follow your institution’s treatment guidelines when applicable.
References:
1. Core Elements of Hospital Antibiotic Stewardship Programs. Centers for Disease Control and Prevention, 23 Feb. 2017, www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html.
2. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 1;52(3):e18-55.
https://academic.oup.com/cid/article/52/3/e18/306145.
www.cdc.gov/antibiotic-use
HOSPITAL PHARMACISTS:
BE ANTIBIOTICS AWARE
Avoid Treatment
of Asymptomatic
Bacteriuria
SCENARIO
A medical resident calls you asking for
your recommendation on antibiotic choice
based on a patient’s urine culture report.
Asymptomatic bacteriuria refers to the isolation of bacteria in urine culture from a patient without
signs or symptoms of urinary tract infection (UTI). A positive urine culture result (with or without
pyuria) alone does not meet criteria for initiation of antibiotics according to infectious diseases
guidelines. Exceptions include pregnancy and invasive genitourinary procedures.1
Pharmacists can help avoid unnecessary treatment
of asymptomatic bacteriuria by:
1. Prompting the provider to consider if the patient has signs and
symptoms consistent with UTI prior to making a recommendation
for treatment. Signs and symptoms may include:1,2
3 urinary urgency
3 urinary frequency
3 dysuria
3 suprapubic pain
3 flank pain
3 pelvic discomfort
3 acute hematuria
3 fever
Note: Delirium or nausea/vomiting should be interpreted with caution as, by themselves,
they have a low specificity for UTI.1
2. Discussing the potential for avoiding antibiotic use with the
provider if the patient has asymptomatic bacteriuria.
The scenarios and recommendations discussed are applicable to most immunocompetent adult patients. Prior to making interventions,
always assess the individual patient and use your clinical judgment. Follow your institution’s treatment guidelines when applicable.
References:
1. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis.
2019 March 21 [Epub] https://academic.oup.com/cid/article/68/10/e83/5407612.
2. Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals. Centers for Disease Control and Prevention,
www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements-small-critical.html.
www.cdc.gov/antibiotic-use
Checklist for Antibiotic Prescribing in Dentistry
Pretreatment
Correctly diagnose an oral bacterial infection.
Consider therapeutic management interventions, which may be sufficient to
control a localized oral bacterial infection.
Weigh potential benefits and risks (i.e., toxicity, allergy, adverse effects,
Clostridium difficile infection) of antibiotics before prescribing.
Prescribe antibiotics only for patients of record and only for bacterial infections
you have been trained to treat. Do not prescribe antibiotics for oral viral
infections, fungal infections, or ulcerations related to trauma or aphthae.
Implement national antibiotic prophylaxis recommendations for the medical
concerns for which guidelines exist (e.g., cardiac defects).
Assess patients’ medical history and conditions, pregnancy status, drug
allergies, and potential for drug-drug interactions and adverse events, any of
which may impact antibiotic selection.
Prescribing
Ensure evidence-based antibiotic references are readily available during
patient visits. Avoid prescribing based on non-evidence-based historical
practices, patient demand, convenience, or pressure from colleagues.
Make and document the diagnosis, treatment steps, and rationale for antibiotic
use (if prescribed) in the patient chart.
Prescribe only when clinical signs and symptoms of a bacterial infection
suggest systemic immune response, such as fever or malaise along with local
oral swelling.
Revise empiric antibiotic regimens on the basis of patient progress and, if
needed, culture results.
Use the most targeted (narrow-spectrum) antibiotic for the shortest duration
possible (2-3 days after the clinical signs and symptoms subside) for otherwise
healthy patients.
Discuss antibiotic use and prescribing protocols with referring specialists.
Patient Education
Educate your patients to take antibiotics exactly as prescribed, take antibiotics
prescribed only for them, and not to save antibiotics for future illness.
Staff Education
Ensure staff members are trained in order to improve the probability of patient
adherence to antibiotic prescriptions.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
CS267105-1
HOSPITAL PHARMACISTS:
BE ANTIBIOTICS AWARE
Avoid Duplicative
Anaerobic
Coverage
SCENARIO
The pharmacy receives medication
orders for piperacillin/tazobactam AND
metronidazole for the same patient.
CDC’s Core Elements of Hospital Antibiotic Stewardship Programs suggests that pharmacists
review antibiotic therapy that is unnecessarily duplicative, including the use of agents with
overlapping spectra. The combination of two agents with anaerobic activity is unnecessary in
most cases.1, 2 Exceptions may include Clostridioides difficile infection, necrotizing fasciitis, and
certain biliary infections.3
Pharmacists can help avoid unnecessary duplicative
anaerobic coverage by:
1. Alerting the provider that the antibiotics ordered have overlapping
spectra of activity.
2. Discussing the clinical case with the provider and consider
recommending discontinuation of metronidazole to avoid
duplicative therapy, when appropriate.
You can apply this action plan to other combinations of agents that have duplicative anaerobic
coverage (e.g., metronidazole and a carbapenem).
The scenarios and recommendations discussed are applicable to most immunocompetent adult patients. Prior to making interventions,
always assess the individual patient and use your clinical judgment. Follow your institution’s treatment guidelines when applicable.
References:
1. Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals. Centers for Disease Control and Prevention, www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements-small-critical.html.
2. Core Elements of Hospital Antibiotic Stewardship Programs. Centers for Disease Control and Prevention, www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html.
3. Huttner B, Jones M, Rubin MA, et al. Double trouble: how big a problem is redundant anaerobic antibiotic coverage in Veterans Affairs medical centers. J Antimicrob Chemother. 2012;67(6):1537-9.
www.cdc.gov/antibiotic-use
5
WAYS HOSPITAL
PHARMACISTS CAN
BE ANTIBIOTICS AWARE
1. Verify Penicillin Allergy
• Although 10% of the population in the United States reports a penicillin allergy, less than 1%
of the population is truly penicillin allergic.1
• When possible, obtain a more detailed history of the penicillin reaction and review previously
prescribed antibiotics. Alert the provider of your findings if you think the patient can tolerate
a beta-lactam antibiotic, when appropriate.
2. Avoid Duplicative Anaerobic Coverage
• Duplicative anaerobic coverage, such as piperacillin/tazobactam and metronidazole,
is unnecessary in most cases.2
• When the pharmacy receives antibiotic orders for two or more agents with anaerobic
activity, alert the provider that the antibiotics have overlapping spectra of activity.
3. Reassess Antibiotic Therapy
• Review the patient’s microbiology results (e.g., rapid diagnostic tests and clinically
relevant cultures).3
• Prompt the provider to consider stopping or tailoring antibiotic therapy as appropriate.
4. Avoid Treatment of Asymptomatic Bacteriuria
• Patients with asymptomatic bacteriuria should not be treated with antibiotics in most cases.4
• Consider the importance of signs and symptoms consistent with urinary tract infection (UTI)
when reviewing positive urine cultures and/or making treatment recommendations.
5. Use the Shortest Effective Antibiotic Duration
• Guidelines for treatment duration are available for common infectious diseases such as
pneumonia, UTI, and skin and soft tissue infection.5,6,7
• Alert the provider if the total days of inpatient and post-discharge antibiotic therapy exceeds
the recommended duration.
The scenarios and recommendations are applicable to most immunocompetent adult patients.
Prior to making interventions, always assess the individual patient and use your clinical judgment.
Follow your institution’s treatment guidelines when applicable.
References:
1. “Is It Really a Penicillin Allergy?” Centers for Disease Control and Prevention, https://www.cdc.gov/antibiotic-use/community/pdfs/penicillin-factsheet.pdf.
2. Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals. Centers for Disease Control and Prevention,
www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements-small-critical.html.
3. Core Elements of Hospital Antibiotic Stewardship Programs. Centers for Disease Control and Prevention, www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html.
4. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis.
2019 March 21 [Epub]. https://academic.oup.com/cid/article/68/10/e83/5407612.
5. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in
adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72. https://academic.oup.com/cid/article/44/Supplement_2/S27/372079.
6. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases
Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-120. https://academic.oup.com/cid/article/52/5/e103/388285.
7. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2014;59(2):e10-52. https://academic.oup.com/cid/article/52/5/e103/388285.
www.cdc.gov/antibiotic-use
5
WAYS HOSPITAL
PHARMACISTS CAN
BE ANTIBIOTICS AWARE
1. Verify Penicillin Allergy
• Although 10% of the population in the United States reports a penicillin allergy, less than 1%
of the population is truly penicillin allergic.1
• When possible, obtain a more detailed history of the penicillin reaction and review previously
prescribed antibiotics. Alert the provider of your findings if you think the patient can tolerate
a beta-lactam antibiotic, when appropriate.
2. Avoid Duplicative Anaerobic Coverage
• Duplicative anaerobic coverage, such as piperacillin/tazobactam and metronidazole,
is unnecessary in most cases.2
• When the pharmacy receives antibiotic orders for two or more agents with anaerobic
activity, alert the provider that the antibiotics have overlapping spectra of activity.
3. Reassess Antibiotic Therapy
• Review the patient’s microbiology results (e.g., rapid diagnostic tests and clinically
relevant cultures).3
• Prompt the provider to consider stopping or tailoring antibiotic therapy as appropriate.
4. Avoid Treatment of Asymptomatic Bacteriuria
• Patients with asymptomatic bacteriuria should not be treated with antibiotics in most cases.4
• Consider the importance of signs and symptoms consistent with urinary tract infection (UTI)
when reviewing positive urine cultures and/or making treatment recommendations.
5. Use the Shortest Effective Antibiotic Duration
• Guidelines for treatment duration are available for common infectious diseases such as
pneumonia, UTI, and skin and soft tissue infection.5,6,7
• Alert the provider if the total days of inpatient and post-discharge antibiotic therapy exceeds
the recommended duration.
The scenarios and recommendations are applicable to most immunocompetent adult patients.
Prior to making interventions, always assess the individual patient and use your clinical judgment.
Follow your institution’s treatment guidelines when applicable.
References:
1. “Is It Really a Penicillin Allergy?” Centers for Disease Control and Prevention, https://www.cdc.gov/antibiotic-use/community/pdfs/penicillin-factsheet.pdf.
2. Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals. Centers for Disease Control and Prevention,
www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements-small-critical.html.
3. Core Elements of Hospital Antibiotic Stewardship Programs. Centers for Disease Control and Prevention, www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html.
4. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis.
2019 March 21 [Epub]. https://academic.oup.com/cid/article/68/10/e83/5407612.
5. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in
adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72. https://academic.oup.com/cid/article/44/Supplement_2/S27/372079.
6. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases
Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-120. https://academic.oup.com/cid/article/52/5/e103/388285.
7. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2014;59(2):e10-52. https://academic.oup.com/cid/article/52/5/e103/388285.
www.cdc.gov/antibiotic-use
HOSPITAL PHARMACISTS:
BE ANTIBIOTICS AWARE
Verify Penicillin
Allergy
SCENARIO
You are verifying an aztreonam order
for a patient who has a penicillin allergy
listed in his medical chart.
Although 10% of the population in the U.S. reports a penicillin allergy, less than 1% of the
population is truly penicillin allergic. Correctly identifying if your patient is penicillin allergic can
decrease the unnecessary use of broad spectrum antibiotics.1,2,3
Pharmacists can help verify penicillin allergy by:
1. Asking questions to evaluate if the patient is truly penicillin allergic.
3 What medication(s) were you taking when the reaction occurred?
3 Can you describe the symptoms you experienced?
3 How long ago did the reaction occur?
3 How was the reaction managed? What was the outcome?
3 Have you been prescribed amoxicillin or another penicillin since your reaction?
Did you tolerate the antibiotic?
2. Reviewing the patient’s health record to obtain previous
prescription history.
If the patient has tolerated a penicillin or cephalosporin in the past, aztreonam may
not be necessary.
3. Discussing your findings with the ordering provider.
Consider preparing a list of alternative agents to discuss with the provider.
Refer to your facility’s penicillin allergy evaluation protocol, if applicable.
You can apply this action plan to other antibiotics that are initiated for penicillin allergy
(e.g., fluoroquinolones, clindamycin).
The scenarios and recommendations discussed are applicable to most immunocompetent adult patients. Prior to making interventions,
always assess the individual patient and use your clinical judgment. Follow your institution’s treatment guidelines when applicable.
References:
1. “Is It Really a Penicillin Allergy,” Centers for Disease Control and Prevention, https://www.cdc.gov/antibiotic-use/community/pdfs/penicillin-factsheet.pdf.
2. Trubiano J, Phillips E. Antimicrobial stewardship’s new weapon? A review of antibiotic allergy and pathways to ‘de-labeling’. Curr Opin Infect Dis. 2013;26(6):526-37.
3. Swearingen SM, White C, Weidert S, Hinds M, Narro JP, Guarascio AJ. A multidimensional antimicrobial stewardship intervention targeting aztreonam use in patients with a reported penicillin allergy. Int J Clin Pharm. 2016;38(2):213-7.
www.cdc.gov/antibiotic-use
HOSPITAL PHARMACISTS:
BE ANTIBIOTICS AWARE
Use the Shortest
Effective Antibiotic
Duration
SCENARIO
You are performing medication
reconciliation and reviewing discharge
antibiotic orders for a patient.
Antibiotic stewardship programs are targeting interventions to reduce unnecessarily long
durations of antibiotic treatment. In adult patients who have a timely clinical response, guidelines
suggest the following durations for uncomplicated cases of these infections:
• Community-Acquired Pneumonia: Five days1
• Hospital-Acquired Pneumonia: Seven days2
• Non-purulent Cellulitis: Five days3
Pharmacists can help optimize antibiotic duration by:
1. Adding the total number of days of uninterrupted inpatient antibiotic
therapy to planned post-discharge antibiotic duration.
2. Alerting the provider if the total duration of inpatient and postdischarge antibiotic therapy exceeds the recommended duration
according to treatment guidelines.
3. Discussing optimizing the duration of post-discharge antibiotic
therapy with the provider if the patient had an uncomplicated
clinical course and has responded appropriately to treatment.
The scenarios and recommendations discussed are applicable to most immunocompetent adult patients. Prior to making interventions,
always assess the individual patient and use your clinical judgment. Follow your institution’s treatment guidelines when applicable.
References:
1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect
Dis. 2007;44 Suppl 2:S27-72. https://academic.oup.com/cid/article/44/Supplement_2/S27/372079.
2. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and
the American Thoracic Society. Clin Infect Dis. 2016. https://www.idsociety.org/practice-guideline/hap_vap.
3. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis.
2014;59(2):e10-52. https://academic.oup.com/cid/article/52/5/e103/388285.
www.cdc.gov/antibiotic-use
Antibiotics aren’t always the answer when you’re sick.
Ask your doctor how you can feel better.
For more information on antibiotic prescribing and use,
visit www.cdc.gov/antibiotic-use.
Antibiotics aren’t always the answer when you’re sick.
Ask your doctor how you can feel better.
For more information on antibiotic prescribing and use, visit
www.cdc.gov/antibiotic-use.
Our Commitment to Antibiotic
Stewardship
Antibiotics save lives, but are frequently prescribed unnecessarily. Harms from antibiotic
overuse can be significant, especially for frail older adults. Potential harms include
adverse drug events, drug interactions, and antibiotic-resistant and Clostridioides difficile
infections.
As part of our continuing commitment to provide the best quality care to our residents, we
are dedicated to improving antibiotic use through antibiotic stewardship implementation.
Antibiotic stewardship refers to a set of commitments and activities designed to “optimize
the treatment of infections while reducing the adverse events associated with antibiotic
use.”
We are committed to improving antibiotic prescribing practices. We will provide staff and
resources to support antibiotic stewardship implementation. We are confident that with
the support of front-line staff, prescribing clinicians, and residents and families, we will
continue to provide residents with the best quality care by improving antibiotic use, and
protecting them from the unintended harms of inappropriate antibiotic use.
Sincerely,
To learn more about appropriate antibiotic prescribing and use, visit
www.cdc.gov/antibiotic-use.
CS263097-A
CS 294480
| File Type | application/pdf |
| Subject | Be Antibiotics Aware |
| Author | HHS/CDC |
| File Modified | 2020-01-24 |
| File Created | 2020-01-24 |