Dentists to Blame for Increasing Spread of C. Difficile

When a patient is infected with C. difficile, physicians would usually be right to assume that exposure occurred in the hospital. But the tide is shifting, according to the Minnesota Department of Health — cases of community acquired C. Difficile are spreading, and the cause is unnerving.

Many dentists are habitually overprescribing antibiotics, according to Stacy Holzbauer, DVM, MPH, of the Minnesota Department of Health, and in so doing, propagating the spread of community acquired C. Difficile.

“We found that 15% of community associated C. difficile patients who had taken an antibiotic prior to their infection took them for a dental procedure,” Holzbauer said at a press conference held at IDWeek 2017 in San Diego, CA. “We also found that many of these prescriptions may not be meeting the current prescribing guidelines.”

In dentistry, antibiotics are commonly prescribed to treat or prevent oral infections in high risk patients who are undergoing dental procedures. However, according to Holzbauer, the Centers for Disease Control and Prevention (CDC) and American Dental Association (ADA) agree that the best treatments for oral infections often do not warrant antibiotic use.

Historically, Holzbauer said, dental recommendations for antibiotic prophylaxis have been reserved for 2 specific groups of patients: those who have heart conditions that may predispose them to a heart infection, and patients with prosthetic joints who are at risk for developing infection at the site of the prosthetic.

Those recommendations are no longer valid, she explained, because the American Heart Association (AHA) has outlined specific heart conditions without warranting antibiotic prophylaxis, and in 2015 the ADA recommended that no antibiotic prophylaxis be given to patients with joint replacements.

Many dentists are not aware of these guidelines, or that complications like C. difficile can develop from antibiotic use, and so continue to overprescribe them.

From 2009 to 2015, researchers with the Minnesota Department of Health Emerging Infections Program interviewed 1,626 people with community associated C. difficile. 57% reported that they had been prescribed antibiotics, and 15% of those had received their prescriptions from dentists.

“Dentists have been overlooked as major partners in programs that promote appropriate antibiotic use. It’s critical that dentists are included in all efforts to improve antibiotic prescribing,” Holzbauer said.

34% of patients studied who had received antibiotics from dentists had no mention of antibiotics in their medical records, illustrating a disconnect between dentists and medical providers that further exacerbates the problem, Holzbauer said.

“Many times dentists are not aware that complications can develop from antibiotic use. Better communication is needed between patients, dentists and medical providers,” she said.

Holzbauer recommended the following action steps as part of an effort to curb the spread of community associated C. difficile from dental overprescribing:

• Patients should mention any dental visits and any medications they are taking for dental reasons during medical visits
• Doctors should ask patients about dental visits and medications they are taking for dental reasons during medical visits
• Dentists should counsel patients about the risk of community associated c. difficile and its symptoms when they prescribe antibiotics

Research from the Minnesota Department of Health is limited to populations within 5 counties in that state. More research is needed to determine whether similar overprescribing is occurring elsewhere, and whether the data can be extrapolated to the larger US population.

“C. difficile is a known complication that accounts for more than 453,000 cases per year, causing an excess financial burden of more than $1 billion annually,” Holzbauer said. “Dentists need to be included in antibiotic stewardship programs. They’ve often been overlooked and it’s absolutely critical that they are included to improve prescribing across all modalities.”