Approach to the Current Rational Use of Antibiotics among the Albanian Dentist Community.

Rising antibiotic use is a serious threat to the success of therapy in dentistry for bacterial resistance and side effects to the patients. The dentist community in Albania prescribing too many antibiotics. This survey assesses the mode of antibiotic use among Albanian dentists, with appropriate dosage and regimen, and antibiotic stewardship and their knowledge of relevant guidelines. Material and
Methods: This survey study was conducted among 180 Albanian dentists. The questionnaire was distributed through e-mail addresses found in the database of the Faculty of Dental Medicine, University of Medicine of Tirana. We assessed 180 dentists out of which 154 (85.56%) completed the entire questionnaire.
Results: There were 24,870 prescriptions in adult patients from 154 dentists for a period of six months with an average of 1,243 prescriptions per week. The most used antibiotics were fixed combinations of amoxicillin-clavulanic acid (67.43%) and azithromycin (39.3%) for allergic patients to beta-lactams. The results for antibiotic stewardship were incorrect in 37.01% of total providers, and gastrointestinal disorders were reported as side effects.
Conclusion: This survey conducted among Albanian dentists shows a different trend of using antibiotics than in other countries. To tackle the current antibiotic resistance, dentists must be an important part of the antimicrobial stewardship program of the Public Health Institution in Albania to change individual behavior. Copyright:

INTRODUCTION

Dentists, among other health care providers, prescribe antibiotics to treat various infectious dental diseases. Rising antibiotic use is a serious global threat of bacterial resistance, and the dentist community is a part of it. Antibiotics are misused in a variety of ways, such as wrong dosage form, wrong regimen and treatment durations as well wrong patients. Some patients are unlikely to have bacterial infections, but use antibiotics for unnecessarily prolonged periods and multiple agents or broad-spectrum agents when not needed. Many studies demonstrated that dentists do not always prescribe according to guidelines, with either unnecessary prescription of antibiotics (overuse) or prescription of the inappropriate antibiotic (misuse).[1-4] Dentists desire to avoid complications, meet the patient's expectations or pressure, and are unaware of the effects of antibiotic resistance; thus they prescribe antibiotics higher than needed. Dentists also tend to put their professional experience before recommendations.[4]

The trend of antibiotic prescriptions in Albania for all providers in dentistry over time is influenced by many factors such as disease levels, access to dental services, missing prescribing guidelines, patients' attitude toward antibiotic prescription, and missing incidence of antimicrobial resistance database.

The aim of this survey was to assess the use of antibiotics among Albanian dentists, with appropriate dosage and regimen, and antibiotic stewardship. Their knowledge of relevant guidelines were a part of prescribed antibiotics.

Overprescription of antibiotics may result in some adverse effects such as hypersensitivity reactions, and dermatological and allergic disorders. The misuse of antibiotics resulted in an increased rate of bacterial resistance that is still a global problem. Moreover, the risk of resistance might increase if antibiotics are administered in an inappropriate way. The literature provides evidence of inadequate prescription by dentists for several reasons ranging from lack of knowledge, absence of infection, to social factors.[256] Many studies and surveys show a huge variations regarding measurement of doses and duration of the dental antibiotic therapy. It is probable that numerous prescriptions of antibiotics in dentistry also turn out to be superfluous. In many cases, antibiotics are being prescribed for a long period and with no standardized frequency and duration.[789]

MATERIALS AND METHODS

Study design

The study was based on a survey of antibiotics used by the community of dentists of Albania in every day work. We selected two group of dentists 63.64% or 98 dentists (Category B)working at own private practiceand 36.35 % or 56 dentists (Category A) working at University DentalClinic at Faculty of Dental Medicine at Tirana University of Medicine. We assessed 180 dentists out of which only 154 (85.56%) correctly completed the questionnaire. The questionnaire was distributed through e-mail using the database of the Faculty of Dental Medicine, University of Medicine of Tirana. The questionnaire was based on a survey for antibiotics used for the period of July–December 2021. Dentists participating in our study were classified as category A (working in the university clinic) and category B (working individually in their own clinic or in small practice settings with mainly two or three family members). We have collected data from dentists working in the capital (Tirana) and in the three biggest cities of Albania. The questionnaire was developed by a multidisciplinary group consisting of dentists and pharmacists. The questions were mainly close-ended, with a few open questions. The questionnaire was composed of three main sections: The first consisted of questions on general and demographic data, the second contained questions relating to antibiotic prescription practices, and the third surveyed the dentist's attitudes towards antibiotics and their knowledge. The questionnaire consisted of 17 questions (Annex I).

Statistical analyses

All data were analyzed using SPSS 25.0. Respondents' demographic and professional characteristics were described as absolute numbers and percentages for categorical variables and as means and standard deviations (SD) for continuous variables (descriptive statistics). Content analysis was used for qualitative data. Data for antimicrobial therapy, defined daily dose, frequency and duration of treatment were presented as numbers and percentages. For each of the 17 questions, we assessed the antibiotic prescription according to the study survey. The assessment considered the indication to prescribe antibiotics, the antimicrobial molecule used, the dosage, the frequency, and the duration of prescription, side effects and knowledge of dentists in prescribing antibiotics. Concerning the duration of antibiotic treatment, we accepted a margin for seven-day recommended durations, that is, six to eight days were considered acceptable. Regarding defined daily doses, we used the available literature.[1011] The missing guideline in our country for target group of dentists is evident; we had inclusion and exclusion criteria. It should be noted that the number of responses for each question may differ because of missing data for some questions, and dentists addressing their questionnaire to the assistant dentists has been classified as exclusion criteria. Inclusion criteria was the voluntary to participation in this study and that they are in direct contact with patients. Analysis excluded questionnaires which contained no response at all or only demographic responses.

RESULTS

One hundred eighty dentists participated in our survey study, but only 154 of them completed the questionnaire (85.56%). The baseline characteristics with demographic and practice characteristics of 154 respondents are shown in Table 1. Most of them were general dental practitioners (59.74%, 92/154) and specialized dental practitioners (40.26%, 62/154) Dentists who operating in the capital were 48.05% (74/154) and the others from the suburban regions of Albania 51.95% (80/154). Category A dentists (working at the university clinic) were 36.36% (56/154) and category B dentists (working in private clinic) were 63.64% (98/154).

Table 1

Baseline Characteristics

	Number	%
Gender
Female	101	65.58
Male	53	34.42
Age (years)	37.2	25-67 (y)
Practice settings
Capital City	74	48.05
Other Cities	80	51.95
Year of Experience
0-10 years	45	29.22
11-20 years	52	33.77
21-30 years	34	22.08
>31 years	23	14.93
Type of activity
Specialized and exclusive activity	62	40.26
General practice	92	59.74
Category qualifications
Category A (dentists) (*)	56	36.36
Category B (dentists) (**)	98	63.64

(*) Dentist working at university clinics (**) Dentists working at own clinics

Dentists' knowledge on antibiotics and practices

There were 24,870 prescriptions for adult patients from 154 dentists for a period of six months with an average of eight prescription per week (SD 4).

The most frequently prescribed antibiotics were beta-lactams: Fixed combinations amoxicillin (0.5 g)–clavulanic acid (0.125 g) t.i.d. 67.43% amoxicillin (0.5 g) 24.74% (t.i.d) and phenoxymethylpenicillin (0.250 g) t.i.d. 4.43%, followed by other antibiotics in very low value with a duration 5 to 10 days.

Antibiotics prescribed as a first line chosen treatment are listed in Graphic 1.

Graphic 1

First-line treatment antibiotic prescribed

Other antibiotics prescribed for allergic patients with beta-lactams and as a second line of treatment were azithromycin (0.5 g) (o.i.d) 39.3%, spiramycin (1.5 MIU) + metronidazole (0.250 mg) fixed-dose combinations (b.i.d to t.i.d) 21.4%, and clindamycin (0.3 g) t.i.d 17.9% followed by gentamycin (0.080 g) (b.i.d) 14.3% and less clarithromycin (0.5 g) (b.i.d to t.i.d) 3.6% and tetracycline (0.250) (t.i.d). Antibiotics prescribed for beta-lactam allergic patients and as a second line treatment are shown in Graphic 2.

Graphic 2

Antibiotic treatment of patients allergic to beta-lactams and second-line treatment

Knowledge of the regimen: Doses, frequency and duration of treatment

The results for the regimen were incorrect for 37.01% of the total providers. They had written the wrong dosage regimen. In terms of regimen, they did not know the dosage per 24 hours and the frequency and period of treatment. They answered incorrectly the maximum daily dosage, frequency, and duration. These results implicate that dentists who underestimated the daily dosage, frequency, and duration could not manage to correct the infection; the success of the therapy is discussed as well antimicrobial resistance to that antibiotic. All the data of dosage regimen are presented in Table 2.

Table 2

Antibiotics misused (doses/frequency/duration)

	Incorrect	Partially correct	Correct
Doses/Frequency/Duration	14.94 %	2.6 %	82.46%
Co -Amoxicillin (500mg/125mg)	(23/154)	(4/154)	(127/154)
Doses/Frequency/Duration	11.68 %	4.55 %	83.77%
Amoxicillin 0.5g)	(18/154)	(7/154)	129/154
Doses/Frequency/Duration	10.39 %	6.5%	79.87%
Spiramycin – Metronidazole (1.5MIU-250mg)	(16/154)	(10/154)	(123/154)

Out of the total, 95.45% (147/154) of respondents declared knowing daily use, frequency, and durations of treatments, but the inappropriate antibiotic prescriptions are too high in our survey. Incorrect answer is considered in cases where the prescriber misused antibiotics in terms of incorrect dosage, frequency, and durations for the right patients. Partially incorrect included prescribers that had made mistakes in the durations of treatment which were shorter or longer than stated in the literature [Graphic 3].

Graphic 3

Antibiotics misused

Knowledge of potential adverse effects of antibiotics

The results for antibiotic stewardship were incorrect in 37.01% of providers. Approximately all of them, that is, 95.45% (147/154) of respondents declared knowing the daily dosage, mode of use, regimen, antimicrobial resistance, adverse events of antibiotics according to the scientific literature. They declared consulting current guidelines for antibiotic use in Europe, USA, and other scientific papers from different sources, but they declared that a national guideline in dentistry for using antibiotic is missing and that it is necessary. The prescriptions by dentists were too high.

Almost all dentists (98.7%, 152/154) participating in the study were informed about potential effects of antibiotics as well as convinced about antibiotic resistance. Antibiotic resistance was a concern for 92.2% (142/154) of them, but only a few of them were convinced that the risk of antibiotic resistance influenced their prescriptions (4.55%, 7/154). Side effects reported by them (from patients) were in terms of hypersensitivity of antibiotics or inefficacy. They explained efficacy in terms of antibacterial resistance. Common, potential adverse effects were gastrointestinal (85.72%, 132/154) which included diarrhea (47.7%, 75/154), nausea (27.27%, 42/154), vomiting (7.14%, 11/154), and hypersensitivity reactions (2.27%, 35/154), etc. The dentists declared that they increased antibiotic prescription through the years (at least two recent years) not only in number but in duration (72,72%, 112/154). Only 27.28% (42/154) declared that their number of prescriptions remained the same for many years [Table 3].

Table 3

Potential adverse drug effects of antibiotics used

Side effects	Number of dentists reporting ADE	%
Hypersensitivity reactions		2.27
Urticaria	15	0.97
Drug Fever	8	0.52
Joint swelling	12	0.78
Pruritus	0
Angioedema	0
Nephritis	0	0
Granulocytopenia	0	0
Hemolytic anemia	0	0
Gastrointestinal		85.72
Nausea	42	27.27
Vomiting	11	7.14
Diarrhea	75	48.7
Anorexia	4	0.26
None	24	4.5

Assessment of the appropriateness of antibiotic prescription

To optimize antibiotic use, the dentists declared they would be ready to evaluate and improve their professional practices regarding antibiotic use. Dentists declared that information for patients on the rational use of antibiotics is essential and the information on their irrational use leads to bacterial resistance as well as an increase in undesirable effects. They declared factors that influenced their prescriptions: (1) the publication of guidelines from the European and USA dentist community (87.66%, 135/154); (b) continuing training from Education Center of Albania and Dentist Order of Albania, (55.84%, 86/154); (c) research papers in scientific journals, conferences (50.65%, 89/154); (d) colleague's influence (17.53% 27/154), (e) antibiotic perception's patients (7.8% 12/154), (f) others (1.94 5 3/154) [Graphic 4].

Graphic 4

Factors influencing antibiotic prescription among Albanian dentists (%)

Most of the respondents (70.13%, 108/154) felt inadequately informed and trained regarding antibiotic use from the Albanian authorities. They wished to approve a national guideline for the Albanian dentist community with regular updates, a database for prescriptions, including reimbursement dentist's antibiotics prescriptions, and a network of health professionals to facilitate prescription of antibiotic.

DISCUSSION

Our study investigated the antibiotic prescription patterns among Albanian dentists. The results demonstrate that fixed combinations of amoxicillin with clavulanic acid (Co-Amoxiclav) is a broad-spectrum antibiotic that is the most prescribed antibiotic by Albanian dentists whereas in almost all European countries and USA it is beta-lactams, but not combined ones. Amoxicillin has also been found to be the most prescribed antibiotic in Spain 86.1% and 94.5%, the United Kingdom 45.6% and 70.5%, Germany, Belgium, the USA 62.5%.[2312131415] From the class of beta-lactams, phenoxy methyl penicillin/amoxicillin and metronidazole are used as the first-line treatment in Norway, Sweden, Scotland, and England.[12916] Amoxicillin was the most frequently prescribed antibiotic (65.8%, 1783/2711), followed by spiramycin + metronidazole fixed-dose combination (11.6%, 312/2711), and amoxicillin–clavulanic acid (10.3%, 279/2711) in a study survey in France.[17] In Albania, fixed, combined antibiotic amoxicillin– clavulanic acid was the first choice followed by amoxicillin. The fixed combination amoxicillin/ clavulanic acid has demonstrated to them therapy effectiveness meanwhile in the other countriesthe first line treatments is amoxicillin alone. It was observed that the dentist who worked in the university clinic used amoxicillin as the first line of treatment.

The second line of treatment for patients allergic to beta-lactams or due to inefficiency of pharmacological group (in terms of antibacterial resistance, but not proven) was azithromycin, spiramycin–metronidazole fixed combinations for Albanian dentist. In England/Scotland metronidazole was commonly prescribed while clindamycin prescriptions were common in Norway, Sweden and in Germany[1291619]. The most prescribed drug in penicillin-allergic patients in Czech Republic was clindamycin which was nearly two-thirds of all prescriptions.[19]

Albanian dentists acknowledged their lack of information about current guidelines. The respondents declared knowing the recommendations for antibiotics and felt inadequately informed, but self-education or participation in conferences or congresses for dentistry where there were few topics for antibiotic use.

Albanian dentists need to have more postgraduate training about clinical indications for antibiotic prescription to optimize their use. Indeed, 70.13% (108/154) felt inadequately informed and trained regarding antibiotic use. They were interested to have a national guideline with updates of national recommendations. Universities of dentistry are not involved in continuing courses after graduation for antibiotic prescription, their pharmacological effects, and stewardship in Albania. At the same time, it is essential to develop postgraduate training to improve current practices and meet the demands of the dentist community of Albania.

CONCLUSIONS

This survey conducted among Albanian dentists shows a different trend of using antibiotics than in other countries where fixed combination of amoxicillin–clavulanic acid is the most used antibiotic, whereas for allergic patients of beta-lactams, Albanian dentists use azithromycin, completely different from the trends in many countries. Since dentists prescribe a wide range of antibiotics, a national guideline for antibiotic use for the dentistry community is an emergency. Dentists must be an important part of the antibiotic stewardship program of Public Health Institution in Albania in order to achieve the objective of changing individual behavior to tackle the current antibiotic resistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.