Farzeen Tanwir*, Saifullah Khan **
The aim of this study was to describe the antibiotic prescription habits and trends of dentists of major cities of Pakistan.
It was a descriptive study of antibiotic usage by dentists of 7 major cities of Pakistan, using data given byAventisPharmaceuticalCompany,Karachi, Pakistan.The data comprise of the total prescriptions, city wise, gender wise, patient wise and specialty wise breakup of sales of antibiotics. The data constituted dental antibiotics prescriptionswhichwere given in percentage and numbers for all the different cities.
The study showed that the antibiotic prescription has increased over the years from 2000 to 2008. Multan 318 to 415 / 1800 showed themost number of prescriptions. Penicillinwas themain group prescribed.Most antibioticswere given for pulpal/periapical disease (343000 in 2008) to the age group 11-40 years old (65-70%from 2000-2008), and in general dental practice clinics (65-68%).
Antibiotic prescription habits of dentists vary in different cities of Pakistan. There is a need to develop guidelines to improve knowledge and to prevent antibiotic resistance.
Antibiotics, prescription habits, dentists, Pakistan, dental infections, pharmaceutical.
Antibiotics and analgesics are the most commonly prescribed medicine by dental practitioners. As antibiotics do not cause a direct affect on host cells, they are often prescribed on a “just in case” basis Dentist prescribe antibiotics for the treatment of acute infections, treatment of non-odontogenic infections, prophylaxis of local and systemic spread. It is also seen that many dental patients ‘expect’ an antibiotic prescription, and therefore they may influence their prescription. Studies on the knowledge of antibiotics prescription reveal that factors other than sound knowledge may influence their prescription practice. .Due to lack of guidelines, differences in prescription practices have been common. Recent changes in antibiotics use for prophylaxis of IE has also resulted in differences in practice amongst dentist in different countries. The British guidelines suggest no use of anti-biotic prophylaxis for any dental treatment (Nice guidelines) , where as the American and Australian guidelines suggest antibiotic prophylaxis for certain conditions.
Over use of antibiotics may also be due to uncertain diagnosis, leading to prescription on “just in case” basis.Often dentists prescribe broad spectrum antibiotics instead of selecting them based on specific indications. Antibiotics are often givenwithout signs and symptoms of infection, to delay appointments, to prevent infection, to avoid later criticism and to ensure everything was done . Recent use of antibiotics and over prescription are well documented risk factors for the colonizationwith resistant strains ofmicro-organism.
Antibiotic resistance is a cause of major concern, as more and more resistant strains are being seen. This makes it difficult to eliminate infections . Many infections now contain bacteria that do not respond to conventional treatment and require more specific and potent antibiotics. The reason suggested for this is the overuse of antibiotics, in which case, certain strains of bacteria are able to survive due tomutational changes
Antibiotic prescribing may be associated with unfavorable side effects ranging from gastrointestinal disturbances to fatal anaphylactic shock and development of resistance. Many dental problems can be treated alone with operativemeasures like fillings, root canal therapy or extraction if the tooth is not restorable.
Unfortunately, antibiotics are still being prescribed in these cases. The increasing resistance problems in recent years are probably related to over- or mis-use of broad-spectrum agents such as cephalosporins and fluoro-quinolones Today, we have reached a stage where bacterial species are resistant to the full range of antibiotics presently available, with the methicillin-resistant Staphylococcus aureus being the most widely known example of extensive resistance It is seen that the knowledge of prescribing antibiotics varies in different countries. A study in Australia suggested a good knowledge of antibiotic prescription , whereas that in Yemen showed considerable differences amongst dentists .A Norwegian study showed that dentists are some what restricted in the prescription of antibiotics, but they usually prescribe correct drugs for different diseases
A study in UK conclude that there is a lack of knowledge of the use of antibiotics, and that dentists often need to know specific guidelines for prescription and proper dosage of antibiotics. Antibiotic prescription habits in Glasgow showed that Amoxicillin and Metronidazole were the most commonly prescribed drugs Same was seen in a study on Fijian dentists and other studies on prescription habits of dentists. Very few studies have been done in Pakistan about the prescribing habits of Pakistani Dentists, this study is done to quantitatively analyze the trends of prescription. The aim of the study is to describe the antibiotic prescription habits of dentists ofmajor cities of Pakistan.
It was descriptive study on antibiotic Prescription by dentists of major cities of Pakistan. It was based on InternationalMedical Statistics (IMS) data of the total and also dental antibiotics prescription habits of dentists of sevenmajor cities of Pakistan.This data in Percentage and numbers was provided by a reputable Pharmaceutical company Aventis, in Pakistan.
The data constitutes the total prescriptions, cities wise breakup of sales, gender wise breakup of sales, patient wise breakup of sales and specialty wise breakup of sales of antibiotics. The data constituted total aswell as dental antibiotics prescriptions which was given in percentage and numbers for all the different cities. According to WHO’s, Anatomical Therapeutic Chemical (ATC) classification system with Defined Daily Doses (DDDs), the data of antibiotic prescription habits were converted into Prescriptions per 1000 inhabitants and also the number of prescriptions were calculated from the given data. Number of prescriptions and prescriptions/ 1000 inhabitantswere calculated for the year 2000 to 2008 for the total as well as dental antibiotic prescriptions. It was also calculated for major antibiotics (Therapeutic classes) used in dentistry as well as for the total antibiotic prescriptions by all the doctors of the7 major cities of Pakistan.
The results show anti-biotic prescriptions by Dental Surgeons in the major cities of Pakistan from the year 2000 to 2008.(Table 1, Figure 1)
General trend shows an increased number of prescription, both in total number aswell as the number of prescriptions per 1000 population. (Table no II, Figure no 2).
The highest number of prescriptions per 1000 inhabitants was noted in Multan (Table II, Figure 2) (415 in 2008).
Karachi, Lahore, Rawalpindi showed similar values in the years studied in this data, where as Peshawar and Quetta showed the least number of prescriptions (23 and 15 respectively). Faisalabad showed a steady decline in the number of prescriptions over the years, with 104 in 2000 to 79 in 2008.An overall increase in prescription by dentists has been noted.(Figure I)
In 2000 it was 41,79,000 which has steadily increased to 63,68,000 in the year 2008.Out of these, antiinfective agents comprised of 19,47,000 in 2000 which has increased to 28,66,000 in 2008. Themale:female ratio has remained approximately 1:1 throughout these years, with minor fluctuation. There was a drastic change in the year 2005 in which males received 71% of all anti-biotic prescriptions. Age distribution for antibiotic prescription showed that 11-40 year age group had the highest prescription rate which has remained between 65-70% in these years. The least prescription was in the age group 0- 11 years, ranging from 7 to 16%. Age 40+ years ranged from 16 to 28% in different years with no specific trends. Data showed that dentists with 20 to 29years of practice prescribe the maximum number of antibiotics, i.e. 44% prescription came from this group. Next group were dentists having a practice of 10-19 years, who prescribed 32% of all antibiotics. Dentists with less than 9 years of practice prescribed least amount of antibiotics being 9% of prescriptions.Reasons for prescription of antibiotics by dentists show the following pattern. For dental caries, prescriptions increased from 1,30,674 in the year 2000 to 4,43,000 in 2008.Antibiotics for pulpal/periapical disease also increased from 230864 in 2000 to 343000 in 2008. Gingival/periodontal disease contribution increased from 445642 in 2000 to 783000 in 2008. The rationale for diagnosis of these diseases is that they are the most common diseases seen by dentists, and the common diseases for which antibiotics are prescribed . Most antibiotics were being prescribed by dentists in general practice clinics ranging from 65-68% of all prescriptions. Hospital prescriptions were between 21-29% whereas the least number of prescriptions came from other specialist clinics.
Notmany studies have been done in the sub-continent on antibiotic prescription habits of dentists. Antibiotic resistance is on the high, and new resistant strains against anti-microbials are being seen. This study shows that the antibiotic prescription in Pakistan by dentists is on an increase during the last few years. This is contrary to the studies in Norway and Scotland. Most antibiotics in Pakistan were prescribed to the age-group 11-40 years. This probably accounts for the major age group visiting dentists in the country. Data shows that dentists working for more than 20 years tend to prescribe most anti-biotics in Pakistan. This is maybe due to lack of knowledge of current guidelines or because they see more patients, thus more prescriptions. Since there are no legal requirements to undertake any ‘Continuing Professional Development’ Courses in Pakistan, therefore these dentist maybe following outdated guidelines. Studies in England and Scotland show that clinicians who attended courses had significantly better knowledge of anti-biotics than those who did not. Reasons for prescription remain different in different parts of the world. This is also affected by the health care facilities in that country. Our study shows that caries and associated pathology remains the main reason for antibiotic prescription. Penicillins remain the most common prescription in our study
This is also seen in studies done inYemen and Italy. The reason for this maybe their wide spectrum action, availability and affordability. Data in Pakistan showed that the male to female ratio remained approximately 1:1 throughout these years. Also most prescriptions came from dentists in private practice. Thismay be due to lesser monitoring, and less knowledge as there is no concept of continuing education. Many dentists in private practice may prescribe antibiotics on demand of patients and to avoid complications.
Antibiotic prescription habits of dentists vary in different cities of Pakistan. There is a trend to overprescribe in many cases. There is a need to develop guidelines and start continuing development programs in dentistry to improve knowledge amongst dentists, and to prevent antibiotic resistance.
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