Oral antibiotic prescribing by NHS dentists in England 2010-2017

Introduction Dentists prescribe a significant proportion of all antibiotics, while antimicrobial stewardship aims to minimise antibiotic-prescribing to reduce the risk of developing antibiotic-resistance and adverse drug reactions. Aims To evaluate NHS antibiotic-prescribing practices of dentists in England between 2010-2017. Methods NHS Digital 2010-2017 data for England were analysed to quantify dental and general primary-care oral antibiotic prescribing. Results Dental prescribing accounted for 10.8% of all oral antibiotic prescribing, 18.4% of amoxicillin and 57.0% of metronidazole prescribing in primary care. Amoxicillin accounted for 64.8% of all oral antibiotic prescribing by dentists, followed by metronidazole (28.0%), erythromycin (4.4%), phenoxymethylpenicillin (0.9%), clindamycin (0.6%), co-amoxiclav (0.5%), cephalosporins (0.4%) and tetracyclines (0.3%). Prescriptions by dentists declined during the study period for all antibiotics except for co-amoxiclav. This increase is of concern given the need to restrict co-amoxiclav use to infections where there is no alternative. Dental prescribing of clindamycin, which accounted for 43.9% of primary care prescribing in 2010, accounted for only 14.6% in 2017. Overall oral antibiotic prescribing by dentists fell 24.4% as compared to 14.8% in all of primary care. Conclusions These data suggest dentists have reduced antibiotic prescribing, possibly more than in other areas of primary-care. Nonetheless, opportunities remain for further reduction

Seasonal variation in Escherichia coli bloodstream infection: a population-based study

AbstractSeasonal variation in the rates of infection with certain Gram-negative organisms has been previously examined in tertiary-care centres. We performed a population-based investigation to evaluate the seasonal variation in Escherichia coli bloodstream infection (BSI). We identified 461 unique patients in Olmsted County, Minnesota, from 1 January 1998 to 31 December 2007, with E. coli BSI. Incidence rates (IR) and IR ratios were calculated using Rochester Epidemiology Project tools. Multivariable Poisson regression was used to examine the association between the IR of E. coli BSI and average temperature. The age- and gender-adjusted IR of E. coli BSI per 100 000 person-years was 50.2 (95% CI 42.9–57.5) during the warmest 4 months (June through September) compared with 37.1 (95% CI 32.7–41.5) during the remainder of the year, resulting in a 35% (95% CI 12–66%) increase in IR during the warmest 4 months. The average temperature was predictive of increasing IR of E. coli BSI (p 0.004); there was a 7% (95% CI 2–12%) increase in the IR for each 10-degree Fahrenheit (c. 5.5°C) increase in average temperature. To our knowledge, this is the first study to demonstrate seasonal variation in E. coli BSI, with a higher IR during the warmest 4 months than during the remainder of the year

Adverse drug reactions due to oral antibiotics prescribed in the community setting – England

Background: Prescribing of oral antibiotics in the community setting is commonplace with ongoing efforts to optimize this practice. There are several concerns related to such prescriptions including antibiotic cost, development of bacterial resistance, and associated adverse drug reactions. We therefore performed an analysis of adverse drug reactions associated with oral antibiotics prescribed in community care (non-hospital) in England to determine adverse drug reaction reporting rates and severity of adverse reactions. Methods: Data for all oral antibiotic use in the primary care settings in England and the National Yellow Card Interactive Drug Analysis Profile was extracted for 2010 through 2017. Results: There were 320,599,292 prescriptions issued for oral antibiotics during the eight-year survey. Although the overall adverse drug reaction rate was relatively low at 58/1,000,000 prescriptions, the reported rates of serious (63.6%) and fatal (1.21%) reactions were striking and probably due to reporting bias as minor adverse drug reactions are less likely to be reported. Conclusions: Continued monitoring of adverse drug reactions rates for oral antibiotics prescribed in the community is warranted, considering the prevalence of serious and fatal reactions identified during the eight-year study period in the Yellow Card profile. These data should be useful in developing strategies to secure optimal prescribing practices

Quantifying infective endocarditis risk in patients with predisposing cardiac conditions

Aims: There are scant comparative data quantifying the risk of infective endocarditis (IE) and associated mortality in individuals with predisposing cardiac conditions. Methods and results: English hospital admissions for conditions associated with increased IE risk were followed for 5 years to quantify subsequent IE admissions. The 5-year risk of IE or dying during an IE admission was calculated for each condition and compared with the entire English population as a control. Infective endocarditis incidence in the English population was 36.2/million/year. In comparison, patients with a previous history of IE had the highest risk of recurrence or dying during an IE admission [odds ratio (OR) 266 and 215, respectively]. These risks were also high in patients with prosthetic valves (OR 70 and 62) and previous valve repair (OR 77 and 60). Patients with congenital valve anomalies (currently considered 'moderate risk') had similar levels of risk (OR 66 and 57) and risks in other 'moderate-risk' conditions were not much lower. Congenital heart conditions (CHCs) repaired with prosthetic material (currently considered 'high risk' for 6 months following surgery) had lower risk than all 'moderate-risk' conditions-even in the first 6 months. Infective endocarditis risk was also significant in patients with cardiovascular implantable electronic devices. Conclusion: These data confirm the high IE risk of patients with a history of previous IE, valve replacement, or repair. However, IE risk in some 'moderate-risk' patients was similar to that of several 'high-risk' conditions and higher than repaired CHC. Guidelines for the risk stratification of conditions predisposing to IE may require re-evaluation

The cost-effectiveness of antibiotic prophylaxis for patients at risk of infective endocarditis

Background: In March 2008, the National Institute for Health and Care Excellence (NICE) recommended stopping antibiotic prophylaxis (AP) for those at risk of infective endocarditis (IE) undergoing dental procedures in the UK, citing a lack of evidence of efficacy and cost-effectiveness. We have performed a new economic-evaluation of AP based on contemporary estimates of efficacy, adverse events and resource implications. Methods: A decision analytic cost-effectiveness model was used. Health service costs and benefits (measured as Quality Adjusted Life Years, QALYs) were estimated. Rates of IE before and after the NICE guidance were available to estimate prophylactic efficacy. AP adverse event rates were derived from recent UK data and resource implications were based on English Hospital Episode Statistics. Results: AP was less costly and more effective than no AP for all patients at risk of IE. The results are sensitive to AP efficacy, but efficacy would have to be substantially lower for AP not to be costeffective. AP was even more cost-effective in patients at high-risk of IE. Only a marginal reduction in annual IE rates (1.44 cases in high-risk and 33 cases in all at-risk patients) would be required for AP to be considered cost-effective at £20,000 ($26,600) per QALY. Annual cost savings of £5.5-8.2m ($7.3-10.9m) and health gains >2,600 QALYs could be achieved from reinstating AP in England. Conclusions: AP is cost-effective for preventing IE, particularly in those at high-risk. These findings support the cost-effectiveness of guidelines recommending AP use in high-risk individuals

Capnocytophaga canimorsus endocarditis with root abscess in a patient with a bicuspid aortic valve

Infective endocarditis caused by a zoonotic micro organism is a rare clinical condition. Capnocytophaga canimorsus is a commensal bacterium living in the saliva of dogs and cats which produces rarely reported endocarditis whose incidence may be underestimated, considering its failure to grow on standard media. We reported the case of a 65-year-old man with bicuspid aortic valve endocarditis and multiple abscesses of the aortic wall caused by the canine bacteria C. canimorsus

Temporal trends of infective endocarditis in North America from 2000 to 2017 – a systematic review

Objectives To examine temporal changes of infective endocarditis (IE) incidence and epidemiology in North America. Patients and Methods A systematic review was conducted at Mayo Clinic, Rochester. Ovid EBM Reviews™, Ovid Embase™, Ovid Medline™, Scopus™, and Web of Science™ were searched for studies published between January 1, 2000 and May 31, 2020. Four referees independently reviewed all studies, and those that reported a population-based incidence of IE in patients aged 18 years and older in North America were included. Results Of 8,588 articles screened, 14 were included. Overall, IE incidence remained largely unchanged throughout the study period, except for two studies that demonstrated a rise in incidence after 2014. Five studies reported temporal trends of injection drug use (IDU) prevalence among IE patients with a notable increase in prevalence observed. Staphylococcus aureus was the most common pathogen in 7 of 9 studies that included microbiologic findings. In-patient mortality ranged from 3.7-14.4%, while the percentage of patients who underwent surgery ranged from 6.4-16.0%. Conclusion Overall incidence of IE has remained stable among the 14 population-based investigations in North America identified in our systematic review. Standardization of study design for future population-based investigations have been highlighted for use in subsequent systematic reviews of IE