C. Diff and how dentists overuse antibiotics

Why do dentists prescribe antibiotic prophylaxis so often?

Because they can.

Why am I dissing my dental colleagues? Because I can.

Perhaps, this is a simple case of dental envy, since their profession remains within secure borders far beyond the health care reform line of fire. Consider these dental incidentals:

• Not a syllable in the ~2000 page health care reform law that affects dentists. Every filling is still worth its weight in gold
• Dentists recover every dime they bill. If their fee is a gazillion dollars, and your generous dental insurance, covers fifty bucks, guess what? There will be a very large cavity in your bank account
• No middle of the night runs to the emergency room, a drill that we physicians endure
• No hospital work, which for many physicians has become an inefficient hassle which became the root of a new medical specialty
• Dentists don’t need an attorney on retainer, or caps on non-economic damages, as their malpractice situation is calm
• We still call them “doctor”

Dentists prescribe prophylactic antibiotics (ATBs) with routine recklessness. Of course, we physicians are also culpable of antimicrobial mania. We all prescribe too many antibiotics for too many days for too many viral illnesses. It has been a tough slog to teach our profession to prescribe antimicrobial agents more judiciously. In fact, it’s been like pulling teeth.

Entrenched physician habits and patient expectations are hard to change. Look how long it took for Americans to accept and practice seat belt safety. When I was a kid, I remember my parents buckling the belts behind them so they wouldn’t hear the annoying warning buzzer. It took a generation of intense education to change cigarette smoking behavior.

Many dentists irrationally prescribe ATBs before teeth cleanings and other procedures. But the vast majority of prophylactic ATBs that dentists prescribe are unnecessary. The theory is to protect the patient’s heart from becoming infected by bacteria that are released into the blood stream during a dental procedure. The missing piece is the absence of a shred of science supporting this practice. Keep in mind that live humans release bacteria into the blood stream during routine tooth brushing and defecation, but I doubt that heart murmur patients are advised to pop penicillin each time they are about to engage in either of these two high risk behaviors.

When physicians and dentists prescribe unnecessary ATBS, there are many adverse consequences. Here is a sampling.

* Money is wasted.
* Resistant bacteria emerge that can be more difficult to treat.
* It teaches patients to expect and demand ATBs when they are not indicated.
* Potential of serious side-effects and drug interactions.

For example, there is a condition called pseudomembraneous colitis caused by the germ Clostridium difficile, affectionately known as C. diff. The primary cause of this diarrheal disease is ATBs. There isn’t a hospital in the country that is not struggling with this stubborn and serious disease. Some of these patients have died or had their entire colons removed. Once the germ is present in your large intestine, or colon, it can be impossible to eradicate. I see a case of C. diff at least every week. For some of these unlucky folks, C. diff becomes a chronic disease.

I have seen many C. diff cases that developed from brief courses of antibiotics prescribed by dentists and physicians. Some of these patients now have an incurable gastrointestinal affliction caused by just a few ATB pills. I help these folks as best I can. I don’t think it helps them for me to share that they never needed the ATBs in the first place. This inconvenient truth would be too hard for them to swallow. I wish that their ATBs had been too hard to swallow.

The next time that your dentist, or your physician, recommends an ATB –- or you demand one -– think again. Is it worth the risk of beating your colon into a pulp?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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    QUOTE:
    “Once the germ is present in your large intestine, or colon, it can be impossible to eradicate.”

    Is that because C diff mutates in response to the antibiotic, or is it because the antibiotic kills off the “good” intestinal bacteria that would normally keep the C diff under control? Would it help to consume a lot of prebiotics and probiotics, including yogurt with live active cultures?

    Jim Purdy

  • Former HBO Tech/Pre-PA

    Please educate me if I’m wrong, but since C.diff is anaerobic, wouldn’t hyperbaric oxygen therapy be a viable mean of GI colonization eradication, especially prior to the consideration of colonic excision? I understand this may not be a viable treatment due the lack of chambers in most hospitals, and the therapy cost may be higher than Antibiotics. Furthermore, since its far down on the protocol list of standards of care, I’m sure by the time it becomes an option, the patient may have declined to the point of developing a contra-indicated condition.
    What about re-populating the GI tract with pro-biotics after a course of anti-biotics? This would colonize the GI tract with residential bacteria, limiting the real estate available to C. diff to monopolize.

    A very pertinent article on over-utilization of Abx and pill-centric entitlement. Perhaps if Docs had more time to sit down with patients, we could educate them that the best medicine at times is not a pill but time itself.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    The germ is protected by a spore, which serves as armor to the bacterium. It is very tough to wipe out. While there is some evidence that probiotics have a therapeutic and preventive role, there is no firm science to support this. There have been some amazing ‘cures’ of intractable C diff from fecal transplants when afflicted patients receive donor stool. I’ve never seen this done, but perhaps other readers here have. These patients would need some counseling for this novel therapy that is probably not on the hospital formulary, but is abundant and inexpensive.

  • reddirt

    The (mis)use(esp prophylactic) of Ab’s in medicine pales in comparison to it’s use in the food animal industry…

  • ninguem

    I know I’ve seen C. diff from dental antibiotics.

    My N=1 series.

  • Dental infection person

    I’m taking Abx ’til my mid-life tragic molar is r/c’d or yanked. In my case (agony, rapid spread of infection) there isn’t a necessity issue. Still, C. Dif stories prompted me to stock up on yogurt, kefir, probiotic tabs of two different varieties. and inulin tabs. So far, so good.

  • ninguem

    My patient ended up in the hospital with what looked like an acute abdomen. Surgeon called, picture didn’t quite look right for appendicitis. They watched, sent home for outpatient follow-up. In my office the next day. C. diff studies were done and reports pending at that moment. They arrived, positive, as I was examining the patient.

    “Hmmmmmm, you often see this after antibiotic treatment. I haven’t given you any antibiotics. Did you have any antibiotics recently from any doctor?”

    “No.”

    “How about, maybe some recent dental work?”

    “Oh, yeah, my dentist just gave me some antibiotics in preparation for some dental surgery.”

    For what it’s worth, one of those N=1 series.

  • Darren

    As a dentist, I’ll readily agree that antibiotics are often prescribed in situations in which they are not indicated. As a dentist who’s done a hospital residency, I can tell you that the ED’s standard was to push antibiotics on dental cases, usually through ignorance of the pathology and indications for proper antibiotic prescription. They wanted to do this even if the dentist on call had seen the patient and recommended against it.

    However, you mentioned antibiotic prophylaxis without comparing the relative risks: does the prevention of infection of an oral surgical wound (for example) warrant the risk of a serious condition like C. diff enterocolitis? And while the AHA bacterial endocarditis prophylaxis guidelines cover fewer conditions and dental procedures with each revision, do you feel they are too aggressive as well?

    When you say this: “The next time that your dentist, or your physician, recommends an ATB –- or you demand one -– think again. Is it worth the risk of beating your colon into a pulp?” I’d get the impression you’re against antibiotic use at all, if I were a layman. Rather than “think again,” perhaps you could encourage our patients to explore the relative risks with their provider. I don’t think it’s wise to encourage them to disregard professional advice, but making an informed decision is to everyone’s benefit.

  • Anonymous

    Seems that the ADA and AHA mostly agree with you that antibiotics for dental work be reserved for special situations, not used generally: http://jada.ada.org/cgi/content/full/131/3/366 . But do individual dentists and oral surgeons follow such recommendations?

  • SASSY

    After almost losing my colon to c-diff and left 2 years later with an utterly broken colon, I try and try to send this message but most friends and family have been so conditioned to do as the dentist/dr says that it is often a lost cause. C-diff and its associated complications has taken so much from me. My QOL has never been the same. I advocate for the judicious use of abx. People, please listen to me!
    Thx for great piece, Dr. Kirsch/KevinMD

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Darren, good comments. Of course, I favor antibiotics – when they are indicated. I agree with you that the decision to receive them, particularly in prophylactic situations, should follow a discussion between the patient and the physican or dentist, as you suggest. I doubt these discussions occur. I suspect that the patient is issued a prescription and directed to take it.

  • http://www.cyberdentist.blogspot.com Dean

    Dentists prescribe Ab’s based on AHA guidelines. These have thankfully been revised (the need for Ab’s reduced) over the years as the apparent risk is now seen to be relatively low in most cases. I have often run into physicians who still recommend Abs for minor dental work for heart conditions long since off the AHA “list”. Should a dentist go against the physicians recommendation?

    Reading the first half of this article, I sense a kind of disdain, jealousy, (or envy as you state) of dentistry that is quite humerous. BTW, You’d be surprised how insurance companies have infiltrated dentistry the way they have medicine, with PPO’s etc. -and many of us work in hospital settings evey week. Still, if you think dentists have it so good (and we do! IMHOP), I’d recommend going back to dental school. There are many fine dual educated physician/dentists out there.

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