The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#214 Antibiotic Stewardship: A Team-Based Prescription for Success
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This episode is a must listen for every member of the entire dental team! The Diva's special guest, Dr. Marie Fluent, explains the development of the concept of antibiotic stewardship in dentistry, how antibiotic resistance develops, the importance of the 2019 ADA guidelines for Dental Pain and Swelling, and the new CDC checklist for prescribing antibiotics in dentistry. Dr. Fluent presents strategies to ensure that the entire team can effectively and cohesively communicate with patients regarding the risks and benefits of antibiotics to treat dental infections.
Resources:
- Association for Dental Safety - Antibiotic Stewardship for Prescribers - Resources https://bit.ly/3I2W2Ww
- American Dental Association - Antibiotics for Dental Pain and Swelling Guideline (2019) https://bit.ly/4mZfliE
- CDC Checklist for Antibiotic Prescribing in Dentistry https://bit.ly/4no0UVb
- American Dental Association - Antibiotic Prophylaxis Prior to Dental Procedures https://bit.ly/41MasB3
Welcome. I'm Leslie Kennedy. I'm Mary Gavoni. I'm Linda Harvey. I'm Olivia Long, and together we are the Compliance Divas. Welcome to the Compliance Divas podcast. I'm Mary Gavoni and I'll be the moderator for this episode. We have a special guest with us today, Marie Fluent, who is a dentist and a lecturer and a consultant and an author on antibiotic stewardship and infection prevention and control. And we're so glad to have her with us today. One of the key reasons we want to talk about this topic is that the CDC issued a new checklist for antibiotic prescribing for dentistry. Marie, I'd love for you to tell us your story about your dental practice and how you evolved in your career because I think it's fascinating, and you make such a wonderful contribution to dentistry. So please tell us your story.
SPEAKER_00Thanks, Mary, and thanks, Leslie. Thanks for your hospitality and inviting me to this podcast. I'm delighted to be here. A little bit about me. I'm a general dentist. I graduated from the University of Michigan back in 1989. And that date's important because prescribing practices have changed a lot since that period of time. And I'll get into that a little bit later. But I practiced for 25 years until my left eye didn't decide it. It was done seeing, and that put an abrupt halt to my clinical career. And I transitioned over to the infection control world exclusively back up to 2014-ish, when ADS, the Association for Dental Safety, was then called OSAP. The executive director of OSAP, Therese Long, came to me and said, Marie, we really want to be on board with this antibiotic stewardship thing. But what are we really asking dentists to do? Can you quantify that and can you write it out? And I did. And she went, Oh, oh, oh my goodness, we need to write this up in a paper. So she coordinated efforts with Dr. Peter Jacobson, who is the author of the Little Dental Drug Booklet and CDC, and we co-authored an article on responsible prescribing in dentistry. And it was one of the first articles that came to being with regard to stewardship in dentistry. And in that article, we made several claims. And that is number one, we really need guidelines for prescribing for antibiotics in dentistry. We were all taught to prescribe empirically, and as we were taught in our dental school training. And what that means is we were all over them the map. So if you had an infection, say you had a urinary tract infection or an upper respiratory infection or an ear infection, there are specific guidelines that should be followed on how to treat those certain infections. But with regard to dental infections or donogenic infections, we really did not have guidance. Yes, we had guidance for antibiotic prophylaxis, but for the treatment of dental infections, not so much. Then the second thing that concerned me as we all co-authored that article, and by the way, the CDC representative was Dr. Lori Hicks, who was then responsible for the antibiotic stewardship program with regard to CDC. The second thing that concerned me that I learned is that our dental software management templates were not really based on any scientific criteria. They were just random templates that are put into our computer systems. And we had the opportunity to modify them per our desire, but they were really not based on scientific data. And that kind of alerted me and opened my eyes and made me think, boy, we have a lot of work to go here. So anyway, we co-authored that article in 2016, I believe is when it was published. And since then, I hit the ground running with the antibiotic stewardship and dentistry, and much has changed since that period of time.
SPEAKER_01It has. And I'm so glad that you gave us that history, Marie, because even some of that I didn't realize about how this came to be within dentistry. So thank you so much for your contribution to all that. And Leslie, I think you have one more question for Marie about antibiotic stewardship.
SPEAKER_02Yes, you know, Marie, what exactly is antibiotic stewardship and why is that so important for dental teams to know about it?
SPEAKER_00Well, first of all, let's back up to that word stewardship. And as I think of stewardship, I think of Teddy Roosevelt and our president at the turn of the last century. And he is the president who created all of our national parks. And last year I was at the Grand Canyon with my family, standing over, looking over the canyon in complete awe, how remarkable and wonderful it was. And it exists because of Teddy Roosevelt's foresight and stewardship. And his thoughts were we must preserve certain areas of our land in our great country so that future generations can enjoy them. And without his foresight, the Grand Canyons would be filled with condominiums, restaurants, billboard signs, and and and and, but it's not. The land is pristine, it's uh breathtaking, it's awe-inspiring, and it's preserved for future generations to enjoy. So let's transferate that principle to antibiotics. Of course, nobody enjoys taking an antibiotic. It's not something we would look forward to, but we certainly enjoy the outcomes and the fact that it will preserve our lives for hopefully a long, long duration of period of time. I'll go back to a little morbid thought. In our in the community in which I live, there's an old, old cemetery where there are gravestones from the late 1700s and on up. And it's common to walk through there and see gravestones of children age two, age four, age nine, age 12, and you think, holy cow, how could that be? Most of these occurred due to common infections because there was no means to treat infections. So a common cold or a scraped knee or a skinned toe, strep throat could turn into a serious infection and threaten life, if you will. Fortunately, we don't see that in this day of period of time, but what we don't want to happen is to enter a post-antibiotic era where antibiotics are no longer effective. I'm a mother, I'm a grandmother, and this is where the passion for antibiotic stewardship within me lies. I want to make sure antibiotics are safe for them and future generations to come.
SPEAKER_02Well, that's really something to think about. So, how would it be come to be that antibiotics would not be safe in future situations where infections occur? Tell us a little bit about that.
SPEAKER_00Well, every time you write a prescription for an antibiotic, you have to weigh the risks versus the benefits. The benefits, of course, are that antibiotics treat bacterial infections or can prevent certain bacterial infections in the case of antibiotic prophylaxis. But there are risks to antibiotics as well. And the number one risk is antibiotic resistance: that the more we take antibiotics, the more that these bugs or bacterial microorganisms can mutate so that they become resistant to antibiotics. And there's one particular demonstration that I'd like to share during my presentations, and it's a huge augar dish that grows like a petri dish, but in the shape of a football field, where they demonstrate how quickly these bacteria can mutate and become resistant. So pretend that you've got a bacteria, uh, an augar plate that is in the shape of a football field. In the end zones, you have no antibiotics. And in the next 10-yard zone, you've got a one-time concentration of antibiotics, the next 10-yard zone a hundred times, the next yard zone a thousand times, and in the center portion, a very, very concentrated portion of antibiotics. And if you would introduce bacteria into the end zones within 11-day period of time, those bacteria mutate, mutate, mutate, and develop colonies and develop resistance to the higher concentration of antibiotics until you're in the center zone where you have mutation left and right. And it only takes about 11 to 14 days for those colonies to mutate and become resistant to antibiotics. So, and it's also important to remember, Leslie, that you as a human being, Leslie Cannum and Mary Gavoni, you are not resistant to antibiotics. But the microorganisms or the bacteria that you're exposed to may be resistant and you may develop those infections, and that makes the antibiotics less resistant to treatment.
SPEAKER_02So not so much that I might be resistant to antibiotics. It's what I was exposed to. The person next to me that gave me whatever bacterial infection they had, they had maybe mistaken, they've misused the antibiotics, didn't finish their dose, and so they have a bacterium that is resistant. And I've caught whatever they have. And so now the normal antibiotic that I might have been prescribed would not be effective. Is that what you're saying?
SPEAKER_00Exactly. Yes, exactly. And these bacteria, once they develop resistance, they develop their genetic characteristic onto future generations, which is pretty scary. So the generations and the colonies they produce are also resistant to bacteria, resistant to antibiotics. So that's pretty scary. And it's scary how quickly it can happen.
SPEAKER_01And Marie, is that why we're seeing these super bugs that are helping?
SPEAKER_00Exactly. Wow. Yes. And it's crazy. There's so much more known to about antibiotic resistance in the medical community than the dental community. And as a matter of fact, hospital systems around the country develop something called an antibiogram, which is a big chart on which bacteria are circulating in the community and which what antibiotics they're susceptible to and which they are resistant to. So you can look at a strain that you culture an infection in your community, look at this antibiogram and determine which antibiotic would be or would not be beneficial to this patient. Now in dentistry, we're not taught to culture infections. So those antibiograms are not really beneficial to us, but it's just interesting to know what's happening in the medical community as well.
SPEAKER_01So if a dental patient had what a dentist believed to be a resistant infection, could they send them for culture and sensitivity testing to find out what would be helped them?
SPEAKER_00And you know what? When I give this lecture to general dentists around the country, say I had 100 dentists, I said, I would ask, how many of you have been taught to culture infections or routinely culture infections on a regular basis? And pretty much zero hands go up. We're not taught to do that as general dentists. But some of our specialty colleagues are taught to do that. For instance, oral surgeons or endodontists are typically more inclined to culture infections than general dentistry is. And of course, you could refer them to a hospital dental program, and they would have more likely access to culturing infections than the outside private practice world.
SPEAKER_01Oh wow, I just have a new respect for one of the endodontists that I worked for when I was in dental hygiene school, who I assisted a couple of days a week in a practice. And there were times where they would do that exact thing. They would send those patients out to find out what exactly was this infection and what it what was it comprised of because they were that concerned about resolving that. Okay. So I mentioned at the beginning of the podcast that the CDC published a checklist for antibiotic prescribing in dentistry. Tell us what we need to know from that, Marie. What's really important for dental practices to know from that checklist? And I'm assuming you would recommend everybody has that checklist, which we will put in the show notes.
SPEAKER_00Yes. And it's a one-pager, actually a one and a half pager. And it goes through what should be done when treating a patient. So first of all, it's important to evaluate the patient. Then the second, you're in the treatment mode, and then third and finally in education mode. So, first of all, it's important to evaluate your patient whenever you're, well, of course, before dental care, but before you're going to prescribe an antibiotic as well. You want to assess your patient's medical history. You want to ask them about their allergies, particularly penicillin allergy, and if they are their immune status, pregnancy status, current medications, and history of C. diff infection or clostridoid difficile infection. Now, C. diff infection is important for us to know about because it comes with a high association with antibiotic, taking an antibiotic. And C. diff is an awful diarrheal infection that can be severe and even life-threatening. And there are unfortunately a number of fatalities associated with C. diff infections. So if a patient has had a C. diff infection, we want to know about it. And that may alter and probably will alter our antibiotic prescribing patterns. Now, with regard to penicillin allergies, we want to know more about penicillin allergies. Historically, if a patient came into our office and they said, Yeah, I have a penicillin allergy, the first thing that we would do is say, hey, let's not prescribe penicillin, let's divert and prescribe something else. But it's important to delve into that because some penicillin allergies are true allergies. It's estimated that 10% of the population reports being allergic to penicillin, but 90% of those are not true allergies. Patients may have had a GI upset or a stomach upset associated with taking an antibiotic or penicillin and say, yeah, I'm allergic and it's plastered all over their medical and dental records, and their provider automatically uh diverts care and prescribes something else. But now we're saying, let's delve into it a little bit further and let's know what happened, when it happened, how it happened, what was the outcome of that infection. So if a patient said to you, yeah, I had an anaphylactic reaction, I ended up being hospitalized, it darn near cut off my airway, it was life-threatening, yeah, you want to take that seriously. But if they say to you, yeah, it was a little bit of a GI upset, or I developed a rash several hours later, but it went away and it was really wasn't a big deal, and I didn't have to take a C healthcare provider and I just took a Benadryl and it happened when I was a child, and now I'm in my 50s, you may be safe prescribing that in that scenario. So you always want to look at a penicillin allergy and determine do I want to delve into that and have a definitive diagnosis with a penicillin allergy? Do I want to absolutely avoid prescribing penicillins in those scenarios? And you always want to delve in a little bit further. Also, it's important to know that if you have had a penicillin allergy over 10 years ago, there's a good chance, an 80% chance, that it is within 10 years your IgE-mediated response goes away and you're no longer allergic. So you want to delve into it before prescribing something else. And the reason is that penicillin, amoxicillin are the best antibiotics for the treatment of dental infections. And you always want to stick with the first line of antibiotics if possible and not prescribe a broad spractum antibiotic that is going to wipe out your entire microbiome. So, evaluation. You want to know C. diff history, you want to know about penicillin allergies, you want to know what happened, when it happened, how it happened, what was the outcome for both of those infections, and inquire about whether or not the patient has been on an antibiotic recently or not. So that takes us through evaluation. The next thing we want to do is follow the guidelines for the treatment and prevention of oral infections and antibiotic prophylaxis. Now, the guidelines for antibiotic prophylaxis are well spelled out. They're developed by the American Dental Association, American Heart Association for the Prevention of Bacterial Endocarditis. And then we have the American Academy of Orthopedic Surgeons who has worked with the ADA for patients with prosthetic joints. And both of those are indications for antibiotic prophylaxis. And keep in mind it's a very, very small subset of patients now who require antibiotic prophylaxis. And in the case of those of patients with prosthetic joints, very few, if any, require antibiotic prophylaxis. Now, switching gears for the treatment of dental infections, the American Dental Association came out with guidelines for dental pain and intraoral swelling that was published in December 2019. And I'm I guess the best way of saying this is that COVID happened shortly thereafter. And I think we in dentistry had bigger fish to fry, and the guidelines were not really well recognized or received or well known amongst our colleagues. So I'm hoping that we've picked up where we've left off with regard to those guidelines. But those guidelines have really changed my eye with regard to prescribing practices. And there are different paradigm shifts that we need to know about. Would you like to hear about them?
SPEAKER_01We would absolutely like to hear about those paradigm shifts. And just as an aside, we will have those guidelines from the ADA in the show notes for everyone who didn't pay attention to them during COVID that they can download a copy.
SPEAKER_00Okay. Now, early on in the podcast, I said I graduated from dental school in 1989 and lots has changed since then. So I will share with you how Marie Fluent was taught to prescribe antibiotics versus the new paradigm. So, first of all, I was taught prescribe just in case. If you had a patient who came into the chair and you were on the fence whether or not they needed an antibiotic, by goodness, you better prescribe it. And now we're saying, no, do not prescribe just in case. Prescribe only when absolutely necessary. The second paradigm shift was we were taught to teach our patients once you get your prescription, your next stop should be the pharmacy. And we want you to start taking this antibiotic right away. Now we're saying in certain scenarios, you can delay starting taking your prescription until certain symptoms occur. And that's called delayed prescribing, and that is based on a case-by-case scenario, and the dentist would decide if delayed prescribing is indicated in your scenario. Now the third paradigm shift is we were taught back in 1989, take this antibiotic, this antibiotic will cure you. Now we're saying no, the antibiotics will not cure you. You absolutely need definitive care. You need to have a root canal, or you need an extraction, or you need a pulpotomy, pulpectomy, or incision and draining, some type of definitive care. And by the way, when you read those new guidelines, there's a new term called DCDT, definitive conservative dental treatment. And they're saying DCDT will cure your tooth and antibiotic will. Will not cure your tooth. The next paradigm shift, we already talked about that, and that is a penicillin allergy. Historically, we were taught switch gears, prescribe something else. Now we're taught time out, really evaluate this penicillin allergy. Penicillin still may be the best antibiotic for you. The next paradigm shift to me is the greatest paradigm shift, and that is the duration of therapy. How many days are you supposed to take your antibiotic for? Historically, we were taught tell your patient, take it for a long, long duration. We want to kill all of those microorganisms in your gut, clear them out so nothing will survive. And now we're saying, no, no, no, no. We need to preserve the microbiome, all of the microorganisms in your entire GI system. Many of them are good, some of them are bad. And we want to preserve that microbiome so we want to take the shortest duration of therapy. So the paradigm shift is that prescribe for a short duration and encourage your patient to discontinue their antibiotic 24 to 48 hours after the resolution of their symptoms. And with that, your patient will have leftover antibiotics. We'll talk about that in just a second, but the shortest duration as possible, and that means you're going to be communicating with your patient on a day-to-day basis, seeing how they are, and making that determination on when they should quit. And it's not a one-size-fits-all. Every patient will be taking for X amount of time. It will be evaluated on a case-by-case duration. And by the way, it's typically in the three to seven-day duration, not the standard 10-day duration of therapy that's on our software templates. And the final paradigm shift is how to manage pain. Historically, when I graduated from dental school, every patient got a prescription of Tylenol 3 with codeine, one to two tablets every four to six hours, PRN pain. I gave them 12 tablets, and I must have done that, I'm embarrassed to say, thousands of times. And we now know that we have a serious opioid crisis going on, and we need to not do that. And the American Dental Association has come out with recommendations that we manage discomfort with over-the-counter medications such as ibuprofen and or acetaminophen. And rarely, if ever, should we be prescribing narcotics to manage dental pain. So that's our uh our final paradigm shift. So all of those paradigm shifts, prescribing only when necessary, taking antibiotics when your symptoms worsen in certain scenarios, you require definitive care, assess penicillin allergies, prescribe for the shortest duration as possible, and control pain with over-the-counter medication. All of those are our new paradigms, and they are reflected in the guidelines that were published in 2019.
SPEAKER_01That is such a great summary, Marie, and the paradigm shift that you touched on a little bit earlier on prophylactic pre-medication has, of course, changed. And Leslie, you probably remember as well as I do in our early days as dental assistants that you prescribed antibiotics for two days before and the day of and two days after the appointment. And I recently had knee replacement surgeries, and my orthopedic surgeon does recommend prophylaxis, but it's just one dose of amoxithylin 30 minutes before the appointment, and that's it. So that has changed so tremendously over the years.
SPEAKER_00Exactly. And by the way, the American Academy of Orthopedic Surgeons does have an appropriate use criteria on their website where you can plug in specifics about you, your medical history, your prosthetic joint to determine if it goes for or in concordance with their guidelines or not. So I would encourage you to do that too and have that conversation with your orthopedic surgeon on why he or she recommends antibiotics for you. Great. Leslie, I think you had a question or a comment.
SPEAKER_02Well, I do have a question for Marie. And it's sort of a recent experience where my husband had to take an antibiotic due to an aggressive staph infection that he had. And it was a period of time where he had to take it every six hours. And so that meant waking up at like two in the morning to take an antibiotic. How important is it to impress on patients to stick with the time frame? So you're not going, you know, eight hours without taking it when it's prescribed four times a day.
SPEAKER_00And that would be a conversation for your medical health provider, not for me, because all infections are a little bit differently. But I can say with regard to uh antibiotics and dentistry, amoxicillin or pen VK are both alternative options and excellent options for the treatment of dental infections. Pen VK is uh QID meaning four times a day, whereas amoxicillin is TID or three times a day. And we have better compliance with the three times a day medications than the four times a day medications. Patients are less likely to forget and more likely to be compliant with those. So it would be up to your healthcare provider to determine which antibiotic and look at the compliance rate, et cetera, for that medication. And then, of course, the your medical health care provider will look at the half-life of that medication and make sure you have constant blood levels of it as well. And the severity of the infection will also come into play as well. So I don't know where the infection was, how severe it was. So I'm I can't really comment on your husband's scenario, but I know that all of those factors went through the mind of the healthcare provider before writing that prescription.
SPEAKER_02So each person should be proactive and ask their healthcare provider exactly what they need to be doing for how long. Talk about those when symptoms go away, and can I stop taking my antibiotic for 24 to 48 hours after instead of taking the the full whatever they prescribe, two-week regime or whatever. That may be overkill then in some cases.
SPEAKER_00Exactly. But in certain scenarios, you must take the entire dose. For instance, pediatric ear infections, you shouldn't quit it, taking that antibiotic early. So it depends on where the infection is. So always listen to your healthcare provider when they make certain recommendations.
SPEAKER_02And just a broad view of what would happen. What could happen? What is the scenario if one were to say, well, I feel better. I'm not going to take my antibiotic anymore.
SPEAKER_00Well, of course, you could get into trouble, and we don't want that to happen either. So your healthcare provider or dentist is always going to weigh those risks versus the benefits and help you decide. And that's where also, Leslie, you bring up an excellent point because the the new guidelines that were published are evidence-based. And what does that mean? Evidence-based dentistry and evidence-based medicine is like a Venn diagram where you have three circles that intersect and come together. And in those three sections, we have patient expectations. You have patients who go to the dentist saying, I really want an antibiotic, please give it to me, or other patients who say, I absolutely do not want an antibiotic, please don't prescribe it. And you always are going to be listening to that patient and taking into consideration their expectations and what they believe is best for them. The second component of that Venn diagram is what does the literature say? And there's when they provided uh or did the studies for this, the ADA guidelines, they did a meta-analysis of the literature to determine what was effective and what was not. So, what does the literature show? And then the third section of that Venn diagram is the dentist's expertise. And this is where an interesting conversation. And if you allow me to go off on a tangent for a second, I will. I speak with a woman who is a phenomenal pharm D who has never really prescribed antibiotics, but knows everything there is about antibiotics. And we kind of butted heads a little bit, and she said, Marie, the guidelines are the guidelines. Everybody should be prescribing by the guidelines, and all you need to do is follow the algorithm and you'll be fine. And I said, Well, that's great and all, but then AI could prescribe antibiotics. And me as a dentist, I'm not needed. Well, there's something to be said for that human touch of dentistry. Dentistry is an art as well as a science, and that human touch, that human interaction. Say I saw Mrs. Smith as a patient for 15 years and she has had infections in the past. I know how in the past how she has trended. I know how she has responded. I know her compliance rate. And I develop this gut feeling, that clinical intuition on what is going well and it is not going well. And please, I encourage all dentists to use that. Those 25 years of experience in the dental chair account for something. Yes, I want to take into consideration those two other circles in our Venn diagram. What does the literature say? What are the guidelines and recommendations and what are the patient's preferences? But also I have a gestalt and an intuition that needs to factor into that equation as well. And if I choose to deviate from the guidelines, that's my clinical prerogative to do that. But I must have a rationale for deviation. I should document the reason for deviation in the patient's record and have a reason, a clinical reason for that. So I'm glad you brought that up, Leslie, because I think that evidence-based dentistry and evidence-based medicine does come into play with regard to antibiotic prescribing.
SPEAKER_01Oh, Marie, this is just such a wealth of information, but we have two more topics to cover on the CDC checklist. Give us a brief synopsis of the treatment and then the education that needs to take place.
SPEAKER_00Okay, let's start with education first because that's an area that I'm passionate about. It's important that we as clinicians are educated on when to prescribe and being up to date on the new guidelines and recommendations, but it's also important to have our team members up to date and on the same page as us. Many times as a dentist, when I leave the dental operatory, it would be common for the patient to say to my dental assistant or dental team members, that's great and all what Dr. Fluent said, but what would you do if you were me? And if that dental assistant or hygienist or front desk personnel is not on the same page, we may have miscommunication and uh not consistent language. It's very, very important that we have consistent language amongst team members. In addition to that, team members can help with stewardship principles. And I'll go off on a quick little deviation. My mother-in-law would go to her health care provider demanding an antibiotic and coming home frustrated and angry that she was not prescribed one. But to explain to her why an antibiotic wouldn't be necessary in this scenario, that I would be suspecting a viral illness instead of a bacterial illness, the risks outweigh the benefits, there are many side effects and bad things that can happen. There would be no reason why a team member could not sit down with that patient and have that discussion and help the patient understand. And there's many educational materials to help them uh communicate better with the patient. And that leads us right into patient education as well. Patients sometimes need to be educated on why an antibiotic would or would not be indicated and how to properly take an antibiotic, what to do with leftover antibiotics, and the list goes on. So education is an important part for the prescribers, team members, and the patients. And it's an integral part of the stewardship program. Now, going back to the treatment, number one, we always already mentioned prescribed per the guidelines, and I mentioned the guidelines for the treatment of dental infections and antibiotic prophylaxis. And it's important to make a definitive diagnosis and document that diagnosis in the patient's record. Sometimes we were, well, historically, yours truly here, prescribed empirically what I thought might be the infection, or if I were on the fence and didn't have a definitive diagnosis, I would prescribe anyway. So the moral of the story there is have a definitive diagnosis, make the diagnosis, document the diagnosis in the patient's record. Number three would be to use the most narrow spectrum antibiotic as possible. And in the case of dental infections, that would be Pen VK or MOXicillin. Those are your best alternatives. And if the patient does have a penicillin allergy and it is documented, a zithromyosin or a ZPAC would be your best antibiotic in that scenario. And by the way, when you have the guidelines, it will give the exact regimens for antibiotics, including those for penicillin allergies. Next is use the shortest duration possible that we can. And typically that's three to seven days, and discontinue therapy 24 to 48 hours after symptoms subside. And then you want to document all of this in the patient's record. Diagnosis, the treatment plan, rationale for the antibiotic use, and pain management as well. And I think I pretty much covered it. Oh, there's one more thing that I do want to touch upon: leftover antibiotics. If you prescribe for a week period of time and you encourage the patient to discontinue antibiotics in a four or five-day period of time, the patient's going to have leftover antibiotics. What do you do with them? What you don't do with them is save them in your medicine cabinet for a future infection or share them with a family member who is coming down with a certain infection and treat empirically within your same household. That's a no. And don't dump them down the toilet, flush them down the toilet, antibiotics get into our waterways and our municipal water systems, and you don't want to dump them down the drain for the same reason. What you do want to do is ideally identify a drug takeback program at your pharmacy, your healthcare provider, somewhere in your community. And if you can't find that, what you do want to do is throw them in the household trash, mix them in a Ziploc bag with something yucky, dirt, coffee grounds, kitty litter, something disgusting where people aren't going to want to sift through, pick them out, and take those tablets individually. If you're throwing away a bottle of a prescription, you want to cross out and mark off any identifiable information. You don't want Marie Fluent at this address with this phone number taking this medication to be found by somebody else. So really scratch off identifiable information as well. And this information is backed up by the Food and Drug Administration as well. Ideally, you want a drug take back program. And if you can't find that, dispose of it, your excess medications in the manner that I just described.
SPEAKER_01Oh, thank you for sharing that, Marie. I know that in my area, our police department has a drug takeback box in the lobby, and it looks like it looks like a mailbox almost. And that's where I take leftover drugs to dispose of. And I think that there's probably other in a major city, it'd probably be a little bit different, but in a small town, then that's probably a great option. And Leslie, you had another comment or question.
SPEAKER_02Well, I want to add that for dental offices, that wouldn't be the option. That would be for individuals who are disposing of their own household pharmaceuticals. But in dental offices, we need to be mindful of the state and local regulations regarding pharmaceutical waste containers. So in California, we couldn't do that in a dental office, but we could either have one of the companies that we send our waste to. There are many that pick up pharmaceutical waste. And then of course the pharmacies are always a good option for sending back the pharmaceuticals. We have kind of a funny little um way of reminding our dental offices when we consult here in California is that a pharmaceutical waste container can be any kind of a container. Like you said, it could be a coffee can if you had an alternate can or something that you have that closes as leafproof, it's closable. And the regulations here say pharmaceutical waste, incinerate only on the top and on the sides of the container. And you can have that in your practice for a long time, including adding in expired uh anesthetic or expired antibiotics or expired other medication that you might direct dispense to patients. And then, of course, it has to be disposed of properly and through the proper channels and not thrown out in the trash here.
SPEAKER_00I'm glad you added that. Thank you. And laws will vary from state to state. It's important to know that as well.
SPEAKER_01Absolutely. It is very important for every dental practice to know what the pharmaceutical waste laws are in their state. I love the whole point about educating patients on what to do or what not to do with their medications because that certainly, and I can see that scenario. Well, Marie, thank you so much for spending time with us today. And I think you have a closing comment for us.
SPEAKER_00I do. I have one more very important morsel to add before we wrap up for today, and that is diarrhea. Sorry to end on such a note, but let's talk about diarrhea. If a patient has been prescribed an antibiotic and they call your office and say, Boy, I've got diarrhea, what do I do? And diarrhea means more than three or more loose bowel movements per day. If a patient is taking an antibiotic that you have prescribed and reports diarrheal symptoms, what you don't want to do is recommend taking over-the-counter antidiarrheal medications, such as imodium. Never, never recommend antidiarrheal medications to a patient with antibiotic-associated diarrhea. And that relates to we're thinking they might be developing C. diff and developing a buildup of toxins within their GI system. We want them to essentially eliminate or poop them out. We don't want them to retain that and cause more damage. Number two, we encourage them to stop taking their antibiotic right away. And number three, contact their medical health care provider or urgent care if it's after hours. We're thinking C diff and C diff can be serious, it can be life-threatening, and we want to identify it right away. And we should train our front desk personnel to be on the lookout for this as well. So to repeat, number one, if a patient calls with antibiotic-associated diarrhea, number one, do not take or recommend over-the-counter antidiarrheal medications. Number two, stop taking your antibiotic immediately. Number three, seek counsel from your medical health care provider. And it would be important to have your whole team know this, understand this, and communicate it if your patient should be in that situation. So that was one more morsel of information that I think is very important to add with regard to antibiotic usage in the dental office and educating patients and team members.
SPEAKER_01Wow, there are so many layers to this whole concept. And again, Marie, thank you so much for sharing your amazing knowledge and expertise in this area. I think that our listeners are really going to learn a lot of very useful things for enhancing better practices for prescribing antibiotics and managing those infections and practice. And we thank you so, so much. The Compliance Divas brings clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. You can submit questions to us at support at the compliancedevas.com. You can access the resources that we talked about today in the show notes on your podcast app. And we ask you on your podcast app when you're finished listening to scroll down and give us a rating or leave us some comments. And we hope that you tune in for our next episode.