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Patience & watchful waiting – Key to antibiotic stewardship

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A recent guideline for treatment of sinusitis suggests that most viral sinusitis is persistently symptomatic for nearly 2 weeks.(1) The symptoms peak at 2 – 3 days time and resolve without any antibiotic treatment by 14 days or so. This suggests a longer watcful waiting period before using antibiotics for treatment of sinusitis. Most sinusitis are of viral origin and antibiotics do not have a role in the treatment of such viral sinusitis. Symptomatic relief could be obtained by using intranasal steroids, saline nasal drops, inhalation of steam and with use of analgesics. “Watchful waiting” is beneficial to a great extent and the infection subsides in about the same time it takes even with the use of antibiotics indicating the futility of routine antibiotic usage in sinus infections.This is an important consideration because irrational use of antibiotics spreads antibiotic resistance. And antibiotic resistance has been declared as pandemic issue by World Health Organisation (WHO). Interestingly when I was interviewed recently, the questions were about the ideal antibiotics to be used for orofacial infections since one of my publication listed on my resume was on rational use of antibiotics among dentists. (2)

In spite of the widespread of antibiotic resistance, most orofacial infections are still very responsive to amoxicillin and related antibiotics. In case of infections that have been there for more than 2-3 days anaerobic infections dominate and addition of metronidazole has been found to be useful.

Established orofacial infections have been found to consist of more than 88% of anaerobes. Considering most orofacial infections do not show resistance to amoxicillin or it’s derivatives, they should remain the first choice unless the patient is known to be allergic to the drug. The irrational use of higher antibiotics should be discouraged in dentistry. Most dental infections do not even require antibiotics. So, prescribing antibiotics irrationaly is not only an unnecessary burden of cost on the patietn, it is also contributory to the widespread antibiotic resistance.

Most dental infections respond well to anti inflammatory agents and in the absence of other immunocompromising factors (diabetes, HIV infections, certain hematopoietic malignancies), the use of antibiotics must be used with great restraint. Antibiotic stewardship among dentists is need of the hour considering dentists fill in more than 10% of the total prescription of the antibiotics – all specialties combined!

Source:

1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Kumar KA, Kramper M, et al. Clinical Practice Guidelin (Update) Adult Sinusitis. Otolaryngology — Head and Neck Surgery. 2015 Apr 1;152(2 suppl):S1–39.

2. .Ramasamy A. A review of use of antibiotics in dentistry and recommendations for rational antibiotic usage by dentists. The International Arabic Journal of Antimicrobial Agents [Internet]. 2014 Sep 20 [cited 2015 Mar 22];4(2). Available from: http://imed.pub/ojs/index.php/IAJAA/article/view/902

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