The Scottish Antimicrobial Prescribing Group (SAPG) and its dental sub-group have revised their antimicrobial prescribing guidance for the management of acute dento-alveolar infections.
Following an extensive period of research and consultation, the SAGP and its dental sub-group now advise that when antibiotics are unavoidable, phenoxymethylpenicillin (penicillin V) should be recommended as first line in acute dento-alveolar infections, with amoxicillin reserved for patients where compliance will be more challenging.
There is no evidence to suggest that addition of a second antibiotic, such as metronidazole, improves clinical outcome, the SAGP added.
Dental abscesses should be treated in the first instance by using local measures, such as extraction or drainage, with removal of the cause where possible, the SAPG noted.
Antibiotics are only required if immediate drainage is not achieved or in cases of spreading infection (significant extra-oral swelling, cellulitis) or systemic involvement (fever, sepsis).
Currently, amoxicillin accounts for 68 per cent of antibiotics prescribed in dental practice in Scotland (2018), but penicillin V has a narrower spectrum of antimicrobial activity than amoxicillin and equivalent efficacy and clinical outcomes in acute dento-alveolar infections.
“Limiting unintended consequences of antimicrobial use is a key principle of antimicrobial stewardship and since amoxicillin has a broader spectrum of activity than penicillin V, it has a greater impact on selection of resistance in the host micro-flora,” said the SAGP.
For severe odontogenic infections requiring hospital admission for incision and drainage with intravenous antibiotics, the first choice antimicrobials remain benzyl penicillin and metronidazole. The use of phenoxymethylpenicillin as a discharge antibiotic should be considered first choice.
Specimens from severe odontogenic infections should be submitted to local hospital microbiology laboratories and empiric antimicrobials modified accordingly, said the SAPG.
The new guidance coincides with World Antibiotic Awareness Week this week, and aligns with other SAPG work to use narrow-spectrum agents wherever possible as a key action to tackle antimicrobial resistance.