Antibiotic use by dentists in Germany: a review of prescriptions, pathogens, antimicrobial resistance and antibiotic stewardship strategies

Background: In Germany, 85% of all antibiotics are prescribed in the outpatient care sector, and dentists account for 11% of the total outpatient antibiotic prescriptions. Objective and Method: Summarise published literature on antibiotic use, pathogens and antibiotic resistance in odontogenic infections and German clinical guidelines and interventions for antibiotic use in dental care. Results: In contrast to other outpatient physicians, the volume of antibiotics prescribed by dentists in Germany did not decrease over the last decade. Penicillins and aminopenicillins are the most frequently prescribed antibiotics (70% of all prescriptions), followed by clindamycin (26%). Streptococcus spp. and Staphylococcus spp. are frequent pathogens isolated from odontogenic infections. However, the infections are often polybacterial with a mixed growth of anaerobic and aerobic bacteria. While the widespread use of penicillin class antibiotics is compatible with German recommendations on empiric antibiotic therapy, there is evidence that pathogens from odontogenic infections frequently exhibit resistance against them. Moreover, the high prescription volume of clindamycin (>25%) appears to be inadequate, since relatively high resistance rates are observed and clindamycin is not recommended as first-line choice in empiric antibiotic therapy. National and international studies show that continuous education of patients and dentists, individual prescription feedback as well as evidence-based guidelines are important measures to improve antibiotic prescription patterns among dentists. Conclusion: To promote rational antibiotic use in outpatient dental care, antibiotic stewardship measures are necessary that include prescription guidelines based on AMR surveillance data as well as continuous education of dentists.