'You had to do something': prescribing antibiotics in Scotland during COVID-19

Why it matters

Antimicrobial resistance is a significant global threat with wide-ranging impacts on health, finances, food sustainability, security, environmental wellbeing, and socioeconomic development. The use of antibiotics in medicine contributes to the development of resistance, and optimisation of antibiotic use is a primary focus of the UK’s 2019-2024 national action plan to tackle antimicrobial resistance.

Efforts to control antimicrobial resistance by reducing exposure to antibiotics had seen some success in recent years. Within dentistry, the rate of antibiotic use reduced by 17.7% from 2015-2019, accounting for around 7% of total antibiotic use in primary care in Scotland during 2018-2019. Dental pain and infection can be effectively managed through physical interventions, but face-to-face dental care was constrained during COVID-19. Evidence has shown that this impacted antibiotic prescribing. In the early months of the pandemic in England (April-July 2020), dental antibiotic prescribing was 25% higher compared with the same months in 2019.

This study focused on Scotland the impact of COVID-19 and remobilisation on dental antibiotic prescriptions, and asked dentists about their intentions and attitudes towards antibiotic prescribing.

Approach

Researchers used two databases held by Public Health Scotland to find out the total number of NHS claims made in the period studied. They looked for prescription data comprising all antibiotic items prescribed by primary care dentists in Scotland and dispensed in community pharmacy, and used this to calculate percentages of change between pre-pandemic levels of antibiotic prescription (January 2019) and post-pandemic levels.

They then piloted a questionnaire with a small number of dentists, whose feedback was used to help improve the clarity of questions. Within the questionnaire, the term ‘lockdown’ was defined as the period of March 2020 when routine dental care was suspended. Researchers then invited dentists to complete the survey in December 2020 and January 2021.

What we found

Peaking in July 2020, the data showed that antibiotic prescribing rose by 49% following the suspension of routine dental care. The increase happened at the same time as reduced dental treatment activity.

The average monthly rate of antibiotic prescriptions per 100 pre-pandemic (the period from January 2019-March 2020) was 5.4 antibiotics per 100, but this increased markedly to an average monthly rate of 148.7 antibiotics per 100 during the period of most intense restrictions (April-August 2020). Rates reduced to 17.7 antibiotics per 100 between September-November 2020.

Data for the remobilisation period (December 2020-May 2021) highlighted that prescribing rates had not reduced to pre-pandemic levels, with an average of 17.3 antibiotics per 100 – around 28% higher than pre-pandemic. The survey revealed that dentists were frustrated about the increased use of antibiotics and intended to reduce the numbers of prescriptions for them, but there were significant challenges.

They raised concerns about harms caused by the impact of the restrictions on treatments, including a loss of satisfaction and trust in dental care, the backlog of patients and extreme reduction in capacity. They pointed to a severe deterioration in the nation’s dental health with an increase in patients attending emergency departments and GPs because they couldn’t access a dentist.

Some respondents were worried that since COVID-19, patients had come to expect antibiotics. They expressed having felt a strong sense of duty to act rather than leave patients in pain. Dentists felt compelled to ‘do something’ for patients and that prescribing antibiotics satisfied this need to provide some level of care during the COVID-19 restrictions when treatment options were so limited. The study showed that previous success within dentistry to protect against the development of antimicrobial resistance suffered a knock-back during the pandemic. A renewed focus on reducing unnecessary antibiotics within dentistry is required but it’s important that this is approached sensitively alongside the current backdrop of challenges within the service.