(1237 words) June 2024.
Antimicrobial resistance (AMR) is one of the biggest threats to public health and development globally. A 2019 WHO report showed that bacterial AMR directly caused 1.27 million deaths worldwide and contributed to 4.96 million more. So, what can we do to limit the problem?
What is antimicrobial resistance?
Antimicrobial resistance (AMR) is the ability of microbes, including fungi, viruses, and bacteria, to evolve defences against substances meant to kill them, such as drugs, disinfectants and topical treatments.
The terms ‘antibiotic resistance’ and ‘antimicrobial resistance’ are sometimes used interchangeably, but they are not the same thing. Antibiotics are a type of antimicrobial, and antibiotic resistance is a kind of antimicrobial resistance (Nankervis et al., 2016). It applies only to antibiotic drugs for bacterial infections becoming less effective over time. Antimicrobial resistance is a broader term.
Why are antimicrobials losing their power?
The more we use our current antimicrobials, the less effective they become. But while microbes are fast evolving the ability to resist our antibiotics and other antimicrobials, science is struggling to keep pace. In fact, we are lagging far behind.
New antimicrobials are being developed, but the pipeline is small and the profits for pharmaceutical companies are low. No new classes of antibiotic drug have been identified since the 1980s, yet the ones we have continue to be widely prescribed (HM Government, 2019).
The high rate of prescription is a big part of the problem.
In AMR, the resistance develops with repeated exposure. The more times the pathogens are exposed to an antimicrobial substance, the faster they will evolve to resist its effects. In this way, rates of AMR are influenced by human actions like the overprescribing of antibiotics, the use of antibiotics to prevent disease in farm animals, and the use of antimicrobials when not warranted (CIDRAP, 2024). According to the WHO, the misuse and overuse of antimicrobials in humans, animals and plants are the main drivers in the development of drug-resistant pathogens.
By overusing antimicrobials, we are destroying their usefulness – and without them, procedures like organ transplants, caesarean sections, cancer chemotherapy and of course dental surgeries will no longer be possible (WHO, 2023).
How does dental practice affect antimicrobial resistance?
For dentists and other practitioners in oral health, AMR is a widely recognised problem, and one that could escalate rapidly in the future. Currently, as many as 1 in 10 primary care antibiotic prescriptions are made by dentists, according to the British Dental Association, and there is evidence that not all of these prescriptions are appropriate (BDA). We need to find ways to curb the problem in individual practices and at an industry-wide level.
Assessing whether to prescribe antimicrobial medication, such as antibiotics, involves complex, time-sensitive decision-making.
As well as the concern around AMR, antimicrobials can produce unwanted side effects like nausea and stomach upsets. Dentists must maintain a balance between limiting unwanted effects and achieving the best likely outcomes for patients – continually weighing up the risks and clinical benefits of prescribing. And where antimicrobials are necessary, time can be of the essence to treat patients and prevent systemic infection, especially for those in vulnerable groups like children and older people.
What is the best practice approach to prescribing antimicrobials in dentistry?
The College of General Dentistry has published specific guidance in collaboration with the Faculty of Dental Surgery (FDS) of the Royal College of Surgeons of England. It offers detailed advice on when and how to use antimicrobials responsibly in a range of different dental conditions.
The guidance describes three types of scenarios where antimicrobials can used.
- When infection is chronic
Antimicrobials can be used as an additional tool for managing of acute or chronic infections.
- When infection is likely
Antimicrobials can be used to prevent infections that may be associated with dental procedures.
- When definitive treatment has to be delayed
The patient may need to wait for a referral for specialist services, or they might need a general anaesthetic or sedation, meaning it’s not possible to carry out drainage of the infected area. Or they may have comorbidities requiring hospitalisation. These patients should be treated as soon as possible to avoid repeat prescribing of antimicrobials.
This document and other valuable resources can be found in the Government’s Dental antimicrobial stewardship toolkit (UK Health Security Agency).
Practical steps against AMR in dentistry
Dental practices, whether they are corporate or on the high street, can manage the need for antibiotics by maintaining effective disinfection.
Infection control practices like environmental cleaning and decontamination of medical devices are emphasised in the Government’s five-year plan for tackling antimicrobial resistance (HM Government, 2019). They are part of a drive to reduce the need for antimicrobial prescriptions by lowering the numbers of people getting infections in the first place.
A dental surgery is kept much cleaner than the average premises, but at the same time it can be a high-risk environment for pathogen transmission (Artasensi et al., 2021), since high numbers of people with dental infections pass through its doors. These patients’ infectious microbes can travel through the air, via the hands of healthcare workers, and on contaminated equipment into the mouths of vulnerable patients.
They can also form a biofilm on surfaces. Biofilms are clusters of bacteria held together by resilient substances which protect them. Some research even suggests that formation of biofilms could accelerate antibiotic resistance (Usui et al., 2023).
The role of hypochlorous acid
No antimicrobial is immune to resistance, but some are more resilient than others. Choosing a powerful disinfectant that effectively attacks a broad range of microbes, including those that may have developed resistance, is as important as maintaining a rigorous programme of hygiene.
Hypochlorous is a natural and powerful solution for disinfection, killing pathogens whether they are free-floating or part of an established biofilm. It is also harder for pathogens to develop resistance to hypochlorous compared to other antimicrobials, because it acts on multiple different structures inside their cells, instead of disrupting one specific pathway (Akl, 2023).
Crucially, hypochlorous is ‘friendly’ to human tissues because it emulates substances already present in the body. That means humans are resilient to concentrations of hypochlorous that would be deadly to microbes.
In dentistry, hypochlorous products have a wide range of applications from surface cleaning to waterline disinfection. Though highly powerful, hypochlorous is gentle enough to be used as an ingredient in oral rinses for patients too.
Simon Davies is founder and Commercial Director of Tec Safe, a dental company that specialises in developing easier and safer decontamination products for a wide variety of dental applications, using eco-friendly solutions.
Visit the website: www.tec-safe.com
For further info, please email: sales@cleancert-hygiene.co.uk
References
Akl, M. M. (2023). Hypochlorous acid has emerged as a potential alternative to conventional antibiotics due to its broad-spectrum antimicrobial activity. International Journal of Clinical Microbiology and Biochemical Technology, 6(1), 001–004. https://doi.org/10.29328/journal.ijcmbt.1001026
Artasensi, A., Mazzotta, S., & Fumagalli, L. (2021). Back to Basics: Choosing the Appropriate Surface Disinfectant. Antibiotics, 10(6), 613. https://doi.org/10.3390/antibiotics10060613
BDA Antimicrobial resistance. (n.d.). British Dental Association. https://www.bda.org/what-we-do/campaigns-and-advocacy/priorities/improving-oral-health/antimicrobial-resistance/
CIDRAP. Global, US data show high antibiotic use, rise in resistant infections during COVID. (2024, April 26). Www.cidrap.umn.edu. https://www.cidrap.umn.edu/antimicrobial-stewardship/global-us-data-show-high-antibiotic-use-rise-resistant-infections-during
HM Government. (2019). Tackling antimicrobial resistance. https://assets.publishing.service.gov.uk/media/6261392d8fa8f523bf22ab9e/UK_AMR_5_year_national_action_plan.pdf
Nankervis, H., Thomas, K. S., Delamere, F. M., Sébastien Barbarot, Rogers, N. K., & Williams, H. C. (2016). Antimicrobials including antibiotics, antiseptics and antifungal agents. Nih.gov; NIHR Journals Library. https://www.ncbi.nlm.nih.gov/books/NBK363143/
UK Health Security Agency (n.d.). Dental antimicrobial stewardship: toolkit. GOV.UK. https://www.gov.uk/guidance/dental-antimicrobial-stewardship-toolkit
Usui, M., Yoshii, Y., Thiriet-Rupert, S., Ghigo, J.-M., & Beloin, C. (2023). Intermittent antibiotic treatment of bacterial biofilms favors the rapid evolution of resistance. Communications Biology, 6(1). https://doi.org/10.1038/s42003-023-04601-y
WHO (2023, November 21). Antimicrobial Resistance. World Health Organization; WHO. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance