The Importance of Hygiene in the Doctor's Practice

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Hygiene in the doctor’s practice prevents resistance to antibiotics.

Medical doctors and dentists still have enormous potential regarding both the number of their prescriptions, as well as the hygiene in their offices, in order to curb the use of antibiotics! Did you know that in Germany alone, about 250 to 300 metric tons of antibiotics are prescribed every year? Austria shows similar values when the size of the country is taken into account. A huge part of that is prescribed by resident doctors, oftentimes for the sole reason of wanting to be “on the safe side.”

Today, we want to discuss why the enormous consumption of antibiotics constitutes a problem and why patients should also be interested in the hygiene of doctor’s offices.

We dare to say that there is hardly any other type of medication that has healed as many diseases and saved as people from death as antibiotics. Today, Alexander Fleming (1881-1955) is regarded as the discoverer of penicillin and thus of antibiotics, although he was hardly aware at first, what kind of natural magic bullet he had discovered. Penicillin and all other modern antibiotics are effective against bacteria and protozoa – but they are useless against viruses.

Penicillin is a side product of a mold and the real challenge in the discovery was how to produce this substance in sufficient amounts. At the beginning, even the urine of people that had been treated with penicillin was recycled in order to separate the valuable penicillin again.

In the course of medical development, scientists found many other antibiotics in plants and molds, and learned to appreciate their value. But why is a high consumption of antibiotics harmful for patients? The key word regarding this issue is the “development of resistance”.

Antibiotics are among the most prescribed medications in dental practices. Antibiotics are understood as those medications that either inhibit the growth of microorganisms such as viruses, bacteria, fungi, parasites or kill them. When administering antibiotics, one should strictly distinguish between a preventive and a therapeutic administration.

A preventive administration is particularly considered prior to surgeries in order to minimize the risk of wound infections after the surgery. In such a case, the objective is the build-up of an antibiotics level in tissues that could possibly be contaminated. It is to prevent the adhesion or multiplication of micro-organisms und to immediately kill contaminating pathogens. Many studies show that such a prophylaxis may be realized for a short period, i.e. in the sense of a one-time or two-time administration of the antibiotic.

But if, on the other hand, an infection has already occurred in the sense of an adhesion, invasion, or multiplication of the pathogen, as well as the immunological reaction of the host, antibiotics must be used in a therapeutic manner. When should antibiotics be administered therapeutically? Antibiotics are indicated in case of infections:

  • In which a bacterial genesis has been proven or is at least probable
  • When a local rehabilitation of the infection site is not possible or not sufficient
Medicine Overdose

Medicine Overdose

The prescription of an antibiotic is required in particular when, in case of infections relating to the teeth, a spreading or a generalization is imminent. Signs of a spreading are, for example, general symptoms such as fever, soft tissue swelling, swelling of the eyelids, or a lockjaw. No indication for antibiotics are virus infections, pains or swellings of unclear cause such as, for example, tumors as well as simple periodontal and chronic abscesses.

Useful for an antibiotic therapy are the identification of the pathogens and the determination of the resistance prior the initial administration. Acute infections requiring an immediate start of the therapy as well as a typical pathogen-specific disease pattern are excluded from this. As a rule, the former applies to dentogenic infections so that a determination of the pathogen and the resistance is not necessary in most cases.

Classification of Antibiotics

There is a multitude of substances available for an antibiotic therapy. By now, this glut is hard to survey even for experts. Therefore, it is helpful to classify antibiotics in categories that do not just provide information about the basic chemical structure of a substance, but also about its other characteristics (e.g. tolerance and costs). However, even within the individual categories of antibiotics, there are, to some extent, significant differences with regard to the spectrum and intensity of the activity of the individual substances.

Spectrum and Intensity of the Activity

The spectrum of the activity of an antibiotic includes all those micro-organisms that, in principle, can be reached by the substance due to its therapeutic effect. One differentiates antibiotics with a broad spectrum that act, for example, on gram-negative and gram-positive bacteria, on cocci, on rod-shaped bacteria, as well as on anaerobic and aerobic micro-organisms, from antibiotics with a small spectrum that act only on gram-positive micro-organisms, for example.

Depending on the action mechanism, one distinguishes bactericidal (bacteria killing) from bacteriostatic (bacteria inhibiting) antibiotics. The antibacterial activity is determined in vitro through the determination of the minimal inhibitor concentration (MIC) and the minimal bactericide concentration (MBC). The MIC is the concentration of the antibiotic that is needed to inhibit the growth of a stem. The MBC is the concentration of the antibiotic that is necessary to kill about 99.9% of the germs in a pathogen population. So every antibiotic has characteristic spectrum of activity. Germs outside of this spectrum are resistant.

However, the term resistance is relative insofar as types of germs are also called resistant if they could only be killed by antibiotic concentrations that cannot be achieved in a living organism (difference between microbiological and clinical efficacy).

After an oral administration, antibiotics are reabsorbed to varying degrees, depending in part on the food intake. Elimination either takes place through renal clearance or through metabolization in the liver.

Antibiotics may have allergic, toxic, and biological side effects. Allergies to antibiotics (penicillin in particular) are not rare (up to 10%). The risk of an allergization is largest in a skin application, and smallest when administered orally. Allergic reactions usually present themselves in the form of skin reactions (erythema, exanthema, and edema). These are to be differentiated from skin rashes caused by the infection itself.

So-called anaphylactic reactions are rare overall and practically do not occur in oral administration. Toxic side effects may occur in case of an absolute overdosage or through an accumulation when the metabolism or elimination is disturbed. Due to the broad therapeutic index, the risk of a poisoning is very low in most antibiotics. Biological side effects are understood as an impairment or shift of the physiological bacterial flora in the oral cavity and in the colon.

Spectrum of Pathogens

There is a multitude of different micro-organisms in the oral cavity, which can lead to a local infection in the area of the oral cavity, but also to infections of other organs in the sense of a focal infection (e.g. endocarditis).

E.coli Bacteria

E.coli Bacteria

In case of dentogenic infections, one finds mainly aerobic and anaerobic germ mixtures that are sometimes composed of more than 10 different pathogenic species. At the same time, the anaerobes reach a bacterial count that is up to 10 to the power of 5 higher than that of the aerobes. They also exceed them considerably with regard to their biodiversity. Germs not part of the physiological resident flora of the mouth such as Escherichia coli, Proteus mirabilis, Streptococcus faecalis, or Clostridium species only account for a very low share of all detected bacterial strains.

This suggests the conclusion that infections in the oral and maxillofacial area are predominantly caused by normally present germs of the mouth and throat cavity and are not from the outside.

Since it is often difficult to breed anaerobic germs in a microbiological nutrient medium, detecting them is not always possible; hence, the suspicion is often just done clinically and a microbiological proof cannot be provided. Clinical indicators for anaerobic infections are:

  • A foul smell
  • A gas-producing proof in the tissue in the sense of an emphysema
  • A lack of treatment success after the administration of antibiotics, which are ineffective against anaerobes

But what can the dentist do to curb the consumption of antibiotics? The instruments of the dentist can be referred to as a good example. Oftentimes, instruments are not sterilized at all, and even if that is the case, all too often they end up in a drawer where they are not protected.

Not a trace of sterility here. As soon as the instrument is touched with the hand or comes into contact with a piece of furniture (e.g. the drawer), it is no longer sterile! The instruments are instantly colonized by bacteria; every invasive intervention with such instruments is an infection risk that could have been avoided – even without antibiotics.

Another simple way to keep infections to a minimum in the course of a dental intervention is the use of a cofferdam in root canal treatments and the use of disposable cover materials when performing surgeries.

With a little bit of understanding and responsibility in our generation, our descendents could still benefit from the enormous achievements of our medicine/pharmaceutics for a long time. But who will be the first one to make a start? Maybe you – by looking very closely and by paying attention as to how the instruments of the doctor are stored and prepared. The ideal would be surgery containers that leave the sterilizer sealed and/or shrink-wrapped instruments!

Click here to see the video: Sterilization of Dental Instruments

 

This post is also available in: German

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