Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : ZC01 - ZC04 Full Version

Influence of CRP on Antibiotics Prescription Pattern for Dental Infections: A Prospective Interventional Study


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55107.16307
Ann Mary George, Anoop Mayya, Arun Mayya, Chai Bin Xuan, Dhanya Laxhmi A/P Velappan, Sharvina A/P Tamil Selvan, Razanah Binti Mohd Jalal

1. Assistant Professor, Department of Oral and Maxillofacial Surgery, Manipal University College, Melaka, Malacca, Malaysia. 2. Assistant Professor, Department of Prosthodontics, Manipal University College, Melaka, Malacca, Malaysia. 3. Assistant Professor, Department of Conservative Dentistry and Endodontics, AJ Institute of Dental Sciences, Mangalore, Karnataka, India. 4. Undergraduate Student, Department of Oral and Maxillofacial Surgery, Manipal University College, Melaka, Malacca, Malaysia. 5. Undergraduate Student, Department of Oral and Maxillofacial Surgery, Manipal University College, Melaka, Malacca, Malaysia. 6. Undergraduate Student, Department of Oral and Maxillofacial Surgery, Manipal University College, Melaka, Malacca, Malaysia. 7. Undergraduate Student, Department of Oral and Maxillofacial Surgery, Manipal University College, Melaka, Malacca, Malaysia.

Correspondence Address :
Dr. Arun Mayya,
Assistant Professor, Department of Conservative Dentistry and Endodontics, AJ Institute of Dental Sciences, Kuntikana, Mangalore, Karnataka, India.
E-mail: mayya.arun@gmail.com

Abstract

Introduction: Over the years, antibiotic prescription rates have increased dramatically for the treatment of dentoalveolar infections. A byproduct of this indiscriminate antibiotic prescription by dentists is the antibiotic resistance. Antibiotic resistant infections are a severe global health problem, putting the capacity to treat common diseases and perform complex medical procedures at risk.

Aim: To compare the amount of antibiotics prescribed for dental infections with and without analysing C-reactive Protein (CRP) value.

Materials and Methods: A prospective interventional study was conducted in Manipal University College Malaysia (MUCM) dental clinic between October 2020 to March 2021 to record the antibiotic prescription by dentists. The study was divided into two phases where phase I had 28 subjects and phase II had 21 subjects and permission from institutional ethical committee clearance was obtained for the study. The study was done to evaluate the effectiveness of C-reactive protein (CRP) to reduce antibiotic prescriptions in MUCM Dental Clinic. Data was summarised by computing frequency and percentages. The antibiotic prescription rate during phase I (n=28) (conventional method or routine pattern of prescribing antibiotics was done) and phase II (n=21) (CRP rapid test was done and the decision whether to prescribe antibiotics or not was done accordingly) was compared. The data was analyzed by using Statistical Package for the Social Sciences software program (SPSS), version 15.0 (South Asia, Bangalore) and compared applying the Chi-square test.

Results: There was no significant difference in the distribution of the presence of medical condition (p=0.201) and distribution of clinical features (p=0.804) of subjects included in phase I and phase II. The antibiotics prescription rate reduced significantly from 89.3% in phase I to 52.4% in phase II (p=0.0014), indicating that CRP rapid test helps in reducing antibiotics prescription.

Conclusion: The CRP rapid test aid in lowering antibiotic prescription in dental clinic settings. This may be useful to combat antibiotic resistance in general.

Keywords

Antibiotic misuse, Antibiotic resistance, C-reactive protein, Inappropriate prescription

There has been a significant increase in incidents where antibiotics have been used to treat infections. Antibiotics have been known as life-saving drugs. Recently, the number of patients presenting to the emergency department (ED) with odontogenic infections has been increasing, likely due to many factors, including cost, fear, mental illness, substance abuse, health literacy, and perceptions of oral disease as low importance (1). Incidence of dentofacial infections may also cause severe, life-threatening conditions which require emergency treatment.

Dentofacial infections are commonly treated with antibiotics in general dental practices. However, antibiotic prescribing may be associated with unfavourable side effects ranging from gastrointestinal disturbances to fatal anaphylactic shock. Additionally, inappropriate, indiscriminate and irrational use of antibiotics has led to the development of antibiotic resistance. Scientific literature suggests that dentists prescribe around 7-11% of common antibiotics (2). Evidence suggests that a large proportion of antibiotic prescribing in hospitals may be inappropriate. Optimising antibiotic prescribing and reducing the use of broad-spectrum agents has been shown to reduce the occurrence of healthcare-associated infections (HCAI) (3).

There has not been a clear justification for antibiotic prescribing practice in dental clinics. This may be due to several factors such as lack of knowledge and awareness of the development of antibiotic resistance, insufficient research done to standardise the prescription of antibiotics in general dental practice and lack of advancement or exposure to recent biotechnology in dental clinics concerning antibiotic prescription (4).

The CRP is a pentameric acute phase reactant discovered in 1930 in pneumococcal pneumonia patients. It is synthesised by the liver, and its production is controlled primarily by IL-6. CRP is the most commonly measured circulating marker for subclinical inflammation, with widely available, stable and standardised assays for its measurement (5).

The serum levels of CRP rise with infection, making it a positive acute phase reactant with a very short half-life of five to seven hours. Thus, the advantage of having short half-lives makes serum CRP levels a sensitive indicator of infection. Serial CRP measurement can be used as a tool for early diagnosis of clinical infections, to monitor the effects of treatment, outcome, and early detection of relapse of the disease. Hence it can be helpful in determining progression of a disease. Several studies have shown that CRP could be useful in infection diagnosis and monitoring the response to antibiotic therapy (5),(6). This is the first study in Malaysia evaluating the influence of C-reactive protein values on the antibiotic prescription percentage for dental infections.

The null hypothesis of the study was that there was no significant difference in the antibiotic prescription (percentage) for dental infections with or without analysing the C-reactive protein value.

Thus, the aim of the study was to compare the antibiotics prescription percentage for dental infections with and without analysing C-reactive protein value.

Material and Methods

A prospective interventional study was conducted in Manipal University College Malaysia Dental Clinic between October 2020 to March 2021 to evaluate the effectiveness of CRP to reduce antibiotic prescriptions.

Ethical approval was obtained from the Institutional Ethical Committee of MUCM (MUCM/FOD/AR/B8/E C-2020 (12)). Before the study, a patient information sheet was prepared and distributed to the subjects. Informed consent was obtained from all the patients. All the data and information were kept confidential.

The reference population for this study was the outpatient attending to MUCM dental clinic who required antibiotics by conventional method (where antibiotics are required conventionally prior to the management of conditions mentioned in the inclusion criteria).

Inclusion criteria: Patients requiring antibiotics in MUCM (Conventional Method) who visited the Department of Oral Surgery, Periodontology, Oral Medicine and Conservative Dentistry and Endodontics for the following reasons were included in the study: Prophylaxis, prior to the management of dentoalveolar conditions such as symptomatic or asymptomatic periapical abscess, pericoronitis, bone grafting, flap surgeries, aggressive or chronic periodontitis, draining sinus, dry socket, infections, cellulitis, and fever.

Exclusion criteria: All systemic medical conditions requiring hospitalisation and antibiotic therapy, patients undergoing antibiotic therapy for other conditions, patients on contraceptives, patients undergoing psychiatric treatment, and pedodontics patients were excluded from the study.

Sample size calculation: The following formula was used to compute sample size to compare two independent groups with binary outcomes (antibiotics prescription) (7).

n= K(P1 (1-P1 )+P2 (1-P2) / (P1-P2)2

Significance level (α) = 0.05

Power of the test (1-β) = 80%

K = (1.96 + 0.84)2 = 7.84

P1 = 0.85, Expected proportion of antibiotic prescription in phase I (no CRP test)

P2 =0.5, Expected proportion of antibiotic prescription in phase II (CRP test criteria)

The required sample size calculated was n = 24 per group.

Study Procedure

About 617 subjects in phase 1 and 1235 subjects in phase II were screened for antibiotic requirement as per the conventional method. In phase I, 28 cases and in phase II, 21 patients were indicated for antibiotic prescription by the conventional method. Of the 28 cases in phase I, three of the patients were not prescribed antibiotics based on the clinician’s judgement. The final decision regarding the prescription of antibiotics in both phases were left to the discretion of the clinicians. For comparison purposes, equal duration was recorded for phase I and phase II, summing up to a total of six months. Intention to treat analysis was carried out in this study.

Phase I: For phase I (October 2020 to December 2020), a study focusing on the antibiotic prescription in all patients was done by going through the GLOCO system and the individual patient’s documented folder. A thorough history of the patients was recorded as well as the clinical findings which leads to the diagnosis by the clinician. This study also recorded the reasons in which dentists in MUCM decided to prescribe the antibiotics.

Following phase I of the study, an academic seminar was held to introduce the usage of CRP among dental staff and students as well as specialists in MUCM.

Phase II: For phase II, (January 2021 to March 2021) patients with conditions requiring antibiotics were sent to the Oral Surgery Department to undergo the CRP rapid test to evaluate their CRP level. The decision whether to prescribe antibiotics or not was done accordingly. The CRP rapid test was done only in phase II, while the conventional method or routine pattern of prescribing antibiotics was done in phase I. Patients with conditions requiring antibiotics by conventional method in phase II was sent to the Oral Surgery Department to undergo the test (before any treatment was given), to aid the dentist’s decision in prescribing antibiotics and to examine whether CRP rapid test helps in reducing antibiotics prescription.

MultiCareâ„¢ Analyser by Medicity was the equipment used for CRP rapid test. It was decided to consider the cut-off point for serum CRP level to be at 5.0 mg/L since it is the generally acceptable range for CRP, which is internationally adopted for inflammation. Normal range: less than or equal to 5mg/L; Elevated range: more than 5 mg/L (8).

Statistical Analysis

The data were analyzed using SPSS software program, version 15.0. South Asia, Bangalore. Data was summarised by computing frequency and percentages. The antibiotic prescription rate during phase I and phase II were compared by applying the Chi-square test. The level of significance was considered <0.05.

Results

Distribution of characteristics of the subjects included in Phase I and Phase II of the study is shown in (Table/Fig 1).

There was no significant difference in the distribution of the presence of medical condition (p=0.201) and distribution of clinical features (p=0.804) of subjects included in phase I and phase II. The antibiotics prescription rate reduced significantly from 89 % in phase I to 52 % in phase II (p=0.0014), indicating that CRP rapid test helps in reducing antibiotics prescription (Table/Fig 2).

A significantly higher antibiotics prescription rate was found associated with the presence of clinical features (p=0.013). The association between the presence of medical condition and antibiotic prescription rate was not significant (Table/Fig 3). There was no significant difference in the distribution of medical conditions and distribution of clinical features in phases I and II in the present study.

Discussion

Testing of CRP in general dental practice in MUCM helped reduce the antibiotic prescription for the patients. Based on the present study, antibiotics were more likely to be prescribed to patients if they presented with clinical features indicating the presence of infection. Besides that, after the intervention or introducing CRP levels, the dental practitioners in MUCM prescribed antibiotics only if the CRP levels were high in the patients, indicated for antibiotics based on the signs and symptoms or medical conditions they had. An essential reason for performing the CRP rapid test is to avoid prescribing unnecessary antibiotics to patients with a dental infection. The CRP rapid test was the factor that exerted the most significant influence on whether a patient with dental disease was prescribed antibiotics. While practicing it, the test result had a substantial impact on the prescribing rate. The patients who tested CRP levels within a normal range were not prescribed any antibiotics in phase II. This is similar to the finding of Bjerrum et al. in which practices using CRP measurement had a lower prescription rate of antibiotics. The difference found might be due to different attitudes to antibiotic prescription for dental infection irrespective of the access to CRP tests (9).

Prophylactic antibiotics are prioritised for medically compromised patients where the risk of secondary infections is high. Simon Murray et al suggested that general practitioners were influenced by four clinical features (runny nose, fever, sore throat, and cough) to prescribe antibiotics for respiratory tract infections (10). This coincides with the findings of the present study that the presence of clinical features increases the chances of antibiotic prescription. However, the study also concluded that a more extensive study with the best evidence from literature could confirm the association between these two variables. Clinicians should be encouraged to use their clinical skills coupled with relevant laboratory investigations to diagnose infections and consult with the infection specialists (3).

The present study did not observe significant association between antibiotic prescription and medical conditions (p=0.052). Since this is the secondary outcome and the sample size was determined according to the primary outcome, the mentioned insignificant association between antibiotic prescription and medical conditions may be due to inadequate sample size. The role of prophylactic antibiotics has a significant impact on dentistry. To avoid any complications in medically compromised patients, antibiotics have become a common practice. Antibiotics must only be used as additive therapy in patients with systemic manifestations. In addition, prophylactic measure is observed in immunocompromised patients or predisposing patients conditions such as endocarditis. In the absence of the reasons mentioned above, the administration of antibiotics has no evidence of therapeutic benefit (11).

Infections or other causes of tissue injury result in a complex set of systemic and metabolic reactions associated with alterations in the hepatic synthesis and serum levels of some proteins, including CRP (12). In this study, 11 (52.4 %) patients presented with high CRP levels, in which all were prescribed with antibiotics. Meanwhile, 10 patients (47.6 %) showed relatively lower CRP levels, and antibiotics prescription was not given. This is in contrast to a Swedish study where CRP pretesting did not significantly affect the prescription of antibiotics or admittance to a hospital (13). This study also examines the awareness and acceptance of the dentists in MUCM to the changes in the conventional antibiotic prescribing guidelines. It was found out that dentists of MUCM did adhere to the recommended value of CRP and the adjunct in prescribing antibiotics. This result was different from a study done in the Netherlands whereby 40% of changes in antibiotic prescribing decisions were not according to guideline recommendations (14).

Compared to Phase II, the mean age of Phase I was higher (43.8 years), which may also contribute to the higher prescription rates. This is also true for the medical condition (35.7%) and the clinical features (46.4%), both of which have relatively higher percentages in subjects of Phase I. There may also be a correlation between the antibiotic prescribing rate in Phase I and the reason the antibiotic prescription was made, since, in this study a higher percentage of patients arrived with a dental emergency (35.7%) in Phase I as compared to zero percent in Phase II.

A minimum of 10 days gap is imposed before any dental treatment as a safety measure to prevent asymptomatic transmission. This practice may contribute to a higher antibiotic prescription in phase I. This occurs due to the public's growing concern towards their general health during the pandemic, which causes the demand to grow explosively (15).

Extensive studies on the response of CRP to antibiotic therapy in infections are lacking. Diagnostic tests, though available, were not routinely used to rationalise antibiotic prescribing (16). Evidence suggests that antibiotic therapy should be considered only after the conventional therapies have not been successful (17). Some studies supports the routine prophylactic use of antibiotics so as to reduce the postoperative complications after third molar surgery (18),(19). However, several studies have revealed an insignificant gain in the patient's postoperative condition after antibiotics use (20),(21).

In the fight against antibiotic resistance, it's also crucial to avoid unnecessary antibiotic prescriptions in order to prevent dentoalveolar infections that might harm patients, which is why the rapid test was created. However, since this study does not include a follow-up of the patients after prescribing antibiotics, there may be unreported secondary infections due to this practice. There may also be false-negative findings that may appear harmful for the patients. A meta-analysis study done by Adamina et al. found that in the absence of postoperative infectious complications, CRP levels were lower in non-invasive procedures than open and invasive procedures (22). The results of the present study does not support the null hypothesis and prove that there exists a statistically significant difference in antibiotic prescription for dental infection with or without analysing CRP value.

Limitation(s)

The study was limited by a small sample size. Another factor that limits the study is the Coronavirus Disease 2019 (COVID-19) pandemic which reduced the total number of patients attending the clinic. Other medical conditions also affect the CRP levels and hence rapid test may not be suitable in an outpatient clinical settings as CRP levels may be influenced by other factors due to medical conditions. Since this study does not include follow-up of the patients, there are chances that patients may develop secondary infections did not report directly to the clinic and opt for another clinic to get other treatment, prescription or consultation. The study also did not evaluate the anticipation of the dentists in MUCM towards this new practice nor their satisfaction with the new adjunct of antibiotic prescription. This may display as a shortfall in the application of the CRP rapid test.

Conclusion

The CRP rapid test does help in lowering antibiotic prescription in dental clinic settings. This may be useful to combat antibiotic resistance in general. This study also found out that antibiotic prescription is associated with signs and symptoms of the patient. It is essential to carefully assess and evaluate patient’s health prior to prescribing antibiotics. A high CRP level is associated with more antibiotic prescriptions. Clinician awareness and knowledge of the significant CRP level is important for the proper antibiotic prescription routine in general private dental settings to reduce antibiotic resistance.

References

1.
Fu B, McGowan K, Sun H, Batstone M. Increasing Use of Intensive Care Unit for Odontogenic Infection Over One Decade: Incidence and Predictors. J Oral Maxillofac Surg. 2018;76:2340-7. [crossref] [PubMed]
2.
Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. Antibiotic prescribing practices by dentists: a review. Ther Clin Risk Manag. 2010;6:301-6. [crossref] [PubMed]
3.
Charani E, de Barra E, Rawson TM, Gill D, Gilchrist M, Naylor NR, et al. Antibiotic prescribing in general medical and surgical specialties: a prospective cohort study. Antimicrob Resist Infect Control. 2019;8:151. [crossref] [PubMed]
4.
Sweeney LC, Dave J, Chambers PA, Heritage J. Antibiotic resistance in general dental practice--a cause for concern? J Antimicrob Chemother. 2004;53:567-76. [crossref] [PubMed]
5.
Sproston NR, Ashworth JJ. Role of C-Reactive Protein at Sites of Inflammation and Infection. Front Immunol. 2018;9:754. [crossref] [PubMed]
6.
Ramamoorthy RD, Nallasamy V, Reddy R, Esther N, Maruthappan Y. A review of C-reactive protein: A diagnostic indicator in periodontal medicine. J Pharm Bioallied Sci. 2012;4:S422-6. [crossref] [PubMed]
7.
Whitley E, Ball J. Statistics review 4: Sample size calculations. Crit Care. 2002;6:335-341. [crossref] [PubMed]
8.
Acharya S, Kale J, Hallikeri K, Anehosur V, Arnold D. Clinical significance of preoperative serum C-reactive protein in oral squamous cell carcinoma. International journal of oral and maxillofacial surgery. 2018;47:16-23. [crossref] [PubMed]
9.
Bjerrum L, Gahrn-Hansen B, Munck AP. C-reactive protein measurement in general practice may lead to lower antibiotic prescribing for sinusitis. Br J Gen Pract. 2004;54:659-62.
10.
Murray S, Del Mar C, O'Rourke P. Predictors of an antibiotic prescription by GPs for respiratory tract infections: a pilot. Fam Pract. 2000;17:386-8. [crossref] [PubMed]
11.
Bansal R, Jain A, Goyal M, Singh T, Sood H, Malviya HS. Antibiotic abuse during endodontic treatment: A contributing factor to antibiotic resistance. J Family Med Prim Care. 2019;8:3518-24. [crossref] [PubMed]
12.
Kwon JH, Jang JW, Kim YW, Lee SW, Nam SW, Jaegal D, et al. The usefulness of C-reactive protein and neutrophil-to-lymphocyte ratio for predicting the outcome in hospitalized patients with liver cirrhosis. BMC Gastroenterol. 2015;15:146. [crossref] [PubMed]
13.
Rebnord IK, Sandvik H, Mjelle AB, Hunskaar S. Out-of-hours antibiotic prescription after screening with C reactive protein: a randomised controlled study. BMJ Open. 2016;6:e011231. [crossref] [PubMed]
14.
Minnaard MC, van de Pol AC, Hopstaken RM, van Delft S, Broekhuizen BD, Verheij TJ, et al. C-reactive protein point-of-care testing and associated antibiotic prescribing. Fam Pract. 2016;33:408-13. [crossref] [PubMed]
15.
Kathree BA, Khan SB, Ahmed R, Maart R, Layloo N, Asia-Michaels W. COVID-19 and its impact in the dental setting: A scoping review. PLoS One. 2020;15:e0244352. [crossref] [PubMed]
16.
Antoñanzas F, Juárez-Castelló CA, Rodríguez-Ibeas R. Using point-of-care diagnostic testing for improved antibiotic prescription: an economic model. Health Econ Rev. 2021;11:29. [crossref] [PubMed]
17.
Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic advances in drug safety. 2014;5:229-41. [crossref] [PubMed]
18.
Ren YF, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials. J Oral Maxillofac Surg. 2007;65:1909-21. [crossref] [PubMed]
19.
Monaco G, Tavernese L, Agostini R, Marchetti C. Evaluation of antibiotic prophylaxis in reducing postoperative infection after mandibular third molar extraction in young patients. J Oral Maxillofac Surg. 2009;67:1467-72. [crossref] [PubMed]
20.
Poeschl PW, Eckel D, Poeschl E. Postoperative prophylactic antibiotic treatment in third molar surgery-a necessity? J Oral Maxillofac Surg. 2004;62:3-8; discussion 9. [crossref] [PubMed]
21.
Calvo AM, Brozoski DT, Giglio FP, Gonçalves PZ, Sant'ana E, Dionísio TJ, et al. Are antibiotics necessary after lower third molar removal? Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114:S199-208. [crossref] [PubMed]
22.
Adamina M, Steffen T, Tarantino I, Beutner U, Schmied BM, Warschkow R. Meta-analysis of the predictive value of C-reactive protein for infectious complications in abdominal surgery. Br J Surg. 2015;102:590-8. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/55107.16307

Date of Submission: Jan 21, 2022
Date of Peer Review: Feb 02, 2022
Date of Acceptance: Apr 15, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 22, 2022
• Manual Googling: Mar 21, 2022
• iThenticate Software: Apr 14, 2022 (19%)

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