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PETER J. JEWE55ON,* B SC (PHARM) ANTHONY W. CHOW,*t MD, FRCP[C], FACP Not long after the introduction of antibiotics it became apparent that these agents were -frequently misused. The problem manifested itself in a number of ways, many of which are generally familiar even today. As early as 1956 there was discussion of the difficulties caused by the exaggerated claims made for and the intense promotion of the products of the drug companies.' A nationwide American study that was reported a year later demonstrated the emergence of a high frequency of untoward reactions in patients given antibiotics.2 Then, in 1959 Finland and associates3 wrote of the increasing incidence of severe bacterial infections that seemed to have followed the introduction of antimicrobial agents; reports of this nature continue to be prominent in the medical literature. Many studies in both community and hospital populations have now documented the extent of inappropriate drug use. Although the criteria used in these studies often differ, the patterns of antibiotic use and misuse that are outlined tend to be much alike. As many as two thirds of the hospital patients given antibiotics are receiving them inappropriately.4 While this finding is useful for alerting us to this important problem, it cannot be applied equally to all hospital settings. It remains the responsibility of each institution to determine its own patterns of antibiotic use. To accomplish this, a systematic approach such as the quality-of-use audit is necessary. The quality-of-use audit has been widely promoted in recent years for the assessment of antibiotic use. The concept of such an audit is based on a number of underlying hypotheses, including the suppositions that the quality of drug use reflects the overall quality of health care, that the need for an audit itself suggests there is room for improvement in the quality of drug use, and that identification of the less well controlled components of the health care system will lead to the intended changes - namely, improvement in the prescribing behaviour of practising physicians. Quality-of-use audits may be oriented towards either From the faculties of *pharmaceutical sciences (division of clinical pharmacy) and tmedicine (division of infectious disease), University of British Columbia, Vancouver, and Vancouver General Hospital Reprint requests to: Dr. Anthony W. Chow, Division of infectious disease, G.F. Strong Research Laboratories, Vancouver General Hospital, 910W 10th Ave., Vancouver, BC V5Z 1M9 the patient outcome or the drug usage decision process. Outcome-oriented audits of the management of individual infections are generally the more difficult to perform. This is because most infections in patients in, hospital occur in the presence of underlying diseases, and it is often the underlying illness, rather than the antibiotic therapy, that determines the outcome. Process-oriented audits are, therefore, more commonly employed when examining antibiotic use, although there is some controversy over the relevance of the results and their relation to actual patient outcomes. Several methods for examining the patterns of antibiotic use have been described,5'6 and these may be placed into six general groups: survey of gross usage based on pharmacy records; survey of use in individual hospital services; survey of routine orders for prophylaxis in surgery; survey of orders for the treatment of specific infectious diseases; case review by independent experts; and evaluation of established guidelines by an audit. Each method of surveillance has inherent advantages and disadvantages, and the approach should be chosen with regard to the resources available and the particular objectives of the hospital. A number of control methods have been developed in an attempt to reduce the misuse of antibiotics. These are largely measures of either physician education or drug restriction. Unfortunately, the educational approaches have been conducted with various degrees of success. Some studies have demonstrated an improvement in antibiotic use following educational efforts that ranged from the distribution of bulletins7'8 to intensive medical seminars,9-" but others have failed to find significant benefit.'2 Although in our own audit, reported in this issue of CMAJ (starting on page 1075), improvement did follow* the release of preliminary results, we felt that the change could not be attributed to our efforts with any certainty. Well controlled studies are still needed to determine the potential short- and long-term benefits of various educational approaches before any conclusions can be drawn regarding the strategy of choice. The alternative of restricting the use of antibiotics is, of course, regarded with less favour by many physicians, but this approach does produce measurable changes in the patterns of drug use within the hospital.'3'5 RestricCAN MED ASSOC J, VOL. 128, MAY 1, 1983 1061 tions can be imposed by means of a hospital formulary system that makes available only a limited number of nonduplicated antibiotics or an automatic stop-order policy for specific antibiotics. Requirements for written justification of antibiotic administration or for consultation either before the drug is released or shortly after therapy is initiated may be effective. The establishment of guidelines for the use of certain drugs coupled with a prospective audit could also prove beneficial. If conducted properly and closely linked to an educational strategy, these measures can promote the more rational prescribing of expensive and potentially toxic antibiotics. References at alternative approaches. Rev Infect Dis 1981; 3: 745-753 6. Veterans Administration ad hoc interdisciplinary advisory committee on antimicrobial drug usage: Guidelines for peer review. JAMA 1977; 237: 1001-1002 7. BERBATIS CG, MAHER MJ, PLUMRIDGE RI: Impact of a drug bulletin on prescribing oral analgesics in a teaching hospital. Am J Hosp Pharm 1982; 39: 98-100 8. BERBATIS CG, SMITH PB: Drug bulletins and local drug utilization studies. Aust J Hosp Pharm 1978; 8: 47-50 9. SOHN CA, WOLTER HA, MCSWEENEY GW: Effectiveness of a cephalosporin education program: a pharmacy education program. Drug Intell Clin Pharm 1980; 14: 272-277 10. GILBERT DN, JACKSON IM: Effect of an educational program on the proper use of gentamicin in a community hospital. J Med Educ 1978; 53: 129-134 11. ACHONG MR. WOOD J, THEAL HK, GOLDBERG R, THOMPSON DA: Changes in hospital antibiotic therapy after a quality-of-use study. Lancet 1977; 2:1118-1122 1. JAwETz E: Antimicrobial chemotherapy. Ann Rev Microbiol 12. JONES SR. BARKS I, BRATTON T, MCCREE E, PANELL J, 1956; 10: 85-114 2. WELCH H, LEWIS CN, WEINSTEIN HI, BOECKMAN BB: Severe YANCHICK VA, BROWNE R, SMITH JW: The effect of an educational program upon hospital antibiotic use. Am J Med Sci 1977; 273: 79-85 13. MA MY, GOLDSTEIN EJC, MEYER RD: Effect of control programs on cefazolin prescribing in a teaching hospital. Am J Hosp Pharm 1979; 36: 1055-1058 14. WOLFSON DJ, WILLIAMSON f.M: Prescribing restriction: implications and reactions. Drug Intel! Clin Pharm 1981; 15: 594-597 15. MCGOWAN J, FINLAND M: Usage of antibiotics in a general hospital: effect of requiring justification. J Infect Dis 1974; 130: 165-168 reactions to antibiotics: a nationwide survey. Antibiot Chemother 1957; 4: 800-8 13 3. FINLAND M, JONES WR JR, BARNES MW: Occurrence of serious bacterial infections since introduction of antibacterial agents. JAMA 1959; 170: 2188-2197 4. KUNIN CM, TUPASI T, CRAIG WA: Use of antibiotics: a brief exposition of the problem and some tentative solutions. Ann Intern Med 1973; 79: 555-560 5. KUNIN CM: Evaluation of antibiotic usage: a comprehensive look Dental care for cancer patients J.H.P. MAIN, BDS, PH D, FDSRCSE, FRC PATH, FRCD[C] Debilitating dental complications can develop as a consequence of a variety of forms of cancer or, more commonly, as a result of cancer treatment. Much of this dental disease is preventable; if appropriate dental care is provided at the appropriate time, patients can be spared much discomfort and disability. From the time radiotherapy was first introduced for the treatment of cancers in the mouth, nose, pharynx and maxillary sinuses, it has been known that the salivary glands are damaged by the radiation. The consequent reduction of salivary flow and accumulation of bacterial plaque cause rampant dental caries and rapidly progressing periodontal disease. In addition, osteoradionecrosis has been reported in 20% or more of these patients."2 The incidence is higher in dentulous patients. It is also directly related to the dose of radiation: at the Princess Margaret Hospital, Toronto, where lower than usual doses of radiation are given for oral cancers, the incidence has been 11%? The pathogenesis of osteoradionecrosis is related to the susceptibility of osteoblasts and osteoclasts to radiation damage, radiation-induced obliterative endarteritis4 and the From the faculty of dentistry, University of Toronto Reprint requests to: Dr. J.H.P. Main, Faculty of dentistry, University of Toronto, 124 Edward St., Toronto, Ont. M5G 1G6 1062 CAN MED ASSOC J, VOL. 128, MAY 1, 1983 spread of infection to the jaws from periapical and periodontal infections, tooth extractions and small traumatic lesions that occur during mastication. The mandible is most frequently affected, presumably because of its less extensive collateral circulation. To minimize these hazards it was standard practice until just a few years ago to extract all of a cancer patient's teeth before administering therapeutic doses of radiation to fields that included the parotid and submandibular salivary glands. However, with appropriate dental treatment and, just as importantly, good compliance, irradiated patients may retain their teeth in health.57 This is possible only in patients who have a high standard of oral hygiene, whose mouths were previously healthy and who are strongly motivated to retain their natural teeth. Probably a quarter of all patients with primary cancer in the relevant areas would be in this group, so the majority of patients receiving radiotherapy should still be rendered edentulous beforehand. For patients whose teeth are to be conserved, continuing and regular dental supervision is essential. This should start immediately before radiation therapy is given and be quite intensive during the next year, as the greatest incidence of caries occurs in the first 6 months. Starting before radiation treatment, the patient must