Download Not long after the introduction of antibiotics it became apparent that

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