Antibiotic Prescribing for Outpatient Dental Infections Across a Michigan Health System

Background Penicillins are recommended first-line for the treatment of dental infections; however, alternatives are often prescribed which may increase risk of treatment failure. This study aimed to describe prescribing patterns for outpatient dental infections across a Michigan healthcare system and to compare patient outcomes associated with different antibiotics. Methods This was a multicenter, retrospective cohort study evaluating adult patients treated for a dental infection from an outpatient site between January 1, 2020 – August 1, 2025. Patients were compared via four groups: amoxicillin/clavulanate, cephalosporins, clindamycin, and other. The primary objective was to compare treatment failure between groups, which was defined as need for new or extension of current antimicrobial therapy within 30 days of presentation. Results 12,365 patients were treated for dental infection. Penicillins were most often prescribed (75.6%) followed by clindamycin (19.1%). 594 patients were evaluated for treatment failure which occurred most frequently in patients receiving clindamycin (11.3%), followed by cephalosporins (4.8%), amoxicillin/clavulanate (2%), and other agents (0.7%) (p<0.001). Of the patients receiving penicillin alternatives, 21.4% had no documented allergy or intolerance while 26.8% had only a mild allergy or intolerance. Clindamycin (OR 6.2 [95% CI 2.5-15.81]) and cefdinir (OR 9.9 [95% CI 2.67-36.97]) were independently associated with treatment failure. Conclusions Outpatient prescribing for dental infections across a health system revealed a preference for first-line penicillins and an opportunity to improve penicillin use in patients with and without beta-lactam allergy. Clindamycin and cefdinir were independently associated with treatment failure; alternative agents should be prioritized in patients unable to receive penicillins.