Additionally, maximum splitting tensile strength reached 8.84 N/mm2 with a mix of 0.62:0.55:2.09:3.86:0.38 for the same components. Conversely, the minimum flexural, splitting tensile and compressive strength within the experimental factor space was 4.25, 2.08 and 19.82 N/mm2 respectively. The results obtained indicated a satisfactory mechanical strength performance at POFA replacement of 35 percent in the concrete mixture. The developed mathematical model was statistically validated using analysis of variance (ANOVA) at a 95% confidence interval which showed satisfactory prediction performance. The findings from this study provide valuable insights into optimizing POFA-blended concrete for enhanced mechanical performance, offering potential sustainable solutions for the construction industry.This study explores the enhancement of mechanical properties in concrete blended with palm oil fuel ash (POFA) through Scheffe's optimization. The utilization of POFA as supplementary cementitious material in concrete has gained attention for its potential environmental benefits. Utilizing a  simplex-lattice design, a systematic approach is employed for optimizing mixture proportions based on response parameters. The laboratory tests to evaluate concrete's mechanical behavior were conducted using the computed mixture ratios from the design experimental points after 28 days of hydration. The results showed maximum flexural strength at 8.84 N/mm An innovative sustainable construction approach involves using agro waste ash in concrete, reducing environmental impact3. Agro waste, from agriculture, can make traditional concrete eco-friendlier and more efficient. This shift diverts agricultural residues from landfills and enhances concrete's performance and sustainability4. Ashes like rice husk, sugarcane bagasse, and palm oil fuel gain importance. Processed, they become valuable additives in concrete, improving workability, durability, and strength while reducing the carbon footprint6. This exploration delves into agro waste ash in concrete, from agricultural remnants to improving the built environment. Agro waste ash showcases sustainability and technology synergy, guiding us towards eco-conscious construction and a greener future7.In concrete technology, the key goal is improving mechanical properties while embracing sustainability. Optimization techniques are pivotal for this purpose8. It identifies optimal combinations of components within a mixture to achieve desired outcomes, considering interactions and component proportions10. In concrete, Scheffe optimization optimizes properties by adjusting proportions of cement, aggregates, and other materials11. Researchers and engineers can efficiently design mixtures, unlocking material potential and achieving desired performance with minimal experimentation12. The optimization of palm oil fuel ash (POFA) concrete using Scheffe's optimization approach has garnered considerable attention in recent literature. Researchers have explored this methodology to enhance various mechanical and durability properties of POFA concrete, contributing to the advancement of sustainable construction practices13. Hamada et al.14 investigated the use of response surface methodology to optimize the mechanical properties of palm oil clinker and nano-palm oil fuel ash blended concrete. Moreover, Mulizar et al.15 examined the engineering characteristics of geopolymer mortar derived from a blend of fly ash and POFA precursor. They achieved the highest compressive strength of 23 MPa when adding 5% POFA to the mix. The scanning electron microscopy analysis revealed that POFA particles have a coarse surface texture, which adversely affected workability and extended the setting time compared to fly ash-based geopolymer blends. Also, Onyia et al.16 carried out mathematical modeling of compressive strength in recycled ceramic tile aggregate concrete using a modified regression theory. The study explores the relationship between variables and compressive strength, offering insights into the properties of this sustainable construction material. Furthermore, The Okere et al.17 focuses on optimizing the cost of concrete mixes using Scheffe's simplex lattice theory. It explores efficient mix designs to minimize costs while maintaining quality. The research emphasized the role of Scheffe's optimization in aligning concrete design with sustainability goals. The literature on optimizing the mechanical properties of Palm Oil Fuel Ash (POFA) concrete using Scheffe's Method reveals several research gaps. These gaps include the limited focus on specific properties, variability in POFA characteristics, the influence of environmental factors, real-world project applications, and optimization under various constraints. Addressing these gaps is essential for advancing the understanding and practical application of Scheffe’s optimization in enhancing POFA concrete's mechanical properties while promoting sustainability in the construction industry.Scheffe mixture optimization is a systematic methodology used in various fields to enhance mixture performance, including materials science, engineering, and manufacturing19. Material proportions, mix design, and mechanical responses take center stage. POFA, a byproduct of the palm oil industry, holds promise for improving concrete properties and responsibly using industrial waste in a sustainable construction context20. Scheffe’s optimization is a statistical approach for systematically identifying the optimal ingredient proportions in concrete to achieve desired properties. It employs mathematical modeling and statistical analysis to discover the ideal combination of factors like cement, water, aggregates, and additives21. In contrast, the traditional method depends on practical experience and intuition, typically requiring multiple trial batches and adjustments, which can be a time-consuming process22. This study on Scheffe’s optimization of POFA concrete is highly relevant in sustainable construction and materials science. It employs Scheffe optimization to enhance mechanical performance while promoting eco-conscious practices23. The research aims to reveal POFA concrete’s untapped potential and establish a paradigm for optimizing concrete properties in line with sustainability. This journey seeks to reshape concrete's mechanical landscape and contribute to an ecologically balanced construction ecosystem. Ultimately, the focus on Scheffe’s optimization for POFA concrete aligns with contemporary construction demands, offering stronger, sustainable, and economically viable concrete solutions for our evolving world.This research explores palm oil fuel ash (POFA), a waste byproduct with potential in concrete applications, using Scheffe’s optimization—a statistical method. The goal is to determine the precise mix proportions and conditions that enhance POFA concrete’s mechanical strength. By leveraging Scheffe’s optimization, this study aims to elevate POFA concrete’s mechanical properties in line with the concrete industry’s shift toward sustainability25. Overall, Scheffe's mixture optimization is a valuable tool for efficiently and effectively optimizing mixture compositions, reducing trial and error, and enhancing material performance. Key steps in Scheffe's mixture optimization deployed in this study according to Attah et al.26:Experimental Design: Designing a set of experiments with varying proportions of components in the mixture.Response Variables: Identifying the properties or responses of interest that need optimization.Data Collection: Conducting experiments and measuring the responses for each mixture.Mathematical Modeling: Developing mathematical models to describe the relationships between component proportions and response variables.Optimization: Using the model to find the optimal mixture proportions that yield desired response values.Validation: Ensuring the optimized results are valid and reliable through additional tests or statistical analysis.The methodology for this research study combines experimental design, mathematical modeling, and statistical validation to systematically optimize the mechanical properties of POFA concrete. Scheffe's mixture optimization is a robust methodology employed to optimize the composition of POFA concrete mixtures by determining the ideal proportions of their components27. This approach is used to enhance specific properties of concrete, such as strength, durability, and workability. By systematically varying the mixture components within predefined ranges, engineers and researchers can determine the optimal combination that maximizes the desired properties while minimizing undesired effects29. Scheffe's optimization technique considers not only the individual contributions of each component but also their potential interactions. This comprehensive approach allows for a more accurate representation of how changes in component proportions affect the overall concrete performance30. Moreover, through mathematical modeling and statistical analysis, Scheffe's concrete mixture optimization helps to navigate the complex relationships among ingredients, ensuring the achievement of targeted concrete properties. This method offers a powerful tool for achieving high-quality concrete formulations that align with specific project requirements and sustainability goals31.Scheffe's concrete mixture optimization is a systematic methodology that employs Scheffe's principles to fine-tune the proportions of concrete constituentsi represents the fractions of mixture components and q is the total number of mixture ingredients32.Scheffe's mixture model reveals a distinct correlation between component levels, impacting mixture uniformity. Changes in one component influence ingredient ratios for a consistent solution. Unlike regression models, it lacks an intercept term, assuring zero response with null factors. It adheres to a sum-to-one constraint and the total factor levels equate to unity, captured in Eqs. , 2 where33.The assessment of mixture response properties involves employing a mathematical  function of degree m-order and q, where q represents the count of mixture components. This yields a  polynomial in the overall structure outlined in Eq.  and the 35. The resulting data is used to create mathematical models that predict how changes in component proportions affect the desired outcomes36. A simplex is a geometrical shape with one more vertex than variable factor spaces (q), projected from n-dimensional space to n-1-dimensional coordinates. For q = 1, it's a two-vertex line; q = 2 forms a triangle, and q = 3 creates a tetrahedron37. Scheffe28 expanded and generalized the simplex lattice design, pioneering it in mixture design. His work established the notion of each component as a vertex within a regular simplex-lattice with q-1 factor space. Scheffe's simplex lattice patterns have become a widely recognized term for lattice designs, setting the stage for optimizing mixture compositions. Scheffe's Simplex lattice design is particularly useful in industries like materials science, where the properties of mixtures  need to be optimized efficiently. It simplifies the experimentation process, reduces resource consumption, and provides insights into the complex relationships among mixture components38.Scheffe's Simplex lattice design is a structured experimental approach used to optimize mixture compositions for various properties. It involves arranging experimental points in a systematic manner on a simplex lattice, where each point represents a specific mixture proportion. This design allows for the exploration of multiple factors simultaneously and accounts for their interactions45. The simplex coordinate system is defined as 39. Proportions assigned to each factor comprise m + 1 evenly spaced levels within the simplex coordinate system, with all feasible combinations stemming from these component concentration values. In the scenario of a quadratic lattice , where the response surface is approximated by second-degree polynomials (m = 2), the simplex cooinate 40. Every combination of these variables is applied in an experiment run, denoted as space points Ai, Aij, or Aijk for . The summation of component volume fractions equates to one, and this constraint defines a regular tetrahedron in the simplex factor space. This arrangement is illustrated in Fig. A simplex design is a form of mixture design where design points are systematically positioned on a simplex lattice. The coordinate system employed for each ingredient's value mentclass2pt{minim41.Mixture experiment designs are arrangements for response surface experiments where each component adheres to a scale value between 0 and 1, with the sum of components equating to one. In a mixture containing q components, the shape and layout of experimental points are defined by q−1 component. These constraints establish a (q−1) dimensional design space known as a simplex. Essentially, the design space dimension is consistently one less than the component count . Consequently, the factor space manifests as a regular (q−1) dimensional simplexi or Aij or Aijk for , is determined by Eq. 3.4 in a simplex lattice design. This result guides the required number of experimental runs42.In a (q−1) dimensional simplex, when q = 2, two connecting points create a straight-line simplex lattice. For q = 3, a triangular simplex lattice forms with equal sides; similarly, q = 4 yields a tetrahedron simplex lattice. (q−1) dimensions shape the boundary where q components interact within a mixture. The number of design space points N, represented as AThus, in the general canonical form of mixture models is mathematically expressed in Eqs. –7; for Li and j in Eq. Multiplying Eq.  by bo we1, X2, X3, X4, and X5 we get the relationship in Eq.  and the tenary blends (βij) as shown in Eqs.  for each component in mixture designs, similar to Scheffe's modeld in Eq. .16\docum47.Z signifies the real components which is the actual fraction of ingredients added to the mixture for a given run of experiment, whereas X stands for the surrogate components, with A as the constant, represented by a 5 × 5 matrix. The matrix A components are derived from the initial five mix ratios, forming a 48.The generation of initial trial mixes was initiated through a combination of expert judgment, practical experience, economic considerations, and insights from pertinent literature. This approach aimed to initiate the calculation of interaction points using Eq.  The aim The initial mix ratios are:Z1 [0.95:0.46:2.0:4.0:0.05], Z2 [0.85:0.46:1.85:3.75:0.15], Z3 [0.70:0.5:2.15:4.15:0.3], Z4 [0.65:0.55:2.25:3.92:0.35], Z5 [0.5:0.6:1.75:3.64:0.5].The corresponding pseudo mix ratios are:X1 [1:0:0:0:0], X2 [0:1:0:0:0], X3 [0:0:1:0:0], X4 [0:0:0:1:0], X5 [0:0:0:0:1].i and Zi into Eq.  for the control test points, the model equation is employed by substituting the respective values of coded units X1, X2, X3, X4, and X551.The effectiveness of the developed Scheffe's model is evaluated using statistical techniques, specifically through analysis of variance (ANOVA). These tests are applied to ascertain any disparities between the actual outcomes and the model-predicted results for the control experimentNull Hypothesis•There is no noteworthy distinction observed between the strength outcomes predicted by the model and those obtained from laboratory tests.Alternative Hypothesis•A considerable contrast exists between the strength outcomes projected by the model and those derived from laboratory testing.51.POFA samples shall be collected in a sack from different location within Cross River South and Central Palm Mill. Global Positioning System (GPS) coordinates and site photographs shall also be taken. The collected POFA samples shall be taken to the laboratory where it is oven dried. Sieving of the POFA samples may be necessary to remove all unwanted materials contained in the sample in agreement with BS 8615-1 (2019) and ASTM C618 standardsThe coarse aggregates shall be 15–22 mm grain size, obtained from Saturn quarry at Akamkpa Local Government Area of the State.Fine aggregates were obtained from the Calabar river and classified within the sharp sand envelope in accordance with BS EN12620 specifications.52.Material shall be obtained from United Cement Company of Nigeria (UNICEM), Akamkpa Local Government Area with 32.5 grade and normal consistency of 30% in accordance with Nigerian Industrial Standard (NIS) 444-1 requirementDrinkable or potable water, a crucial element, influences the mechanical and rheological characteristics of concrete, meeting the specifications outlined in ASTM C1602-12.The area of study under review was tailored around the availability of the concept material in view which is central and southern Cross River State shown in Fig. 2 was aimed for, with a cement content of 290 kg/m3, coarse aggregate content of 1198.65 kg/m3, and fine aggregate content of 766.35 kg/m3 for the design53. The concrete ingredients were mixed thoroughly with water to ensure uniformity before compaction and placement into the mold for mechanical strength assessments. Fresh concrete was also tested to evaluate setting time and workability. Following this, the concrete samples were cured in a tank at room temperature for 28 days after which they were subjected to structural property investigations. This study aims to explore the structural attributes of POFA concrete54.The concrete mix involves partially substituting cement in the matrix with POFA. Utilizing Scheffe's statistical technique, the mix formulation was determined using the mathematical relationship between real and pseudo-components. The target strength of 25 N/mm55.Sieve analysis is a fundamental technique used to determine the grain size distribution of aggregates in concrete. This method involves passing a sample of aggregates through a series of sieves with progressively smaller openings in accordance with BS EN 933-1:2012 specification. The amount of material retained on each sieve is measured and used to create a particle size distribution curve. This curve provides valuable insights into the composition and grading of aggregates, which directly influence the properties of concrete, such as workability, strength, and durability. By analyzing the distribution of different particle sizes, engineers and researchers can optimize concrete mix designs, ensuring the right balance of coarse and fine aggregates for desired performance characteristics56.The slump test is a commonly employed method to assess the workability or cohesion of newly mixed concrete. This technique offers insights into the concrete's capacity to flow and adapt without separation or excessive liquid release. Furthermore, it offers valuable insights into how effortlessly the concrete can be positioned, condensed, and refined during the construction process. Fresh concrete's workability is assessed through slump tests. These tests adhere to the guidelines stipulated in BS EN 12350-2:20092 per minute until failure occurs. The compressive strength of each cube will then be calculated as the load at failure divided by the sample's surface area, expressed mathematically as shown in Eq. (58.2)The compressive strength experiment is a fundamental test conducted on concrete specimens to assess their ability to withstand axial loads without failure. This procedure will be conducted on solidified concrete cubes with dimensions of 150mm x 150mm x 150mm, following the guidelines outlined in BS EN 12390-3:2019 for concrete compressive strength testing. After casting, the concrete cubes will be allowed to solidify for 24 h, followed by a 28-day curing period before testing. Subsequently, each cured sample will be placed between two plates in a Universal Test Machine (UTM), which will apply a load uniformly across the two opposing faces. The load will aim to flatten the sample, causing compression along the load's direction and expansion perpendicular to it. The loading will be incrementally increased at a rate of 140 kg/cmn in Eq. 57,58.17\60The splitting tensile strength experiment is a test conducted on cylindrical concrete specimens to evaluate their resistance to cracking and failure under tensile stresses. The cylindrical specimens are prepared and cured for a specific duration, commonly 28 days. After curing, the specimens are placed horizontally in a testing machine, and a diametrical load is applied to the cylindrical surface following the specifications defined in BS EN 12390-6:2019. The blended concrete mixture is filled into cylindrical molds measuring 100mm in diameter and 300mm in height. Following a day's period, the specimens are extracted from the molds and transferred to a water bath maintained at a consistent temperature range of 23–25 °C. This step is undertaken to determine the tensile strength of the mixture after it has been cured for 28  days, utilizing a crushing apparatus. The splitting tensile strength of the specimen is calculated using the formula presented in Eq. 59,6018\d2 is determined using the mathematical expression in Eq.  concrete reveal significant insights into the behavior and performance of the optimized concrete mixture. Through the utilization of Scheffe's statistical approach, the study aimed to enhance the mechanical properties of concrete by incorporating POFA as a partial replacement for cement. The investigation began with the development of mixture ratios using mathematical models based on Scheffe’s approach. The desired characteristic strength of 25 N/mm65.Laboratory tests were conducted on the mixture components to assess their overall engineering behaviour as civil construction materials. The test aggregates and admixtures underwent sieve analysis and specific gravity tests to evaluate their gradation and particle size distribution. Figure 2 (62.8%), Al2O3 (4.6%), and Fe2O3 (3.02%), totaling 70.52% by composition indicating good pozzolanic properties in line with ASTM C618, 98 specifications. The test Portland cement and POFA under study from the obtained results, exhibit significant levels of calcium oxide (CaO) at 10.23% and 7.6% respectively. This abundance of CaO boosts complete hydration of cement, improving the mechanical strength and durability characteristics, as depicted in Table 67.Table ), Al2O3 .6%, and 1 experimental point achieved a maximum slump of 125mm with ratio of 0.92:0.44:2.18:3.85:0.03 for cement, water, coarse agg., fine agg., and POFA respectively. In contrast, Y5 experimental point achieved a minimum slump of 41mm with mix ratio of 0.5:0.6:1.95:3.72:0.5 for cement, water, coarse agg., fine agg., and POFA respectively. The findings indicate a linear decrease in slump response as the admixture percentages in the mix increase. In the context of this study, the slump test results for palm oil fuel ash (POFA) concrete offer valuable insights into the concrete’s ability to flow, deform, and retain its homogeneity without excessive segregation or bleeding68Laboratory tests were conducted to assess the workability properties of the freshly mixed POFA-cement blend concrete. The aim was to determine the place ability and workability properties of the fresh concrete mixture with varying ratios of POFA-cement combinations from Scheffe’s mixture design. The experimental results signify that the slump test value decreases with increasing POFA fractions in the concrete mixture, requiring more water to enhance workability. This may be due to the presence of alumino-silica content in the admixtures and increased surface area. The obtained experimental result is presented in a graphical plot shown in Fig. 4 had the highest compressive strength at 31.16 N/mm2, while Y5 had the lowest at 19.82 N/mm2 . Graphical representations in Fig. 74.Regression model validation is a crucial step in the analysis of data and the development of predictive models. In the context of a regression model, validation refers to the process of assessing the model's accuracy and reliability in predicting outcomes for new or unseen data. This helps in gauging the model's generalization capability, which is essential for its practical applicability75.Statistical evaluation of model performance using ANOVA is a powerful technique commonly used to assess the accuracy and significance of regression models. ANOVA helps to determine whether the variation in the response variable can be adequately explained by the model's predictors. It essentially compares the variability of the observed data to the variability of the data predicted by the regression model. The main objective is to evaluate whether the model's predictors (independent variables) have a significant impact on the response variable (dependent variable)76.A significant ANOVA result indicates that the regression model is valid and provides valuable insights into the relationship between the predictors and the response variable. However, a non-significant ANOVA result suggests that the model might not be appropriate, and further investigation or model refinement may be necessary. In summary, ANOVA is a fundamental tool for statistical evaluation in regression analysis, helping researchers and analysts determine the adequacy and significance of their models, ultimately leading to better decision-making and insights from the data78.Analysis of variance (ANOVA) was carried out using Microsoft Excel statistical software which was deployed to evaluate the prediction performance of the developed second-order regression models for the compressive, flexural and splitting tensile strength optimization. This evaluation is based on the comparison of laboratory and model-predicted values at a 95% confidence interval, as presented in Tables 80.Similarly, for the flexural strength we obtained F = 0.538, F crit = 4.196 and p-value of 0.47. Also, we observe the criteria that F crit > F. finally, for the splitting tensile strength results, F = 0.000188, F crit = 4.196 and p-value of 0.989 was calculated which indicated that F crit > F. The statistical examination outcome showed that the difference between the actual laboratory-derived results and the model results was not significant which signified that the models developed possessed good prediction accuracyThe study employs Scheffe's quadratic polynomial to predict mechanical properties in POFA-cement concrete. The model estimates strength values based on mix ratios or determines ratios for desired strengths.The evaluation of the rheological properties of the freshly mixed POFA-cement blended concrete shows that the incorporation of admixtures led to a reduction in the slump response of the fresh blended concrete specimens.2 and 8.84 N/mm2, achieved with a mix of 0.65:0.54:2.3:3.96:0.35 for cement, water, coarse aggregate, Fine aggregate and POFA respectively. Additionally, splitting tensile strength reached 8.84 N/mm2 with a mix of 0.62:0.55:2.09:3.86:0.38.The maximum compressive and flexural strength at 28 days were 31.16 N/mm2 and 4.25 N/mm2, was achieved with a mix of 0.5:0.6:0.95:3.72:0.5 for cement, water, coarse aggregate, Fine aggregate and POFA respectively. Similarly, splitting tensile strength was minimal at 2.08 N/mm2 with a mix of 0.97:0.44:2.18:3.85:0.03.The lowest compressive and flexural strength, at 19.82 N/mmThe model's accuracy was assessed through ANOVA, revealing a strong correlation between the model's predictions and the laboratory-derived control results. The strengths predicted by the model closely align with the corresponding experimentally observed outcomes, indicating good agreement between them.Furthermore, using desired percentages of agricultural waste and their derivatives such as POFA in concrete production leads to cost savings, promoting sustainability, and playing a significant role in waste management.The study focused on exploring the mechanical behaviour of green concrete containing palm oil fuel ash (POFA) through an optimization process using Scheffe's theory. The conclusions drawn from the research findings and results are as follows:Limited Scope of Variables: One limitation of this research is the focus on specific variables for optimization, such as mix proportions and curing conditions.Short-Term Evaluation: The mechanical properties of concrete were evaluated after 28 days of curing. Longer-term studies tracking the performance over several years or decades would provide a more comprehensive understanding of how POFA concrete behaves over time.Laboratory Setting: The research was conducted in a controlled laboratory environment. Real-world construction sites may have variations in conditions that could affect the performance of POFA concrete differently. Field studies and on-site assessments could complement these findings.Material Variability: The properties of POFA can vary based on its source and processing methods. Future research should explore how these variations impact the effectiveness of Scheffe's optimization in different contexts.Although the current research on Scheffe's optimization of POFA concrete offers valuable insights, there are opportunities for future work to address limitations and further advance the understanding and practical implementation of this sustainable construction material. Future research on the optimization of POFA concrete using Scheffe's method should encompass a broader range of variables, emphasize long-term performance, consider environmental and economic aspects, comprehensive life cycle assessments and focus on practical implementation in real-world construction projects. These recommendations can contribute to the sustainable advancement of the construction industry.


To assess and analyse the knowledge of recommended antibiotic treatments, focusing on the appropriate drugs and treatment durations for the most common community-acquired infections in general medical practice in Occitanie region, France. A web-based survey was conducted over a 3-month period, from October, 2018 to January, 2019. All participants answered directly through the online platform. For the analysis of overtreatment risk, a score based system was adopted and two scores were produced: the duration score and the treatment score. 413 general practitioners completed the survey. The overall rate of concordance with guidelines in terms of both drug choice and treatment length was 2974/4956 (60%) answers. Diseases with at least 70% good answers included cystitis, group A streptococcal pharyngitis, and bacterial superficial skin infections. Diseases with fewer than 50% good answers included pyelonephritis, dog bite wounds, and community-acquired pneumonia in patients aged ≥ 65 years. Factors associated with the risk of overtreatment were age > 40 years, country setting and hospital employment. Knowledge of treatment durations is satisfactory with 60% of recommendations being met. However, varying levels were observed according to different diseases. This study highlighted a very high rate of adherence when recommendations were clear. In contrast, low levels of adherence were observed when recommendations were ambiguous or when conflicting guidelines existed. In terms of public health, it is advisable to reduce the treatment duration to minimize the risk of selecting and proliferating resistant bacteria. Consequently, antibiotic stewardship programs focused on reducing antibiotic treatment durations. In alignment with this objective, the French Society of Infectious Diseases (Societé de Pathologie Infectieuse de Langue Française or SPILF) released guidelines in 2017 specifically aimed at reducing antibiotic treatment durations2. These guidelines were updated in 20213.Antibiotic over-prescription is a significant public health issue. Indeed, excessive antibiotic use escalates public expenditure and propels the spread of antibiotic-resistant bacteria4. Currently, the rate stands at 32.1 daily defined dose (DDD)/1000 habitants/day in France, compared to the European Union’s 22.4 DDD/1000 habitants/day. A staggering 93% of these prescriptions come from the outpatient sector, with general practitioners (GP) accounting for 71% of them. Primary drivers for antibiotic prescriptions include ear-nose-throat (ENT) infections (42%), lower respiratory tract infections (25%) and urinary tract infections (8%)1. These statistics place France among the top antibiotic consumers in Europe5.Over the past two decades, antibiotic consumption in France has followed a three-phase trend. Between 2000 and 2004, there was a notable decrease of 18.9%, coinciding with the national campaign “Antibiotics are not systematic”. This was followed by a period of stability from 2005 to 2010. However, from 2011 to 2020, there was an increase in antibiotic consumption by 8.6%6. In practical terms, this entails a judicious antibiotic prescription, with the appropriate drug, for a set duration, and adhering to a specified dosage regimen. Nonetheless, few studies have assessed the knowledge level concerning the recommended antibiotic treatments in terms of appropriate molecule and treatment duration for community-acquired infections in general practice.Alterations in antibiotic prescription behaviours and emphasizing the appropriate use of antibiotics are fundamental aspects of antibiotic stewardship programs. The appropriate use of antibiotics refers to conditions that ensure an optimal benefit-to-risk ratio when administering a specific drug to an individualThe primary objective of this study was to evaluate and analyse the knowledge level of recommended antibiotic treatments in terms of appropriate drug and treatment duration for the most common community-acquired infections encountered in general practice.i.Identifying the conditions most often associated with a treatment duration exceeding guideline recommendations.ii.Determining the factors associated with extended antibiotic treatment.The secondary objectives included:Occitanie region in France had free access to the survey on the WebQuest® online platform. The survey was distributed via web mails, scientific journals, and social media. Collaborative entities included: the regional union of health care professionals of Occitanie, the network of general medicine residents from Toulouse-Purpan University’s Medical Faculty, the group of referents in extra-hospital infective surveillance, and the young infectious diseases specialists. To maximize GP participation, the survey was also promoted on social media platforms. All respondents submitted their answers directly through the online platform. Submissions were fully anonymized. The survey in French language is available on reasonable request to the corresponding author. Data from all respondents were analysed without exclusions.A web-based survey was conducted over a span of three months, from October 15th, 2018, to January 15th, 2019. GPs and general medicine residents from the 3. The basis for the questionnaire was the study by Cecilia Costa, validated at Marseille University on May 23rd, 20187. The survey was anonymous and structured in two sections : (i) Demographic and professional characteristics of the respondent ; (ii) Clinical cases covering 12 distinct conditions: group A streptococcal pharyngitis (GASP), bacterial maxillary sinusitis, bacterial frontal sinusitis, congestive otitis in children, cystitis in women, pyelonephritis in women, urinary tract infections (UTI) in men, bacterial superficial skin infections, dog bite wounds, community-acquired pneumonia (CAP) in patients aged ≥ 65 years, and mild exacerbation of chronic obstructive pulmonary disease (COPD). Respondents were presented with open-ended questions regarding empirical antibiotic treatment and multiple-choice questions on treatment duration. The gold standard for treatment was established using the 2017 French national guidelines endorsed by the SPILF2. Exceptionally, for COPD exacerbation, guidelines from both the SPILF and the French Agency for the Sanitary Safety of Health Products (Agence Française de Sécurité Sanitaire des Produits de Santéor AFSSAPS) were referenced due to their divergent recommendations (antibiotic treatment as per SPILF vs no antibiotic treatment as per AFSSAPS)8.The survey was designed by two infectious diseases specialists, members of the board of the French Society of Infectious Diseases and authors of the French guidelines on antibiotic treatment durationTo analyse the overtreatment risk, a scoring system was implemented, resulting in two scores: the duration score and the treatment score. In practice, answers to the twenty-four questions (twelve on the choice of molecules and twelve on antibiotic treatment duration) submitted by each respondent were analysed. Responses aligning with the durations and/or types of drugs suggested by the national guidelines were deemed correct. For both the duration and treatment scores, a value of 0 points was allocated for each correct answer, while 1 point was allocated for each incorrect answer. The cumulative score was then calculated. Finally, prescribers with a duration or treatment score exceeding the 75th percentile were identified.The required number of participants was calculated based on a standard p-value of 0.05, a precision of 0.05, and an arbitrarily designed expected proportion (p) of physicians in agreement with the measures set at 20%. Using the formula n = 1.962 × p (1–p), the minimal number of physicians necessary to yield a statistically significant outcome was determined to be 245.Diseases were categorized into three groups based on the percentage of correct answers: (i) diseases with a low level of knowledge (≤ 50% of correct answers); (ii) diseases with a moderate level of knowledge (51–69% of correct answers); (iii) diseases with a high level of knowledge (≥ 70% of correct answers).Excel 2016® software and the pvalue.io© website. Descriptive analysis displayed data as either mean values or observed number of events. Student’s t test was used for inferential analysis. The following analysis were performed : (i) descriptive analysis of the characteristics of each practitioner ; (ii) descriptive analysis of the responses to all 12 questions; (iii) comparison between the characteristics of practitioners with a duration score exceeding the 75th percentile and those with a duration score equal to or below the75th percentile; (iv) comparison between the characteristics of practitioners with a treatment score above the 75th percentile and those with a duration score equal to or below the 75th percentile.For statistical analysis, we used 10. Methodological and ethical considerations received approval from the Medical Department of Pierre and Marie Curie University in Paris, France, on January 25th, 2018. An electronic consent form was signed by each respondent.This study was conducted in accordance with the Declaration of Helsinki, as well as other national and institutional standardsA total of 413 physicians responded to the survey. The characteristics of the participants are detailed in Table Diseases with a correct response rate higher or equal to 70% included cystitis, GASP, paediatric congestive otitis, and bacterial superficial skin infections. Paediatric congestive otitis  was incorrectly prescribed antibiotics by 123/413 (30%) physicians.Diseases with a correct response rate between 51 and 69% included bacterial frontal sinusitis, bacterial maxillary sinusitis, and UTIs. For bacterial sinusitis , the combined correct response rate was approximately 60%.Diseases with a correct response rate lower or equal to 50% included pyelonephritis, dog bite wounds, CAP in patients aged 65 and above, and COPD exacerbations. The combined correct response rate for these diseases was 43%.Pyelonephritis in women was accurately treated in 48% of cases, despite 30% of the prescriptions suggesting a treatment duration longer (10 to 14 days) than guidelines (7 days).For prophylactic management of dog bite wounds, only 41% of physicians adhered to the recommended treatment duration. Treatment durations frequently exceeded guidelines, with an average of 6.1 days (+ 1.1 days) for the first-line antibiotic (Amoxicillin/clavulanic acid), 7.0 and 7.2 days (+ 2 and + 2.2 days) for the second-line antibiotics (Doxycycline and Pristinamycin). In some instances, the treatment extended to as long as 10 days in 7% of prescriptions.As for COPD exacerbations, approximately 1/3 of the physicians adhered to the AFFSAPS recommendations, opting not to prescribe antibiotics, while 2/3 of the physicians prescribed antibiotics, in alignment with the SPILF guidelines. Within this context, an appropriate answer in terms of both drug and treatment duration was observed in 37/413 (12%) responses.For the management of community-acquired pneumonia in elderly patients (aged ≥ 65 years), a mere one-third (27%) of physiciens adhered to the guidelines regarding the first-line antibiotic (amoxicillin/clavulanic acid) and treatment duration (7 days).Factors associated with the propensity for overtreatment included: age over40 years, practising in rural settings, and holding a hospital-based position, as detailed in Table 13. The inclination for over-treatment among hospital doctors (p < 0.001) is more challenging to interpret. One hypothesis is that their responses could be influenced by their routine exposure to critically ill patients, often requiring broad spectrum antibiotic treatments.This study assessed the knowledge level of GPs for recommended treatments and the factors associated with the over-prescription of antibiotics for community-acquired infections. We found that physicians aged over 40 years (p = 0.001) were associated with antibiotic over-prescription. This finding is consistent with previous data on antibiotic consumption in France, which suggests an association between antibiotic over-prescription and the age of the practitionerHeterogeneous levels of knowledge were observed according to the different diagnoses: low (≤ 50% of correct answers), mild (51–69% of correct answers) and high (≥ 70% of correct answers).14. In our study, the duration of antibiotic prophylaxis for dog bite wounds exceeded the recommended duration . This discrepancy might be attributed to the French guidelines, which allow for an extension of treatment duration up to 10 days when signs of local or general infection are presents2. Yet, the likelihood of infection post-animal bites vary based on the context and the animal species involved. In particular, cat bite wounds tend to be more frequently infected than dog bite wounds15. Moreover, surgical intervention plays a significant role in reducing wound infection. In some instances, surgical repair proves as effective as antibiotic prophylaxis in preventing wound infection post-animal bites17, Further research is required in order to determine the optimal management strategy for animal bites while reducing antibiotic over-prescription.Prescription of antibiotic prophylaxis following an animal (dog) bite is a standard practice endorsed by several national guidelines, including French guidelines18. Still, there’s room for improvement, especially concerning the antibiotic duration. Indeed, shorter treatment durations (5 days) for simple acute pyelonephritis are recommended by guidelines endorsed by the European Association of Urology19.Our research showed that over 30% of practitioners recommended a longer antibiotic treatment (10 to 14 days) than guidelines (7 days) for treating pyelonephritis in women. Such findings are of significant concern, given that fluoroquinolones (first-line antibiotics) are broad-spectrum antibiotics, which play a pivotal role in the emergence of bacterial resistance. The problem also arises, albeit to a lesser extent, with second line antibiotics . As part of ongoing efforts to fight antibiotic resistance, new French guidelines for the management of urinary tract infections were published in 2021. In these recommendations, fluoroquinolones have been downgraded to third-line drugs, with trimethoprim-sulfametoxazole emerging as the preferred first-line antibiotic20.UTIs in males were generally managed appropriately in terms of antibiotic selection, but results were poor when duration of antibiotic treatment was considered. Indeed, 19% of prescriptions exceeded the recommended duration (14 days). The optimal duration for antibiotic treatment for UTIs in males remains controversial. The various presentations of UTIs in males  are often difficult to define, especially in a community-based setting9. Furthermore, prevailing medical practices might be influenced by other factors, either intrinsic  or extrinsic , as corroborated by prior research22. Our findings emphasize the lack of information and highlight the need for improving the distribution of endorsed guidelines. New French guidelines are currently in progress considering the results of a recent trial which demonstrated the non-inferiority of 5-day treatment versus the standard treatment (7 days) for patients with a CAP and a favourable evolution23. However, improvements are required for the choice of molecules as well. Indeed, France ranks as one of the top consumers of extended spectrum penicillins ± beta lactamase inhibitors within the European Union24. One of the main indication for extended spectrum penicillins in France is pneumonia, while narrow spectrum penicillins are preferred in other European countries25. Moreover, guideline recommendations are predominantly shaped by hospital-based specialists who face routinely severe pneumonia cases requiring an urgent life-saving antibiotic treatment. Consequently, broad-spectrum molecules (e.g. beta-lactam + beta-lactamase inhibitor) are usually prescribed in hospital settings. Conversely, narrow-spectrum antibiotics are more fitting for non-severe outpatient cases, aligning with guidelines from other European countries. This strategy is similar to the United Kingdom’s approach, which favours amoxicillin as first-line treatment26. The variations in national guidelines can be attributed to the level of knowledge of CAP microbiology. Further research is necessary to improve knowledge of pneumonia epidemiology in France with the objective to minimize the use of broad spectrum penicillins.In this study, only one-third (27%) of practitioners adhered to the guidelines regarding the choice of first line drug (amoxicillin/clavulanic acid) and duration (7 days) for managing CAP in individuals aged 65 and above. A potential confounding factor may be the older guidelines endorsed by SPILF and AFFSAPS in 2010, which recommended the use of amoxicillin for 7–14 days for both adults and the elderly2. It is possible that many practitioners would be misled by other guidelines which recommended amoxicillin as first line treatment of otitis media27. These findings are in line with those from others studies, and emphasize the necessity of improving educational interventions among GPs28. Indeed, antimicrobial stewardship programs can focus on situations where “antibiotic treatment is contraindicated or not beneficial”29. The decrease of antibiotic prescriptions after antimicrobial stewardship programs was demonstrated in case of viral infections in community30.This study showed moderate findings related to the treatment of ear-nose-throat infections. For bacterial sinusitis, the combined accuracy rate  was almost 60%. Moreover, an inclination to prescribe a treatment exceeding the recommended duration (7 days) was observed for second line drugs . For congestive otitis in children, 30% of practitioners prescribed antibiotic therapy, even though no antibiotic treatment is recommended according to SPILF guidelines, as the majority of congestive otitis cases are viral in origin31. While antibiotics are fundamental to treating COPD exacerbations, their appropriate administration in instances of severe, albeit non- life-threatening exacerbations remains a subject of debate. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest using oral antibiotics in the presence of signs of infections, but the best strategy to detect infection remains controversial. The most prevalent method to evaluate infection risk during a COPD exacerbation is the evaluation of sputum purulence, though its use in a GP’s clinical practice is limited by its interpretive subjectivity. Additionally, sputum culture isn’t practical in community settings. Similarly, the use of biomarkers of infection during COPD exacerbation  remains controversial, with research yielding inconclusive outcomes32. Moreover, an important confounding factor is the existence of divergent guidelines. In France, AFSSAPS 2011 guidelines did not recommend any antibiotic treatment, while SPILF 2017 guidelines recommended a 5-day antibiotic course8. Given this lack of clear consensus, the management of COPD exacerbations is often based more on the practitioner’s clinical experience rather than established guidelines34. Thus, the prescription of an antibiotic treatment during a COPD exacerbation frequently presents a conundrum for GPs. In this context of confusion, harmonization of guidelines is advisable.Exacerbations of COPD are common in a GP’s daily practice. As the general population ages, with the consequent increase in comorbidities, its burden is expected to grow in the following yearsFor cystitis in women, GASP, and bacterial superficial skin infections, no criticisms were highlighted by this study.This study presented several limitations: (i) the survey was diffused principally through internet and social media. Consequently, a younger population was selected (31 years old for this study vs 57.1 years old for French GP populations). Because age is a cause of over-treatment, our study likely underestimates prescription times; (ii) the absence of some data in the clinical cases included in the survey  reduced the evaluation of treatment duration; (iii) The survey was designed to be completed by each prescriber in less than 15 min. For this reason, some frequent community-acquired infectious diseases were excluded, such as: cystitis in pregnant woman, acute diarrhoea, otitis media in children less than 2 years old; (iv) This study was based on a web questionnaire. Answers could attest the global knowledge of GPs rather than their attitude in daily clinical practice.Occitanie). It analysed the knowledge of 413 GPs about official guidelines concerning 11 infectious diseases which are routinely managed in GP’s office: GASP, bacterial maxillary sinusitis, bacterial frontal sinusitis, congestive otitis in children, cystitis in women, pyelonephritis in women, UTI in men, bacterial superficial skin infections, dog bite wounds, CAP in ≥ 65-year-old patients, COPD mild exacerbation.This study presented the answers to a Web based survey in a French region  diseases with low level of knowledge (≤ 50% of correct answers) were pyelonephritis, dog bite wounds and CAP in patients ≥ 65-year-old.; (ii) diseases with mild level of knowledge (51–69% of correct answers) were bacterial frontal sinusitis, bacterial maxillary sinusitis and UTI; (iii) diseases with high level of knowledge (≥ 70% of correct answers) were cystitis, group A streptococcal pharyngitis and bacterial superficial skin infections. Moreover, the study identified age > 40-year-old, country setting and hospital job as factors associated with the risk of overtreatment.Results of this study shows that rate of adherence is high when recommendations are clear while it falls when different guidelines existed or are not clear. According to data presented in this article, there is a limited margin of progression for the proper use of antibiotics when guidelines are clear. It is necessary to provide simplified and updated guidelines through channels accessible to GPs.


Antibiotics have undoubtedly revolutionized medicine and the health and survival of patients with life-threatening infections, being nonetheless free from potential adverse effects, and the risk of intestinal dysbiosis, antimicrobial resistance, and the resulting consequences for the patient’s health and the public purse. The present study narratively reviewed the epidemiological data on worldwide antibiotic consumption and administration in dental practice, patients’ adherence to prescriptions, the antimicrobial resistance phenomenon in dentistry, and the evidence supporting and recommending appropriate antibiotic use in dental care. Eligible systematic reviews and original studies in humans published in the English language from January 2000 to 26 January 2023 were considered. A total of 78 studies, 47 on the epidemiology of antibiotic use and prescription in dentistry, 6 on antibiotic therapy in dentistry, 12 on antibiotic prophylaxis in dentistry, 0 on adherence of dental patients to antibiotic prescription, and 13 on antimicrobial resistance in dentistry, were presently considered. Retrieved evidence revealed that antibiotics are frequently overused and misused in dental practice, dental patients frequently do not adhere to prescriptions, and antimicrobial resistance in dentistry is a still rising phenomenon also secondary to improper oral antiseptics use. The present findings highlighted the need to establish more evidence-based and accurate antibiotic prescriptions to sensitize dentists and dental patients to minimize and rationalize the use of antibiotics only when it is indicated and necessary, improve patients’ adherence, and enhance knowledge and awareness of the antimicrobial resistance in dentistry. The development and use of antibiotics were one of the most important discoveries of the 20th century, revolutionizing the treatment of infectious diseases, thus saving millions of lives  and enabMost antibiotics used in medicine today are compounds produced naturally by bacteria or fungi, despite how they can also be purely synthetic or semisynthetic compounds, being thus referred to as chemotherapeutic agents . Among tClostridioides difficile, and antibiotic-induced colitis [Indeed, the potential benefit of antibiotic administration must be weighed against the risk of side effects, such as severe allergic reactions and anaphylaxis, infections caused by the bacterium  colitis . Specifi colitis .In light of these considerations, the present study narratively reviewed the epidemiological data on global antibiotic consumption and antibiotic administration in dental practice, prescription adherence of dental patients, and the phenomenon of antimicrobial resistance in dentistry, as well as the evidence supporting and recommending appropriate antibiotic use in dental care.The present narrative review focused the research questions on the current prevalence of antibiotic administration in dental practice for therapeutic and prophylactic purposes, reported indications for antibiotic prescriptions, and evidence concerning dental patients’ adherence to the therapy, antimicrobial resistance phenomenon, and antibiotic stewardship in dentistry, as well as the evidence supporting and recommending appropriate antibiotic use in dental care.An electronic search of the PubMed/MEDLINE, Web of Science, and Scopus databases was conducted through 26 January 2023 to find pertinent records. The present study had the systematic reviews and original human studies published in English from January 2000 to 26 January 2023 as the inclusion criteria, with the epidemiology of antibiotic use and prescription in dentistry; or antibiotic therapy in dentistry; or antibiotic prophylaxis in dentistry; or adherence of dental patients to antibiotic prescription; or antimicrobial resistance in dentistry as the main topics. Exclusion criteria were as follows: narrative and scoping reviews, commentaries, short communications, in vitro, preclinical and animal studies, non-English language articles, and being published before January 2000.The following filters were used for the electronic search of the PubMed database: Classical Article, Clinical Study, Clinical Trial, Comparative Study, Controlled Clinical Trial, Evaluation Study, Meta-Analysis, Multicenter Study, Observational Study, Randomized Controlled Trial, Systematic Review, Validation Study, English language, and published articles from 1 January 2000 to 26 January 2023. The following filters were used for the electronic search of the Web of Science database: English language and published articles from 1 January 2000 to 26 January 2023. The following filters were used for the electronic search of the Scopus database: Article, Review, English language, and published articles from 2000 to 2023.Antibiotic OR AntibioticsThe following keywords were used:ANDStewardship OR Administration OR Prescription OR Use OR Adherence OR Compliance OR ResistanceANDBacterial resistance OR Antimicrobial resistanceANDDentist OR Dentistry.Relevant references were collected, and related citations were managed using Mendeley Reference Manager software. Study selection was independently conducted by three reviewers .Three independent reviewers  extracted the data using a standardized form for data extraction. In case of any disagreements, the reviewers resolved them through discussion, and if necessary, a third author (R.S.) was consulted to reach a consensus.The author’s name, the year and journal of publication, the reference number, and the title of the study were collected for each record.The studies were categorized into five main topics: epidemiology of antibiotic use and prescription in dentistry; antibiotic therapy in dentistry; antibiotic prophylaxis in dentistry; adherence of dental patients to antibiotic prescription; antimicrobial resistance in dentistry.A total of 287 records were found from the electronic search, 50 from PubMed/MEDLINE, 123 from Scopus, and 114 from Web of Science databases; 93 duplicate records were removed before the screening. The remaining 194 titles and abstracts were screened, and 51 were excluded. The full texts of the remaining 143 reports assessed for eligibility were evaluated. Additionally, 65 articles were excluded because 40 records were narrative reviews, 17 involved only dental students, 5 did not report the use of antibiotics in dental practice, and in 3 articles, data concerning dentistry were not discernible.Finally, 78 studies were included .An additional electronic search was performed on the Google Scholar database to obtain additional records for discussion of the results.The 78 studies included were categorized into five main topics: 47 on the epidemiology of antibiotic use and prescription in dentistry, 6 on antibiotic therapy in dentistry, 12 on antibiotic prophylaxis in dentistry, 0 on adherence of dental patients to antibiotic prescription, and 13 on antimicrobial resistance in dentistry.In the present review, of the 78 included studies, 48 were cross-sectional studies, 9 were systematic reviews, 8 were retrospective studies, 5 were clinical trials, 4 were systematic reviews with meta-analysis, 2 were randomized control trials, 1 was a comparative study, and 1 was a qualitative study.In the present review, of the 47 studies reporting the epidemiology of antibiotic consumption and prescription in dentistry, 38 were cross-sectional studies, 4 were retrospective studies, 4 were systematic reviews, and 1 was a randomized control trial.The findings of the various studies about the epidemiology of antibiotic consumption and prescription indicated a lack of adherence to professional guidelines in prescribing antibiotics in dentistry. Only a small percentage of dentists refer to published guidelines for proper antibiotic prescribing, and an even smaller percentage were aware of national action plans on antibiotic resistance ,28,29,54Antibiotic overprescription, in particular of amoxicillin or other broad-spectrum antibiotics, was prevalent in cases where surgical treatment was the preferred choice, irreversible pulpitis, necrotic pulp, acute apical periodontitis, and endodontic emergencies ,31,42,53The COVID-19 pandemic significantly impacted antibiotic prescribing, with a substantial increase in prescriptions during and after the pandemic .Factors influencing antibiotic prescriptions in dentistry were identified as clinical context-related , patEducational interventions, postgraduate courses, and training programs have positively improved appropriate antibiotic prescribing in dentistry ,36. DentIn the present review, of the six studies reporting antibiotic therapy in dentistry, four were cross-sectional studies, one was a qualitative study, and one was a systematic review with meta-analysis.The findings of the studies about antibiotic therapy in dentistry highlighted the need for better adherence to guidelines and more appropriate prescribing patterns among dentists ,68.In periodontal and implant practice, there was significant heterogeneity in the prescription, duration, and initiation of antibiotics across various therapeutic treatments. These treatments include acute and chronic periodontitis, sinus lifts or crest augmentation surgery, and immediate or delayed implant placement . NonetheThe prescription of antibiotics by dentists for the treatment of inflammatory endodontic diseases was also inappropriate, indicating a lack of adherence to recommended prescribing practices .The study revealed the overuse of antibiotics and analgesics, particularly in the postoperative phase, by general dentists rather than specialists, for pain control and treatment of infections, even in children and adolescents .The general practitioner often considered antibiotics as the first-line treatment for the immediate management of acute dental problems, and patients themselves often requested antibiotics .In the present review, of the 12 studies reporting antibiotic prophylaxis in dentistry, 4 were cross-sectional studies, 4 were systematic reviews, 2 were retrospective studies, 1 was a systematic review with meta-analysis, and 1 was a randomized control trial.The findings of the studies about antibiotic prophylaxis showed the heterogeneity in the choices made by dentists for different procedures . ResponsThe choices made by dentists regarding antibiotic prescriptions for preventing infections in post-extraction surgical sites were very heterogeneous . The useAmoxicillin, with or without clavulanic acid, was found to be the most commonly prescribed antibiotic, at varying dosages and durations, for preventing infectious complications following the extraction of third molars . CompareThe use of antibiotics prophylactically for implant placement had limited supporting evidence. There was high variability in the pre-and post-operative prescription regimens of antibiotics in dental implant practice . ProphylThe prophylactic administration of 2/3 g of amoxicillin one hour before bone augmentation procedures in oral implantology was found to reduce the rate of early implant failure and the infection risk of grafted bone particles .In the present review, no study reporting dental patients’ adherence to antibiotic prescriptions was found. In the present review, of the 13 studies reporting antibiotic antimicrobial resistance in dentistry, 5 were clinical trials, 2 were systematic reviews with meta-analysis, 2 were cross-sectional studies, 2 were retrospective studies, 1 was a comparative study, and 1 was a systematic review.The findings of the studies on antimicrobial resistance highlighted the spread of antibiotic resistance ,84, in pAmpicillin, tetracyclines, and metronidazole showed the highest resistance rates, while azithromycin and ciprofloxacin had the lowest ,86,87,91The resistance increased with repeated cycles of antibiotic administration for the selection of microorganisms . FrequenAntibiotic consumption is steadily increasing worldwide, with penicillins being the most used class of broad-spectrum antibiotics in dentistry . In AustUnfortunately, a British study found that 80% of antibiotics used to treat acute dental diseases were unnecessary . AnotherAntimicrobial resistance is a public health problem that requires a global solution and, if not controlled, will have high human and economic costs. During the COVID-19 pandemic, the phenomenon of antimicrobial resistance continued to accelerate dramatically , and itsThe ineffectiveness of interventions implemented worldwide is evidenced by the fact that between 2000 and 2015, antibiotic consumption in 76 countries, expressed in defined daily doses (DDDs), increased by 65% (21.1–34.8 billion DDDs), and the rate of antibiotic consumption increased by 39% (11.3–15.7 DDDs per 1000 population per day) .In response to this growing global threat, the World Health Organisation launched a Global Action Plan on Antimicrobial Resistance in 2015 and published the Global Action Plan on Antimicrobial Resistance. Therefore, knowing the type and dosage of recommended antibiotics and the measures to combat antimicrobial resistance in dentistry is of utmost importance.Odontogenic infections are a group of diseases originating in the dental hard tissues or periodontium from microorganisms constituting dental and gingival biofilm. If not promptly intercepted and treated, they can lead to severe local or systemic complications. Odontogenic infections may derive from dental caries, trauma, pulpitis, periapical periodontitis, endoperiodontal lesions, pericoronitis, and periodontal disease. The most common cause of infection is periapical periodontitis, which in most cases is due to destructive caries, with the most affected teeth being the lower molars .Non-odontogenic infections include pyogenic infections of the face and neck region, oral mucosal infections, oropharyngeal candida, parotitis, and sialadenitis ,103,104.Despite the high incidence of odontogenic infections, there are no specific criteria for prescribing antibiotics in this area. A high percentage of cases of dental pain are due to pulp infections, which require operative intervention by the dentist rather than antibiotic treatment .Clinical situations requiring antibiotic therapy on an empiric basis are limited to and include oral infections associated with signs of systemic spread of infection ,65, suchAccording to the pathophysiology of pulp disease, blood circulation in the root canals is reduced; therefore, antibiotics cannot reach the pulp and eliminate the pathogens ,57. OnlyOf note, a systemic antibiotic prescription is recommended for necrotizing gingivitis and periodontitis ,107,108,Oral antibiotics effective for odontogenic infections include penicillin, clindamycin, erythromycin, cefadroxil, metronidazole, and tetracyclines. The type of antibiotics or their combinations and dosage depend on the severity of the infection and the predominant bacterial species . HoweverGuidelines for the judicious use of antibiotics have been published, suggesting that an accurate diagnosis should be obtained before prescribing a drug and that the specific antibiotic for the bacterium causing the infection should be used, rather than broad-spectrum antibiotics. The duration of treatment should be determined by the shortest amount of time required to eliminate all bacteria causing the infection, as shorter antibiotic cycles reduce the time the bacterium is exposed to the antibiotic and lower the rate at which the pathogen develops resistance, as well as reduce side effects and costs . AdditioProphylaxis of local infections includes the preoperative, intraoperative, and postoperative administration of antibiotics to prevent the multiplication and spread of bacteria at the level of the surgical lesion ,79. VariThe use of antibiotics for systemic prophylaxis is a common practice ,66,97. HIn the case of bacterial endocarditis, which is an inflammatory, proliferative, and exudative condition of the endocardium caused by a bacterial infection involving the heart valves, the absolute risk after dental procedures, even in high-risk patients, is considered very low ,110.The two principal indications for antibiotic prophylaxis in dentistry are the prevention of bacterial endocarditis and the prevention of surgical site infection (SSI) ,113,114.For bacterial endocarditis prevention, the British Society for Antimicrobial Chemotherapy and American Heart Association guidelines recommend antibiotic prophylaxis only for high-risk patients ,112,113.The National Institute for Health and Care Excellence (NICE) recommended antibiotic prophylaxis for high-risk subjects, such as those with prior endocarditis and heart valve replacement, undergoing high-risk dental procedures, including tooth extractions, scaling, and root planing, or undergoing periodontal surgery, by administering amoxicillin 3 g (or clindamycin 600 mg) orally 1 h before the procedure .For the prevention of surgical site infection, in addition to sterile surgical technique, proper perioperative administration and antibiotic selection is considered necessary for most surgical procedures performed on the mucous membranes of the respiratory, gastrointestinal, and urinary tract and in the presence of an active infection. However, antibiotic prophylaxis is not required for most dentoalveolar procedures ,118,119.The use of prophylactic antibiotics in tooth extractions is a topic that has been extensively studied, but the findings are mostly limited to third-molar extractions ,78. In tFor dental implant placement, there is moderate evidence that preoperative prophylactic antibiotics reduce the risk of implant loss by up to 2%, although likely unnecessary in low-risk patients undergoing single implant surgery. When prophylactic antibiotic administration is warranted, preoperative dosing is recommended. A preoperative dose of 2 g of amoxicillin has been shown to produce the same reduction in implant failure as a dose of 1 g with an additional two days of postoperative treatment ,125.Most studies support preoperative prophylactic antibiotic administration in oral and maxillofacial surgery in patients with serious underlying diseases or immunocompromised patients, such as those undergoing radiotherapy or chemotherapy ,80,126. In combating the phenomenon of antimicrobial resistance, one of the most important measures is to ensure patient adherence to therapy.Adherence to therapy can be understood as the extent to which a person’s behavior conforms to recommendations agreed upon by a healthcare provider. Patient adherence to antibiotic therapy is paramount in achieving therapeutic success and reducing the development of resistant bacterial strains. As a counterpart, nonadherence to drug therapy is a complex problem influenced by several non-modifiable and modifiable factors .The influence of non-modifiable factors such as age and gender on patients’ adherence to antibiotic prescription is still uncertain, the available evidence is still insufficient and often contradictory, and it is currently difficult to determine whether they influence adherence .Conversely, modifiable factors, on the other hand, significantly influence adherence and can be improved by targeted interventions.Knowing how to communicate with one’s patient is vital to improve adherence , and it Cognitive and educational interventions can improve adherence by increasing the patient’s awareness of his condition and the purpose of the prescribed therapy and motivating him to follow the dentist’s instructions .Moreover, combining medication administration with daily activities and interventions that affect patient behavior correlates with improved adherence .Furthermore, interventions based on electronically monitored adherence feedback have been shown to be effective, with an average increase in adherence of almost 20% .Simplification of drug therapy is desirable whenever possible, as a complex drug regimen is associated with lower adherence. In fact, treatment adherence is inversely related to the number of drug doses administered daily, being highest at one or two doses per day .Direct methods are generally not applicable to dental patients and measuring drug levels in body fluids, such as blood or urine, or measuring biomarkers.Indirect methods include electronic adherence monitoring devices, pill counting, pharmacy refill rates, and self-report ,131.The adherence measurement also has a significant positive impact when performed regularly . There aDirect measurement involves medications or biomarkers at regular or irregular intervals. It is an accurate and objective method that detects the patient’s medication use. However, it is a more invasive and costly procedure than other methods and does not allow an understanding of the causes of non-adherence. In addition, there is a risk of bias if the patient takes the medication just before the measurement .The main indirect methods of measuring adherence are electronic monitoring, pill counting, pharmacy refill rates, and self-report.The mechanisms that bacteria use to become resistant to antibiotics can be divided into four different classes : determiSeveral factors are involved in the development of antimicrobial resistance, mainly distinguishable into intrinsic factors due to natural bacterial resistance to one or more antibiotics, and acquired factors occurring when a population ordinarily sensitive to a given antibiotic becomes resistant to a given antibiotic thanks to the mutation of one or more genes (endogenous acquisition), or thanks to the external environment (exogenous acquisition) through horizontal gene transfer from the environment or other bacteria, which can originate from microbial or human factors ,21,135.Biofilm formation is triggered by several factors, including exposure of cells in the planktonic state to subinhibitory antibiotic concentrations . PathogeMarcinkiewic et al. reported that biofilm-related antimicrobial resistance depends on several factors . First, 2 concentration of the microenvironment or the vegetative state of the cells themselves. For example, a change in pH reduces the activity of aminoglycosides, while a nutrient deficiency can cause a state of cell non-growth, leading to the failure of β-lactam drugs that require actively growing cells to be effective [Various nutrients may become scarce or fluctuate in concentration, altering bacterial metabolism and, consequently, the pH and COffective . Finallyffective .Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Tannerella forsythia, Prevotella spp., Streptococcus spp., Staphylococcus aureus, and Candida spp. [Recent studies have investigated the emergence of antimicrobial resistance in some of the major pathogenic species of the oral cavity, including ida spp. ,91,93.At the oral level, the difficulty in eradicating periodontal pathogens means the progression of periodontitis with increased destruction of tooth-supporting tissues and loss of alveolar bone and teeth, eventually leading to masticatory dysfunction and the need for complex dental prosthetic rehabilitation ,139,140.Failure to eradicate antibiotic-resistant dental and periodontal pathogenic species results in an inflammatory condition in the oral cavity that can have systemic consequences . ChronicIn addition to a systemic inflammatory state, oral bacteria may be associated with specific diseases such as cardiovascular disease, lung infections, oral cancer, diabetes, and neurodegenerative diseases such as Alzheimer’s disease . The sprChlorhexidine is a potent antiseptic widely used in dentistry. It was synthesized in the early 1950s in the United Kingdom by Imperial Chemical Industries as a potential antimalarial and introduced into dentistry in the late 1960s .Chlorhexidine, 0.2% mouthwash, is one of the most used mouthwashes in dentistry and by the general population to reduce the bacterial load in the oral cavity  to contrVeillonella species, which help regulate blood pressure by reducing nitrates to nitrites  [Studies by Tribble et al. and Brookes et al. on the effects of chlorhexidine on the oral microbiome show a decrease in colonizing species ,152,153. muscle) .However, exposure to subinhibitory concentrations of chlorhexidine promotes the development of resistance . In the Low chlorhexidine concentrations lead to increased antimicrobial resistance in Gram-negative and Gram-positive bacteria due to changes in their cell membrane structure and ion pump function .S. mutans and Porphyromonas [Short-term but repeated exposures to 0.12% chlorhexidine initially allow the inactivation of oral bacteria but may cause rapid re-growth of biofilms later. Prolonged and repeated exposures lead to the development of pathogenic species such as yromonas .A study by Saleem et al. investigated the chlorhexidine resistance of bacteria isolated from the dental plaque of five healthy patients and found that the bacteria were resistant not only to the antiseptic but also to several antibiotics such as ampicillin, gentamicin, tetracycline, and kanamycin .Candida albicans biofilms, leading to a higher risk of developing candidiasis, especially in immunocompromised patients [The review by Cieplik et al. highlighted how chlorhexidine rinses could induce the formation of “persisters” (cells with a specific phenotype that gives them lower susceptibility) in patients ,156.General factors and those specifically related to dental problems and practice contributing to antimicrobial resistance and/or antibiotic unresponsiveness are synthesized in Healthcare professionals play a critical role in maintaining the effectiveness of antibiotics . In factThe term “stewardship” refers to the careful and responsible use of something relied upon for one’s health, such as natural resources . To curbResponsible use of antibiotics in clinical practice is based on proper diagnosis and prescribing antibiotics only when indicated and is based on the following principles: Prescribing the most appropriate drug at the correct dose, by the proper route of administration, and for the most appropriate duration .Among the measures introduced by the World Health Organization to promote the conscious use of antibiotics is the new classification of these drugs into three groups with the acronym AWaRe  .The first group, Access, includes all antibiotics that offer the best therapeutic benefit with the lowest potential for resistance.The second group, Watch, includes the agents most susceptible to selective resistance.The third group, Reserve, consists of all those antibiotics, such as meropenem, that should be used little, especially in those microorganisms that have developed multi-resistance .In addition, the WHO experts recommend a mnemonic trick to help dentists and physicians to remember the components of good antimicrobial stewardship, using the acronym MIND ME: “M—Microbiology must guide therapy whenever possible; I—Indications should be evidence-based; N—Narrowest spectrum required; D—Dosage appropriate to the site and type of infection; M—Minimize the duration of therapy; E—Ensure monotherapy in most cases” .It begins with a careful clinical evaluation by taking the patient’s history and performing an objective examination. It must then be determined if further diagnostic testing is needed to decide what therapy to offer the patient.In this scenario, it has been recognized that it is necessary to control the phenomenon of antimicrobial resistance by promoting coordinated interventions in different areas  164,165165,166.Like all narrative reviews, the present study is limited by the fact that it lacks a systematic and rigorous methodology for searching, selecting, and synthesizing evidence and is, therefore, subject to various biases, including publication, selection, and reviewer biases. Narrative reviews, however, can be useful in providing a broad overview of a topic and conveying knowledge in a simple and understandable way that is appropriate for clinicians. Indeed, the present review aimed at the discursive synthesis of current evidence to popularize the topic in a simple manner to readers who are not familiar with the topic itself, and increase their awareness of antimicrobial resistance in dentistry secondary to both overuse and misuse of antibiotics. This may be particularly important when addressing dentists’ attitudes toward antibiotic administration and awareness of antimicrobial resistance.Retrieved evidence highlighted the need to establish more evidence-based and accurate antibiotic prescriptions in dentistry. Future perspectives should rely on sensitizing dentists and dental patients to minimize and rationalize the use of antibiotics only when it is indicated and necessary, enhancing knowledge and awareness of the antimicrobial resistance in dentistry, improving patients’ adherence to antimicrobial treatment, and developing alternative treatments, such as nutraceuticals, probiotics, or prebiotics. Moreover, the increasing knowledge of the oral microbiota brings us closer to personalized medicine and dentistry, based on individualized therapies and considering each person with its unique characteristics, and should be considered by current and future dentists to treat oral cavity infections better than before.A total of 78 studies, 47 on the epidemiology of antibiotic use and prescription for therapy and prophylaxis in dentistry, 6 on antibiotic therapy in dentistry, 12 on antibiotic prophylaxis in dentistry, 0 on adherence of dental patients to antibiotic prescription, and 13 on antimicrobial resistance in dentistry, were presently considered.A significant proportion of antibiotics prescribed for acute dental diseases and prophylaxis are unnecessary and inappropriate, leading to antibiotics overuse and misuse, increased bacterial resistance, and associated adverse outcomes. Antibiotics should only be prescribed in clinical situations requiring empiric antibiotic therapy and not for all odontogenic infections, and systemic antibiotics are recommended only for specific situations.The two primary indications for antibiotic prophylaxis in dentistry are preventing bacterial endocarditis and surgical site infection.Patient adherence to therapy is crucial for therapeutic success and for reducing the development of resistant bacterial strains.Improper prescribing of antibiotics is the main factor that promotes the emergence of resistant microorganisms, and many factors can lead to neglect of good practice. Indeed, every physician must know how to properly use antibiotics and educate their patients and colleagues.In conclusion, the responsible use of antibiotics in clinical practice is based on proper diagnosis and prescribing antibiotics only when indicated, and the World Health Organization recommends measures such as the new classification of antibiotics into three groups and the MIND ME acronym to promote the conscious use of antibiotics.