Evidence-based suggestions to promote antibiotic stewardship in dermatology

Antibiotics are highly effective treatments for a variety of dermatologic conditions, but overprescribing of these agents contributes to the emergence of antibiotic resistance and places patients at risk for resistant infections and treatment failures. To reduce the occurrence of antibiotic resistance, prescribers should reevaluate the frequency, dose and duration of antibiotic prescriptions, to eliminate unnecessary use. Dermatologists commonly prescribe oral antibiotics for skin and soft tissue infections, cutaneous surgeries and chronic inflammatory skin conditions. Tetracyclines are the most frequently prescribed antibiotics, followed by cephalexin and trimethoprim-sulfamethoxazole. Prescription trends have shown a recent decrease in the use of extended antibiotic courses for acne and rosacea, but this has been accompanied by a concerning increase in short antibiotic courses after surgical visits. Read: Comparing two therapeutic regimens to treat frontal fibrosing alopecia Antibiotic regimens typically used in dermatology can trigger a rise in antibiotic-resistant skin bacteria, which have been isolated from skin up to 336 days after the start of antibiotic treatment. Therefore, the skin may represent an underappreciated reservoir for antibiotic-resistant microbes. Antimicrobial resistance can lead to treatment failures. For example, in patients with acne, the presence of antibiotic-resistant Cutibacterium acnes on skin may be associated with suboptimal patient outcomes from inadequate responses to both topical and oral antibiotics. As skin can harbour antibiotic-resistant bacteria for extended periods, routine keratinocyte shedding has the potential to transfer resistant skin bacteria or antimicrobial resistance genes to the environment or possibly to other individuals. This is particularly concerning in the context of multidrug-resistant Staphylococcus epidermidis strains persisting on skin. It is very important for dermatologists to incorporate principles of antibiotic stewardship into prescribing practices, particularly since dermatologists in the United States continue to prescribe antibiotics at higher rates than other specialists. Strategies to promote antibiotic stewardship in dermatologic practice A recent editorial highlights strategies to promote antibiotic stewardship in dermatologic practice. Specific recommendations for antibiotic stewardship in common dermatologic conditions are summarized below. Acne Use alternatives to systemic antibiotics (e.g., spironolactone, oral contraceptives, systemic retinoids). Avoid oral antibiotics as monotherapies. Consider concurrent use with topical retinoids, with or without benzoyl peroxide. Prescribe the optimal dose and shortest effective duration of antibiotic treatment. Follow this with a topical retinoid, with or without benzoyl peroxide, for maintenance therapy. Use narrow-spectrum antibiotics (e.g., tetracyclines). Rosacea Encourage proper skin care, sun protection and trigger avoidance. Consider topical ivermectin, topical metronidazole, topical azelaic acid and physical modalities (e.g., laser and light devices), or oral isotretinoin for refractory cases. Consider concurrent use of antibiotics and topical metronidazole or topical azelaic acid. Consider sub-antimicrobial tetracycline dosing (although this can still lead to resistance development). Hidradenitis suppurativa Consider intralesional steroids (for acute lesions), procedural-based interventions (e.g., laser hair removal, deroofing, excision), hormone-based therapies or biologics. Surgical site infection prophylaxis Consider not using prophylactic antibiotics in low-risk groups. This may not be appropriate for high-risk patients (e.g., immunocompromised, high-risk cardiac conditions, joint prostheses) or high-risk anatomic sites (e.g., lower limb, groin). Consider topical decolonization with an antiseptic (e.g., chlorhexidine). Consider intra-incisional antibiotics. Consider a single preoperative oral antibiotic dose (this may not be appropriate for patients at high risk). Consider primary coverage (e.g., cephalexin) for gram-positive species of Staphylococcus and Streptococcus. Using the shortest effective duration of oral antibiotic has been suggested (e.g., three to four months for acne and hidradenitis suppurativa; One to two months for rosacea); however, antibiotic resistance to doxycycline has been detected as early as 14 days from the start of treatment. Read: Many acne vulgaris patients not using antibiotics for long enough By incorporating antibiotic stewardship principles into dermatologic prescribing practices, healthcare providers can optimize appropriate antibiotic use, limit the development and spread of antimicrobial resistance, and minimize antibiotic-associated complications. Reference 1. MacGibeny MA, Jo JH, Kong HH. Antibiotic stewardship in dermatology—reducing the risk of prolonged antimicrobial resistance in skin. JAMA Dermatol 2022;158(9):989-91. (accessed September 27, 2022).

Evidence-based suggestions to promote antibiotic stewardship in dermatology

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