Antibiotic Stewardship in Dermatology

Unnecessary antibiotics account for approximately 30% of all antibiotic prescriptions, according to a 2017 Centers for Disease Control and Prevention (CDC) report.¹ 

And among specialists, dermatologists have the highest antibiotic prescriptions per provider rate.^2,3 

Dermatologists are prescribing fewer antibiotics in recent years, with the per provider rate falling from 700 in 2013 to 628 in 2015.^2-3 A recent study published in JAMA Dermatology by John S. Barbieri, MD, MBA, and colleagues on oral antibiotic prescriptions in dermatology showed a similar trend, with a 36.6% decrease in oral antibiotic prescriptions among dermatologists from 2008 to 2016.⁴ While this decrease is significant, the JAMA Dermatology study also showed increases among antibiotic use for surgical procedures and conditions, suggesting that more needs to be done to improve antibiotic stewardship in dermatology. 

“Multiple factors influence prescribing, such as patient demand, time constraints and decision fatigue,” wrote Joslyn Kirby, MD, MS, MEd, and Jordan S. Lim, MB, BCH, BAO, in an editorial that accompanied the article.⁵ “Curbing the use of antibiotics is a challenge, not only for dermatologists but also for practitioners in other disciplines.” 

Positive Trends 

Since the early 2000s, the CDC and World Health Organization have stressed the importance of antibiotic stewardship to prevent the growing threat of antibiotic resistance. In 2013, the CDC estimated that more than 2 million individuals developed antibiotic-resistant infections in the United States and these infections were associated with about 23,000 deaths.⁶ “Since dermatologists frequently prescribe antibiotics, it is important to understand how we can optimize the use of antibiotics to decrease antibiotic-associated complications in our patient population and antibiotic resistance in the community,” said Dr Barbieri. 

He and his colleagues identified 985,866 oral antibiotic courses prescribed by 11,986 unique dermatologists using Optum Clinformatics Data Mart de-identified commercial claims data. There were improvements overall in the field, with a drop from 3.36 to 2.13 courses per 100 visits with a dermatologist.⁴ Prescriptions for acne and rosacea, where extended antibiotic courses dropped by 28.1% and 18.1%, respectively, accounted for the majority of this decrease. 

While antibiotic use for acne and rosacea decreased significantly, antibiotic duration did not, which suggests that other factors, like less use of antibiotics overall, may be responsible for this drop in antibiotic use.⁴ “It was exciting to see decreased antibiotic use overall and particularly for chronic inflammatory diseases such as acne and rosacea,” said Dr Barbieri. “The efforts of specialty societies and guideline committees have been encouraging limited use of antibiotics in these populations, which may be part of the underlying factors responsible for this trend.” In addition, alternative therapies for acne, such as isotretinoin and in women, spironolactone, are being used more frequently and are effectively treating symptoms. These therapies, and other alternatives, may be responsible for decreased use of antibiotics in patients with acne, he noted. 

A Growing Problem 

Not all the news was good, however. From 2008 to 2016, short-term antibiotic use increased for surgical procedures by 69.6% and for treating cysts by 35.3%. Reasons for the increase in antibiotic prescribing for surgical procedures is unclear, Dr Barbieri noted. Although the overall risk of dermatologic surgical site infection is low, one possibility is an increase in the proportion of high-risk patients indicated for antibiotic use, such as those undergoing procedures with flaps or grafts, or those with prosthetic heart valves. Concerns for surgical site infections and complications could also influence antibiotic prescribing patterns, particularly for cosmetically sensitive areas that can lead to significant morbidity, such as the face, he added. 

The use of antibiotics for surgical procedures in dermatology lacks data on efficacy to determine best practices. “We need more research on the value of antibiotic use associated with dermatologic surgery to understand how best to use antibiotics in this patient population,” said Dr Barbieri. The use of antibiotics for epidermal inclusion cysts also does not have enough evidence to determine best practices for treatment with or without antibiotics, said Dr Kirby. 

Research Needed 

There are also some conditions where antibiotic use is still one of the best therapies available. Hidradenitis suppurativa (HS), for which there are limited treatment options available, is one such condition. Dr Barbieri and his colleagues found that short- and long-term antibiotics courses for HS remained high.⁴ 

“Antibiotics may be an important part of the treatment plan for these patients,” Dr Barbieri said. Few alternative therapies to antibiotics are available for patients with HS, and even fewer high-quality clinical trials assess the efficacy of antibiotics compared with other treatment options. “We need to continue to support excellent research to develop new therapeutic modalities like tumor necrosis factor inhibitors for HS and to conduct comparative effectiveness studies to identify the best alternative treatment strategies to optimize antibiotic use,” he added. 

“These 2 challenges are linked,” added Dr Kirby. “We need to reflect on our practices but lack data on other treatment options. However, I am optimistic that we will soon have more options for HS that are not antibiotics.” 

Challenges Ahead 

There are several challenges to improving antibiotic stewardship in dermatology, as well as medicine overall. “A lack of evidence is one of the biggest challenges,” said Dr Barbieri. “For instance, we have very little research about how to best use antibiotics in the setting of dermatologic surgical procedures and need well-designed, prospective trials to better understand which perioperative antibiotic use is of the highest value.” Optimal treatment approaches for acne and rosacea also require further investigation. HS will need more therapies and studies to determine the best route for treating this inflammatory disease. 

Dermatologists should consider the risk and benefits of antibiotic use before prescribing an antibiotic, Dr Barbieri recommended. “While we want to be good stewards of antibiotics for the community and to protect our patients from complications associated with antibiotic use, we also should not shy away from prescribing them when needed,” he added. 

Despite the lack of evidence for determining best practices, there are several resources available for practicing dermatologists such as “Antibiotic Prophylaxis in Dermatologic Surgery: Advisory Statement 2008” by Wright et al and “Prophylactic and Empiric Use of Antibiotics in Dermatologic Surgery: A Review of the Literature and Practical Considerations” by Rossi and Mariwalla.^7,8 

“I know I tend to make better decisions for prescribing antibiotics when I carry cards in my pocket with the risk factors and guidelines,” Dr Kirby said. Another strategy she suggests dermatologists adopt is to set patients’ expectations for treatment from the beginning and develop a treatment plan based on the evidence and patients’ concerns. “I have a conversation with my patients about my rationale for managing their condition in a certain way and listen to their concerns,” she said. “We come up with a strategy together, based on their condition, for when I will prescribe antibiotics.” In addition, Dr Kirby recommends dermatologists recognize the potential for decision fatigue and take a moment to slow down and think through their rationale for prescribing antibiotics. 

Future Outlook 

While antibiotic use in dermatology has steadily decreased since 2008, the fact that dermatologists continue to have the highest antibiotic prescriptions per provider rate means there is still room for improvement. “It is concerning to see increased use of antibiotics associated with dermatologic procedures,” said Dr Barbieri. “There may be opportunities to better utilize antibiotics in this population. We need to do more research to better understand why antibiotic use is increasing in these patient populations and whether this use is optimal.” 

“In the coming years, we need to keep building on these gains by continuing to develop alternative treatment strategies and new medications to reduce reliance on oral antibiotics for these noninfectious, chronic inflammatory conditions,” said Dr Barbieri. With the development of more and better therapies for acne, rosacea, and other chronic inflammatory conditions, and further research into best practices for appropriate antibiotic use, this rate will hopefully continue to drop.

References 

1. Centers for Disease Control and Prevention. Antibiotic use in the United States: Progress and opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. 

2. Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions — United States, 2013. Updated September 12, 2017. https://www.cdc.gov/antibiotic-use/community/programs-measurement/state-local-activities/outpatient-antibiotic-prescriptions-US-2013.html. Accessed February 13, 2019. 

3. Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions — United States, 2015. Updated September 12, 2017. https://www.cdc.gov/antibiotic-use/community/programs-measurement/state-local-activities/outpatient-antibiotic-prescriptions-US-2015.html. Accessed February 13, 2019. 

4. Barbieri JS, Bhate K, Hartnett KP, Fleming-Dutra KE, Margolis DJ. Trends in oral antibiotic prescription in dermatology, 2008 to 2016 [published online January 16, 2019]. JAMA Dermatol. doi:10.1001/jamadermatol.2018.4944 

5. Kirby JS, Lim JS. Dermatologists and antibiotics—reflecting on our habits, the evidence, and next steps [published online January 16, 2019]. JAMA Dermatol. doi:10.1001/jamadermatol.2018.4877 

6. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. Published April 2013. https://www.cdc.gov/drugresistance/pdf/ ar-threats-2013-508.pdf. Accessed February 13, 2019. 

7. Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in dermatologic surgery: Advisory statement 2008. J Am Acad Dermatol. 2008;59(3):464-473. doi:10.1016/j.jaad.2008.04.031 

8. Rossi AM, Mariwalla K. Prophylactic and empiric use of antibiotics in dermatologic surgery: A review of the literature and practical considerations. Dermatol Surg. 2012;38(12):1898-1921. doi:10.1111/j.1524-4725.2012.02524.x