Faster response to antibiotic therapy failure needed

Acne patients take oral antibiotics for an average of 11 months before switching to isotretinoin. That’s much longer than guidelines for acne therapy with antibiotics recommend, suggesting that dermatologists need to recognize within weeks-not months-that antibiotic therapy for acne patients has failed, according to NYU Langone Medical Center researchers, whose findings were published online on October 29 in the Journal of the American Academy of Dermatology.

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Researchers reviewed more than 5,000 acne cases under dermatologists’ care at the New York City medical center; 137 cases were included in this study.

The study’s lead author, Arielle R. Nagler, M.D., instructor, The Ronald O. Perelman Department of Dermatology at NYU Langone Medical Center, told Dermatology Times, on average, patients in this study who were eventually prescribed isotretinoin received 331.3 days of antibiotics. Nearly 34 percent of the patients studied received a year or more of antibiotics.

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“These durations far surpass current guideline recommendations, including those of the Global Alliance to Improve Acne Outcomes and the European Consensus, which advise three to six months of treatment with oral antibiotics. This study identifies a potential practice gap in the use of antibiotics for the treatment of acne,” Dr. Nagler says. “Armed with the knowledge of this trend, dermatologists are encouraged to decrease extended courses of antibiotics in the treatment of acne through early recognition of antibiotic failure at six to eight weeks and immediate planning for alternative therapies. Dermatologists must be proactive in guiding patients to alternative therapies, including isotretinoin, when necessary. Additionally, dermatologists should attempt to obtain a detailed prior treatment history in order to avoid duplicate failed antibiotic trials.”

Few studies have assessed duration of antibiotic use in the treatment of acne, according to Dr. Nagler.

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“A recent study by Lee et al., which was specifically designed to quantify the duration of individual courses of antibiotics in acne patients, reported a mean duration of 129 days,” she says. “Our study, though smaller in size and designed to calculate cumulative duration of antibiotic use, was able to specifically link the antibiotic prescriptions to acne treatment and found durations of antibiotic therapies far exceeding those previously reported. Moreover, our study focused on a subset of patients with severe acne who ultimately received isotretinoin following the failure of systemic antibiotics.”

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Dermatologists, she says, can take this important step to reduce the time patients spend on failed antibiotic therapy: If a patient’s acne has not improved sufficiently after six to eight weeks of antibiotic therapy, dermatologists should begin to discuss this with their patients and create alternative treatment plans.

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Isotretinoin, while not appropriate for all acne patients, provides an alternative, effective therapeutic option in patients who have failed to improve on antibiotics, she says.

“On average 155.8 days elapsed between the first mention of isotretinoin in the chart and its prescription. This delay of over five months is likely multifactorial in etiology including logistical barriers of iPLEDGE, as well as patient and parent hesitation,” Dr. Nagler says. “This study was the first to document this delay in clinical practice.”

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NEXT: Reasons for prolonged antibiotic use

Reasons for prolonged antibiotic use

Physicians might not be recognizing antibiotic failure in their acne patients. Another possible explanation is antibiotic use might be prolonged due to delays in isotretinoin prescription, according to Dr. Nagler.

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“The prescription of isotretinoin can be burdensome for both the patient and the physician, particularly in female patients where pregnancy testing is required, due to the iPLEDGE requirements,” she says. “There are also may be patient and parental concerns regarding the medication. Isotretinoin has been associated with several controversies covered in the lay-press, including its possible association with inflammatory bowel disease and psychiatric disturbance.”

The study also brought to light that patients often transition care to other dermatologists during the course of their acne treatment.

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“We found that patients who had been seen at multiple practices were more likely to experience extended antibiotic durations, perhaps because each time a patient saw a new provider, the acne treatment algorithm was reset,” She says. “Finally, there are likely other factors that were not evaluated in this study that may contribute to prolonged antibiotic exposure, including lapses in patient follow up or non-adherence to topical maintenance therapies, such as retinoids.”

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Other interesting findings

The researchers report minocycline was the antibiotic most commonly prescribed, comprising 72.5% of all prescriptions.

“Interestingly, when minocycline failed as the initial antibiotic, the most commonly used second antibiotic was azithromycin,” Dr. Nagler says. “In contrast, when doxycycline failed as the first antibiotic, minocycline was the most commonly used second antibiotic.”

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The prescription pattern could reflect prior opinions that minocycline was superior to doxycycline for the treatment of acne - recommendations that were contested in a 2012 Cochrane review, according to Dr. Nagler.

“Moreover, cross-resistance among ‘cyclines’ is common, suggesting that the practice of replacing a failed prescription of doxycycline with minocycline may not be effective. If ineffective, this practice may actually prolong antibiotic treatment durations. Proper antibiotic selection may be another tool to decrease antibiotic durations in acne patients,” Dr. Nagler says.

Curbing unnecessary antibiotic use is essential

The patients in NYU’s study, who ultimately required an alternative treatment, represent an ideal target population to decrease unnecessary antibiotic use, according to Dr. Nagler.

Extended antibiotic use is associated with antibiotic resistance, which can contribute to worsening acne, changes in the normal flora of the gut and increased incidence of upper respiratory tract infections. 

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“As a result of increasing antibiotic resistance worldwide, the CDC has made antibiotic stewardship a top priority,” Dr. Nagler says.

Dermatologists, according to a recent Dermatology Times article, play a critical role in antibiotic stewardship efforts. Dermatologists, according to new government data, prescribe more antibiotics per provider than doctors in any other specialty.

Disclosure: Dr. Nagler reports no disclosures.

Reference: Nagler AR, Milam EC, Orlow SJ. The use of oral antibiotics before isotretinoin therapy in patients with acne. J Am Acad Dermatol. 2015 Oct 29. http://www.ncbi.nlm.nih.gov/pubmed/26525749