While overall antibiotic prescribing declined 36.6% in dermatology over the past decade, an increase was observed in prescribing following surgical care visits, a repeated cross-sectional analysis found.
From 2008 to 2016, antibiotic prescribing dipped from 3.36 to 2.13 courses for every 100 dermatologist visits, driven mostly by fewer acne and rosacea scripts, reported John Barbieri, MD, MBA, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues in JAMA Dermatology.
But oral antibiotic prescribing following surgical visits rose by 69.6% during this period, from 3.92 to 6.65 courses for every 100 surgical visits. This increased “use of postoperative antibiotics after surgical visits is concerning and may put patients at unnecessary risk of adverse events,” they wrote.
Antibiotic prescribing over an extended course of 28 days decreased by 28.1% for acne and 18.1% for rosacea, but increased by 3.2% for hidradenitis suppurativa; and short-course antibiotic prescriptions for treating cysts increased by 35.3%.
Prescribing antibiotics to prevent surgical complications and to treat rosacea, acne, and other inflammatory conditions, may have downstream consequences like antimicrobial resistance, the investigators noted. Oral antibiotic use has also been linked with resultant pharyngitis, inflammatory bowel disease, collagen vascular diseases, and oropharyngeal flora.
Prior research has found an association between chronic antibiotic use and increased risk for breast and colon cancers, according to the study.
“As a result, there have been calls to reduce antibiotic use throughout medicine,” the authors wrote. “Multiple clinical guidelines for acne recommend reducing antibiotic use through non-antimicrobial therapies and by limiting the duration of antibiotic therapy.”
Two trends in acne treatment in recent years may have led to a decrease in oral antibiotic use, including the use of spironolactone, Barbieri told MedPage Today.
“Spironolactone may have similar effectiveness as oral antibiotic for the treatment of women with acne, and we’ve also seen that its use has increased in recent years,” he said. “And then there has also been some research that suggests that using isotretinoin, or Accutane, earlier in patients with severe acne could potentially decrease the use of oral antibiotics, so that’s another factor that may be at play.”
In an accompanying editorial, Joslyn S. Kirby, MD, MS, and Jordan S. Lim, MB BCh, BAO, both of Penn State Dermatology in Hershey, said that “curbing the use of antibiotics is a challenge, not only for dermatologists but also for practitioners in other disciplines, and several studies have shown promising strategies to meet this challenge.”
Kirby and Lim explained that a number of factors affect antibiotic prescribing, including patient demand, time constraints, and physicians’ decision fatigue.
However, a number of strategies can be employed to offset these factors, they said, including clinical decision-aids, a “wait-and-see” technique, educational efforts, and prescriber feedback.
For the current study, Barbieri’s group assessed 985,866 oral antibiotic prescriptions from 11,986 dermatologists over a 9-year period. They used National Drug Codes, National Uniform Claim Committee taxonomy codes, and Optum Clinformatics Data Mart claims. Prescriptions were excluded if they were filled over 28 days after the patient’s last dermatology visit.
Patients were most frequently prescribed minocycline (25.8%), cephalexin (19.9%), and doxycycline hyclate (26.3%). Overall antibiotic prescribing declined 53.2% for courses of >28 days and went up 8.4% for courses ≤28 days.
Barbieri said both the retrospective nature of the study and use of claims data are a limitation of the findings.
“There’s a potential for misclassification of antibiotics and the associated visits because we have to use diagnosis codes to identify what the patients are being seen for,” he said. “There’s potential misclassification of patient diagnosis in that way as well.”
But he noted that for many of the codes used in the study, there are studies that validate their accuracy in identifying patients with those diseases.
This study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Barbieri and Kirby reported no relevant conflicts of interest.