CME Author: Vicki Brower
Study Authors: John S. Barbieri, Ketaki Bhate, et al.
Target Audience and Goal Statement:
Dermatologists, dermatologic surgeons, family medicine specialists, internists, and pediatricians
The goal was to identify and characterize the temporal trends among dermatologists for the diagnoses most commonly associated with oral antibiotic use, including duration of use.
What are the trends in oral antibiotic prescribing practices in dermatology from 2008 to 2016?
Study Synopsis and Perspective:
Overall prescribing practices for antibiotics declined 36.6% in dermatology from 2008 to 2016, but there were increases of 69.9% following surgical care visits and 35.3% for cysts, most of which were short-term prescriptions, according to a new repeat cross-sectional analysis.
During this time period, antibiotic prescriptions 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.
At the same time, oral antibiotic prescribing increased from 3.92 to 6.65 courses for every 100 surgical visits and from 1.24 to 1.68 courses for every 100 cyst diagnoses. The increased use of postoperative antibiotics is concerning, and may put patients at unnecessary risk of adverse events, the researchers wrote.
“The risk of surgical site infections resulting from dermatologic procedures, including Mohs surgery, is low,” Barbieri and colleagues wrote. “Procedures in the groin, skin grafts, wedge excisions of the lip or ear, and procedures below the knee may be associated with higher surgical site infection risk, and single-dose perioperative antibiotics may help decrease the risk of surgical site infection for these higher-risk cases.”
In the past, conditions for which dermatologists prescribed extended courses of antibiotics included chronic dermatologic conditions, such as acne and rosacea; recent guidelines, however, suggest attenuating the duration of therapy for these patients.
During the study period, antibiotic prescriptions over an extended course decreased by 28.1% for acne and 18.1% for rosacea, while increasing by 3.2% for hidradenitis suppurativa. But “course duration has remained stable over time,” the authors noted, “suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”
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.”
According to 2013 data from the CDC, dermatologists were identified as the most frequent prescribers of oral antibiotics per clinician.
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, which covers 12 to 14 million privately insured patients annually in the U.S.
Researchers stratified courses of therapy into two categories: extended duration (>28 days) and short duration (≤28 days). Prescriptions were excluded if they were filled more than 28 days after the patient’s last dermatology visit. Researchers used Poisson regression models to determine changes in the frequency of antibiotic prescribing over time.
Patients were most frequently prescribed doxycycline hyclate (26.3%), minocycline (25.8%), and cephalexin (19.9%). Overall antibiotic prescribing declined 53.2% for extended courses and rose 8.4% for short-term courses.
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.
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.
Source Reference: JAMA Dermatology, online Jan. 16, 2019; DOI:10.1001/jamadermatol.2018.4944
Study Highlights: Explanation of Findings
There has been a reduction in the prescribing of antibiotics by dermatologists overall from 2008 to 2016, but at the same time, this study also documents rising rates of prescriptions for patients post-surgery, and for cysts.
Prescribing antibiotics to prevent surgical complications and to treat rosacea, acne, and other inflammatory conditions may have downstream consequences, the investigators noted. Oral antibiotic use has also been linked with resultant pharyngitis, inflammatory bowel disease, collagen vascular diseases, C. difficile infection, significant changes to the microbiome and oropharyngeal flora, and antibiotic-resistant infections.
In addition, researchers noted that prior research has found an association between chronic antibiotic use and increased risk for breast and colon cancers.
“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.”
Indeed, the researchers cited a 2012 survey sent to members of the American College of Mohs Surgery members that identified that many antibiotic prescribing practices were not aligned with guideline recommendations, and concluded that dermatologic surgeons prescribe more antibiotics than needed to prevent infection.
A 2008 advisory statement on antibiotic prophylaxis recommended single-dose perioperative antibiotics for patients at increased risk for surgical site infection. And guidelines from the American Heart Association and American Academy of Orthopedic Surgeons recommend limited use of single-dose perioperative antibiotics for the prevention of infective endocarditis and joint infections, and do not support prolonged courses of postoperative antibiotics.
The CDC has developed a framework for improved antibiotic prescribing in the outpatient setting.
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.”
As an example, they described the use of antibiotics for treating inflamed epidermal inclusion cysts (EICs). While dermatologists might describe them as “inflamed” or “ruptured,” 94% treat these with cephalosporins, which implies a concern for gram-positive infections.
But if inflammation is a concern, then intralesional triamcinolone — a topical corticosteroid — could be an option. At least one study has shown that while non-inflamed EICs may also harbor bacteria, “there was no significant difference in the kinds of bacteria in inflamed vs non-inflamed EICs, which calls into question the rationale for antibiotic use,” they wrote.
The editorialists added that they could not find any studies “evaluating the efficacy of antibiotics or intralesional triamcinolone (or a comparison of the two) for inflamed EIC management, and these data, when available, might help clinicians feel more confident in their decision to avoid prescribing an antibiotic.”
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, educational efforts, prescriber feedback, and a “wait-and-see” (delayed) technique, which has been studied in acute otitis media.
For patients undergoing procedures, they acknowledged that dermatologists should not stop antibiotic prescribing “cold turkey,” and pointed to tools and guidelines reviewed in the study that can help identify patients at high-risk for infection and bacterial seeding of the joints and heart.
Barbieri’s group wrote that “just as the shift from topical antibiotics to plain white petrolatum has improved outcomes at reduced cost for postoperative wound care, there may be an opportunity to optimize oral antibiotics prescribing in dermatologic surgery.”
They added that “additional evidence, including data from well-controlled prospective studies, is needed to determine the appropriate role for perioperative and postoperative oral antibiotics for dermatologic procedures, particularly for Mohs surgery, in which the risk of postoperative complications may be higher and the morbidity of these complications is more significant.”
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco