Derms prescribe the most antibiotics: US study

5 minute read

However, an Australian dermatologist says the use of antibiotics is much lower down under due to different prescribing practices.

Dermatologists prescribe more oral antibiotics than other specialties, a US study has found. 

And while an Australian dermatologist notes that US dermatologists have different prescribing practices to Australian clinicians, the findings are important. 

Dr Jo-Ann See, of Central Sydney Dermatology, told The Medical Republic Australian dermatologists prescribe antibiotics for moderate to severe acne less frequently than their American counterparts, who have a harder time prescribing oral isotretinoin.  

“This paper is a reflection of that,” said Dr See, fellow of the Australasian College of Dermatologists. 

Dr See also noted while the findings were not reflective of Australian dermatology prescribing, they did highlight some important issues. 

Australian guidelines recommend prescribing antibiotics for acne for no longer than three to six months, but Dr See said the guidelines were not enforced by any governing agency. 

“You’re not rapped over the knuckles if you prescribe for more than six months, but I think most dermatologists recognise the need to limit it to three months and occasionally six months,” she said. 

The researchers, writing in JAMA Dermatology, said dermatologists had good knowledge of antibiotic guidelines, but that “few reported strict guideline adherence”. 

The US study included 30 clinicians – dermatologists, dermatology advanced practice practitioners, dermatology residents and infectious disease specialists – who did online surveys and took part in interviews.  

“Current calls to action on antibiotic stewardship based on expert opinions suggest that clinician education should be the key intervention,” the authors wrote. 

“[However], passive education alone would likely be insufficient to curtail unnecessary antibiotic use, and any antibiotic stewardship program should be actively tailored to actual clinical practice in acne treatment.” 

The researchers found five barriers which affected long-term antibiotic prescribing practices: a perceived lack of evidence to justify changing dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, issues with iPLEDGE (the FDA’s system to manage the risk of birth defects caused by isotretinoin) and the absence of an effective system to measure progress on antibiotic stewardship. 

“While clinicians consider antibiotic stewardship a professional responsibility and they are aware of antibiotic stewardship guidelines in acne treatment, future interventions must address the need for robust evidence-based knowledge on the clinical implications of long-term antibiotic prescriptions for acne and clearly disseminate this information to clinicians and patients,” they wrote. 

Dr See told TMR it was well known that long-term antibiotics were not good for the gut microbiome. 

“We all see patients given antibiotics for a year or two years or longer,” she said.  

“You wouldn’t want a patient on it for six months. It’s not great for the patient or the microbiome, and it’s delaying effective treatment. 

“If after three months they’re not better, I’d better start doing something else, start peddling faster and looking at another treatment. 

“GPs and dermatologists should have a discussion with the patient over the merits of having oral therapies but limiting the therapies to a time frame of three months and discussing other options.”  

Dr See said other treatment options included hormonal contraception or isotretinoin.  

“Patients who needed continuous oral antibiotics for acne may need to be considered for other treatments such as isotretinoin or the oral contraceptive,” she said. 

Dr See suggested prescribing benzoyl peroxide and a topical agent, then considering another three-month course of antibiotics if they had been effective.  

The US researchers found dermatologists were less likely to prescribe oral contraceptive pills to women with acne than primary care clinicians or gynaecologists. 

Interviews with the clinicians revealed comments such as this observation from a dermatologist: “It’s really easy to limit antibiotics. You just don’t prescribe them again”. 

But others noted that it wasn’t always so clear-cut. One dermatology attending physician observed:  

“I guess the main conflict would be if the antibiotic was working while the patient was on it, and then it’s withdrawn because of the treatment duration limitation. Then that would be a conflict, because the patient’s going to say, ‘Well, it’s working. Why can’t I just stay on it?” 

Another dermatology attending physician said: “Patients that flare as soon as they come off, basically, or I try something different, they don’t tolerate it and just want to go back to the antibiotic. Those are things that would make it difficult to follow the [guidelines]”.   

And one dermatologist admitted that ego played a part in her decision-making: “[limiting antibiotic use] conflicts with my goal of, I like being well-liked by my patients. I like it when they give me positive reviews.” 

One dermatologist noted the difficulties of prescribing isotretinoin: “Doxycycline takes seconds to renew. Isotretinoin takes, depending on circumstances, hours sitting on iPLEDGE”. 

JAMA Dermatology 2024, online 3 April 

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