Abstract and Introduction
The spread of COVID-19 serves as a reminder of the might of microbes in the era of modern medicine. For years, another threat has preoccupied infectious disease experts and public health officials alike: rising antimicrobial resistance (AMR). Resistance is exceeding stewardship efforts as well as the rates of new drug development and approval in the market. A dry antimicrobial pipeline is threatening regression to a preantibiotic era. While the consequences of resistance may seem far removed from daily clinical practice, awareness of AMR is essential to dermatological care given that dermatologists prescribe more antibiotics per physician than other providers. Antibiotics in dermatology are often used for prolonged courses, with significant potential for microbiome alteration and antibiotic-related adverse effects. Through this review we hope to contribute to efforts of bringing the crisis of AMR to the forefront of daily dermatological practice.
Antimicrobial-resistant pathogens cause 700 000 deaths each year and, according to the World Health Organization, antimicrobial resistance (AMR) is estimated to lead to 10 million deaths annually by 2050.[1–3] AMR is accelerated by overuse and misuse of antibiotics in agriculture, livestock and human medicine.[4–7]
Of all antibiotics sold globally, 70% are used to treat food animals for disease, and at subinhibitory doses for growth promotion.[5,6] In 2017, the US Food and Drug Administration banned the use of medically important antibiotics for growth promotion in livestock. However, similar regulatory measures have yet to be established in low-income countries, where unregulated supply chains and use of banned antimicrobials, including chloramphenicol, tylosin and TCN (a mixture of oxytetracycline, chloramphenicol and neomycin), continue to persist. Global increase in demand for animal products and a shift to large-scale farming have contributed to the accumulation of antibiotic residues and bacteria carrying antibiotic resistance genes in animals, water, soil and, ultimately, in humans through the food chain.[7,8]
Further contributors to global antibiotic resistance include self-prescribing of over-the-counter systemic antibiotics or topical steroid/anti-infective combinations, the latter leading to resistance through a dysregulated immune response and increased susceptibility to persistent infections.[9,10] Worrying antibiotic consumption is also noted in medical prescribing trends. Between 2000 and 2010, human antibiotic use rose by 40%. According to the US Centers for Disease Control and Prevention, one-half of prescribed outpatient antibiotics are inappropriately selected or dosed, and one-third are given unnecessarily.[11–14]
Most human antibiotic use occurs in the outpatient setting, making outpatient prescribers and dermatologists alike an important audience for stewardship calls.[12,15–17] Although these have not been ignored by the specialty, there is room for improvement. Systemic antibiotic prescribing for chronic inflammatory conditions, such as acne and rosacea, decreased by 36·6% between 2008 and 2016. Nevertheless, prescribing of short-course oral antibiotics associated with surgical visits increased by 69·6%. Additionally, data from 2006 to 2015 demonstrate continued topical antibiotic use following clean procedures, despite evidence suggesting more favourable outcomes with petrolatum.[16,17] This is significant, as indiscriminate use of topical antibiotics has the potential to select for multidrug-resistant (MDR) bacterial strains.
Herein we discuss concerns of bacterial resistance from an outpatient dermatological perspective, and review innovative strategies in the fight against AMR.
The British Journal of Dermatology. 2022;187(1):12-20. © 2022 Blackwell Publishing