Stephanie Rude
Anjie Boyok
October 2, 2009
Policy Paper
Background:
One of the conventional treatments for moderate to severe acne has been the use of systemic broad spectrum antibiotics. These low dose antibiotic treatments generally continue for a minimum of three months and often for several years (2). One of the potential side effects of long term, low dose antibiotic treatment is antibiotic resistance which is a threat not only to the individual receiving the treatment but to all people. Studies have shown this concern to be very legitimate.
Antibiotics offer an effective treatment for acne because it is caused in part by propionibacteria. This is often referred to as P acne. Until the late 1970s all propionibacteria were sensitive to therapeutic treatment with antibiotics (3). There were no resistant strains of P acne. However, by the late 1980s resistant strains of propionibacteria were emerging and they have continued to increase steadily (8). A study in 1993 examined 468 patients with acne, most of whom had previously received one or more courses of antibiotic treatments. Of those test subjects, 178 carried propionibacterial strains that were resistant to one or more antibiotics and 27 patients carried multiple strains with different antibiotic resistances (3). Adding to the problem is the fact that resistant strains of P acnes are capable of spreading to those in close contact with the carrier (8).
Long term, low dose antibiotic treatment has also been implicated in antibiotic resistant forms of Streptococcus pyogenes and staphylococcus aureus. Studies to measure the prevalence and resistance of Streptococcus pyogenes and staphylococcus aureus in the oropharynx of individuals on long term, low dose antibiotic treatments have confirmed a 3 fold increase in the prevalence of S pyogenes campared to those acne patients not using any antibiotics. 33% of patients receiving antibiotic treatment for acne actually had levels of S pyogenes ( 26.3% to 45%)comparable to patients with symptomatic pharyngitis. The study concluded that long term, low dose antibiotic treatments increase the colonization and resistance of s pyogenes in the oropharynx of acne patients receiving oral antibiotic treatments (5). Another study confirmed these findings, with results showing a 2.15 increase in upper respiratory tract infections for individuals receiving antibiotic treatment for acne (6).
In another study involving long term, low dose tetracycline therapy for acne, the proportion of patients with resistant E coli increased from 50% before treatments to 69% after 1 week of treatment, to 75% after 4 weeks, and to 88% in the group treated for more than 4 weeks. After the course of 4 weeks multiple-resistant (resistant to 3 or more antibiotics) E coli increased from zero to 49%. Also, bacteria possessing R plasmids (molecules possessing genes that produce enzymes capable of inactivating the effects of antibiotics) increased from 63% to 83%. The result of this study clearly demonstrates the ability of long term low dose antibiotic treatments to create drug resistant bacteria that are often resistant to several antibiotics (7).
Policy:
The FDA has begun addressing the issue of antibiotic resistance. In 1999 the National Institute of Health (NIH) an Interagency Task Force on Antimicrobial Resistance was formed to develop a Public Health Action Plan to combat Antimicrobial Resistance (4). The first part of their plan was introduced in June of 2000. Part of that plan took effect in the beginning of 2001 and involved new labeling on all antibiotic prescriptions, stating that the antibiotic is to be used only to treat infections caused by bacteria and that the patient is responsible for completing the drug treatment exactly as prescribed (1). However, the NIH has not as yet addressed the antibiotic resistance risks associated with long term, low dose antibiotic use.
It is the position of this paper that the NIH policy should include the following: doctors/dermatologists prescribing long term, low dose systemic antibiotic use for acne are required to discuss brochures explaining the potential hazard of antibiotic resistance with the patient and receive the signature of the patient confirming their understanding of the potential risks associated with antibiotic resistance.
The NIH will be responsible for designing, printing, and distributing the brochures explaining antibiotic resistance and containing a patient signature page. Funding for the brochures will be covered by NIH. Signed signature pages will be sent by the attending physician to the NIH where they will be able to track the number of patients receiving long term low dose antibiotics for acne.
Arguments:
• Some people believe that since antibiotic resistance is a serious problem, there needs to be a more aggressive approach.
o We agree that antibiotic resistance is a serious problem in today’s global society. We believe that education is the first step in solving the problem. Also by informing physicians about the growing concerns, they may think twice before prescribing antibiotics so frequently. We do acknowledge that more aggressive action may be needed in the future.
• People taking low dose antibiotics might not take seriously the precautions, warnings, or advice from their physicians.
o Our intention with this policy is to make people aware of antibiotic resistance and the serious problems it can cause, and to help inform people of the full magnitude of this global problem. We want patients to be aware of antibiotic resistance and the actions they can take to help reduce the problem. Our hope is that this knowledge will lead to less long term low dose antibiotic use for acne. However, we do acknowledge there may be a need for stricter guidelines regarding when to prescribe long term low dose antibiotics for acne and the length of prescription use.
Conclusion:
Antibiotic resistance is a global problem that poses a major threat to the health of all people in the United States as well as people around the world! Long term, low dose systemic antibiotic treatments increase the threat of antibiotic resistance. Patients receiving this type of treatment need to be aware of the risks and potential hazards of antibiotic resistance. Educating people is the first step in working toward a solution to antibiotic resistance. It’s going to take cooperation and effort on the part of all people to solve this problem. That cooperation and effort will begin only as people are educated to be aware of this serious threat.
References:
1.Biotech, Ortho. "Antibiotic Resistance Information on Drug Labels." U.S. Food and Drug Administration (2003). U.S. Department of Health and Human Services. Web. Sept. 2009.
2.Cheesbrough, M. J. "Contributers to Acne Resistance." BMJ helping doctors make better decisions 318 (1999). PubMed Central. Web. Sept. 2009.
3.Eady, E. A., C. E. Jones, J. L. Tipper, J. H. Cove, W. J. Cunliffe, and A. M. Layton. "Antibiotic resistant propionibacteria in acne." BMJ helping doctors make better decisions 306 (1993): 555. PubMed Central. Web. Sept. 2009.
4.Henney, Jane E. "Issues Related to Antimicrobial Resistance." U.S. Food and Drug Administration (200). U.S. Department of Health and Human Services. Web. Sept. 2009.
5.Levy, Ross M., Eric Y. Huang, Daniel Roling, James J. Leyden, and David J. Margolis. "Effect of Antibiotics on the Oropharyngeal Flora in Patients With Acne." Archives of Dermetology. Apr. 2003. Web. Sept. 2009.
6.Margolis/PhD, David A., Whitney P. Bowe/BS, Ole Hoffstad/MA, and Jesse A. Berlin/ScD. "Antibiotic Treatment of Acne May Be Associated With Upper Respiratory Tract Infections." Archives of Dermetology 141 (2005): 1132-136. JAMA & Archives. Web. Sept. 2009.
7.Moller, J. K., A. Leth Bak, A. Stenderup, H. Zacharias, and H. Afzelius. "Changing Patterns of Plasmid-Mediated Drug Resistance During Tetracycline Therapy." Antimicrob Agents Chemother 11.3 (1977): 388-91. American Society for Microbiology. Web. Sept. 2009.
8.Zaenglein/MD, Andrea L., and Diane M. Thiboutot/MD. "Expert Committee Recommendations for Acne Management." American Academy of Pediactrics (2006): 1188-977. Pediatrics.org. Web. Sept. 2009.
