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Scientific Panel on Antibiotic Use in Dermatology

Meeting Background

On September 6, 2014, the third meeting of the Scientific Panel on Antibiotic Use in Dermatology (SPAUD) took place in Las Vegas, Nevada. SPAUD was founded in 2005 by AARS Past President James Q. Del Rosso, DO, and held its first two meetings in April 2006 and November 2007.

The faculty for the 2014 SPAUD meeting was comprised of AARS President Dr. Lawrence Eichenfield, AARS Honorary Chairman Dr. James Leyden, AARS Committee Chair Dr. Guy Webster, AARS Past President Dr. Diane Thiboutot, Dr. Theodore Rosen, Dr. Richard Gallo, Dr. Clay Walker, AARS Past President Dr. James Del Rosso, and Guillermo Sanchez, PA-C, MPH. Mr. Sanchez participated on behalf of the Centers for Disease Control and Prevention (CDC). Through a media partnership with the CDC annual initiative, ‘Get Smart: Know When Antibiotics Work,’ the AARS is in a position to impact the level of education in dermatology, increase research efforts in the areas of antibiotic usage, resistance, and prescribing patterns.

The SPAUD faculty gratefully acknowledges Dr. George Zhanel, a microbiologist and pharmacologist from the University of Manitoba in Canada and Director of the Canadian Antimicrobial Resistance Alliance (CARA), who contributed significantly to the meeting content.

What Is the Purpose of SPAUD?

For the last decade, a high noise level about antibiotic resistance has persisted in the US. The lack of new antibiotics being developed is a reality that continues to be major challenge. While dermatologists are one of the main prescribers of antibiotics out of all physicians, SPAUD was formed so that the discipline of dermatology would initiate its own scientific and practical assessment of how antibiotics are used in dermatology and suggest approaches that mitigate the risk of inducing resistant bacterial strains. This was achieved by bringing together a select group of dermatologists with established interest in the subject, infectious disease specialists, and microbiologists to discuss how oral and topical antibiotics are used in dermatology and to look closely at issues related to antibiotic prescribing patterns and the impact of bacterial resistance. A natural sequence to these discussions was the development of recommendations on optimal antibiotic prescribing and avoidance of antibiotic use when it is not needed.

Dr. James Leyden discusses the role of Propionibacterium acnes in acne pathophysiology and the observation that antibiotic sensitivity of some P. acnes has decreased.
Dr. James Leyden discusses the role of Propionibacterium acnes in acne pathophysiology and the observation that antibiotic sensitivity of some P. acnes has decreased. The prevalence of antibiotic resistant P acnes strains in a given geographic location correlates directly with frequency of use in that region over time.

Outcomes of the 2014 SPAUD Meeting

A publication based on the information presented and discussed at SPAUD is in progress. The following are a few highlights from the meeting discussions:

  • The use of antibiotics in livestock feed comprises almost 80% of total antibiotic use in the US.1 Antibiotic resistant bacterial strains as well as antibiotics themselves gain access to wastewater from livestock and poultry farms.
  • The addition of antibiotics to livestock feed may alter the microbial ecology, can contribute to emergence of infections in humans, and can increase carriage of resistant bacteria. For example, 30% of workers employed at farms using tetracycline in animal feed were positive nasal carriers of tetracycline-resistant MRSA nasal colonization as compared to 2% of workers employed at antibiotic-free farms.2 In addition, a specific MRSA strain induced in hogs fed with tetracycline has subsequently been recovered from human infection, and has been found in 30% of tested supermarket beef and pork (30%), and on 10% of shopping cart handles.3
  • Human use of antibiotics represents 19.1% of annual antibiotic use in the US.1 The most commonly prescribed oral antibiotics among all US clinicians in 2010 were azithromycin (166 Rx per 1000 persons), amoxicillin (166 Rx per 1000 persons), amoxicillin-clavulanate (70 Rx per 1000 persons), ciprofloxacin (66 Rx per 1000 persons), and cephalexin (65 Rx per 1000 persons).4,5 When prescribing patterns of a specific antibiotic lead to a high prevalence of emergence of an antibiotic-resistant pathogenic bacteria, studies have shown that altering prescribing of the antibiotic can reduce the antibiotic resistance rate.6,7
  • Much of the data evaluating the sensitivity of Propionibacterium acnes to various antibiotics such as the tetracyclines and clindamycin is based on studies that were completed ten to fifteen years ago. More recent data shows increasing levels of less sensitive strains to commonly used antibiotics, with geographic variations correlating with the frequency of use of specific antibiotics.8-11 Over time, some strains of P. acnes have become much less sensitive to clindamycin, which appears reduce efficacy in patients with acne vulgaris who harbor a high population of these less sensitive organisms.
  • Oral isotretinoin induces cutaneous changes that alter the microbial flora. The microbial effects include reduction in P. acnes, decrease in surface Gram-negative bacteria, and increase in S. aureus colonization.12
  • MRSA continues to be a common cause of cutaneous infection encountered in outpatient clinics, including dermatology. Updated practice guidelines for the management of skin and soft tissue infections from the Infectious Disease Society of America have been published in 2014.13 
Dr. Richard Gallo MD presents on the cutaneous microbiome and effects that antibiotic and antimicrobial use can cause beyond just the ability to eradicate a target bacterium.
Dr. Richard Gallo MD presents on the cutaneous microbiome and effects that antibiotic and antimicrobial use can cause beyond just the ability to eradicate a target bacterium.

The forthcoming AARS SPAUD publication will include a wide range of information on antibiotic resistance and its significance to dermatologists. A major objective is to provide information useful to clinicians in practice and to aid in the publication of patient materials.

SPAUD Highlights

We hope that you will take a few moments to view our relevant videos of recent updates from two members of the SPAUD initiative, Drs. James Del Rosso and Ted Rosen. The AARS is actively reviewing our next steps to better educate the dermatologist, as well as the patient, on this important issue.

All presentations were provided during the Dermatology Essential Resource Meeting (DERM) 2015 CME Conference and are used with permission of the AARS and Dermatology Education Foundation, respectively. All rights reserved. See more at www.dermcme.com.

Please submit your questions or comments to us at info@aarsmember.org.

What Does Antibiotic Resistance Mean?

Defining the Scientific Panel on Antibiotic Use in Dermatology (SPAUD)

Antibiotic Resistance Evolution

Why Dermatologists Should Care About Antibiotic Resistance

Associations with Emergent Resistance Around the World

Antibiotic Prescribing Patterns in Dermatology: Know Your Exit Strategy

Methicillin-Resistant Staphyloccocus Aureus (MRSA) Overview

MRSA Treatment

References

1. Hollis A, Ahmed Z. Preserving antibiotics, rationally. N Engl J Med. 2013:369:2474-2476.
2. Rinsky JL, Nadimpalli M, Wing S, et al. Livestock-associated methicillin and multidrug resistant Staphylococcus aureus is present among industrial, not antibiotic-free livestock operation workers in North Carolina. PLoS One. 2013 Jul 2;8(7):e67641.
3. Mole B. MRSA: Farming up trouble. Nature. 2013. 25;499(7459):398-400.
4. Sanchez G. Get smart: know when antibiotics work. American Acne and Rosacea Society And Scientific Panel on Antibiotic Use in Dermatology Meeting, Las Vegas, NV, September 6, 2014.
5. IMX Xponent Data, 2011.
6. Seppälä H, Klaukka T, Vuopio-Varkila J, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish study group for antimicrobial resistance. N Engl J Med. 1997;14;337(7):441-446.
7. Cristino MJ. Correlation between consumption of antimicrobials in humans and development of resistance in bacteria. Int J Antimicrob Agents. 1999;12:199-202.
8. Bowe WP, Leyden JJ. Clinical implications of antibiotic resistance: risk of systemic infection from Staphylococcus and Streptococcus. In: Shalita AR, Del Rosso JQ, Webster GF, Eds. Acne Vulgaris, Informa healthcare, London, UK, 2011, pp 125-133.
9. Leyden JJ, Del Rosso JQ, Webster GF. Clinical considerations in the treatment of acne vulgaris and other inflammatory skin disorders: focus on antibiotic resistance. Cutis. 2007;79(suppl 6):9-25.
10. Del Rosso JQ, Leyden JJ, Thiboutot D, Webster GF. Antibiotic use in acne vulgaris and Rosacea: clinical considerations and resistance issues of significance to dermatologists. Cutis. 2008;82(suppl 2[ii]):5-12.
11. Levy RM, Huang EY, Roling D, et al. Effect of antibiotics on the oropharyngeal flora in patients with acne. Arch Dermatol. 2003;139(4):467-471.
12. James W, Leyden JJ. Treatment of gram-negative folliculitis with isotretinoin: positive clinical and microbiologic response. J Am Acad Dermatol. 1985:12:319-324.
13. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014;59(2):147-159.