Five barriers to antibiotic stewardship for acne treatment
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Key takeaways:
- Researchers found five themes that inhibit proper antibiotic stewardship.
- The researchers suggest that a stewardship program be implemented that addresses these concerns.
Researchers identified five barriers to proper antibiotic stewardship in acne treatment and recommended the implementation of an antibiotic stewardship program, according to a study.
“Dermatologists continue to prescribe more outpatient systemic antibiotics than do clinicians in any other specialty,” Ronnie A. Festok, BA, a student in the department of dermatology at Emory University School of Medicine, and colleagues wrote. “Oral antibiotics remain the most commonly prescribed systemic acne treatment, despite potential associations with rising antibiotics resistance, collateral damage to the normal microbiome and potential adverse outcomes such as upper respiratory infections, pharyngitis, inflammatory bowel disease, breast cancer and colon cancer.”
According to the American Academy of Dermatology acne treatment guidelines, oral antibiotics should only be taken for no more than 3 to 4 months; however, this limit is not always heeded. Therefore, the researchers advised that an outpatient antibiotic stewardship program should be implemented.
“Successful design and implementation of antibiotic stewardship programs in dermatology require careful consideration of the clinical factors associated with long-term antibiotic treatment for acne, including clinician and patient values, institutional context and resources,” the authors explained.
As a result, the researchers conducted a study to identify the salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment by dermatologists in the clinical setting. Thirty clinicians, including dermatologists, infectious disease physicians, dermatology resident physicians and nonphysician clinicians, were surveyed on what they believed to be the salient themes that affect long-term prescribing habits in acne. These experts settled on the following five themes.
Perceived lack of evidence to justify practice changes
While most clinicians were familiar with the guidelines and understood the concept of limiting antibiotic use for acne treatment, many were not familiar with evidence supporting these guidelines or they simply felt the evidence was weak.
For example, some participants expressed that the literature on antibiotic resistance in acne treatment is not convincing. Some also claimed that limiting the duration of antibiotics for the treatment of acne to 3 months was an unrealistic goal.
Additionally, clinicians felt that they held competing responsibilities between professional obligations and commitment to the patient, with many believing that it was necessary to break antibiotic resistance guidelines when it was in the best interest of the patient.
“I do not believe that the societal harm of putting a single individual on longer-term antibiotics outweighs a potential benefit to that individual,” one dermatology attending physicians said in the study.
“My responsibility to that patient sometimes trumps my responsibility to stewardship,” another attending physician concurred.
These findings have led the authors to believe that developing high-quality evidence on the relationship between long-term antibiotic use for acne and antibiotic resistance is urgently needed.
Difficulty navigating patient demands, satisfaction
Patient satisfaction was a large influence on acne prescribing practices with many clinicians reporting that they felt forced to choose between keeping their patients satisfied with their effective antibiotics and practicing proper antibiotic stewardship.
In fact, many clinicians believed that if they did not continue the antibiotic with which a patient was highly satisfied, the patient would simply switch to a clinician who would.
“If that practitioner sticks to the 3-month rule, then the patient simply goes to a different practitioner, gets antibiotics and then they’re actually getting more antibiotics,” one of the dermatology attending physicians in the study said. “They’re starting over and over and what’s worse than being on an antibiotics continuously is starting and stopping an antibiotic and developing resistance.”
One clinician also expressed difficulty with explaining antibiotic resistance to a patient when attempting to discontinue their acne treatment.
“Antibiotic resistance doesn’t really have a face or a way of really identifying it,” they said. “So, as with a lot of things in public health, when you have a patient in front of you who’s like, ‘This is really debilitating. I have a real problem with this. Why can’t you give me more of this?’ It puts the provider under a lot of pressure and in a bad place to be able to say no.”
Lastly, clinicians were concerned with the impact that discontinuing antibiotic treatment would have on their practice, with one citing a concern over receiving negative reviews.
“Limiting antibiotic use conflicts with my goal of, I like being well-liked by my patients,” a dermatology attending physician said. “I like it when they give me positive reviews.”
Discomfort with discussing contraception
“Discomfort around discussing and prescribing combined oral contraceptive pills (OCP) was frequently reported despite several combined oral contraceptive pills being FDA-approved to treat acne,” the authors wrote.
Women who were prescribed teratogenic medications were frequently not prescribed OCP and reported nonadherence. The study found that dermatologists were much less likely than primary care physicians or gynecologists to prescribe OCP to women with acne.
Patients that received isotretinoin reported that their experience with contraceptive counseling was inadequate, brief, not patient-centered and even anxiety provoking. They also reported that their providers did not provide enough information on pregnancy avoidance strategies and contraceptive options during isotretinoin treatment.
According to the authors, clinicians can prescribe OCP to women who desire contraception and are medically eligible instead of antibiotics, thus reducing the risk for antibiotic resistance and improving antibiotic stewardship.
Barriers with iPLEDGE
The authors found that clinicians cited a need for nonantibiotic alternative therapies that are comparably effective, easy to prescribe, well tolerated and simple to use. However, one of the most common alternatives, isotretinoin, is the opposite of “easy to prescribe” and “simple to use” due to barriers with iPledge, the U.S. Food and Drug Administration safety program that is intended to manage the risks of isotretinoin’s impact to a developing fetus.
Clinicians expressed that iPledge is an unnecessarily complex element that makes prescribing isotretinoin very difficult. Patients described iPledge as a burden to their finances and schedules due to the frequent office visits for pregnancy tests. Physicians also found it difficult to fit these iPledge follow-up visits into their busy schedules.
“When you present somebody with a consent form to take a drug, [they think], ‘OK, this is really serious,’ and it is,” a dermatology attending physician said. “But we don’t have them sign a consent form for some of the other drugs that we use which are equally serious, like methotrexate, for instance.”
Absence of effective system to measure progress of antibiotic stewardship
“There’s no flagging feature. There’s no buddy. We don’t have clinical pharmacists looking over us to kind of give us warnings or notifications,” a dermatology attending physician said, echoing the need for antibiotic stewardship efforts from dermatologists.
According to the study, an outpatient antibiotic stewardship program would be effective in decreasing antibiotic prescribing without adversely affecting patient outcomes.
The Core Elements of Outpatient Antibiotic Stewardship that clinicians should practice, as outlined by the CDC, include commitment, action for policy and practice, tracking and reporting, and education and expertise.
In light of these elements, the authors suggest a list of solutions that may address the problematic themes that clinicians have reported:
- “training clinicians on shared decision-making and communication skills;
- implementing clinical pathways and order sets in electronic health records;
- displaying commitment posters on reducing inappropriate antibiotics use;
- auditing antibiotic prescription rates prospectively with individual feedback and peer comparison; and
- requiring documentation of guideline discordant and antibiotic prescribing.”
“Adapting and implementing antibiotic stewardship interventions in dermatology should address specific behavioral determinants of long-term antibiotic prescriptions for acne treatment,” the authors concluded. “An antibiotic stewardship program for acne treatment should be adapted, piloted and evaluated in dermatology practices to assess its acceptability, feasibility and effectiveness.”
Reference:
- iPledge: Committed to pregnancy prevention. https://ipledgeprogram.com. Accessed May 1, 2024.
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