Dermatologists' Antibiotic Prescribing Habits Have Shifted

John S. Barbieri, MD, MBA

Between 2008 and 2016, overall antibiotic prescribing by dermatologists in the US decreased by 36.6%. However, antibiotic use following dermatologic surgery increased dramatically by 69.6%, according to a new study.

Investigators concerned about the high rates of antibiotic prescriptions written by dermatologists and mindful of the growing importance of antibiotic stewardship sought to characterize the changes in antibiotic prescribing patterns in the dermatology specialty.

“Dermatologists prescribe more oral antibiotic courses per clinician than any other specialty, and many of these courses of antibiotics are prescribed for several months in duration,” wrote lead author John S. Barbieri, MD, MBA, Department of Dermatology, University of Pennsylvania Perelman School of Medicine, and colleagues.

Investigators conducted repeated cross-sectional analyses of antibiotic prescribing information from the Optum Clinformatics Data Mart deidentified commercial claims data, which has patient demographic information similar to the general US population. Antibiotic prescriptions were connected to the primary diagnosis from the closest previous dermatology visit and separated by duration (extended duration, >28 days; short duration, ≤28 days).

Between 2008 and 2016, 11,986 unique dermatologists prescribed 985,866 courses of antibiotics. Most commonly prescribed were doxycycline hyclate (26.3%), minocycline (25.8%), and cephalexin (19.9%). During that timeframe, overall prescriptions decreased by 36.6% (1.23 courses per 100 visits) from 3.36 (95% CI, 3.34-3.38) to 2.13 (95% CI, 2.12-2.14) courses per 100 visits with a dermatologist.

The investigators called this decrease “encouraging” and noted that the shift is “estimated to result in almost 480,000 fewer antibiotic courses per year being prescribed by dermatologists in 2016 than in 2008.”

Longer duration courses of antibiotics accounted for much of the reduction in prescriptions. These prescriptions decreased 53.2% (1.30 courses per 100 visits) from 2.45 (95% CI, 2.43-2.47) to 1.15 (95% CI, 1.14-1.16) courses per 100 visits with a dermatologist.

In 2016, acne was associated with 57.5% of extended duration prescriptions while rosacea was associated with 13.5%. From the beginning to end of the study, prescriptions associated with acne and rosacea decreased 28.1% and 18.1%, respectively.

Antibiotic courses of short duration actually increased over the study period, rising 8.4% (.07 courses per 100 visits) from .91 (95% CI, .90-.92) to .98 (95% CI, .98-.99) courses per 100 visits with a dermatologist. Short-term antibiotics associated with surgical visits jumped 69.6% (2.73 courses per 100 visits) from 3.92 (95% CI, 3.83-4.01) to 6.65 (95% CI, 6.57-6.74) courses per 100 visits associated with a surgical visit.

The investigators noted that a possible cause of the decrease in long-term antibiotic use is patient preference. “Given increasing concerns about complications associated with antibiotic use, patients may be more reluctant to opt for extended courses of antibiotics,” they wrote, noting that alternative options may also have contributed to the decrease.

Study authors called the increase in short-term antibiotic prescriptions associated with surgical procedures “concerning” as the risk for infections in most cases is low. Given the risk of complications from antibiotics, such as C difficile infection and the development of antibiotic-resistant bacteria, the authors stated that “the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits.”

Authors of a commentary piece suggest a “wait-and-see” approach to help reduce antibiotic prescriptions. They add that stronger communication with patients can help providers understand the patient perspective and allow them to recommend keeping antibiotics as a back-up option.

The study authors concluded that despite the observed reduction in prescriptions, there may be further opportunities for dermatologists to improve their antibiotic stewardship practices, particularly in the area of postoperative prescriptions.

The study, “Trends in Oral Antibiotic Prescription in Dermatology, 2008 to 2016,” and editorial, “Dermatologists and Antibiotics—Reflecting on Our Habits, the Evidence, and Next Steps,” were published in JAMA Dermatology.