Today, like most days, I have 35 plus patients on my schedule. I walk into my exam room to find a young, 21-year-old female, sitting on the exam table. My initial assessment of her: mild comedonal acne with scattered papules and pustules distributed on her forehead and cheeks. She had been seen previously at another dermatology practice and prescribed a ‘cream’ which she admits, ‘worked’. But this time, she doesn’t want a cream, she just wants ‘a pill’ to take ‘as needed’. She states a friend of hers, a physician, prescribes such a medication for her patients ‘all the time.’ I start my explanation of acne, seeking to educate her, as acne is not an infection but rather an inflammatory process. She turns to her phone and texts her friend. I continue my explanation on the role of topical retinoids, the gold standard of acne therapy, as both a treatment and a method of prevention. She interrupts me, saying “Its doxycycline. I just want doxycycline to take when I need it”.
In the Fall of 2013, The CDC released their “Threat Report” which was a hundred plus pages in length, discussing the pressing topic of antimicrobial resistance.
(https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf) They are expected to update the report later this year. Currently, it is estimated at least 23,000 people die annually in the US due to antimicrobial resistance (AMR). Globally, the number is closer to 700,000 with current predictions of an additional 10 million dying by 2050 due to this crisis alone. In addition to vaccine hesitancy, The World Health Organization has listed antimicrobial resistance as one of their top ten threats for 2019.
When the CDC’s original report was released, it was estimated that nearly half of the antibiotic prescriptions written were ‘unnecessary’. Providers have taken notice, and currently, the estimate is around 25%. But we still have a way to go with this crisis. Weekly, patients enter my office on medications such as minocycline, prescribed endlessly, for acne. The CDC’s recommendation: prior to prescribing antibiotics, a culture should be obtained, proving the necessity of the medication. In addition, a re-evaluation is recommended if the patient has shown no improvement in 48-72 hours. Considering the diagnosis of acne in light of this protocol, in most cases, antibiotics are not indicated. The majority of cultures and sensitivities will reveal ‘normal skin flora’ and improvement will not be appreciated in the 48-72 hour timeframe.
With schedules packed to the brim with patients, it can be difficult to find the time to discuss the personal and global risks of PO antibiotics overuse. Sometimes patients (and parents) present with a pre-conceived wish list, like my patient above. If their ideas do not make sense based on pathophysiology and/or safety, it can be a challenge to convince them to accept a different therapeutic approach. But now, more than ever, it is imperative we take the time to decrease our own individual antibiotic footprint. There are 10 million more lives at stake.