Title: Long-term antibiotics for acne: antimicrobial resistance and economic cost.
Funder: Department of Health and Social Care

Abstract: Background:Given the global health emergency of antimicrobial resistance (AMR) and the high prevalence of acne, the dominant role of antibiotics in acne treatment in young healthy people is a major concern. There is a lack of evidence on how medications, including antibiotics are prescribed in the UK to treat acne, and there is minimal research on whether long-term antibiotic use for acne results in AMR, at an individual or population level. Both patients and healthcare professionals have prioritized research that investigates how best to use antibiotics to treat acne.Aim:To explore how treatments are used for acne in the UK, if oral antibiotics for acne are associated with the development of AMR and if this impacts the NHS and UK economically. Specific questions: Evidence-synthesis: i) What is the existing evidence for the role of long-term antibiotics used to treat acne in contributing to AMR? ii) What is the existing evidence for the efficacy of antibiotics used to treat acne compared to a) placebo, b) topical therapy and c) other oral medication such as isotretinoin? 2. What are the prescribing patterns for acne in primary care? 3. Using antibiotic treatment failure in subsequent lower respiratory and skin/soft-tissue infections as a proxy for AMR, what are the rates of antibiotic treatment failure in patients with acne treated with long-term oral antibiotics in comparison to people with acne not exposed to long-term oral antibiotics?4.What are the NHS specific and economic costs of AMR in the UK as a result of long-term antibiotics used totreat acne?Methods and Timelines:Evidence will be synthesized with systematic-reviews using PRISMA guidance (year-1). The Clinical-Practice-Research-Datalink (CPRD), a nationally representative repository of electronic health records from primary care will be used to conduct a drug-utilization study (year-2). The CPRD will also be used to conduct a cohort-study to investigate antibiotic treatment failure in those treated with antibiotics for acne compared to those with acne not treated with oral antibiotics (year-2). A cost analysis study using UK data will estimate the economic-cost of AMR as a result of antibiotics for acne (year-2/3).People with acne and members of the public will help inform study design, interpret findings, review manuscripts and be involved in dissemination.Impact:This study will provide information on whether there is an increased risk of AMR resulting from long-term antibiotics for acne which will: Motivate an antibiotic stewardship initiative. Provide evidence to help policy makers and guideline developers to make evidence-based recommendations on the risk of long-term exposure to antibiotics for acne. Instigate a national audit to monitor antibiotic use. Provide a contribution to the evidence-base which may inform new or alternative acne treatments. Estimating economic cost will provide further evidence for changes to practice to lessen the impact of AMR.Dissemination:I will disseminate the results of my research to academic stakeholders through publications and conference presentations. I will work with patient representatives and acne charities to ensure that I effectively disseminate my results to patients, the wider public and policymakers.

Lay abstract: Why?Antibiotics have overhauled healthcare over the last 70 years and have been key in improving the treatment of infections and therefore the survival of people. However, recently, there has been an increase in people who are given antibiotics for infections and then not getting better with them. This is because the bacteria causing the infections develop ways to change themselves so they are no longer killed by antibiotics. We call this antibiotic resistance. This is a huge problem because if antibiotics stop working, then we have limited ways of treating infections. Many teenagers get acne or spots' and doctors often give them antibiotics by mouth for many weeks or even months to treat it. Antibiotics are used not because acne is an infection, but more because antibiotics are anti-inflammatory, which means they reduce the redness and soreness of spots. This study will find out for the first time how many of the people using antibiotics to treat acne develop difficult to treat infections, and how much this costs the NHS now and is going to cost in the future.How?To do this study, I will first find out how much evidence other studies in the past have on:a) How good antibiotics are at treating acne. b) What other studies have found in terms of developing resistance to antibiotics because of their use in treating acne.I will then use a large collection of GP records called the Clinical-Practice Research Datalink which holds anonymous information on over 6 million people to find out how antibiotics for acne are prescribed in the UK and how other acne medicines are prescribed. The duration of acne treatments and what treatment combinations are prescribed will be the main focus.Then, I will see if those who have antibiotics for acne develop more difficult to treat infections and use this as a way of measuring antibiotic resistance. Lastly, I will find out how much this antibiotic resistance costs the NHS now, and how much it will cost if we continue to use antibiotics for acne in this way.The ideas for this study have come directly from what people; including acne sufferers, members of the public, nurses, doctors, pharmacists and researchers all think is important to find out about the treatment of acne.It is also important that people with acne or their carers are involved from the beginning to make sure that I address the key questions for people with acne and those managing acne in the NHS and other settings. This is why, at every step, I will involve people to help guide the study. Near the end, ten people with acne and carers of those with acne will be invited to help create posters and information to be put on websites like Facebook and Twitter so that I can make sure the messages from this study are sent out in a way that is accessible to a wide audience.Benefit:If the study finds that antibiotics for acne cause resistance, then current guidelines will be changed so that antibiotics are used less or only as long as recommended. Antibiotics for acne will be monitored more and not be allowed to be given for too long. This will mean that antibiotics will work for more people in the future when they really need them. Telling the NHS how much resistance because of antibiotics for acne might cost will help them to plan their money better. There will also be more drive for researchers to create other acne drugs to be used instead of antibiotics which might work better for acne too.

Research activity codes: 6.1 PHARMACEUTICALS
Health categories: SKIN;GENERIC HEALTH RELEVANCE