An audit of oral antimicrobial therapy against acne vulgaris NICE guidelines
Authors: Williams O , Fischetti C , Power B 
Published: November 2023

Abstract

Introduction
The suggested therapy for moderate to severe acne vulgaris (AV) is a choice of lymecycline or doxycycline, in combination with topical adapalene and topical benzyl peroxide or topical azelaic acid. The guidelines state care should be taken when prescribing tetracyclines and topical retinoids in pregnancy given the potential harm.1 Antimicrobial resistance is rapidly emerging worldwide, endangering the efficacy of antimicrobial therapy which can be attributed to overuse and misuse of antimicrobials. This audit was conducted to identify inappropriate antimicrobial prescribing to allow discussion of therapy options with patients, thus reducing antimicrobial prescribing.2

Aim
The audit objectives were to ensure appropriate therapy choice, therapy duration and contraception consideration in women of a childbearing age (WOCBA). To assess the aim of alignment to NICE guidelines, the following audit criteria and standards were used: 100% of patients should be prescribed appropriate therapy for moderate to severe AV; 100% of patients should receive less than 6 months of antimicrobial therapy; 100% of WOCBA should be considered for contraception at the initiation of tetracycline therapy.

Methods
A search was conducted on the VISION software on 20/01/2023 identifying which of the 25,000 patients registered as applied or permanent in a single GP practice had a repeat prescription issued for lymecycline or doxycycline in the previous 12 months. A pilot of approximately 10% of the sample size was successfully conducted, requiring no alterations to the search. Each included patient record was accessed individually for the required information and recorded under headings using Microsoft Excel. Patients without AV were excluded. The data were subjected to descriptive statistical analysis. As a clinical audit, this study did not require ethics approval.

Results
The search produced 157 results, leaving 102 patients after the exclusion criteria was applied. Of the included patients, 9.8% (n=10) were on the correct oral and topical therapy aligned with NICE guidance. In 90.2% (n=92) of patients, the duration of oral antimicrobial therapy was longer than 6 months. In 30.4% (n=17) of WOCBA, contraception was not prescribed at the initiation of tetracycline therapy.

Discussion/Conclusion
All set aims and objectives were met. A lack of adherence to NICE guidelines surrounding choice and duration of therapy was found. This may be attributed to unawareness of updated guidelines. Raising awareness of the guidelines and the implication of antimicrobial resistance may improve the inappropriate prescribing, thereby improving patient outcomes long term. The results suggested inadequate consideration of contraception, which was noted as a priority for being addressed within the practice. Healthcare professionals should be reminded of the potential teratogenicity caused by tetracyclines in pregnancy and the importance of thorough documentation.3 Further audits would be beneficial to address the limitations of the study, which included not knowing whether contraception had been discussed with WOCBAs on initiation, if not documented in the patient’s record, as the audit was conducted retrospectively. It would be useful to observe ordering patterns, issues of acute prescriptions, and the use of topical retinoids to WOCBA to further improve practice.

References
1. Acne Vulgaris [Internet]. NICE. [cited 2023Feb20]. Available from: https://cks.nice.org.uk/topics/acne-vulgaris/.
2. Ventola CL. The antibiotic resistance crisis. Pharmacy and Therapeutics. 2015Apr;40(4):277–83.
3. Hill EM, Howard CD, Bale TL, Jašarević E. Perinatal exposure to tetracycline contributes to lasting developmental effects on offspring. Animal Microbiome. 2021;3(1).