Spread of antibiotic-resistant bacteria from acne patients to personal contacts-a problem beyond the skin? (1997)

For at least a decade, concern has been raised regarding the emergence of antibiotic-resistant skin flora in acne patients receiving long-term topical or oral antibiotic therapy.1Eady EA Jones CE Tipper JL Cove JH Cunliffe WH Layton AM Antibiotic resistant propionibacteria in acne: need for policies to modify antibiotic usage.BMJ. 1993; 306: 555-556Crossref PubMed Scopus (169) Google Scholar Most studies have focused on two microorganisms, Propionibacterium acnes and coagulase-negative staphylococci, including Staphylococcus epidermidis. For example, the topical application of erythromycin has been associated with an overgrowth of erythromycin-resistant coagulase-negative staphylococci,2Harkaway KS McGinley KJ Foglia AN et al.Antibiotic resistance patterns in coagulase-negative staphylococci after treatment with topical erythromycin, benzoyl peroxide, and combination therapy.Br J Dermatol. 1992; 126: 586-590Crossref PubMed Scopus (95) Google Scholar and strains of P acnes resistant to tetracycline and/or erythromycin were isolated from acne patients who had received long-term antibiotic therapy.3Leyden JJ McGinley KJ Cavalieri S Webster GF Mills OH Kligman AM Propionibacterium acnes resistance to antibiotics in acne patients.J Am Acad Dermatol. 1983; 8: 41-45Summary Full Text PDF PubMed Scopus (205) Google Scholar These studies of antibiotic resistance have provided clinicians with a rational explanation for treatment-resistant acne as well as a strategy for avoiding or circumventing this therapeutic problem-eg, the use of benzoyl peroxide and reuse of the same antibiotics whenever possible.1Eady EA Jones CE Tipper JL Cove JH Cunliffe WH Layton AM Antibiotic resistant propionibacteria in acne: need for policies to modify antibiotic usage.BMJ. 1993; 306: 555-556Crossref PubMed Scopus (169) Google Scholar, 2Harkaway KS McGinley KJ Foglia AN et al.Antibiotic resistance patterns in coagulase-negative staphylococci after treatment with topical erythromycin, benzoyl peroxide, and combination therapy.Br J Dermatol. 1992; 126: 586-590Crossref PubMed Scopus (95) Google Scholar, 3Leyden JJ McGinley KJ Cavalieri S Webster GF Mills OH Kligman AM Propionibacterium acnes resistance to antibiotics in acne patients.J Am Acad Dermatol. 1983; 8: 41-45Summary Full Text PDF PubMed Scopus (205) Google Scholar One theoretical concern that arose from these studies is the potential risk for serious systemic infections with such antibiotic-resistant organisms. However, systemic infections with P acnes are rare and usually follow neurosurgical procedures or are associated with cerebrospinal fluid shunts or prosthetic devices such as heart valves.4Murray PR Kobayashi GS Pfaller MA Rosenthal KS Medical microbiology. 2nd ed. Mosby, St Louis1994: 176Google Scholar Moreover, the antibiotics to which P acnes is commonly resistant are erythromycin, clindamycin, and tetracycline,1Eady EA Jones CE Tipper JL Cove JH Cunliffe WH Layton AM Antibiotic resistant propionibacteria in acne: need for policies to modify antibiotic usage.BMJ. 1993; 306: 555-556Crossref PubMed Scopus (169) Google Scholar, 3Leyden JJ McGinley KJ Cavalieri S Webster GF Mills OH Kligman AM Propionibacterium acnes resistance to antibiotics in acne patients.J Am Acad Dermatol. 1983; 8: 41-45Summary Full Text PDF PubMed Scopus (205) Google Scholar, 5Crawford WW Crawford IP Stoughton RB Cornell RC Laboratory induction and clinical occurrence of combined clindamycin and erythromycin resistance in Corynebacterium acnes.J Invest Dermatol. 1979; 72: 187-190Crossref PubMed Scopus (108) Google Scholar not vancomycin, a profile that is of more importance to dermatologists than neurosurgeons. In addition, to the best of our knowledge, there has been no reported increase in the incidence of serious antibiotic-resistant systemic infections with P acnes in the setting of long-term antibiotic therapy for acne. Risk factors for systemic infection with coagulase-negative staphylococci include intravascular catheters, an immunocompromised state (eg, neutropenia), prosthetic devices, and a disrupted skin barrier.4Murray PR Kobayashi GS Pfaller MA Rosenthal KS Medical microbiology. 2nd ed. Mosby, St Louis1994: 176Google Scholar As a result, the population “at risk” is fairly small, creating minimal overlap with the group of patients receiving long-term antibiotic therapy for acne. In addition, the antibiotics to which coagulase-negative staphylococci are resistant are multiple (both baseline and following antibiotic therapy) and include penicillins, tetracycline, erythromycin, and clindamycin.6Leyden JJ Cunliffe WJ Shalita AR Strauss JS Aly R Resistance of P acnes to antibiotics used in the treatment of acne.J Geriatr Dermatol. 1997; 5: 1A-13AGoogle Scholar However, none of these antibiotics are routinely administered for systemic infections with coagulase-negative staphylococci and none have cross-resistance with vancomycin, the initial drug of choice for proven infections with these organisms. Y W Miller and colleagues7Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy for acne promotes the carriage of resistant staphylococci on the skin of contacts.J Antimicrobiol Chemother. 1996; 38: 829-837Crossref PubMed Scopus (87) Google Scholar have reported on the skin flora of close personal contacts (eg, parents, siblings, and partners) of acne patients who had been treated with at least three different antibiotics over a period of at least 2 years. They chose to look for antibiotic resistance in strains of coagulase-negative staphylococci. Neither controls nor contacts had received oral or topical antibiotics in the past 2 years. Using a scrub-wash technique, the authors found that the facial skin of personal contacts (as compared with the controls) was more likely to have strains of coagulase-negative staphylococci resistant to antibiotics such as erythromycin, clindamycin, chloramphenicol, and/or fusidic acid (p < 0·05). Serial samples were not obtained, so the persistence of resistance cannot be assessed. This study by Miller et al7Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy for acne promotes the carriage of resistant staphylococci on the skin of contacts.J Antimicrobiol Chemother. 1996; 38: 829-837Crossref PubMed Scopus (87) Google Scholar did provide evidence that the number of individuals whose skin is colonised by antibiotic-resistant coagulase-negative staphylococci can exceed the number of acne patients who are receiving chronic antibiotic therapy and become colonised with such organisms. As a result, these personal contacts are at risk of treatment-resistant acne and perhaps more. Although the study provides a cautionary note, the story would be more worrying if antibiotic resistance had been identified in more pathogenic organisms (eg,Staphylococcus aureus), or resistance had developed to antibiotics that are routinely used to treat systemic infections with such organisms (eg, vancomycin). Obviously, resistance to vancomycin or an increase in the virulence of coagulase-negative staphylococci would be of significant clinical importance. In conclusion, the theoretical concern about serious systemic infections secondary to antibiotic-resistant skin flora has not been translated into a practical problem. This antibiotic resistance does, however, remain an issue for those who treat patients with acne.