Considering Antibiotic Resistance in Aesthetics

By Gemma Fromage / 09 Jan 2020

Prescribing pharmacist Gemma Fromage details how aesthetic practitioners can assist in slowing the rate of antibiotic resistance

As all medical professionals know, antibiotic resistance is the ability of microbes to withstand the effects of medications. Germs are therefore not killed and as a result of this resistance they continue to grow.1 Since the development of antibiotics, millions of lives have been saved. However, if the rate of resistance continues, as it currently is, it is estimated that there will be 10 million deaths per year by 2050 and take society back to a pre-antibiotic existence.2 According to the World Health Organisation, antibiotic resistance is one of the biggest threats to global health.1 Resistance cannot be stopped, however it can be slowed. Although this needs to be tackled globally, there are steps that individuals and clinics within the aesthetic field can take to reduce infection and, in turn, assist in the reduction of spread of resistance.

To prevent infection arising from aesthetic treatments such as dermal fillers or laser treatments, it is important that we keep the numbers of antibiotics we are prescribing, and therefore antibiotics consumed, to a minimum.

The best way to do this is to prevent the need for them in the first place by minimising the risks of infection. If treatment is required, ensure that first line choices are always given, unless contraindicated and that both the practitioner and patient are well educated in the correct use of the drug.

Causes of antibiotic resistance

It is generally accepted that the rise in antibiotic resistance is attributed to four main causes: overuse, inappropriate prescribing, agricultural use and fewer new antibiotics on the market.

Overuse

Studies have shown there is a direct link between the overuse of antibiotics and the increasing rates of bacterial resistance.12 Overuse can have many effects; resistance can not only occur spontaneously via mutation, but also antibiotics remove drug-sensitive competitors, resulting in resistant bacteria being left behind to reproduce due to natural selection.13

It is well-established that antibiotics are overused worldwide, despite repeated warnings.14 Whilst in the UK, antibiotics are still prescription-only medications, they are freely available over the counter in a number of countries like Norway, Germany, Slovakia and Romania. As such, their use is unregulated with no need for a prescription or to see a medical professional beforehand.14 With no regulation behind their sale and often being both cheap and plentiful, it is inevitable that overuse will occur.15 In addition, with the prevalence of online sales of these products, their accessibility is increasing even in countries where their usage is regulated, like the UK.15

Inappropriate prescribing

Studies have shown that incorrect prescribing of antibiotics, with the indication, choice of agent or duration of treatment being suboptimal, occurs in 30-50% of antibiotic prescriptions.12,16-18

The use of subinhibitory and subtherapeutic antibiotic doses has prompted the development of resistance via gene generic alterations, such as changes in gene expression, horizontal gene transfer and mutagenesis.19

Incorrect prescribing of antibiotics has not only contributed to resistance,12 but it also has questionable therapeutic benefit and leaves patients open to potential complications, such as increased severity of infection, longer hospital stays and mortality.20

Agricultural use

Antibiotics are reported to improve both the health of the animal and produce a larger yield and higher-quality product,15 so are commonly used worldwide as growth supplements in livestock.9 As a result, antibiotic use for this purpose in agriculture can potentially lead to the ingestion of antibiotics in humans via the consumption of animal meat.21

As with humans, the use of antibiotics in food-producing animals leads to susceptible bacteria being killed, leaving antibiotic resistant bacteria to thrive. These bacteria can be transmitted to humans through the food supply, leading to infection and ill health.12

Fewer new antibiotics

As antibiotics are commonly prescribed for short-term, curable conditions, the development of new antibiotics is no longer considered to be as much of an economical investment22 or as profitable compared to drugs used to treat chronic conditions.21 As such, the search for new antibiotics by pharmaceutical companies has essentially stalled.

Any new antibiotic developed would basically be considered a ‘last-line’ agent, reserved for serious illness only.13 This is due to the constant advice that antibiotic usage should be restricted, with any new antibiotics in particular not to be used as a first-line treatment, but held in reserve.21 This means that return on investment is much lower for these drugs8 and with eventual resistance being inevitable, profits will not only be lower, but limited.7

How aesthetic practitioners can help

The fight against antibiotic resistance is a global matter, but I believe that there are steps that both individuals and clinics can take at a local level which will help slow the rate of resistance developing.

 It is generally accepted that the rise in antibiotic resistance is attributed to four main causes: overuse, inappropriate prescribing, agricultural use and fewer new antibiotics  

Appropriate prescribing

Empirical antibiotic treatment should be started and the practitioner should consider the clinical presentation of the patient’s condition, the suspected prevalent pathogen and any resistance pattern present locally. Guidelines are available to consult for first and second-line treatments; locally there will be a formulary. The British National Formulary23 also provides guidelines, as do more specialist groups within aesthetics such as the Aesthetic Complications Expert (ACE) Group.24 The ACE Group’s guidelines are to prescribe first-line treatment of flucloxacillin 500mg QDS PO (if penicillin allergic, clarithromycin 500mg BD PO) and for second-line treatment, the prescriber should consider the addition of penicillin, amoxicillin or co-amoxiclav (if penicillin allergic, clindamycin 300mg QDS PO).24

Care must be taken to ensure the patient has no antibiotic allergies and, if they do, that these are taken into consideration when prescribing. First-line treatment of infection is recommended for seven days, however if improvement is slow, it should be continued for a further seven days.25 Patients should be closely monitored and if no response is seen at 48-72 hours then a change in regime should be considered. If available, a swab for microbiology, culture and sensitivity should be taken at this point, which would allow the correct antibiotic needed to be identified.

Prescriber education

Practitioners should have in-depth knowledge and understanding of infection control. It is important that the practitioner is able to thoroughly assess the patient as the start of an infection may be easily confused for the initial reaction to treatment, such as heat, redness and swelling. The risk of necrosis and allergic reaction should always be ruled out before the diagnosis of infection and therefore inappropriate treatment.

The practitioner should be confident in selecting an appropriate antibiotic, knowing when to choose an alternative treatment and when to refer for further testing. If a patient requires antibiotics and the practitioner is not a prescriber, then a protocol should be in place to refer to a prescriber confident in dealing with aesthetic complications who can quickly and effectively provide appropriate treatment to the patient with minimal delay. A delay in treatment means more time for the bacteria to develop, multiply and strengthen.

Patient education

Patients should be informed of and given written aftercare advice relating to the procedure they have undergone on the possibilities of infection and how they can minimise their risk. For example, no makeup for eight hours after treatment and no touching of the area that has been treated for four hours after treatment.17 Patient education is linked to speed of diagnosis and treatment. Patients should also be made aware of signs and symptoms to look out for such as redness, swelling or heat in the area that is not settling over the following 48 hours, as well as systemic symptoms such as fever, malaise or nausea. If patients do require antibiotics, then patient education on compliance is a must. Studies have shown that more than one third of patients were non-compliant to their antibiotic regimen and one quarter kept the unused antibiotics for future use.26-28 The course must be completed regardless of if the patient believes the infection to be gone. Conversely, it is also essential that if patients feel an infection is returning, that they make their practitioner aware of the situation.

The practitioner should be confident in selecting an appropriate antibiotic, knowing when to choose an alternative treatment and when to refer for further testing

Aseptic non-touch technique

At the core of the aseptic non-touch technique (ANTT) framework is the aim of asepsis; an accurate and achievable quality standard relating to the absence of pathogenic microorganisms.29 ANTT is achieved by ensuring the asepsis of key parts and sites of the procedure. Better defined, the infection control methods and precautions necessary during invasive clinical procedures to prevent the transfer of microorganisms from health professionals, equipment or the immediate environment to the patient. Studies have shown that a number of infections are caused due to failed aseptic techniques, especially in procedures that breach patients’ natural defence mechanisms.30 With regard to healthcare-associated infections, aseptic technique can be seen as the most common and critical infection prevention practice in healthcare.30 Some pointers for best practice include:

  • Identifying and protecting key parts and key sites (i.e. clinical equipment that comes into contact with the patient and the areas on the patient of which the protective skin barrier is broken)
  • Non-touch technique is the most important component of ANTT, as the safest way to protect a key part is to not touch it
  • Ensuring the highest level of hygiene is adopted (i.e. clean surfaces, clean environment, clean disposal, clean hands, gloves)
  • Educating your patient to not touch the areas for the hours following the treatment, not to apply make up for the rest of the day etc.
  • Ensure you have access to your local guidelines or are a member of ACE Group and have access to their guidelines for treatment
  • Be confident in identifying infection and knowing what to prescribe and when to change antibiotic regime if necessary
  • If you are not a prescriber, ensure you have quick access to a local prescriber who is confident in the above and can prescribe if necessary

Infections can unfortunately occur following any treatment that involves breach in the skin’s integrity. In most case this follows needle trauma to skin during injectable treatments such as toxin or fillers, but in some cases may occur following non-penetrating treatments such as chemical peels or laser procedures. The rates of infection following dermal filler are low, estimated at 0.04-0.2%, although many may not be reported, and risk and can be attributed to several factors.25

Conclusion

Antibiotic resistance is a complex problem with a variety of contributing factors. The spread of resistance cannot be stopped but it can be slowed. Unfortunately, it is not a problem that can be solved by individual groups or countries and must be tackled universally. Joint efforts are required from both patients and practitioners, to international policy makers.

References
  1. WHO, Antibiotic resistance, February 2018 <https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance>
  2. O’neill J, Tackling drug-resistant infections globally, Amr-review.org, 2016, <https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf>
  3. Sengupta S, Chattopadhyay MK, Grossart HP, The multifaceted roles of antibiotics and antibiotic resistance in nature, Front Microbiol, 2013
  4. STMU History Media, Fleming, Chain, Florely and Heatley: The minds behing the discovery of penicillin, May 2019 <https://stmuhistorymedia.org/fleming-chain-florey-and-heatley-the-minds-behind-the-discovery-of-penicillin/>
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  8. Piddock LJV, The crisis of no new antibiotics—what is the way forward? Lancet Infect Dis, 2012
  9. ECDC/EMEA Joint Technical Report, The bacterial challenge: time to react. European Centre for Disease Prevention and Control, 2009. EMEA. doc. ref. EMEA/576176/2009
  10. Cassini A et al., Attributable deaths and disability adjusted life years caused by infections with antibiotic resistant bacteria in the EU and the European Economic rea in 2015, The Lancet, 2018
  11. Antibiotic Resistance Threats in the United States, US Department of Human and Health Services, Centre for Disease Control and prevention, 2013
  12. Centers for Disease Control and Prevention Office of Infectious Diseases, Antibiotic resistance threats in the United States, 2013
  13. Read AF, Woods RJ. Antibiotic resistance management, Evol Med Public Health, 2014
  14. Nature, The antibiotic alarm, Nature. 2013
  15. Michael CA, Dominey-Howes D, Labbate M. The antimicrobial resistance crisis: causes, consequences, and management, Front Public Health, 2014
  16. Centers for Disease Control and Prevention, Office of Infectious Disease Antibiotic resistance threats in the United States, April 2013
  17. Luyt CE et al., Antibiotic stewardship in the intensive care unit, Crit Care, 2014
  18. Swami O et al., Strategies to Combat Antimicrobial Resistance, Journal of clinical and diagnostic research, 2014
  19. Viswanathan VK, Off-label abuse of antibiotics by bacteria. Gut Microbes, 2014
  20. Lushniak BD, Antibiotic resistance: a public health crisis, Public Health Rep. 2014
  21. Golkar Z, Bagasra O, Pace DG, Bacteriophage therapy: a potential solution for the antibiotic resistance crisis, J Infect Dev Ctries, 2014
  22. Bartlett JG, Gilbert DN, Spellberg B, Seven ways to preserve the miracle of antibiotics. Clin Infect Dis. 2013
  23. British National Formulary, <bnf.nice.org.uk>
  24. The Aesthetics Complications Expert Group <https://acegroup.online/>
  25. Ferneini, E et al., An Overview of Infections Associated With Soft Tissue Facial Fillers: Identification, Prevention, and Treatment, Journal of Oral and Maxillofacial Surgery, 2017
  26. Kardas P et al., A systematic review and meta-analysis of misuse of antibiotic therapies in the community. International Journal of Antimicrobial Agents. 2005
  27. Fernandes M et al., Non-adherence to antibiotic therapy in patients visiting community pharmacies. International Journal of Clinical Pharmacy, 2013
  28. Axelsson, M. Report on personality and adherence to antibiotic therapy: a population-based study, BMC Psychology, 2013
  29. Hauswirth K, Sherk SD, Aseptic Technique, Encyclopedia of Surgery, 2013
  30. Nursing Times, ANTT: a standard approach to aseptic technique, Nursing Times, 2019

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