Is there an association between long-term antibiotics for acne and subsequent infection sequelae and antimicrobial resistance? A systematic review.

Bhate, Ketaki; Lin, Liang-Yu; Barbieri, John S; Leyrat, Clemence; Hopkins, Susan; Stabler, Richard; Shallcross, Laura; Smeeth, Liam; Francis, Nick; Mathur, Rohini; Langan, Sinéad M; Sinnott, Sarah-Jo

BACKGROUND Antimicrobial resistance (AMR) is a global health priority. Acne vulgaris is a common skin condition for which antibiotic use ranges from a few months to years of daily exposure. AIM To systemically search for and synthesise evidence on the risk of treatment-resistant infections, and other evidence of AMR, following long-term oral antibiotic use for acne. DESIGN & SETTING Embase, MEDLINE, Cochrane and Web of Science databases were searched using MeSH, EMTREE or other relevant terms and following a pre-registered protocol. METHOD Search strategies were developed with a librarian and run in July 2019. All searches date from database inception. The primary outcome was antibiotic treatment failure or infection caused by a resistant organism. Secondary outcomes included detection of resistant organisms without an infection, rate of infection, or changes to flora. RESULTS 6,996 records were identified. 73 full-text articles were shortlisted for full review, of which five were included. Two investigated rates of infection and three resistance or changes to microbial flora. Three studies had 35 or fewer participants (range 20-118,496). Three studies had a 'serious' or 'high' risk of bias, one 'moderate' and one a 'low' risk of bias. We found weak evidence for an association between antibiotic use for acne and subsequent increased rates of upper respiratory-tract infections and pharyngitis. CONCLUSION There is a lack of high-quality evidence on the relationship between oral antibiotics for acne treatment and subsequent AMR sequelae. This needs to be urgently addressed with rigorously conducted studies.