Considering Antibiotic Resistance in Aesthetics

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 drugsensitive 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

The history of antibiotics The modern era of antibiotics began in 1928 with the discovery of penicillin by Sir Alexander Flemming. 3 He then spent years trying to persuade scientists to take an interest in it and it wasn’t until 1939 that a team in Oxford, headed by Foley, Heatley and Chain began work with penicillin. 4 The first human to be trialled on was Albert Alexander on in February 1941. The treatment was a success, but due to a lack of product to continue treatment he relapsed and died. The problem was producing enough product. So, they headed to America in a bid to industrialise penicillin production. The plan was to have enough penicillin supply for medical support for the planned invasion in Europe. By D-Day, June 6th, 1944, the armies were well stocked with penicillin to treat war wounds. In March 1945, penicillin was made available over the counter in US pharmacies and then available in the UK as a prescription-only drug in June the following year. 4 However, within just a decade, resistance was already becoming a problem. 5 The discovery and subsequent use of antibiotics has without a doubt been one of the most significant cornerstones of clinical medicine in the latter half of the 20 th century, saving lives, extending life spans 6 and playing a key role in both medical and surgical advances. 7 In contrast, the last decade of the 20 th century and first two decades of the 21 st century has seen the spread of antibiotic resistance. Antibiotic resistance is on the rise among many microorganisms in all health-care settings, as well as in the community. 8 In 2007 the European Medicines Agency (EMA) and European Centre for Disease Prevention and Control (ECDC) reported 25,000 deaths per year as a direct consequence of multidrug resistance (MDR) with a total cost of €1.5 billion. 9 The study was then repeated in 2015 and it was estimated that the number of deaths per year has increased to 33,000. 10 Reported data also suggests that almost two million cases of infection with resistant bacteria have been reported in the US every year, leading to $20 billion incremental direct healthcare cost.

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 investment 22 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 drugs 8 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.

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 Formulary 23 also provides guidelines, as do more specialist groups within aesthetics such as the Aesthetic Complications Expert 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.

(ACE) Group. 24 The ACE Group’s guidelines 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

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

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

gone. Conversely, it is also essential that if patients feel an infection is returning, that they make their practitioner aware of the situation.

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 healthcareassociated 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. guidelines or are a member of ACE Group and have access to their guidelines for treatment Be confident in identifying infection and

• Ensure you have access to your local 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.

Gemma Fromage is a prescribing pharmacist and received her Master’s in Pharmacy in 2006. She started working in the aesthetics industry in 2010 and now runs her own clinic, Your Skin Health in Raynes Park.

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