PracticeUpdate Dermatology February 2019

EDITOR’S PICKS 15

Trends in Oral Antibiotic Prescription in Dermatology JAMA Dermatology Take-home message • This repeated cross-sectional analysis evaluated data from the Optum Clinformatics Data Mart to examine the trends in oral antibiotics prescribed by dermatologists between 2008 and 2016. Prescrip- tions for extended courses of antibiotics (>28 days) decreased (2.45 courses per 100 visits in 2008 vs 1.15 courses per 100 visits in 2016). Extended courses of antibiotics were most commonly associated with diagnoses of acne, rosacea, and hidradenitis suppurativa. Conversely, short courses of antibiotics (<28 days) increased from 0.91 per 100 visits to 0.98 courses per 100 visits. These were most commonly associated with skin and soft-tissue infections, surgical visits, hidradenitis suppurativa, and cysts. • The authors estimated a total of 480,000 fewer antibiotic prescrip- tions by dermatologists in 2016 vs 2008. These findings suggest that the increase in short courses of antibiotics associated with surgical visits is an area in which dermatologists should focus to improve antibiotic stewardship. Caitlyn T. Reed MD Abstract IMPORTANCE Dermatologists prescribe more oral antibiotic courses per clinician than any other specialty, and this use puts patients at risk of antibiotic-resistant infections and antibiotic-associated adverse events. OBJECTIVE To characterize the temporal trends in the diagnoses most commonly associated with oral antibiotic prescription by dermatologists, as well as the dura- tion of this use. DESIGN, SETTING, AND PARTICIPANTS Repeated cross-sectional analysis of antibiotic prescribing by dermatologists from January 1, 2008, to December 31, 2016. The setting was Optum Clinformatics Data Mart (Eden Prairie, Minnesota) deidentified commercial claims data. Participants were dermatology clinicians identified by their National Uniform Claim Committee taxonomy codes, and courses of oral antibiot- ics prescribed by these clinicians were identified by their National Drug Codes. EXPOSURES Claims for oral antibiotic prescriptions were consolidated into courses of therapy and associated with the primary diagnosis from the most recent visit. Courses were stratified into those of extended duration (>28 days) and those of short duration (≤28 days). MAIN OUTCOMES AND MEASURES Frequency of antibiotic prescribing and associated diagnoses. Poisson regression models were used to assess for changes in the fre- quency of antibiotic prescribing over time. RESULTS Between 2008 and 2016 among 985 866 courses of oral antibiotics pre- scribed by 11 986 unique dermatologists, overall antibiotic prescribing among dermatologists decreased 36.6% (1.23 courses per 100 visits) from 3.36 (95% CI, 3.34-3.38) to 2.13 (95% CI, 2.12-2.14) courses per 100 visits with a dermatologist (prevalence rate ratio for annual change, 0.931; 95% CI, 0.930-0.932), with much of this decrease occurring among extended courses for acne and rosacea. Oral antibiotic use associated with surgical visits increased 69.6% (2.73 courses per 100 visits) from 3.92 (95% CI, 3.83-4.01) to 6.65 (95% CI, 6.57-6.74) courses per 100 vis- its associated with a surgical visit (prevalence rate ratio, 1.061; 95% CI, 1.059-1.063). CONCLUSIONS AND RELEVANCE Continuing to develop alternatives to oral antibiotics for noninfectious conditions, such as acne, can improve antibiotic stewardship and decrease complications from antibiotic use. In addition, the rising use of postopera- tive antibiotics after surgical visits is concerning and may put patients at unnecessary risk of adverse events. Future studies are needed to identify the value of this prac- tice and the risk of adverse events. Trends in Oral Antibiotic Prescription in Dermatology, 2008 to 2016. JAMA Der- matol 2019 Jan 16;[EPub Ahead of Print], JS Barbieri, K Bhate, KP Hartnett, et al. www.practiceupdate.com/c/78730

Science University, and University of Minnesota) from Jan- uary 1, 2015, to December 31, 2017, was performed along with a literature review of related articles published between January 1, 1980, and December 31, 2017. Data were obtained from medical records as well as Medline and Embase data- bases. All patients had signs resembling necrotizing infection and had a final diagnosis of pyoderma gangrenosum with systemic features or necrotizing Sweet syndrome. Patients were excluded if a diagnosis other than neutrophilic derma- tosis was made, if key clinical information was missing, and if reported in a non-English language. MAIN OUTCOMES AND MEASURES Description of key character- istics of necrotizing neutrophilic dermatosis. RESULTS Overall, 54 patients with necrotizing neutrophilic dermatosis were included, of which 40 had pyoderma gan- grenosum with systemic features and 14 had necrotizing Sweet syndrome. Of the 54 patients, 29 (54%) were male and 25 (46%) were female, with a mean (SD) age of 51 (19) years. Skin lesions commonly occurred on the lower (19 [35%]) and upper (13 [24%]) extremities and developed after a surgical procedure (22 [41%]) or skin trauma (10 [19%]). Shock was reported in 14 patients (26%), and leukemoid reaction was seen in 15 patients (28%). Of the patients with necrotizing neutrophilic dermatosis, 51 (94%) were initially misdiagnosed as necrotizing fasciitis and subsequently received inappro- priate treatment. Debridement was performed in 42 patients (78%), with a mean (SD) of 2 (2 [range, 1-12]) debridements per patient. Four amputations (7%) were performed. Forty-nine patients (91%) received antibiotics when necrotizing neutro- philic dermatosis was misdiagnosed as an infection, and 50 patients (93%) received systemic corticosteroids; all patients responded to immunosuppressants. CONCLUSIONS AND RELEVANCE A complex spectrum of clinical findings of pyoderma gangrenosum and Sweet syndrome with prominent systemic inflammation exists that defines a new subset of neutrophilic dermatoses, termed necrotizing neutrophilic dermatoses; recognizing the difference between this variant and severe infection may prevent unnecessary surgical procedures and prolonged disease morbidity asso- ciated with a misdiagnosis and may expedite appropriate medical management. Clinical Features of Neutrophilic Dermatosis Variants Resembling Necrotizing Fasciitis. JAMA Dermatol 2018 Oct 31;[EPub Ahead of Print], IM Sanchez, S Lowenstein, KA John- son, et al. www.practiceupdate.com/c/75780

VOL. 3 • NO. 1 • 2019