Antibiotic Susceptibility of Propionibacterium Acnes Isolated from Patients with Acne in a Public Hospital in Southwest China: Prospective Cross- Sectional Study

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Antibiotic Susceptibility of Propionibacterium Acnes Isolated from Patients with Acne in a Public Hospital in Southwest China: Prospective Cross- Sectional Study Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-022938 on 3 February 2019. Downloaded from Antibiotic susceptibility of Propionibacterium acnes isolated from patients with acne in a public hospital in Southwest China: prospective cross- sectional study Tingting Zhu,1,2 Wenyi Zhu,2 Qisa Wang,2 Li He,2 Wenjuan Wu,2 Jinju Liu,2 Yan Li,2 Dongjie Sun2 To cite: Zhu T, Zhu W, Wang Q, ABSTRACT Strengths and limitations of this study et al. Antibiotic susceptibility Objective Antibiotics have been routinely used for several of Propionibacterium acnes decades against Propionibacterium acnes (P. acnes), but isolated from patients with acne ► The study sample was representative of the popula- antibiotic resistance of P. acnes is becoming a global in a public hospital in Southwest tion of patients with acne. problem. Only one related Chinese study is available. The China: prospective cross- ► The sample size was small, and the subjects were aim of this study was to assess the antibiotic susceptibility sectional study. BMJ Open from a single centre. of P. acnes obtained from patients with acne in Southwest 2019;9:e022938. doi:10.1136/ ► The cross-sectional design prevented the determi- China. bmjopen-2018-022938 nation of any cause–effect relationship. Design This was a prospective cross-sectional study. ► Prepublication history and Cutaneous samples were obtained from acne lesions additional material for this on the face of 375 patients. Samples were cultured in paper are available online. To is characterised by pleomorphic lesions, view these files, please visit anaerobic medium to identify the presence of P. acnes. including comedones, pustules, papules, Susceptibility tests of isolated were performed the journal online (http:// dx. doi. P. acnes nodules and cysts.2 Its pathogenesis is multi- for tetracycline, doxycycline, clindamycin, erythromycin, org/ 10. 1136/ bmjopen- 2018- factorial and includes abnormal sebum 022938). azithromycin and clarithromycin using the Epsilometer test. Results P. acnes was isolated from 227 patients; 224 secretion, follicular hyperkeratinisation, http://bmjopen.bmj.com/ TZ and WZ contributed equally. isolates (98.7%) were susceptible to doxycycline and Propionibacterium acnes (P. acnes) hypercoloni- 3 220 (96.9%) were susceptible to tetracycline, followed sation, inflammation and immunity. P. acnes Received 3 April 2018 by clindamycin and clarithromycin in 101 (44.5%) and is also considered an opportunistic pathogen Revised 2 August 2018 Accepted 30 November 2018 102 (44.93%) isolates, respectively. Susceptibility of causing multiple inflammatory diseases (eg, P. acnes was detected for erythromycin in 96 (42.3%) endophthalmitis, endocarditis, osteomyelitis, patients, followed by azithromycin in 94 (41.4%). Subjects sarcoidosis, keratitis and the synovitis, acne, who received antibiotics (topical and oral) had higher pustulosis, hyperostosis, osteomymyelitis frequencies of antibiotic-resistant P. acnes as well as (SAPHO) syndrome) as well as inflammatory increased antibiotic minimum inhibitory concentrations on September 28, 2021 by guest. Protected copyright. ailments after surgery or the implantation of compared with patients without antibiotic treatment. foreign devices, including prosthetic aortic Conclusions P. acnes was highly sensitive to cyclines 4 (doxycycline and tetracycline). P. acnes showed valve, hip and shoulder implants. © Author(s) (or their higher resistance rates to macrolides–lincosamides– P. acnes plays a vital role in the pathogen- employer(s)) 2019. Re-use esis of acne by activating the innate and permitted under CC BY-NC. No streptogramins antibiotics (such as erythromycin, commercial re-use. See rights azithromycin, clarithromycin and clindamycin). The adaptive immunity. Chemotactic factors and and permissions. Published by irrational use of antibiotics for acne treatment is probably proinflammatory cytokines are produced by BMJ. a problem in China and elsewhere. These results suggest immune reactions, resulting in local inflam- 1Department of Dermatology, that dermatologists should be more prudent in prescribing mation and potential scarring.5 Anti-inflam- First Affiliated Hospital of antibiotics for acne. matory and antimicrobial medications are the Soochow University, Suzhou, Jiangsu, China basis of acne therapy. Therefore, antibiotics 2Department of Dermatology, are widely used in patients with acne, inhib- First Affiliated Hospital of INTRODUCTIOn iting or eradicating the P. acnes colonisation, Kunming Medical University, Acne is one of the most common skin and reducing the production of proinflam- Kunming, China disorders throughout the world, affecting matory mediators. Topical and systemic anti- 1 Correspondence to 67%–95% of adolescents. Actually, acne is biotics are frequently used in the treatment of 6 Dr Dongjie Sun; clearly a chronic inflammatory skin disease acne. For the past 30 years, a decrease in the sundongjie@ kmmu. edu. cn and not primarily an infectious disease. It percentage of susceptibility of P. acnes strains Zhu T, et al. BMJ Open 2019;9:e022938. doi:10.1136/bmjopen-2018-022938 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-022938 on 3 February 2019. Downloaded from to these antibiotics has been reported in many countries, plastic strip with the MIC interpretative on one side and indicating that antibiotic-resistant P. acnes among patients a predefined antibiotic in gradient concentration (totally with acne is a global problem.7–14 29 concentrations, ranging 0.016–256 µg/mL) on the With routine and long-term use of antibiotics, the other side. A susceptibility test was performed on brucella resistance profile of P. acnes has been gradually altered, agar using six E-strips (tetracycline, doxycycline, clinda- and varies greatly from one region to another. In China, mycin, erythromycin, azithromycin and clarithromycin). antimicrobial resistance is generally a severe problem, All antibiotics were from BioMerieux (Marcy-L’Etoile, but acne treatment with antibiotics (both topical and France), and incubations were performed at 37°C under oral) is a common practice. Apart from one multicentre anaerobic conditions.16 The E-test MIC is defined as cross-sectional observational study,14 little is known about the point on the scale at which the ellipse of growth antibiotic-resistant P. acnes among patients with acne in inhibition intercepts the strip. Data interpretation was China. Therefore, this study aimed to evaluate the anti- performed according to the recommendations given by biotic susceptibility of P. acnes isolated from patients with the Clinical and Laboratory Standards Institute (CLSI) acne in Southwest China. The resulting findings could and the National Committee for Clinical Laboratory help optimise therapeutic strategies for acne in South- Standards as susceptibility and resistance.17 An MIC below west China. the breakpoint value was defined as susceptibility. Break- points for the six antibiotics were tetracycline ≤4 µg/mL, Methods patients doxycycline ≤4 µg/mL, clindamycin ≤2 µg/mL, eryth- This was a prospective study. Patients with acne vulgaris romycin ≤0.5 µg/mL, azithromycin ≤0.5 µg/mL and attending the dermatology outpatient clinic of The First clarithromycin ≤0.5 µg/mL.18 Affiliated Hospital of Kunming Medical University were consecutively enrolled between September 2015 and July Relationship between MIC and patients’ treatment history 2017. Inclusion criteria were: (1) 12–50 years of age; and We compared the MICs of different antibiotics between (2) mild-to-severe acne vulgaris.15 Exclusion criteria were: topical use and oral administrations. To further analyse (1) oral or topical antibiotic in the past month; (2) oral the associations of MIC with various antibiotics and treat- isotretinoin in the past 2 months and (3) other facial skin ment history, the patients were divided into three groups, diseases. The washout period was the period considered namely antibiotic (group 1), non-antibiotic (group 2; necessary for the disappearance of the efficacy of topical treatment with other medications or new treatments) or systemic treatment according to the half-life of drug: and no previous therapy (group 3) groups. Other medi- 1 month for topical antibiotics and 1 month for systemic cations frequently used for treating acne included reti- treatment (at least 2 months for isotretinoin therapy). All noids, traditional Chinese medicine (TCM) and benzoyl patients matching the criteria during the study period peroxide (BPO). The new treatments included intense were asked to participate in this study. pulsed light (IPL), blue and red light, photodynamic http://bmjopen.bmj.com/ Basic clinical information (including age, gender, age therapy (PDT), radiofrequency (RF) and alpha hydroxy of onset and duration of disease) were obtained at the acid (AHA).19–23 time of patient enrolment or subsequently retrieved from consultation records. Statistical analysis Prior to the initiation of the study, informed consent SPSS V.22.0 (IBM, Armonk, NY, USA) was used for statis- was obtained from all patients. When patients were <18 tical analysis. Continuous variables were expressed as years, informed consent was obtained from parents. median (IQR) and compared using the Mann-Whitney U test for two groups or the Kruskal-Wallis and the post hoc on September 28, 2021 by guest. Protected copyright. Specimen collection, culture and P. acnes identification rank-sum test for more than two groups. Categorical vari- Acne lesions were
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