Potential association between the oral tetracycline class of antimicrobials used to treat acne and inflammatory bowel disease

Elevated risk of adverse effects from foodborne contaminants and drugs in inflammatory bowel disease: a review

The global burden of Inflammatory bowel disease (IBD) has been rising over the last decades. IBD is an intestinal disorder with a complex and largely unknown etiology. The disease is characterized by a chronically inflamed gastrointestinal tract, with intermittent phases of exacerbation and remission. This compromised intestinal barrier can contribute to, enhance, or even enable the toxicity of drugs, food-borne chemicals and particulate matter. This review discusses whether the rising prevalence of IBD in our society warrants the consideration of IBD patients as a specific population group in toxicological safety assessment. Various in vivo, ex vivo and in vitro models are discussed that can simulate hallmarks of IBD and may be used to study the effects of prevalent intestinal inflammation on the hazards of these various toxicants. In conclusion, risk assessments based on healthy individuals may not sufficiently cover IBD patient safety and it is suggested to consider this susceptible subgroup of the population in future toxicological assessments.

The role of antibiotic exposure as risk factor for IBD epidemic: an updated meta-analysis

BACKGROUND AND AIM

The rising prevalence of IBD globally has raised concerns about antibiotic exposure. This study's meta-analysis examines antibiotic exposure, frequency, year before diagnosis, regional differences, and IBD incidence.

METHODS

The literature review used PubMed, Web of Science, Elsevier, ScienceDirect, and Cochrane CENTRAL databases up to June 2024 to explore the link between antibiotic exposure and IBD risk. Stratified analysis was conducted by years of antibiotic exposure before IBD diagnosis, frequency, and region. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were combined using a random effects model.

RESULTS

Eighteen case-control studies and five cohort studies were included (n = 99, 104 IBD patients and n = 2 273 336 controls). The findings indicate that antibiotic exposure significantly has a positive association with the risk of developing IBD (OR, 1.66; 95% CI, 1.28-2.16). Antibiotic exposure of ≥3 years (OR, 1.49; 95% CI, 1.12-1.98), 2 years (OR, 1.46; 95% CI, 1.37-1.55), and ≤1 year (OR, 1.55; 95% CI, 1.17-2.04) prior to the diagnosis of IBD is associated with a higher risk of developing IBD. Cumulative exposure of ≥3 dispensations (OR, 2.02; 95% CI, 1.49-2.74) and two dispensations (OR, 1.36; 95% CI, 1.03-1.78) also had a positive association with IBD risk, while one dispensation did not (OR, 0.96; 95% CI, 0.72-1.26). No significant association was found in developing countries (OR, 1.92; 95% CI, 0.71-5.19), but developed countries showed a significant positive association with the risk (OR, 1.58; 95% CI, 1.27-1.96).

CONCLUSION

The meta-analysis suggests that antibiotic use has a positive association with the risk of IBD, and limiting unnecessary antibiotic use may be one way to reduce the risk of developing IBD.

Challenges in designing a randomized, double-blind noninferiority trial for treatment of acne: The SD-ACNE trial

BACKGROUND/AIMS

Excessive use of antibiotics has led to development of antibiotic resistance and other antibiotic-associated complications. Dermatologists prescribe more antibiotics per clinician than any other major specialty, with much of this use for acne. Alternative acne treatments are available but are used much less often than antibiotics, at least partially because dermatologists feel that they are less effective. Spironolactone, a hormonal therapy with antiandrogen effects that can address the hormonal pathogenesis of acne, may represent a therapeutic alternative to oral antibiotics for women with acne. However, the comparative effects of spironolactone and oral antibiotics in the treatment of acne have not been definitively studied. The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation (SD-ACNE) trial aims to answer whether spironolactone, in addition to standard topical therapy, is noninferior to doxycycline (an oral antibiotic) for women with acne. Several interesting challenges arose in the development of this study, including determining acceptability of the comparative regimens to participating dermatologists, identifying data to support a noninferiority margin, and establishing a process for unblinding participants after they completed the study while maintaining the blind for study investigators.

METHODS

We present the scientific and clinical rationale for the decisions made in the design of the trial, including input from key stakeholders through a Delphi consensus process.

RESULTS

The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation trial (NCT04582383) is being conducted at a range of community and academic sites in the United States. To maximize external validity and inform clinical practice, the study is designed with broad eligibility criteria and no prohibition of use of topical medications. Participants in the trial will be randomized to receive either spironolactone 100 mg/day or doxycycline hyclate 100 mg/day for 16 weeks. The primary outcome is the absolute decrease in inflammatory lesion count, and we have established a noninferiority margin of four inflammatory lesions. Secondary outcomes include the percentage of participants achieving Investigator Global Assessment success, change in quality of life, and microbiome changes and diversity.

CONCLUSIONS

The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation trial will have substantial implications for the treatment of acne and antibiotic stewardship. In addition, this study will provide important information on the effect of these systemic agents on the development of changes to the microbiome and antibiotic resistance in a healthy population of patients.

Association between Isotretinoin Exposure and Inflammatory Bowel Disease: A Nationwide Case-Control Study in South Korea

Context

Isotretinoin is commonly prescribed for the treatment of acne. However, its association with inflammatory bowel disease (IBD) could not be confirmed due to inconsistencies in the literature. Furthermore, no related study has been conducted on an Asian population.

Aims

The aim of this study was to investigate the association between isotretinoin and inflammatory bowel disease.

Methods and Material

A nationwide, population-based, case-control study using the National Health Insurance Service database of South Korea was conducted. The case group comprised 107,434 patients with IBD, while the control group comprised 393,830 patients who were matched using a 1:4 propensity score. Data on isotretinoin exposure within the previous 5 years were extracted, and a multivariable-adjusted, conditional, logistic, regression analysis was performed.

Results

After adjusting for age, sex, underlying disease, the Charlson co-morbidity index, and tetracycline use, a significant association between isotretinoin exposure and IBD was found, with an odds ratio of 1.20 (95% confidence interval, 1.10-1.30). Furthermore, the association appeared to become stronger with longer exposure, more of a cumulative dose, and a longer time since the first exposure. When analyzed separately for ulcerative colitis and Crohn's disease, isotretinoin exposure was significantly associated with both diseases.

Conclusions

Our study reveals a dose-response relationship between isotretinoin exposure and IBD risk in an Asian population. Healthcare professionals should be aware of the association and consider alternative medications for acne treatment, particularly in patients who are at a higher risk of developing IBD.

Exploring Acne Treatments: From Pathophysiological Mechanisms to Emerging Therapies

Acne vulgaris is a common dermatological condition that can present across different ages but predominantly affects adolescents and young adults. Characterized by various lesion types, the pathogenesis of acne is complex, involving genetic, hormonal, microbial, and inflammatory factors. This review comprehensively addresses current and emerging acne management strategies, emphasizing both topical and systemic treatments, procedural therapies, and dietary modifications. Key topical agents include retinoids, benzoyl peroxide, antibiotics, and other specialized compounds. Systemic options like antibiotics, hormonal therapies, and retinoids offer significant therapeutic benefits, particularly for moderate to severe cases. Procedural treatments such as laser devices, photodynamic therapy, chemical peels, and intralesional injections present viable alternatives for reducing acne symptoms and scarring. Emerging therapies focus on novel biologics, bacteriophages, probiotics, and peptides, providing promising future options. This review underscores the importance of personalized approaches to treatment due to the multifaceted nature of acne, highlighting the potential of innovative therapies for improving patient outcomes.

Guidelines of care for the management of acne vulgaris

BACKGROUND

Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older.

OBJECTIVE

The objective of this study was to provide evidence-based recommendations for the management of acne.

METHODS

A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations.

RESULTS

This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements.

LIMITATIONS

Analysis is based on the best available evidence at the time of the systematic review.

CONCLUSIONS

These guidelines provide evidence-based recommendations for the management of acne vulgaris.

Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment

Importance

Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice.

Objective

To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Design, Setting, and Participants

This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024.

Main Outcomes and Measures

Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Results

Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship.

Conclusions and Relevance

The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

Dermatologic manifestations in pediatric patients with inflammatory bowel disease

BACKGROUND

Despite studies of dermatologic manifestations in adults with inflammatory bowel disease (IBD), little is known about the prevalence of IBD-associated skin lesions and their correlation with IBD severity in children. We aimed to address these knowledge gaps in our single-center cohort of children with IBD.

METHODS

Retrospective chart review of 528 children and adolescents (≤18 years old) with IBD and seen at Mayo Clinic (Rochester, MN) between 1999 and 2017 was conducted. The Chi-Square/Fischer's exact test (with p ≤ .05 to signify statistical significance) was applied to compare categorical outcomes between Crohn's disease (CD) and ulcerative colitis (UC) patients.

RESULTS

In total, 425 IBD patients (64.9% CD, 53% males) and ≥1 dermatologic diagnosis were included. Presence of ≥1 cutaneous infection was recorded in 42.8% of participants. Acne was the most common non-infectious dermatologic condition (30.8%), followed by eczema (15.8%) and perianal skin tags (14.6%). Angular cheilitis (p = .024), keratosis pilaris (KP, p = .003), and perianal skin complications (i.e., skin tags, fistula, and abscesses; all p < .001) were more frequently diagnosed among children with CD, while fungal skin infections (p = .017) were more frequently diagnosed in UC patients. Severity of IBD correlated with higher prevalence of perianal fistula (p = .003), perianal abscess (p = .041), psoriasis (p < .001), and pyoderma gangrenosum (PG, p = .003).

CONCLUSIONS

Both IBD-specific and IBD-nonspecific dermatologic conditions are very prevalent in childhood IBD, the most common being infectious. Children with CD are more likely to experience angular cheilitis, KP, and perianal skin findings than those with UC. Perianal disease, psoriasis, and PG are associated with more severe IBD.

Antibiotic Exposure and Risk of New-Onset Inflammatory Bowel Disease: A Systematic Review and Dose-Response Meta-Analysis

BACKGROUND & AIMS

The association between antibiotic exposure and inflammatory bowel disease (IBD) remains controversial, especially whether there is a dose-response relationship. We aimed to conduct a systematic review and meta-analysis to thoroughly evaluate the risk of new-onset IBD associated with antibiotic exposure.

METHODS

Four databases were searched from their inception to September 30, 2023 for all relevant studies. The risk estimates were pooled together using random-effects models, and pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, stratified by IBD subtype, age, exposure period, study type, and antibiotic classes. Dose-response relationship between the number of antibiotic prescriptions and IBD risk was assessed using generalized least squares regression analysis.

RESULTS

Twenty-eight studies involving 153,027 patients with IBD were included. Antibiotic exposure was significantly associated with an increased risk of new-onset IBD for prescription-based studies (pooled OR, 1.41; 95% CI, 1.29-1.53) and for questionnaire-based studies (pooled OR, 1.35; 95% CI, 1.08-1.68). This association existed for both Crohn's disease and ulcerative colitis, as well as in children and adults for prescription-based studies. The majority of antibiotic classes were associated with an increased IBD risk, with metronidazole (OR, 1.70; 95% CI, 1.38-2.10) and quinolones (OR, 1.56; 95% CI, 1.37-1.77) having relatively higher risk estimates. A positive nonlinear dose-response association was observed between the number of antibiotic prescriptions and IBD risk.

CONCLUSIONS

Antibiotic exposure was significantly associated with an increased risk of new-onset IBD, and a positive nonlinear dose-response relationship was observed. Antibiotic stewardship may be important for reducing IBD risk.

Isotretinoin Exposure and Risk of Inflammatory Bowel Disease: A Systematic Review with Meta-Analysis and Trial Sequential Analysis

BACKGROUND

Cases of inflammatory bowel disease (IBD) following isotretinoin use have been reported previously, but whether isotretinoin exposure is associated with IBD has been unclear.

OBJECTIVE

The aim was to evaluate whether isotretinoin use is associated with IBD.

METHODS

We performed a systematic review and searched MEDLINE, Embase, and CENTRAL databases from inception to January 27, 2023 for relevant case-control and cohort studies. Our outcome was the pooled odds ratio (OR) for IBD and its two subtypes (Crohn disease and ulcerative colitis) in relation to isotretinoin exposure. We conducted a random-effects model meta-analysis and a sensitivity analysis by excluding low-quality studies. A subgroup analysis was undertaken by including studies considering antibiotic use. A trial sequential analysis (TSA) was performed to test the robustness of the conclusiveness of our results.

RESULTS

We included eight studies (four case-control and four cohort studies) with a total of 2,522,422 participants. The meta-analysis found no increased odds for IBD among patients receiving isotretinoin (OR 1.01; 95% confidence interval [CI] 0.80-1.27). Nor did the meta-analysis find increased odds for either Crohn disease (OR 0.87; 95% CI 0.65-1.15) or ulcerative colitis (OR 1.27; 95% CI 0.94-1.73) associated with isotretinoin exposure. The sensitivity and subgroup analyses produced similar results. In TSA, the Z-curve reached the futility boundaries when using relative risk reduction thresholds ranging from 5% to 15%.

CONCLUSION

This meta-analysis with TSA found no evidence of an association of isotretinoin use with IBD. Isotretinoin should not be withheld because of unnecessary concerns for the development of IBD.

PROSPERO REGISTRATION NO

CRD42022298886.

Isotretinoin and the risk of inflammatory bowel disease and irritable bowel syndrome: A large-scale global study

INTRODUCTION

Risk of inflammatory bowel disease under isotretinoin is a scope of a long-standing controversy. The burden of isotretinoin-related irritable bowel syndrome has not been investigated.

OBJECTIVE

To evaluate the risk of Crohn's disease, ulcerative colitis (UC), and irritable bowel syndrome in patients with acne starting isotretinoin vs oral antibiotics treatment.

METHODS

A global population-based retrospective cohort study assigned 2 groups of patients with acne initiating isotretinoin (n = 77,005) and oral antibiotics (n = 77,005). Comprehensive propensity-score matching was conducted.

RESULTS

The lifetime risk of Crohn's disease (hazard ratio [HR], 1.05; 95% CI, 0.89-1.24; P = .583) and UC (HR, 1.13; 95% CI, 0.95-1.34; P = .162) was comparable between study groups, whereas the lifetime risk of irritable bowel syndrome was lower in isotretinoin-prescribed patients (HR, 0.82; 95% CI, 0.76-0.89; P < .001). In time-stratified analysis, isotretinoin-related risk of UC was significantly increased during the first 6 months following drug initiation (HR, 1.93; 95% CI, 1.29-2.88; P = .001), but decreased afterward to level the risk of the comparator group. The absolute risk difference within the first 6 months was clinically marginal (5.0 additional UC cases/10,000 patients starting isotretinoin; 95% CI, 2.5-7.7).

LIMITATIONS

Retrospective data collection.

CONCLUSION

Isotretinoin does not confer an elevated risk of Crohn's disease, whilst it might be associated with a slight and transient increase in UC risk.

A propensity score matched cohort study identifying an association of acne, but not oral antibiotic or isotretinoin use, with risk of incident inflammatory bowel disease

BACKGROUND

Concerns remain regarding whether oral antibiotic or isotretinoin use for acne is associated with increased risk of inflammatory bowel disease (IBD); little is known about whether acne itself is associated with IBD.

OBJECTIVE

To determine whether isotretinoin exposure, oral tetracycline-class antibiotic exposure, and/or acne itself are associated with IBD.

METHODS

A propensity score matched cohort study was performed using TriNetX between 2001 and 2022 to compare the 1-year incidence of IBD between those without acne compared to those with acne managed without systemic medications, acne managed with oral tetracycline-class antibiotics, and acne managed with isotretinoin.

RESULTS

There was a statistically significant association between acne and risk of incident IBD (odds ratio: 1.42; 95% confidence interval: 1.23-1.65). There was no statistically significant association between oral tetracycline-class antibiotic or isotretinoin exposure and IBD.

LIMITATIONS

Use of electronic health data; potential for misclassification bias.

CONCLUSION

This matched cohort study identifies an association between acne and IBD. These data provide further reassurance regarding the use of isotretinoin in the treatment of acne.

Truncal Acne and Scarring: A Comprehensive Review of Current Medical and Cosmetic Approaches to Treatment and Patient Management

Acne vulgaris is one of the most common skin disorders worldwide. It typically affects skin areas with a high density of sebaceous glands such as the face, upper arms, chest, and/or back. Historically, the majority of research efforts have focused on facial acne vulgaris, even though approximately half of patients with facial lesions demonstrate truncal involvement. Truncal acne vulgaris is challenging to treat and poses a significant psychosocial burden on patients. Despite these characteristics, studies specifically examining truncal acne vulgaris are limited, with treatment guidelines largely derived from facial protocols. Therefore, truncal acne remains an understudied clinical problem. Here, we provide a clinically focused review on the epidemiology, evaluation, and available treatment options for truncal acne vulgaris. In doing so, we highlight knowledge gaps with the goal of spurring further investigation into the management of truncal acne vulgaris.

Effects of antimicrobials on the gastrointestinal microbiota of dogs and cats

Among several environmental factors, exposure to antimicrobials has been in the spotlight as a cause of profound and long-term disturbance of the intestinal microbiota. Antimicrobial-induced dysbiosis is a general term and includes decreases in microbial richness and diversity, loss of beneficial bacterial groups, blooms of intestinal pathogens and alterations in the metabolic functions and end-products of the microbiota. Mounting evidence from human and experimental animal studies suggest an association between antimicrobial-induced dysbiosis and susceptibility to gastrointestinal, metabolic, endocrine, immune and neuropsychiatric diseases. These associations are commonly stronger after early life exposure to antimicrobials, a period during which maturation of the microbiota and immune system take place in parallel. In addition, these associations commonly become stronger as the number of antimicrobial courses increases. The repeatability of these findings among different studies as well as the presence of a dose-dependent relationship between antimicrobial exposure and disease development collectively require careful consideration of the need for antimicrobial use. There are limited studies are available in dogs and cats regarding the long-term effects of antimicrobials on the microbiota and subsequent susceptibility to diseases. This review discusses the effects of antimicrobials on the gastrointestinal microbiota and the most important associations between antimicrobial-induced dysbiosis and diseases in humans, dogs, and cats.

Comparison of intestinal flora between patients with chronic and advanced Schistosoma japonicum infection

Background

Schistosoma japonicum infection is an important public health problem, imposing heavy social and economic burdens in 78 countries worldwide. However, the mechanism of transition from chronic to advanced S. japonicum infection remains largely unknown. Evidences suggested that gut microbiota plays a role in the pathogenesis of S. japonicum infection. However, the composition of the gut microbiota in patients with chronic and advanced S. japonicum infection is not well defined. In this study, we compared the composition of the intestinal flora in patients with chronic and advanced S. japonicum infection.

Methods

The feces of 24 patients with chronic S. japonicum infection and five patients with advanced S. japonicum infection from the same area were collected according to standard procedures, and 16S rRNA sequencing technology was used to analyze the intestinal microbial composition of the two groups of patients.

Results

We found that alteration occurs in the gut microbiota between the groups of patients with chronic and advanced S. japonicum infections. Analysis of alpha and beta diversity indicated that the diversity and abundance of intestinal flora in patients with advanced S. japonicum infection were lower than those in patients with chronic S. japonicum infection. Furthermore, Prevotella 9, Subdoligranulum, Ruminococcus torques, Megamonas and Fusicatenibacter seemed to have potential to discriminate different stages of S. japonicum infection and to act as biomarkers for diagnosis. Function prediction analysis revealed that microbiota function in the chronic group was focused on translation and cell growth and death, while that in the advanced group was concentrated on elevating metabolism-related functions.

Conclusions

Our study demonstrated that alteration in gut microbiota in different stages of S. japonicum infection plays a potential role in the pathogenesis of transition from chronic to advanced S. japonicum infection. However, further validation in the clinic is needed, and the underlying mechanism requires further study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05539-6.

Inflammatory bowel disease-associated adherent-invasive Escherichia coli have elevated host-defense peptide resistance

Adherent-invasive Escherichia coli (AIEC) are isolated from inflammatory bowel disease (IBD) patients at a higher rate than from control patients. Using a collection of E. coli strains collected from Crohn's disease (CD), ulcerative colitis (UC), or non-IBD control patients, antibiotic and resistance to the antimicrobial peptides HBD-3 and LL-37 was assessed. Carriage of bacterial-encoded omptin protease genes was assessed by PCR and omptin protease activity was measured using a whole-cell based fluorescence assay. Elevated resistance to antibiotics and host defense peptides in IBD-associated AIEC were observed. IBD-associated strains showed increased (but statistically non-significant) antibiotic resistance. CD-associated strains showed greater (but statistically non-significant) resistance to HBD3-mediated killing while UC-associated strains showed statistically greater resistance to LL-37 mediated killing. High-level resistance to LL-37 was associated with carriage of omptin protease genes and with increased omptin protease activity. Antimicrobial host defense peptide resistance may be an adaptive feature of AIEC leading to enhanced pathogenesis during the initiation or progression of IBD.

Antibiotic Resistance Risk with Oral Tetracycline Treatment of Acne Vulgaris

Almost 1 billion people worldwide have acne, and oral tetracyclines, including doxycycline and minocycline, are effective and frequently prescribed treatments for acne. However, there is growing concern for the development of antibiotic resistance with such widespread utilization by dermatologists. Additionally, tetracyclines are known to have various potential side effects, including gut dysbiosis, gastrointestinal upset, photosensitivity, dizziness, and vertigo. However, in 2018 a novel narrow-spectrum tetracycline, sarecycline, was Food and Drug Administration-approved to treat moderate-to-severe acne vulgaris in patients 9-years-old and above. Sarecycline was designed to target Cutibacterium acnes, the pathogenic bacterium in acne vulgaris, which may reduce the risk of resistance. This paper examines the growing concerns of antibiotic resistance due to oral tetracycline usage in the treatment of acne vulgaris, with a focus on the promising third-generation, narrow-spectrum tetracycline, sarecycline.

Occurrence of inflammatory bowel disease in patients with chronic inflammatory skin diseases: a cohort study

BACKGROUND

Several studies linked various chronic inflammatory skin diseases (CISDs) with inflammatory bowel disease (IBD) in a range of data sources with mixed conclusions.

OBJECTIVE

We compared the incidence of IBD-ulcerative colitis (UC) and Crohn's disease (CD)- in patients with a CISD versus similar persons without a CISD.

METHODS

In this cohort study using nationwide, longitudinal, commercial insurance claims data from the US, we identified adults and children who were seen by a dermatologist between 2004-2020, and diagnosed with either psoriasis, atopic dermatitis, alopecia areata, vitiligo, or hidradenitis suppurativa. Comparator patients were identified through risk-set sampling; they were eligible if they were seen by a dermatologist at least twice and not diagnosed with a CISD. Patient follow-up lasted until either IBD diagnosis, death, disenrollment, or end of data stream, whichever came first. IBD events, ulcerative colitis (UC) or Crohn's (CD), were identified via validated algorithms-hospitalization or diagnosis with endoscopic confirmation. Incidence rates were computed before and after adjustment via propensity-score (PS) decile stratification to account for IBD risk factors. Hazard ratios (HR) and 95% confidence intervals were estimated to compare the incidence of IBD in CISD versus non-CISD.

RESULTS

We identified patients with atopic dermatitis (n=123,614), psoriasis (n=83,049), alopecia areata (n=18,135), vitiligo (n=9,003) or hidradenitis suppurativa (n=6,806), and comparator patients without a CISD (n=2,376,120). During a median follow-up time of 718 days, and after applying PS adjustment for IBD risk factors, we observed increased risk of both UC (HR_UC =2.30; 1.61-3.28) and CD (HR_CD =2.70; 1.69-4.32) in patients with hidradenitis suppurativa, an increased risk of CD (HR_CD =1.23; 1.03-1.46) but not UC (HR_UC =1.01; 0.89-1.14) in psoriasis, and no increased risk of IBD in atopic dermatitis (HR_UC =1.02; 0.92-1.12, HR_CD =1.08; 0.94-1.23), alopecia areata (HR_UC =1.18; 0.89-1.56, HR_CD =1.26; 0.86-1.86) or vitiligo (HR_UC =1.14; 0.77-1.68, HR_CD =1.45; 0.87-2.41).

CONCLUSIONS

IBD was increased in patients with hidradenitis suppurativa. Crohn's disease alone was increased in patients with psoriasis. Neither ulcerative colitis nor Crohn's disease was increased in patients with atopic dermatitis, alopecia areata or vitiligo.

Sarecycline Demonstrated Reduced Activity Compared to Minocycline against Microbial Species Representing Human Gastrointestinal Microbiota

Prolonged use of broad-spectrum tetracycline antibiotics such as minocycline and doxycycline may significantly alter the gut and skin microbiome leading to dysbiosis. Sarecycline, a narrow-spectrum tetracycline-class antibiotic used for acne treatment, is hypothesized to have minimal impact on the gastrointestinal tract microbiota. We evaluated the effect of sarecycline compared to minocycline against a panel of microorganisms that reflect the diversity of the gut microbiome using in vitro minimum inhibitory concentration (MIC) and time-kill kinetic assays. Compared to minocycline, sarecycline showed less antimicrobial activity indicated by higher MIC against 10 of 12 isolates from the Bacteroidetes phylum, three out of four isolates from Actinobacteria phylum, and five of seven isolates from the Firmicutes phylum, with significantly higher MIC values against Propionibacterium freudenreichii (≥3 dilutions). In time-kill assays, sarecycline demonstrated significantly less activity against Escherichia coli compared to minocycline at all time-points (p < 0.05). Moreover, sarecycline was significantly less effective in inhibiting Candida tropicalis compared to minocycline following 20- and 22-h exposure. Furthermore, sarecycline showed significantly less activity against Lactobacillus paracasei (recently renamed as Lacticaseibacillus paracasei subsp. paracasei) (p = 0.002) and Bifidobacterium adolescentis at 48 h (p = 0.042), when compared to minocycline. Overall, sarecycline demonstrated reduced antimicrobial activity against 79% of the tested gut microorganisms, suggesting that it is less disruptive to gut microbiota compared with minocycline. Further in vivo testing is warranted.

Challenges of repurposing tetracyclines for the treatment of Alzheimer's and Parkinson's disease

The novel antibiotic-exploiting strategy in the treatment of Alzheimer's (AD) and Parkinson's (PD) disease has emerged as a potential breakthrough in the field. The research in animal AD/PD models provided evidence on the antiamyloidogenic, anti-inflammatory, antioxidant and antiapoptotic activity of tetracyclines, associated with cognitive improvement. The neuroprotective effects of minocycline and doxycycline in animals initiated investigation of their clinical efficacy in AD and PD patients which led to inconclusive results and additionally to insufficient safety data on a long-standing doxycycline and minocycline therapy in these patient populations. The safety issues should be considered in two levels; in AD/PD patients (particularly antibiotic-induced alteration of gut microbiota and its consequences), and as a world-wide threat of development of bacterial resistance to these antibiotics posed by a fact that AD and PD are widespread incurable diseases which require daily administered long-lasting antibiotic therapy. Recently proposed subantimicrobial doxycycline doses should be thoroughly explored for their effectiveness and long-term safety especially in AD/PD populations. Keeping in mind the antibacterial activity-related far-reaching undesirable effects both for the patients and globally, further work on repurposing these drugs for a long-standing therapy of AD/PD should consider the chemically modified tetracycline compounds tailored to lack antimicrobial but retain (or introduce) other activities effective against the AD/PD pathology. This strategy might reduce the risk of long-term therapy-related adverse effects (particularly gut-related ones) and development of bacterial resistance toward the tetracycline antibiotic agents but the therapeutic potential and desirable safety profile of such compounds in AD/PD patients need to be confirmed.

Sarecycline treatment for acne vulgaris: Rationale for weight-based dosing and limited impact of food intake on clinical efficacy

Tetracycline‐class antibiotics are frequently prescribed by dermatologists, commonly for acne vulgaris. Gastrointestinal absorption of first and second‐generation tetracycline‐class antibiotics, including doxycycline and minocycline, may be reduced by co‐administration with food, resulting in potentially lower clinical efficacy. Development of novel compounds and formulations that are not impacted by diet could improve compliance, absorption, and effectiveness among patients. The objective of this study is to investigate weight‐based dosing protocols and the impact of food intake, including high‐fat meals, on the absorption, and clinical efficacy of sarecycline, a novel oral narrow‐spectrum third‐generation tetracycline‐class antibiotic approved by the Food and Drug Administration for acne vulgaris treatment. Data from 12 clinical studies were analyzed using population pharmacokinetic modeling, exposure–response modeling and pharmacodynamics to evaluate sarecycline dosing recommendations. The extent of exposure is estimated to decrease by 21.7% following co‐administration of a sarecycline tablet with a high‐fat meal. Based on the PopPK‐PD model, this is equivalent to a decrease in efficacy of 0.9 inflammatory lesions, which is not clinically meaningful. Sarecycline can be administered using weight‐based dosing with or without food. Co‐administration with high‐fat food has a limited impact on clinical efficacy. The pharmacokinetics of oral sarecycline may provide added convenience and support ease of use and improved compliance for acne vulgaris patients.

Management of Acne Vulgaris: A Review

IMPORTANCE

Acne vulgaris is an inflammatory disease of the pilosebaceous unit of the skin that primarily involves the face and trunk and affects approximately 9% of the population worldwide (approximately 85% of individuals aged 12-24 years, and approximately 50% of patients aged 20-29 years). Acne vulgaris can cause permanent physical scarring, negatively affect quality of life and self-image, and has been associated with increased rates of anxiety, depression, and suicidal ideation.

OBSERVATIONS

Acne vulgaris is classified based on patient age, lesion morphology (comedonal, inflammatory, mixed, nodulocystic), distribution (location on face, trunk, or both), and severity (extent, presence or absence of scarring, postinflammatory erythema, or hyperpigmentation). Although most acne does not require specific medical evaluation, medical workup is sometimes warranted. Topical therapies such as retinoids (eg, tretinoin, adapalene), benzoyl peroxide, azelaic acid, and/or combinations of topical agents are first-line treatments. When prescribed as a single therapy in a randomized trial of 207 patients, treatment with tretinoin 0.025% gel reduced acne lesion counts at 12 weeks by 63% compared with baseline. Combinations of topical agents with systemic agents (oral antibiotics such as doxycycline and minocycline, hormonal therapies such as combination oral contraception [COC] or spironolactone, or isotretinoin) are recommended for more severe disease. In a meta-analysis of 32 randomized clinical trials, COC was associated with reductions in inflammatory lesions by 62%, placebo was associated with a 26% reduction, and oral antibiotics were associated with a 58% reduction at 6-month follow-up. Isotretinoin is approved by the US Food and Drug Administration for treating severe recalcitrant nodular acne but is often used to treat resistant or persistent moderate to severe acne, as well as acne that produces scarring or significant psychosocial distress.

CONCLUSIONS AND RELEVANCE

Acne vulgaris affects approximately 9% of the population worldwide and approximately 85% of those aged 12 to 24 years. First-line therapies are topical retinoids, benzoyl peroxide, azelaic acid, or combinations of topicals. For more severe disease, oral antibiotics such as doxycycline or minocycline, hormonal therapies such as combination oral conceptive agents or spironolactone, or isotretinoin are most effective.

Drug-Induced Colitis

Drug-induced colitis encompasses a wide spectrum of colon disorders that can manifest microscopically or macroscopically. Patients present with new-onset colitis or exacerbations of inflammatory bowel diseases; in some cases, colitis resolves with discontinuation of medication. Mucosal injury can be focal or extensive, involving the entire colonic mucosa, and sometimes involves other parts of the gastrointestinal tract. It has been a challenge to determine the proportion of new-onset colitis caused by medication and there are few data on the overall prevalence. We review the drugs that have been linked with development of drug-induced colitis and strategies for physicians who believe their patients have this disorder-usually discontinuation of the drug believed to cause colitis and treatment with steroids or immune-modulating therapies. Physicians must be aware of medications that can cause colitis.

Isotretinoin for acne vulgaris - an update on adverse effects and laboratory monitoring

A significant barrier to the usage of isotretinoin has been concerns regarding its adverse effect profile. The dose-dependent mucocutaneous side effects of isotretinoin are well recognised and easily managed, particularly if a lower dose is used. A possible association with depression has gained widespread media attention and is a source of concern for many patients and their carers, but data from prospective studies and recent meta-analyses has been reassuring. Furthermore, there has been much confusion amongst both patients and physicians regarding a possible association with inflammatory bowel disease, as well the ocular and rheumatological adverse effects of isotretinoin. We provide an update on the evidence surrounding the adverse effects of isotretinoin, and discuss practical strategies to prevent and manage these adverse effects. We also discuss appropriate laboratory monitoring for patients taking isotretinoin.

Antibiotic Use Associated With Risk of Colorectal Polyps in a Nationwide Study

BACKGROUND & AIMS

Use of antibiotics affects the composition of the microbiome and might affect development of colorectal polyps, which are precursors to colorectal cancer.

METHODS

We performed a nested case-control study in Sweden of 45,744 patients with a colorectal polyp (cases) in the nationwide gastrointestinal ESPRESSO histopathology cohort, using unaffected full siblings as controls (n = 93,307). Polyps were classified by morphology SnoMed codes into conventional adenomas and serrated polyps. Through linkage to the Prescribed Drug Register, we assessed use and cumulative dispensations of antibiotic until 1 year prior to polyp diagnosis for cases and their sibling controls.

RESULTS

During a median study period of 6.9 years, compared with non-users, users of antibiotics (including 28,884 cases [63.1%] and 53,222 sibling controls [57.0%]) had a higher risk of colorectal polyps (odds ratio [OR], 1.08; 95% CI, 1.04-1.13). Risk increased with higher number of dispensations (OR for ≥ 6 dispensations, 1.33; 95% CI, 1.25-1.43) (Ptrend < .0001). We observed a stronger association with polyps for broad-spectrum antibiotics (OR comparing users to non-users, 1.23; 95% CI, 1.18-1.29) than for narrow-spectrum antibiotics (OR, 1.05; 95% CI, 1.01-1.10), and for tetracyclines and quinolones (OR, 1.21) than penicillin and other classes (ORs ranged from 1.04 to 1.16). The findings remained robust with several sensitivity analyses, including use of a 2-year lead-in period for antibiotic assessment and correction for misclassification in controls. Use of broad-spectrum antibiotics was more strongly associated with risk of serrated polyps (OR, 1.29; 95% CI, 1.21-1.38) compared with risk of conventional adenomas (OR, 1.17; 95% CI, 1.11-1.24). We found no differences in risk of colon vs rectal polyps with antibiotic use (Pheterogeneity > .10). We found stronger associations for younger (<50 years) vs older adults (≥50 years) for users of quinolones, sulfonamides, trimethoprim, and cephalosporins (Pinteraction < .001).

CONCLUSIONS

In a nationwide case-control study in Sweden, after accounting for hereditary and early life environmental factors, antibiotic use was associated with increased risk of colorectal polyps. Our findings indicate a role for intestinal dysbiosis in early stages of colorectal carcinogenesis.

Treatment challenges in adult female acne and future directions

Introduction: Acne is a chronic, inflammatory, and immune-mediated disease of the pilosebaceous unit, highly prevalent in adolescents. However, an increasing number of adults over 25 years old with facial acne, particularly women, have been observed. It is considered a different disease when compared to acne vulgaris. Face is the mainly involved area with inflammatory lesions and more sensitive skin, pointing out the need of a holistic approach.Areas covered: We performed a comprehensive literature search on PubMed database, up to January 2021, regarding adult female acne. We synthesized data about pathogenesis; differences compared to acne vulgaris; and treatment, with focus in the management challenges and perspectives.Expert opinion: It is essential to value the negative impact on quality of life of adult female acne, independently of severity. The disease has prolonged evolution, and patient might be resilient once the improvement, regardless of the treatment option, will just be noticeable after 3 months. Aggravating factors should be clearly discussed, such as the need of changing many habits, especially lesions manipulation. The therapeutic regimen includes make-up and tailored skin care (considering proneness to sensitivity), while anti-acne drugs should be chosen in accordance with desire to be pregnant, presence of pregnancy or breastfeeding.

Analysis of intestinal flora and inflammatory cytokine levels in children with non-infectious diarrhea

BACKGROUND

Non-infectious diarrhea is a common symptom in infants and young children. We aimed to analyze the intestinal flora and serum inflammatory cytokine levels of children with non-infectious diarrhea.

METHODS

Eighty-nine children with non-infectious diarrhea and 76 healthy children were enrolled from the First Affiliated Hospital of Hainan Medical University between February 2017 and June 2020. Fecal bacterial samples were collected in sterile containers. Following serial dilution, the bacterial samples were cultured in an aerobic medium to cultivate Escherichia coli (E. coli), Enterococci, Lactobacilli, and Bifidobacteria. The levels of inflammatory cytokines in the serum, including interleukin (IL)-2, IL-8, IL-10, and tumor necrosis factor-alpha (TNF-α), were determined by enzyme-linked immunosorbent assay. Results between the groups were compared using the paired t-test. The chi-square test was employed to analyze categorical data, with analysis of variance used for multiple-group comparisons.

RESULTS

No significant differences were observed between the diarrhea and control groups in terms of sex, age, or body mass index distribution. Compared to the control group, the diarrhea group had significantly elevated levels of E. coli and Enterococci but significantly decreased levels of Bifidobacteria and Lactobacilli. In terms of inflammatory cytokines, the levels of IL-2, IL-8, IL-10, and TNF-α were significantly higher in the diarrhea group than in the control group (all P<0.05). In children with non-infectious diarrhea, the levels of IL-2, IL-8, IL-10, and TNF-α were positively correlated with the amount of E. coli (r values of 0.412, 0.381, 0.479, and 0.216, respectively) and Enterococci (r values of 0.257, 0.336, 0.357, and 0.328). Further, the amount of Lactobacilli was positively correlated with IL-2 and IL-10 levels (r values of 0.342 and 0.438, respectively), and that of Bifidobacteria was negatively correlated with IL-2, IL-8, IL-10, and TNF-α levels (r values of -0.252, -0.336, -0.328, and -0.293, respectively). Finally, the level of Lactobacilli was also negatively correlated with IL-8 and TNF-α levels (r values -0.301 and -0.464, respectively; both P<0.05).

CONCLUSIONS

The abundance and abnormality of E. coli, Enterococci, Lactobacilli, and Bifidobacteria in the intestinal flora of children with non-infectious diarrhea are associated with increased levels of IL-2, IL-8, IL-10, and TNF-α.

Antibacterial Mechanisms and Efficacy of Sarecycline in Animal Models of Infection and Inflammation

Prolonged broad-spectrum antibiotic use is more likely to induce bacterial resistance and dysbiosis of skin and gut microflora. First and second-generation tetracycline-class antibiotics have similar broad-spectrum antibacterial activity. Targeted tetracycline-class antibiotics are needed to limit antimicrobial resistance and improve patient outcomes. Sarecycline is a narrow-spectrum, third-generation tetracycline-class antibiotic Food and Drug Administration (FDA)-approved for treating moderate-to-severe acne. In vitro studies demonstrated activity against clinically relevant Gram-positive bacteria but reduced activity against Gram-negative bacteria. Recent studies have provided insight into how the structure of sarecycline, with a unique C7 moiety, interacts with bacterial ribosomes to block translation and prevent antibiotic resistance. Sarecycline reduces Staphylococcus aureus DNA and protein synthesis with limited effects on RNA, lipid, and bacterial wall synthesis. In agreement with in vitro data, sarecycline demonstrated narrower-spectrum in vivo activity in murine models of infection, exhibiting activity against S. aureus, but reduced efficacy against Escherichia coli compared to doxycycline and minocycline. In a murine neutropenic thigh wound infection model, sarecycline was as effective as doxycycline against S. aureus. The anti-inflammatory activity of sarecycline was comparable to doxycycline and minocycline in a rat paw edema model. Here, we review the antibacterial mechanisms of sarecycline and report results of in vivo studies of infection and inflammation.

Oral Antibiotics for Acne

Oral antibiotics are integral for treating inflammatory acne based on what is understood about the pathogenesis as well as the role of Cutibacterium acnes. However, rising concerns of antibiotic resistance and the perception of "antibiotic phobia" create potential limitations on their integration in an acne treatment regimen. When prescribing oral antibiotics, dermatologists need to consider dosage, duration, and frequency, and to avoid their use as monotherapy. These considerations are important, along with the use of newer strategies and compounds, to reduce adverse-event profiles, antibiotic resistance, and to optimize outcomes. Aside from concomitant medications, allergies, and disease severity, costs and patient demographics can influence variability in prescribing plans. There are multiple published guidelines and consensus statements for the USA and Europe to promote safe antibiotic use by dermatologists. However, there is a lack of head-to-head studies and evidence for comparative superiority of any individual antibiotic, as well as any evidence to support the use of agents other than tetracyclines. Although oral antibiotics are one of the main options for moderate to severe acne, non-antibiotic therapy such as isotretinoin and hormonal therapies should be considered. As newer therapies and more outcomes data emerge, so will improved management of antibiotic therapy to foster patient safety.

Long-Term Follow-Up, Association between CARD15/NOD2 Polymorphisms, and Clinical Disease Behavior in Crohn's Disease Surgical Patients

Background

CARD15/NOD2 is the most significant genetic susceptibility in Crohn's disease (CD) even though a relationship between the different polymorphisms and clinical phenotype has not been described yet. The study is aimed at analyzing, in a group of CD patients undergoing surgery, the relationship between CARD15/NOD2 polymorphisms and the clinical CD behavior after a long-term follow-up, in order to identify potential clinical biomarkers of prognosis.

Methods

191 surgical CD patients were prospectively characterized both for the main single nucleotide polymorphisms of CARD15/NOD2 and for many other environmental risk factors connected with the severe disease form. After a mean follow-up of 7.3 years, the correlations between clinical features and CD natural history were analyzed.

Results

CARD15/NOD2 polymorphisms were significantly associated with younger age at diagnosis compared to wild type cases (p < 0.05). Moreover, patients carrying a 3020insC polymorphism presented a larger Δ between diagnosis and surgery (p = 0.0344). Patients carrying an hz881 and a 3020insC exhibited, respectively, a lower rate of responsiveness to azathioprine (p = 0.012), but no difference was found in biologic therapy. Finally, the risk of surgical recurrence was significantly associated, respectively, to age at diagnosis, to familial CD history, to diagnostic delay, to arthritis, and to the presence of perioperative complications.

Conclusions

3020insC CARD15 polymorphism is associated with an earlier CD onset, and age at CD diagnosis < 27 years was confirmed to have a detrimental effect on its clinical course. In addition, the familiarity seems to be connected with a more aggressive postoperative course. Finally, for the first time, we have observed a lower rate of responsiveness to azathioprine in patients carrying an hz881 and a 3020insC.

Consensus on the use of oral isotretinoin in dermatology - Brazilian Society of Dermatology

BACKGROUND

Isotretinoin is a synthetic retinoid, derived from vitamin A, with multiple mechanisms of action and highly effective in the treatment of acne, despite common adverse events, manageable and dose-dependent. Dose-independent teratogenicity is the most serious. Therefore, off-label prescriptions require strict criteria.

OBJECTIVE

To communicate the experience and recommendation of Brazilian dermatologists on oral use of the drug in dermatology.

METHODS

Eight experts from five universities were appointed by the Brazilian Society of Dermatology to develop a consensus on indications for this drug. Through the adapted DELPHI methodology, relevant elements were listed and an extensive analysis of the literature was carried out. The consensus was defined with the approval of at least 70% of the experts.

RESULTS

With 100% approval from the authors, there was no doubt about the efficacy of oral isotretinoin in the treatment of acne, including as an adjunct in the correction of scars. Common and manageable common adverse events are mucocutaneous in nature. Others, such as growth retardation, abnormal healing, depression, and inflammatory bowel disease have been thoroughly investigated, and there is no evidence of a causal association; they are rare, individual, and should not contraindicate the use of the drug. Regarding unapproved indications, it may represent an option in cases of refractory rosacea, severe seborrheic dermatitis, stabilization of field cancerization with advanced photoaging and, although incipient, frontal fibrosing alopecia. For keratinization disorders, acitretin performs better. In the opinion of the authors, indications for purely esthetic purposes or oil control are not recommended, particularly for women of childbearing age.

CONCLUSIONS

Approved and non-approved indications, efficacy and adverse effects of oral isotretinoin in dermatology were presented and critically evaluated.

Nonclostridium difficile enteric infection and the risk of developing inflammatory bowel disease: A systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic inflammatory intestinal disorder. Some studies have investigated the association between non-Clostridium difficile infection (CDI) enteric infection and the risk of developing IBD with conflicting conclusions. The objective of our study was to perform a meta-analysis of available studies evaluating the possible association between non-CDI enteric infection and the risk of developing IBD.

METHODS

We performed a systematic literature search of multiple online electronic databases. Inclusion criteria entailed studies about non-CDI enteric infection and IBD; A meta-analysis was conducted to evaluate relative risk (RR) and 95% confidence intervals (CIs) of combined studies for the association between non-CDI enteric infection and the risk of developing IBD. Publication bias was assessed by funnel plot analysis.

RESULTS

Eight studies comprising 345,490 enteric infected patients, 3223 ulcerative colitis (UC) patients, and 2133 CD patients were included in the meta-analysis. Meta-analysis showed a significantly higher risk of UC in patients with enteric infection compared with noninfected patients (RR, 2.28; 95% CI, 1.85-2.8) (I2 = 91.3%, P < 0.001). It also showed a significantly higher risk of CD in patients with enteric infection compared with noninfected patients (RR, 1.88; 95% CI, 1.66-2.14) (I2 = 49%, P = 0.024).

CONCLUSION

Our meta-analysis has found that patients with non-CDI enteric infection were associated with an increased risk of IBD. Future studies are needed to determine the association between non-CDI enteric infection and the risk of developing IBD and elucidate the potential underlying mechanisms.

Antibiotic use and the development of inflammatory bowel disease: a national case-control study in Sweden

BACKGROUND

Use of antibiotics in early life has been linked with childhood inflammatory bowel disease (IBD), but data for adults are mixed, and based on smaller investigations that did not compare risk among siblings with shared genetic or environmental risk factors. We aimed to investigate the association between antibiotic therapy and IBD in a large, population-based study.

METHODS

In this prospective case-control study, we identified people living in Sweden aged 16 years or older, with a diagnosis of IBD based on histology and at least one diagnosis code for IBD or its subtypes (ulcerative colitis and Crohn's disease). We identified consecutive patients with incident IBD from the ESPRESSO (Epidemiology Strengthened by histoPathology Reports in Sweden) study, cross-referenced with the Swedish Patient Register and the Prescribed Drug Register. We accrued data for cumulative antibiotic dispensations until 1 year before time of matching for patients and up to five general population controls per patient (matched on the basis of age, sex, county, and calendar year). We also included unaffected full siblings as a secondary control group. Conditional logistic regression was used to estimate multivariable-adjusted odds ratios (aORs) and 95% CIs for diagnosis of incident IBD.

FINDINGS

We identified 23 982 new patients with IBD (15 951 ulcerative colitis, 7898 Crohn's disease, 133 unclassified IBD) diagnosed between Jan 1, 2007, and Dec 31, 2016. 117 827 matched controls and 28 732 siblings were also identified. After adjusting for several risk factors, aOR in patients who had used antibiotics versus those who had never used antibiotics was 1·88 (95% CI 1·79-1·98) for diagnosis of incident IBD, 1·74 (1·64-1·85) for ulcerative colitis, and 2·27 (2·06-2·49) for Crohn's disease. aOR was higher in patients who had received one antibiotic dispensation (1·11, 1·07-1·15), two antibiotic dispensations (1·38, 1·32-1·44), and three or more antibiotic dispensations (1·55, 1·49-1·61) than patients who had none. Increased risk was noted for ulcerative colitis (aOR with three or more antibiotic dispensations 1·47, 95% CI 1·40-1·54) and Crohn's disease (1·64, 1·53-1·76) with higher estimates corresponding to broad-spectrum antibiotics. Similar but attenuated results were observed when siblings were used as the reference group, with an aOR of 1·35 (95% CI 1·28-1·43) for patients who had received three or more dispensations, compared with general population controls.

INTERPRETATION

Higher cumulative exposure to systemic antibiotic therapy, particularly treatments with greater spectrum of microbial coverage, may be associated with a greater risk of new-onset IBD and its subtypes. The association between antimicrobial treatment and IBD did not appear to differ when predisposed siblings were used as the reference controls. Our findings, if substantiated by longer-term prospective studies in humans or mechanistic preclinical investigations, suggest the need to further emphasise antibiotic stewardship to prevent the rise in dysbiosis-related chronic diseases, including IBD.

FUNDING

National Institutes of Health. Crohn's and Colitis Foundation.

Sarecycline: A Review of Preclinical and Clinical Evidence

Sarecycline is a tetracycline-derived oral antibiotic, specifically designed for acne, and is approved by the Food and Drug Administration (FDA) in 2018 for the treatment of inflammatory lesions of non-nodular moderate to severe acne vulgaris (AV) in patients 9 years of age and older. It has been decades since a novel systemic antibiotic was approved to treat AV, a disease that affects up to 90% of teenagers and young adults worldwide and lasts well into adulthood. Sarecycline holds promise to yield fewer side effects than other commonly used broad-spectrum tetracyclines, including minocycline and doxycycline. The narrower spectrum of antibacterial activity of sarecycline, which specifically targets C. acnes and some Gram-positive bacteria with little or no activity against Gram-negative bacteria, suggests not only the potential for reduced emergence of antibiotic-resistant bacterial strains but also less disruption of the human gut microflora. Here, we review the key preclinical and clinical evidence on sarecycline.

The use of isotretinoin for acne - an update on optimal dosing, surveillance, and adverse effects

INTRODUCTION

Acne is a chronic, inflammatory, and immune mediated disease of pilosebaceous unit, highly prevalent in adolescents. It involves face, trunk, and back; may leave scars and affect quality of life. Early, effective, and safe treatment is the key for disease resolution. Oral isotretinoin is the unique treatment for cure or prolonged remission for moderate and severe acne, preventing psychosocial impact and scars. It inhibits sebaceous glands activity and has anti-inflammatory and immunoregulatory properties.

AREAS COVERED

We performed a comprehensive literature search on PubMed database, up to March 2020, regarding oral isotretinoin for acne treatment. We synthetized data about acne pathogenesis and mechanism of action, efficacy, and safety of isotretinoin.

EXPERT OPINION

This drug is effective, despite common, controllable, and reversible mucocutaneous side effects. Serious adverse events are rare and represent individual reactions. Teratogenicity is the most severe, requiring rigorous control. We believe that no other therapeutic option, even topicals combined to oral antibiotics accomplish same results. Recurrence after treatments other than isotretinoin is the rule, prolonging risk of scars, compromising skin appearance, and causing emotional distress in teenagers. If there is no absolute contraindication, isotretinoin should be the first line treatment for moderate to severe inflammatory acne.

Risk of new-onset inflammatory bowel disease among patients with acne vulgaris exposed to isotretinoin

BACKGROUND

Data on the risk of inflammatory bowel disease (IBD) among isotretinoin-exposed patients with acne vulgaris (AV) is controversial.

OBJECTIVE

To compare IBD risk in isotretinoin-exposed and unexposed patients with AV.

METHODS

Retrospective cohort analysis of patients with AV with and without isotretinoin exposure identified using electronic health records. Primary outcomes were 6-month and 1-year IBD incidence.

RESULTS

The crude 6-month IBD incidence was 0.08% (21/27,230) among isotretinoin-exposed patients with AV compared to 0.04% (254/631,089) among those unexposed. The crude 1-year IBD incidence was 0.10% (28/27,230) among isotretinoin exposed patients with AV and 0.08% (477/631,089) among those unexposed. The odds of developing IBD within 6 months were 87% higher among isotretinoin-exposed patients with AV compared to those unexposed (adjusted odds ratio, 1.87; 95% confidence interval [CI], 1.20-2.93), although the absolute difference was small (risk difference, 2.6 more cases per 10,000 patients; 95% CI, 0.7-4.5). There was no significant difference in the odds of developing IBD at 1 year between isotretinoin-exposed and unexposed patients with AV (adjusted odds ratio, 1.40; 95% CI, 0.95-2.05).

LIMITATIONS

Isotretinoin-exposed patients may be more likely to have IBD detected by a health care provider.

CONCLUSIONS

IBD incidence among isotretinoin-exposed patients with AV is very low, and the risk appears similar to that for unexposed patients with AV.

Allergic and Immunologic Perspectives of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic immune-mediated inflammatory condition primarily involving the gastrointestinal tract. It includes Crohn's disease (CD), ulcerative colitis (UC), and a less common phenotype-indeterminate colitis. It is thought to result from a complex interplay of environmental, microbial, and host factors including genetic factors, although the exact mechanism is not known. Dietary factors have been shown to play a role in the pathogenesis of IBD and can potentially alter the intestinal microbiota as well as disrupt the immune function in the gut. CD is characterized by transmural inflammation, sometimes associated with granulomatous lesions, and involves the entire gastrointestinal tract but often spares the rectum. UC is characterized by mucosal inflammation typically confined to the colon and rectum. Although IBD is mostly seen in western world, recent data suggests that the incidence and prevalence are increasing worldwide. Enteral nutrition has been shown to be effective in inducing remission in pediatric population with CD; however, there is mixed data in adult population. Nutritional deficiencies such as vitamin D and zinc deficiency are often noted in IBD patients. Several extraintestinal manifestations are noted in patients with IBD. Some of them parallel with the disease activity and others are independent of the disease course. Assessment of IBD disease activity clinically, radiologically, if indicated, biochemically and endoscopically is important to guide therapy in IBD. To ensure comprehensive care, it is important to assess associated conditions such as nutritional and psychological well-being, as well as age appropriate health maintenance status prior to starting treatment for IBD. Several biologic agents including anti-tumor necrosis factor alpha (anti-TNF-α) drugs, anti-integrins, and antibodies to the p40 subunit of IL12/23 are approved for induction and maintenance of remission of IBD. Steroids are also often used for induction. Anti-metabolites and thiopurines are also useful either as monotherapy or in combination regimens. Potential side effects of anti-TNF-α drugs such as serious infections, malignancy, worsening of heart failure, and infusion-related reactions should be considered prior to starting these drugs. Anti-TNF-α drugs with or without immunomodulators (azathioprine, 6-mercaptopurine, methotrexate) are often used for the induction and maintenance of remission. Treating to target of endoscopic and clinical remission provides the best long-term outcomes. Our knowledge and understanding of IBD has grown significantly. However, there are several unanswered questions on pathogenesis, disease behavior, and drivers of inflammation in various patient subgroups which require further research.

Trends in Oral Antibiotic Prescription in Dermatology, 2008 to 2016

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 duration 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 antibiotics 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 frequency of antibiotic prescribing over time.

Results

Between 2008 and 2016 among 985 866 courses of oral antibiotics prescribed 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 visits 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 postoperative 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 practice and the risk of adverse events.

Antibiotic Use in Childhood and Adolescence and Risk of Inflammatory Bowel Disease: A Case-Control Study in the UK Clinical Practice Research Datalink

BACKGROUND

Inflammatory bowel disease (IBD) causes serious morbidity and disability, and the incidence is increasing. The disease etiology is not well understood, though inflammatory reactions after antibiotic exposure may be associated with development of IBD. We investigated the association between IBD and prior antibiotic use.

METHODS

We conducted this case-control study among individuals in the United Kingdom Clinical Practice Research Datalink GOLD (CPRD GOLD). Each case of IBD was matched to 4 controls on age, sex, general practice, and registration year in the CPRD GOLD. Antibiotic exposure was classified by ever or never use, number of prescriptions, and class of antibiotic before the index date. Odds ratios were calculated using conditional logistic regression.

RESULTS

We identified 461 cases of ulcerative colitis (UC) and 683 cases of Crohn's disease (CD). There was no association between ever use of any antibiotic and UC (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.72-1.44) or CD (OR, 1.01; 95% CI, 0.73-1.39) compared with never use. A slightly increased CD risk was observed among ever users of quinolones (OR, 1.76; 95% CI, 1.00-3.11) and metronidazole (OR, 1.43; 95% CI, 0.87-2.34) compared with never users. CD was associated with antibiotic exposure before age 5 (OR, 2.20; 95% CI, 0.75-6.43) in an analysis restricted to individuals followed from birth.

CONCLUSIONS

There was no association between UC or CD and overall prior use of antibiotics, though prior use of metronidazole and quinolones was associated with a slightly increased risk of CD. Antibiotic use in early childhood may increase the risk of CD.

Role of environmental factors in the pathogenesis of Crohn's disease: a critical review

PURPOSE

To review role of environmental factors in the pathogenesis of Crohn's disease.

METHODS

We systematically reviewed trials and systematic reviews using PubMed and Web of science databases. Here, we review the current information on the causative factors and mechanisms of CD, including smoking, exercise, diet, animal protein, breastfeeding, history of childhood infection and vaccination, oral contraceptives, and antibiotics of CD. We also highlight important knowledge gaps that need to be filled in order to advance the field of CD research.

RESULTS

Epidemiological studies have indicated the significance of environmental factors in the disease behavior and outcome of Crohn's disease (CD). There are a few recognized environmental factors, such as cigarette smoking, exercise, dietary habits, and breastfeeding, which are associated with the pathogenesis of CD. These factors are hypothesized to change the epithelial barrier function, which disturbs both the innate and adaptive immune systems and the intestinal flora. However, the effect of several risk factors, such as appendectomy and pharmaceutical use, differs across several studies, indicating the need for more rigorous research. Furthermore, few studies have examined effective interventions based on environmental factors that can improve disease outcomes. Recent studies have indicated that the pathogenesis of CD is related to environmental and genetic factors.

CONCLUSION

We review the current information on the causative factors and mechanisms of CD, including smoking, exercise, diet, animal protein, breastfeeding, history of childhood infection and vaccination, oral contraceptives, and antibiotics of CD. However, further studies are needed to understand knowledge gaps in the field of CD.

Depression increases the risk of inflammatory bowel disease, which may be mitigated by the use of antidepressants in the treatment of depression

OBJECTIVE

Depression is associated with IBD, but the effect of antidepressants on IBD has been sparsely studied. We assessed the impact of depression and antidepressant therapies on the development of IBD.

DESIGN

The Health Improvement Network (THIN) was used to identify a cohort of patients with new-onset depression from 1986 to 2012. THIN patients who did not meet the defining criteria for depression were part of the referent group. The outcome was incident Crohn's disease (CD) or ulcerative colitis (UC). Cox proportional hazards modelling was performed to evaluate the rate of Crohn's disease or UC development among patients with an exposure of depression after controlling for age, sex, socioeconomic status, comorbid conditions, smoking, anxiety and antidepressant use including atypical antidepressants, mirtazapine, monoamine oxidase inhibitors (MAOI), serotonin norepinephrine reuptake inhibitors (SNRI), selective serotonin reuptake inhibitors (SSRI), serotonin modulators; and tricyclic antidepressants (TCA).

RESULTS

We identified 403 665 (7.05%) patients with incident depression. Individuals with depression had a significantly greater risk of developing CD (adjusted HR=2.11, 95% CI 1.65 to 2.70) and UC (adjusted HR=2.23, 95% CI 1.92 to 2.60) after controlling for demographic and clinical covariates. SSRI and TCA were protective against CD, whereas mirtazapine, SNRI, SSRI, serotonin modulators and TCA were protective for UC.

CONCLUSION

Patients with a history of depression were more likely to be diagnosed with IBD. In contrast, antidepressant treatments were selectively protective for Crohn's disease and UC. These results may impact counselling and management of depression and IBD.

Gut Microbiome: Profound Implications for Diet and Disease

The gut microbiome plays an important role in human health and influences the development of chronic diseases ranging from metabolic disease to gastrointestinal disorders and colorectal cancer. Of increasing prevalence in Western societies, these conditions carry a high burden of care. Dietary patterns and environmental factors have a profound effect on shaping gut microbiota in real time. Diverse populations of intestinal bacteria mediate their beneficial effects through the fermentation of dietary fiber to produce short-chain fatty acids, endogenous signals with important roles in lipid homeostasis and reducing inflammation. Recent progress shows that an individual’s starting microbial profile is a key determinant in predicting their response to intervention with live probiotics. The gut microbiota is complex and challenging to characterize. Enterotypes have been proposed using metrics such as alpha species diversity, the ratio of Firmicutes to Bacteroidetes phyla, and the relative abundance of beneficial genera (e.g., Bifidobacterium, Akkermansia) versus facultative anaerobes (E. coli), pro-inflammatory Ruminococcus, or nonbacterial microbes. Microbiota composition and relative populations of bacterial species are linked to physiologic health along different axes. We review the role of diet quality, carbohydrate intake, fermentable FODMAPs, and prebiotic fiber in maintaining healthy gut flora. The implications are discussed for various conditions including obesity, diabetes, irritable bowel syndrome, inflammatory bowel disease, depression, and cardiovascular disease.

Antibiotic removal by agricultural waste biochars with different forms of iron oxide

Pollution by antibiotics has become a serious threat to public health. In this study, agricultural waste, corn husk, in the form of biochar, was utilized for antibiotic removal from wastewater. Two kinds of iron-loaded biochars, impregnation-pyrolysis biochar (IP) and pyrolysis-impregnation biochar (PI), were synthesized to adsorb the typical antibiotics tetracycline (TC) and levofloxacin (LEV). PI contained amorphous hydrated iron oxide, whereas the major component of IP was γ-Fe2O3. Compared with IP, PI had a much higher adsorption capacity for both TC and LEV. This was because PI could provide more -OH, especially -OHads, to serve as the adsorption sites. In comparison with TC, -OH was prone to combine with LEV. FT-IR and XPS results indicated that the mechanisms of LEV adsorption included hydrogen bonding, F-replacement, electrostatic attraction and bridging bidentate complexation. TC adsorption may involve complexation, hydrogen bonding and electrostatic attraction.