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Prolonged clindamycin and rifampicin for hidradenitis suppurativa: resist to prevent resistance

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that has multiple systemic comorbidities and a significant impact on quality of life. The combination of clindamycin 300-mg twice daily and rifampicin 600-mg daily for 10 weeks is recommended for Hurley stage II and III. It may also be reintroduced for the treatment of HS recurrence if previously effective. In this issue, Albrecht et al. discuss in a Critically Appraised Topic, the safety of long-term use of these antibiotics beyond 10 weeks. The authors undertook a literature review to identify if prolonged treatment posed additional risks. They assessed specifically drug-induced liver injury, interstitial nephritis, community-acquired clostridium difficile infection, drug interactions and enzyme induction. They concluded that prolonged treatment did not pose any additional risks over standard treatment duration and that adverse effects occur typically in the first few weeks of treatment. The combination of clindamycin/rifampicin for 10 weeks was first introduced for the treatment of folliculitis decalvans in the late 1990s and was used subsequently in HS. There are five studies assessing this antibiotic combination in HS but there are no randomized controlled trials reported. These studies report on a total of 213 patients with reported efficacy in 71–85% of patients. Two studies reported data on follow-up and identified that approximately 60% had relapsed after a mean of 4–5 months. The combination of clindamycin/rifampicin may be effective in HS because of their anti-inflammatory rather than their antimicrobial properties. The choice of 10 weeks of treatment duration was arbitrary. Clindamycin was combined with rifampicin in order to reduce the likelihood of developing rifampicin resistance, as rifampicin is highly mutagenic. The induction of the cytochrome P4503A4 pathway by rifampicin reduces significantly the plasma concentration of clindamycin, effectively resulting in rifampicin monotherapy after the first 2 weeks. Prolonged treatment with clindamycin/rifampicin does not appear to confer any additional risks to the individual beyond standard 10-week treatment. Although the risk for individual patients appears not to be increased, the public health importance of prolonged antibiotic use needs to be considered. The World Health Organization describes antimicrobial resistance as one of the biggest threats to global health today, and recommend that antibiotics are prescribed only when needed and according to the current guidelines. We, as physicians, have a responsibility to prescribe antibiotics appropriately and the issue of antibiotic resistance should always be a factor when prescribing antibiotics. This is particularly true if prolonged treatment with antibiotics is used for their anti-inflammatory properties rather than treating a specific infection. Rifampicin remains one of the important drugs in the treatment of tuberculosis worldwide. Its prolonged use and the resultant increased risk of rifampicin resistance needs to be justified not just for the individual but also for the general population.