Prevalence and contributing factors of antimicrobial resistance in bacterial skin infections. A clinical and microbiological analysis

Nº de DOI: 10.34896/RSI.2026.80.35.002

AUTHORS

1. Celia Belén Ortega Almendariz. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the University of Cuenca. (Quito, Ecuador). https://orcid.org/0009-0008-3547-5029
2. Celene Lisseth Larcos Herrera. General Practitioner. Master’s Degree in Education, Technology, and Innovation. Attached to the Zapotillo Health Center. Graduate of the Central University of Ecuador. (Latacunga, Ecuador). https://orcid.org/0000-0003-3479-6206
3. Adriana Pamela Moya Guerra. Medical Surgeon. Attached to INFES Clinic. Graduate of UTE University. (⁠Quito, Ecuador). https://orcid.org/0009-0001-6736-2781
4. Luis Gabriel Jimbo Lupercio. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the University of Cuenca. (Cuenca, Ecuador). https://orcid.org/0009-0006-1081-3189
5. Gino Paúl Espinal Peña. General Practitioner. Attached to Portoviejo General Hospital. Graduate of the Technical University of Manabí. (Portoviejo, Ecuador). https://orcid.org/0009-0006-6909-4502

ABSTRACT

The focus of this paper will be a comprehensive analysis of the current levels of AMR in the diagnosis and treatment of bacterial skin infections, an exploration of factors both clinical and environmental contributing to bacterial skin infection AMR, and a description of the microbiological characteristics of bacterial skin infections demonstrating AMR, ultimately providing a framework to understand the effect of AMR on treatment outcomes as well as to provide potential strategies to halt or at least slow the public health threat presented by this growing issue.

KEY WORDS

Antimicrobial resistance, bacterial skin infections, methicillin-resistant staphylococcus aureus, multidrug-resistant organisms, topical antibiotics, antibiotic stewardship, dermatology.

RESUMEN

El enfoque de este artículo será un análisis exhaustivo de los niveles actuales de resistencia antimicrobiana (RAM) en el diagnóstico y tratamiento de las infecciones bacterianas de la piel, una exploración de los factores clínicos y ambientales que contribuyen a la RAM en estas infecciones, y una descripción de las características microbiológicas de las infecciones bacterianas de la piel que presentan RAM. Todo esto con el objetivo de proporcionar un marco para comprender el efecto de la RAM en los resultados del tratamiento, así como para ofrecer posibles estrategias para detener o al menos ralentizar la amenaza para la salud pública que representa este problema creciente.

PALABRAS CLAVE

Resistencia antimicrobiana, infecciones bacterianas de la piel, Staphylococcus aureus resistente a meticilina, organismos multirresistentes, antibióticos tópicos, uso racional de antibióticos, dermatología.

INTRODUCTION

Antimicrobial resistance (AMR) is now a serious public health threat, with resistant organisms causing an estimated 700,000 deaths per year worldwide; as current trends continue, we can expect that number to grow significantly. The increase in AMR is primarily due to the overuse and misuse of antimicrobial agents in many different settings, including two primary areas of use—medicine and agriculture—where livestock are routinely given subtherapeutic doses of antibiotics to promote feed efficiency and growth. These same residual antibiotics find their way into the food supply, where people ingest low doses of these drugs, ultimately selecting for antibiotic-resistant pathogens. In dermatology, the over-the-counter availability of topical antibiotics; however, the inappropriate prescribing of topical antibiotics further complicates the management of bacterial skin infections, thereby serving to undermine effective treatment of these infections. The patterns of bacterial resistance include many different organisms and mechanisms of resistance, with some of the most common organisms causing skin infections becoming increasingly resistant to multiple different classes of antibiotics. Specifically, Staphylococcus aureus, Pseudomonas aeruginosa and Enterobacteriaceae represent three common organisms causing skin infections, each now exhibiting an increasing number of multidrug-resistant (MDR) phenotypes, resulting in fewer treatment options and an increased chance for treatment failure. Recent microbiological research has used newly developed methods for molecular detection and characterization of MDR organisms in clinical settings, and alarming trends have been demonstrated by recent measures of antimicrobial resistance. The relationship between environmental factors, such as antibiotic use in agriculture, and microbiology is essential for understanding the complexities of the global AMR crisis.

OBJECTIVE

To comprehensively analyze the current global status of antimicrobial resistance (AMR) in bacterial skin infections, identify the principal clinical and environmental factors contributing to resistance development, evaluate microbiological detection and characterization strategies for resistant pathogens, and assess the impact of AMR on treatment outcomes in dermatological practice in order to propose evidence-based mitigation strategies.

METHODOLOGY

The purpose of this study was to conduct a narrative literature review on the topic of infection with antimicrobial resistant (AMR) bacteria (e.g., Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacteriaceae) in dermatology-related infections. Researchers searched the scientific literature databases for Articles that reported data related to AMR in dermatology including epidemiology of AMR, resistant strains of bacteria, clinical determinants involved with AMR, environmental contributors to AMR, microbiological methods used to diagnose bacterial infection, and outcomes of treatment of individuals infected with AMR Gram-negative and Gram-positive bacteria.

Studies included in the study were those that examined trends in bacterial skin infections due to antimicrobial resistance, mechanisms of antimicrobial resistance in the most common bacteria that infect the skin (e.g. Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacteriaceae), articles that evaluated the impact of systemic and topical antimicrobial therapy on the development of antimicrobial resistance, literature describing diagnostic tests (e.g. minimum inhibitory concentration testing (MIC), polymerase chain reaction (PCR), whole genome sequencing, automated systems) utilized to identify bacterial infections, and studies evaluating the clinical impact of antimicrobial resistance on treatment outcomes.

Studies excluded were literature that was not peer-reviewed, peer-reviewed literature that did not relate to infection of the skin, and peer-reviewed literature that did not provide adequate epidemiological or microbiological data regarding antimicrobial resistance.

The analysis was performed qualitatively through the synthesis of the following data: epidemiology of AMR and its contributions, mechanisms of AMR and their development, and implications for the development of new therapeutic agents. The focus of the review was on identifying the occurrence of organisms with multidrug resistance (MDR), the evolution of resistance, and the interaction between healthcare delivery practices and environmental determinants of drug-resistant bacterial infections.

RESULTS

Prevalence of Antimicrobial Resistance in Bacterial Skin Infections:

What is the current global prevalence of antimicrobial-resistant bacterial skin infections?

This multifaceted public health issue of antimicrobial-resistant bacterial skin infections globally can be attributed to a combination of microbial evolution, healthcare practices, and health dynamics of the population. The rising incidence rate (age-standardized) of bacterial skin disease is related to the increasing number of drug-resistant bacteria. These two factors create difficulty in clinical management and epidemiological control of the infections¹. The high incidence of drug-resistant organisms associated with bacterial skin infections limits treatment effectiveness and adds to the complexity of the diseases, making them harder to form an effective and appropriate management plan, leading to increased morbidity, and increased use of healthcare resources¹. Also, increasing numbers of immunocompromised individuals (e.g., organ transplant recipients and patients receiving biologic immunosuppressive therapy) may increase the number of resistant infections they acquire and may additionally function as reservoirs of resist-ant bacterial strains in health care and community settings¹. Although antimicrobial resistance is becoming an increasingly recognised and serious problem associated with bacterial skin diseases, the ability to quantify the impact globally is limited due to the lack of reliable and accessible laboratory microbiologic diagnostic services, this absence of services hinders surveillance, differenti-ation, and the ability to effectively implement interventions¹. To address these interrelated challenges, there is an urgent need to invest in laboratory infrastructure, improve surveillance systems, and implement specific strategies to decrease the transmission and impact of antimicrobial resistance in bacterial skin infections.

How do resistance patterns vary among common bacterial pathogens in skin infections?

There is a considerable amount of variation in the resistance patterns exhibited by the group of bacterial pathogens most frequently implicated in skin infections, which creates a challenge to clinicians trying to manage skin infection cases, and demonstrates an urgent need for optimized treatment strategies². An example of this would be the resistance of MRSA’s (Methicillin Resistant Staphylococcus Aureus) creation of resistance to the traditional most effective antibiotic agents used to treat S.aureus, the penicillin antibiotic agent class. In addition, the presence of other resistance genes in MRSA will create additional complications in finding effective antibiotics³. The result of this increasing number of resistance patterns in MRSA has resulted in reduced availability of effective oral antibiotics used to treat MRSA when the skin infection occurs outside of a hospital setting³. Furthermore, the implications of resistant organisms create a greater impact in making peri-operative decisions for procedures such as joint replacement or plastic surgery, where the risk of an infection caused by a resistant organism would drive the selection of prophylactic and therapeutic agents³. Taken together, the relationship between the outpatient care and surgical aspects of managing bacterial skin infections highlights the importance of continuing to monitor resistance patterns and establishing a variety of interventions (stewardship programs, adherence to evidence-based guidelines) to help mitigate the growing threat posed by antimicrobial-resistant organisms in skin infections.

What are the documented trends in resistance rates over recent years?

Resistance rates have had a complicated and changing pattern over the last few years based on observed trends, this pattern demonstrates how public health efforts, the evolution of microbes, and the operations of health care have an interrelationship. A notable decline from 2012 to 2016 occurred, therefore, from 2012 to 2016, the rate of resistant infections fell from 209.6/10,000 hospitalizations to 179.6/10,000 hospitalizations, these trends would suggest the success of directed infection control and stewardship measures during this time⁴. Resistance rates remained stable from 2016 to 2018, and began to rise again in 2019, reaching 197 cases/10,000 hospitalizations in 2020, driven by the impact of the COVID-19 pandemic and changes made to health care delivery⁴. Resistance rates again fell through 2022, indicating a likely rebound of resistance rates once health care systems adjusted to the pandemic and infection prevention measures were put back in place⁴. Fluctuations in resistance rates are seen in both community-onset and hospital-onset infections, suggesting that resistance trends are not confined or limited to any one area, as they result from the interaction of hospital policies, community health behavior, and other societal factors⁴. The fluctuation of resistance rates indicates a need for ongoing adaptive policy action and ongoing monitoring to prevent further upward trend surges and sustain the reduction in drug-resistant infections.

Clinical and Environmental Contributing Factors to Antimicrobial Resistance:

How does antibiotic overuse in medical and agricultural settings contribute to resistance?

The overprescription of Antibiotics in both medicinal and agricultural industries has created a complex network of selectivity, which leads to antibiotic-resistant bacteria, thus threatening the Global Health of Humans⁵. Using Antibiotics in farming as a means to promote animal growth, contributes to the creation of conditions supportive of multi-drug-resistant bacteria⁶. The growth of these multi-drug-resistant bacteria can contaminate the food chain leading to increasing difficulty in managing human infections due to the limited effectiveness of existing medications⁶. The overprescription of antibiotics in hospitals has similarly led to the development of antibiotic-resistant bacteria and these same robust bacterial strains have frequently been introduced into agriculture through environmental routes or direct interaction between Animals and Humans^5,6. The linkages between these different sectors can be further illustrated through the dynamics of transmission of Resistance genes/pathogenic bacteria which cross the boundaries of farms, hospitals, and communities, contributing to reduced efficacy of life-saving medications and putting millions of lives at risk⁷. As practices associated with creating and sustaining resistant bacteria continue, so too does the need for coordinated efforts between the health care and agricultural sectors to avert the loss of therapeutic efficacy of antibiotics for future generations^6,8.

In what ways do over-the-counter topical antibiotics affect resistance development?

Antimicrobial resistance (AMR) can be caused by many mechanisms. Over-the-counter (OTC) topical antibiotics have significant roles in both the community and environment. The overutilization and underutilization of OTC topical antibiotics has a direct relationship to antibiotic resistance and therefore contributes to less effective treatment of skin infections. Difficulties in controlling infections are also a result of antibiotic resistance⁹. The full impact of resistance is not limited to the individual using the antibiotic, people in close proximity to the user (close contacts) are also at increased risk, showing that the community is impacted by antibiotics applied topically, thereby increasing the burden of AMR¹⁰. Additionally, topical antibiotics create selection pressure for resistance amongst the commensal flora of the skin, and could be potential reservoirs for resistance genes. These gene reservoirs allow for the horizontal transfer of resistance gene(s) to pathogenic organisms¹⁰. The emergence of resistance to topical antibiotics, particularly amongst pathogens such as Staphylococcus aureus, illustrates the interdependent nature of individual and community health as well as the health of entire households^9,10. Even with some researchers stating that topical antibiotics would contribute to AMR to a lesser degree than systemic antibiotics, there exists volumetric evidence that untampered use of topical antibiotics is a major cause/driver of AMR, particularly amongst dermatology pathogens^9,10. At the global level, increasing use of products and agents such as mupirocin and fusidic acid have continued to correlate with an increase in the rate of S. aureus resistance, driving the international community to call for increased regulation and stewardship of OTC topical antibiotics to help reduce the spread of AMR⁹. To combat the growing threat of AMR, there is an urgent need for coordinated efforts, including improved monitoring/surveillance of the use of OTC topical antibiotics, stricter regulation on the dispensing of OTC topical antibiotics, and public education on the appropriate use of OTC topical antibiotics for the preservation of existing treatment methods, for maintaining good public health.

What is the impact of inappropriate prescription practices on resistance in skin infections?

Prescribing practices that are not appropriate have a significant influence on the development of resistance patterns for skin infections and further limit already sparse treatment options as discussed above¹¹. By prescribing broad spectrum antibiotics and choosing not to use narrow spectrum alternatives that would have had efficacy, clinicians will create tremendous selective pressure on skin flora and create a higher likelihood of the emergence and spread of resistant organisms¹². The effects do not only affect the individual patient, resistant organisms can also disseminate within communities and across healthcare settings creating a cycle of needing even broader and / or more toxic treatment. The interrelation of these dynamics further complicates the management of skin infections, particularly with regard to the management of skin infections that are due to multidrug-resistant organisms, such as MRSA, and underscores the urgent need to implement interventions (such as robust antimicrobial stewardship programs and increased education for prescribers) in order to support more rational, evidence-based prescribing practices^11,12.

Microbiological Analysis of Resistant Pathogens in Dermatology:

What are the most common resistant bacterial species identified in skin infections?

The insufficiency of information for the various resistant bacterial species responsible for skin infections clearly indicates a lack of availability within the existing literature or publicly available data¹³. The absence of specific information hinders the ability of clinicians to develop targeted treatment methods and does not support the potential implementation of public health programs geared toward minimizing the spread of resistance. The connection between clinical microbiology, epidemiology, and antibiotic stewardship programs is demonstrated clearly when information concerning which bacterial species are most commonly resistant to treatment for skin infections is absent, thus, healthcare providers have no option but to rely on general empirical protocols, which could encourage further resistance and negatively affect ongoing patient care. Therefore, there is an immediate need for systematic surveillance and extensive reporting on the use of resistant pathogens in the specialty of dermatology to enable the timely diagnosis of patients, establish treatment guidelines, and ultimately improve patient care and infection control practices¹³.

How are resistant pathogens detected and characterized in clinical microbiology laboratories?

The emergence of antimicrobial resistance has prompted a new paradigm of detection, identification, and characterization methods for pathogenic organisms that are resistant to antibiotic therapy. This multifaceted approach combines traditional and newer methods in clinical microbiology labs worldwide. Culturing pathogenic organisms is routine in microbiology laboratories through solid and broth dilution methods, these methods help us understand how pathogenic microorganisms resist antibiotics since they show whether an organism dies or continues to grow with the presence of an antibiotic drug (minimal inhibitory concentration (MIC)) thus providing important information on phenotype and antibiotic resistance¹⁴. However, culturing has some limitations, including time-consuming (days, at minimum, 24 hours) results and not commonly yielding pathogens of interest or having prolonged incubation times prior to obtaining results, making it inadequate for urgent patient care requiring timely diagnosis¹⁴. Many clinical laboratories are now using molecular techniques (e.g., PCR/Q-PCR) for rapid identification and quantification of resistance genes in resistance-testing pathogens via specific PCR tests, PCR responds rapidly, but also is limited because PCR requires existing knowledge of a resistance gene prior to use. Furthermore, these tests are unable to identify new and unknown resistance mechanisms¹⁴. Whole genome sequencing (WGS) is a promising alternative to existing methods that allows comprehensive and untargeted identification of known and unknown resistance determinants by using WGS technology when an urgent clinical situation develops, and the individual presents with severe infections, however widespread implementation of WGS is limited due to resource and financial constraints¹⁴. Automation of clinical microbiology laboratories, such as Vitek 2 compact, has been extremely beneficial to clinical microbiology laboratories by providing rapid and accurate identification of MDR (multi-drug resistant) pathogens and by providing more accurate antibiograms from pathogens unable to be routinely identified by regularly used biochemical assays¹⁵. The ability to use multiple methods concurrently in combination to give a comprehensive assessment of an organism’s resistance phenotype demonstrates the relationship between phenotypic and genotypic methods of organism characterization. Innovation in these methods is needed for reducing turnaround time, and increasing accuracy in detecting resistance among pathogenic organisms, particularly in patients with compromised immune systems who are susceptible to developing severe MDR infections. In order for clinical microbiology laboratories to continue to provide these services to physicians and their patients, clinical microbiology laboratories should focus on developing new technologies and streamlining current processes to rapidly and accurately detect and characterize microbial pathogens to optimize antimicrobial therapy processes and to prevent the transmission of resistant bacteria.

What are the implications of resistance for treatment outcomes in dermatological practice?

Resistance implications in dermatology practice will significantly impact the effectiveness of existing treatments and the overall approach to managing inflammatory skin diseases (e.g., acne and rosacea). The development of resistant strains (e.g., antibiotic-resistant C. acnes) dramatically diminishes the odds of successfully improving after receiving standard treatment regimens. When treatment is received by a patient who has a resistant strain as opposed to a patient with a susceptible strain, the patient with the resistant strain will have a lesser likelihood of achieving a successful treatment result than the patient with the susceptible strain¹⁶. With reduced efficacy come longer-lasting treatment courses (e.g., patients with resistant infections receive an average of 16 weeks of treatment, compared to 12 weeks for those without resistance) requiring significant financial investment to provide (due to cost) especially within resource-poor nations where extended or alternative treatments may not be available¹⁶. Alternatively, patients who require more aggressive or alternative therapies (e.g., oral isotretinoin) will incur increased chances of negative side effects as well as will require increased clinical monitoring, further impacting the healthcare system and patient compliance with treatment¹⁶. Thus, these factors (i.e., the need for prolonged/complicated case therapies due to resistance, the need for alternative therapies, etc.) create additional obstacles within access to care through the further need for combination therapy (coordinating various providers for improved outcomes) or through non-antibiotic therapies (enhancing outcomes through a different mechanism)¹⁶. The interconnected variables of treatment outcomes, resistance, and healthcare system will enhance the need for a multifaceted approach for comprehensive interventions through improved antibiotic stewardship, alternative therapies, and increased patient education to improve treatment outcomes in dermatology and to limit further development of resistance.

DISCUSSION 

The results of this research highlight the multifaceted and fluid nature of antimicrobials resistance (AR) in skin infections caused by bacteria, the results show that challenges associated with utilising AR interventions, as well as opportunities for developing AR interventions, will continue to be ongoing. Resistant organisms have shown fluctuations in resistance rates over time. The identified declining rates of resistance associated with MRSA over the last several years, followed by increasing rates of MRSA, particularly during the pandemic period, demonstrate the need for continuing adaptive surveillance systems. This trend indicates that there are external influences on the prescribing patterns for antimicrobials and the associated resistance patterns that are caused by global health crises, and therefore, public health responses must be resilient. Moreover, this research indicates that the presence of contributing factors (e.g., overuse and misuse of antibiotics in clinical settings and agriculture and unregulated over-the-counter topical antibiotic use) places significant selective pressure on organisms harbouring resistant strains of bacteria (i.e., MRSA), and raises issues relating to your organisation for appropriateness of use in your community and other patients. The limited amount of microbiologic data on the infectious agents associated with resistant strains of bacteria also presents significant obstacles in developing appropriate targeted therapies for use in your community, therefore, there is an urgency to develop improved technologies for rapid diagnosis (i.e., molecular technologies and whole genome sequencing), which will allow faster detection and use of targeted interventions. Although the results of this research are informative, there were several limitations in the research process, specifically, gaps in comprehensive data collection and the potential biases in the geographic or healthcare-specific studies used in the research, which may not completely reflect the global patterns of resistance in the organism being studied. Future studies should continue to emphasise standardised surveillance protocols, collaborative evaluation of mechanisms related to the transfer of resistance genes and evaluate the effectiveness of stewardship programmes on optimally managing the use of antibiotics in different healthcare environments. Further, public educational outreach and reform of policies on regulating the use of antibiotics will contribute to efforts designed to reduce AR development. Overall, this research demonstrates the significance of a multidisciplinary team approach to effectively address the growing threat of AMR in skin infections and to preserve the efficacy of existing antimicrobials.

CONCLUSIONS

1. Bacterial skin infections caused by resistant microbes are an evolving, increasing worldwide public health threat. The expansion of the number of different types of drug resistant infections, especially those caused by the Gram positive Staphylococcus aureus (including methicillin resistant S. aureus), Gram-negative Pseudomonas aeruginosa, and Enterobacter bangui/Enterobacter cloacae family of bacteria, has dramatically decreased our treatment options and increased the risk of an unsuccessful outcome from treatment.
2. The trends in antimicrobial resistance are complex, and the rate at which bacterial resistance occurs is not consistent over time. This variability has been impacted by the practice of routinely prescribing antibiotics in clinical pratice, the improper selection of antibiotics to treat patients (i.e. prescribing an antibiotic that kills bacteria not on the patient’s skin), the availability of over-the-counter topical antibiotics, agricultural use of antibiotics, and environmental routes of transmission. The increased amount of selective pressure from over-prescribing disseminates the One Health concept and demonstrates how multi-facetted antimicrobial resistant organisms are.
3. The advancements in diagnostic techniques (i.e. different types of molecular diagnostic methods, whole genome sequencing, and automated susceptibility testing methods) have assisted physicians in the detection and identification of resistant organisms, however, the number of diagnostic techniques implemented in various regions of the world is still low due to lack of infrastructure and funding for new technology.
4. In dermatology, the clinical implications are severe: lengthened duration of treatment, increased cost of treatment, increased use of alternative medications or medications that may be more toxic than previously available therapies, and decreased quality of care. In order to address this growing crisis, there needs to be a collaborative approach between stakeholders in public health, agriculture, and public education (e.g., public education regarding antimicrobial resistance).
5. To preserve the usefulness of currently available antimicrobials requires a global coordinated effort, ongoing epidemiologic surveillance, and continued funding for the development and promotion of new diagnostic methods and stewardship programs.

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