20 November 2023: Articles
Unknown etiology, Unusual or unexpected effect of treatment, Adverse events of drug therapyLina I. Alnajjar 1ABDE, Shakir Bakkari 2D, Reem Mohammed Alkahtani3EF, Malak A. Alasqah 4EF, Ali I. Almuwinea 5EF, Alaa A. Alhubaishi 1AEF*
Am J Case Rep 2023; 24:e941424
BACKGROUND: Clostridium difficile (C. difficile) is a gram-positive, anaerobic, spore-forming bacillus. It can lead to pseudomembranous colitis characterized by electrolyte disturbances, toxic megacolon, and septic shock. The risk of C. difficile infection is higher with use of certain classes of antibiotics, or when an antibiotic used for a long time. Azithromycin is a macrolide antibiotic known to be safe, with few adverse effects such as diarrhea, stomach pain, and constipation. Azithromycin is currently used for the treatment of acne, with different dosing regimens for patients who cannot receive traditional treatment based on practice guidelines.
CASE REPORT: A 41-year-old woman was treated with a course of azithromycin 500 mg by mouth 3 times weekly for 6 weeks for acne vulgaris. This was her second antibiotic course of acne treatment within 10 months. A few days after completion of the second azithromycin course, she presented to the clinic with worsening abdominal pain and frequent soft bloody stool. A complete blood count test, C. difficile toxin test, stool culture, and colonoscopy were ordered. She was diagnosed with C. difficile infection confirmed by C. difficile toxin and symptoms.
CONCLUSIONS: Despite the safety profile of azithromycin, our patient was predisposed to a non-severe case of C. difficile-associated diarrhea, most likely due to the repeated course of the azithromycin regimen that was used to treat her acne vulgaris. This report highlights the importance of managing patients with acne vulgaris according to current practice guidelines, and to report a link between the use of azithromycin as an acne treatment and the occurrence of C. difficile colitis.
Keywords: Abdominal Pain, acne vulgaris, Azithromycin, Clostridium Infections, diarrhea
Azithromycin is an antimicrobial medication classified as a macrolide antibiotic . It is considered a broad-spectrum antibiotic and has activity against gram-negative, gram-positive, and anaerobic bacteria, including
Based on the American Academy of Dermatology guidelines, macrolides are not the first-line treatment for acne vulgaris, and they are only used when traditional antibiotics cannot be used . However, macrolides such as azithromycin are currently used in clinical practice for acne treatment due to its antimicrobial and anti-inflammatory activity, in addition to its good safety profile . Using azithromycin in the treatment of acne vulgaris can be in different dosing regimens, from 3 times a week to 4 days a month, with a duration of 2–3 months . Many studies that compared azithromycin and doxycycline showed doxycycline was more effective, especially in patients older than 18 years, but showed a similar effect when administered with topical treatments like tretinoin and adapalene gel . A meta-analysis of randomized controlled trials comparing the efficacy of azithromycin with doxycycline in acne treatment found that doxycycline causes more adverse effects than azithromycin . The reported adverse effects include diarrhea, nausea, epigastric pain, photosensitivity, vaginitis, abnormal blood cell count, and vertigo .
A few studies have linked macrolide use, including azithromycin, with
Here, we report the case of a 41-year-old woman with acne vulgaris who developed
A 41-year-old woman presented to a dermatology clinic with a past medical history of severe acne vulgaris, hyperlipidemia, and migraine, with no past surgical history or prior hospitalization. She has been primarily treated with clindamycin 1% topical solution 2 times daily and azithromycin 250 mg by mouth 3 times weekly for 6 weeks based on her case and the dermatologist’s diagnosis. Eight months later, she had a dental implant in which she was prescribed amoxicillin/clavulanic acid 1 g by mouth for 10 days.
Ten months later, after completion of the first acne treatment regimen, the patient returned to the clinic with inflammatory acne vulgaris. The therapeutic plan was to reuse the previous regimen of azithromycin. Four days following her completion of the second course of azithromycin, she started to have mild abdominal pain, frequent soft stool (3 times a day) with abdominal gasses, and unusual stool odor. The pain was more frequent and kept worsening with softer bloody stool (around 5–6 times a day).
She presented to the gastroenterology clinic, and a complete blood count (CBC) test and
The patient was started on metronidazole 500 mg by mouth 3 times daily for 10 days. No improvement was noticed after completing the course. She still had mild abdominal pain and bloody diarrhea (3–4 times per day). As a result, the
We report the case of a woman diagnosed with
Acne vulgaris is a common cutaneous disorder characterized by inflammation of the pilosebaceous unit of a hair follicle and commonly caused by the anaerobic bacterium
In our case, the patient was initially treated with clindamycin 1% topical solution 2 times daily and azithromycin 250 mg by mouth 3 times weekly for 6 weeks, which was not the first-line option in her case. Then, exactly the same course of azithromycin was repeated 10 months later, which might have increased her risk of
Our patient was initially treated with metronidazole 500 mg by mouth 3 times daily for 10 days based on the hospital practice guidelines and had failed the treatment. Metronidazole treatment failure was unknown. However, she was re-treated successfully with vancomycin 125 mg by mouth 4 times daily for 10 days
Although azithromycin has a good safety profile and is rarely associated with reported cases of
The acne vulgaris regimen of azithromycin of 250 mg 3 times weekly has been increasingly used in dermatology clinics for the treatment of acne vulgaris, despite being considered an alternative treatment based on the American Academy of Dermatology guidelines. A thorough assessment of the patient’s history, including the previous antibiotic regimen used and patient eligibility, needs to be considered before prescribing azithromycin for acne vulgaris. This report highlights the importance of managing patients with acne vulgaris according to current practice guidelines, and to report a link between the use of azithromycin as an acne regimen and the risk of
1.. Mounsey A, Lacy Smith K, Reddy VC, Nickolich S: Am Fam Physician, 2020; 101(3); 168-175
2.. Brown KA, Fisman DN, Moineddin R, Daneman N: PLoS One, 2014; 9(8); e105454
3.. Brown KA, Khanafer N, Daneman N, Fisman DN: Antimicrob Agents Chemother, 2013; 57(5); 2326-32
4.. Kim JE, Park AY, Lee SY, Comparison of the efficacy of azithromycin versus doxycycline in acne vulgaris: A meta-analysis of randomized controlled trials: Ann Dermatol, 2018; 30(4); 417-26
5.. Sandman Z, Iqbal OA, Azithromycin. [Updated 2023 Jan 15]: StatPearls [Internet], 2023, Treasure Island (FL), StatPearls Publishing Available from: https://www.ncbi.nlm.nih.gov/books/NBK557766/
6.. Kardeh S, Saki N, Jowkar F, Efficacy of azithromycin in treatment of acne vulgaris: A mini review: World J Plast Surg, 2019; 8(2); 127-34
7.. Zaenglein AL, Pathy AL, Schlosser BJ, Guidelines of care for the management of acne vulgaris: J Am Acad Dermatol, 2016; 74(5); 945-73 e33
8.. Gorenek L, Dizer U, Besirbellioglu B: Hepatogastroenterology, 1999; 46(25); 343-48
9.. Teng C, Reveles KR, Obodozie-Ofoegbu OO, Frei CR: Int J Med Sci, 2019; 16(5); 630-35
10.. Brown KA, Khanafer N, Daneman N, Fisman DN: Antimicrob Agents Chemother, 2013; 57(5); 2326-32
11.. Slimings C, Riley TV: J Antimicrob Chemother, 2014; 69(4); 881-91
12.. Schaeverbeke T, Lequen L, de Barbeyrac B, Propionibacterium acnes isolated from synovial tissue and fluid in a patient with oligoarthritis associated with acne and pustulosis: Arthritis Rheum, 1998; 41(10); 1889-93
13.. Revuz J, Disseminate recurrent folliculitis as the presenting picture of hidradenitis suppurativa: Ann Dermatol Venereol, 2017; 144(11); 715-18
14.. McLaughlin J, Watterson S, Layton AM, Propionibacterium acnes and acne vulgaris: New insights from the integration of population genetic, multi-omic, biochemical and host-microbe studies: Microorganisms, 2019; 7(5); 128
15.. Eichenfield DZ, Sprague J, Eichenfield LF, Management of acne vulgaris: A review: JAMA, 2021; 326(20); 2055-67
01 Dec 2023 : Case reportLife-Threatening Electrical Storm Following Liver Transplantation: A Case Report
Am J Case Rep In Press; DOI:
01 Dec 2023 : Case reportInnovative Approach to Difficult Airway Management: Utilizing the Cook® Airway Exchange Catheter for Double...
Am J Case Rep In Press; DOI:
01 Dec 2023 : Case reportSuccessful Conservative Therapy for Infected Penile Implants: A Case Series
Am J Case Rep In Press; DOI:
Most Viewed Current Articles
06 Dec 2021 : Case reportLipedema Can Be Treated Non-Surgically: A Report of 5 Cases
Am J Case Rep 2021; 22:e934406
07 Dec 2021 : Case reportEdwardsiella tarda: A Classic Presentation of a Rare Fatal Infection, with Possible New Background Risk Fac...
Am J Case Rep 2021; 22:e934347
19 Jul 2022 : Case reportAtlantoaxial Subluxation Secondary to SARS-CoV-2 Infection: A Rare Orthopedic Complication from COVID-19
Am J Case Rep 2022; 23:e936128