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Trimethoprim vs doxycycline (Gibson and Smith, 2008). The difference in efficacy can be clinically important. However, some authors suggest a small benefit to doxycycline, that is unlikely influence overall antibiotic use and should influence patients' the public's perceptions towards this drug, and thus the overall use of doxycyclin and other antibiotics (McBride Smith, 2007; Stolwijk et al, 2011). However, other authors argue for the benefits of doxycycline and for a more balanced approach between use of antibiotics and its non-therapeutic use. The authors of Cochrane review concluded that patients with acne should be treated azithromycin; use of doxycycline or tetracyclines as a first line; and antibiotics to be tried after the patient has failed one or more treatment regimens. The risk of overuse will still exist with either drug, the risk increasing with number of antibiotic prescriptions. Both doxycycline and tetracyclines are recommended for use after a second or third ineffective antibiotic regimen and for those who are at a high risk of becoming refractory to a treatment regimen, such as women with HIV infection, or those recurrent and uncomplicated vulvae or urinary tract infections (Krabbendam et al, 2007; Ouellette 2010). They also indicate a benefit of tetracyclines in those who have recently or develop vulseps recurrent infections. Both azithromycin and doxycycline have the capability to produce a moderate bacteriocidal, erythromycin-induced bactericidal dose in cultured human keratinocytes (O'Donoghue et al, 2008). The authors of Cochrane review found that tetracycline is associated with increased antibiotic resistance from these gram-negative rods, which is an important consideration considering the potential for serious infection, including death, due to infection (Schmidt et al, 2010). A Cochrane review (Matsuzaki et al, 2010) on the safety of azithromycin for acne-associated dysbacteriosis found several small study limitations. It noted that in the studies were included, there was a moderate to high rate of adverse events that were dose-related, such as headache, nausea, vomiting, rashes, abdominal pain and itching. In the studies which duration of treatment period was long duration, and there no placebo control, Ultram for sale online was more adverse event with azithromycin than doxycycline. The use of any treatment without a complete medical history for any chronic symptoms or medical condition such as diabetes, hypertension, diabetes mellitus and cancer in children is not recommended with azithromycin (Krajmalnik et al, 2010). An extensive review of the benefits and harms azithromycin, tetracyclines, antibiotics their use in acne (Foster and Mowat, 1997; Mowat Beral, 2001, 2002) found a number of benefits for patients and clinician. In fact, the only major adverse effect noted from azithromycin was a short-term increase in mortality among some patients at an early stage of infection (Beral 2001). Overall, antibiotic use for acne is safe, but a number of important clinical outcomes are associated with antibiotic use. The use of tetracyclines as a monotherapy in acne is recommended as its mechanism of action is to act on both gram positive and negative organisms there is an association with improved outcomes compared use of other antibiotic monotherapies (McLean et al, 2000; O'Donoghue 2008). This is particularly the case of patients with recurrent or chronic infections and those with more extensive infections (Krajmalnik et al, 2010). Although the use of azithromycin in acne is still recommended with a moderate-to-major safety concern due to its potential bactericidal activity (Krajmalnik et al, 2010; O'Donoghue 2008; Schulte et al, 2009) it has also emerged that the combination of azithromycin with other antibiotics appears to be safer than the use of either agent alone (Foster and Mowat, 1997). There are concerns that antibiotic sensitivity can also have a harmful effect in patients who have an underlying metabolic disease (Mowat and Beral, 2001, 2002; McLean et al, 2000; O'Donoghue 2008). Furthermore, this is particularly of concern in children with bacterial infections. These concerns have not been addressed in the evaluation of acne using monotherapy antibiotics. Azithromycin has been reported to be bactericidal against Gram Positive rods in vitro (Mowat and Beral et al, 2001). Although a dose-response relation was observed, there a significant increase in resistant organisms as the drug was increasingly diluted between dilution groups (McLean et al, 2000).
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