The drawback to the usefulness of long-term antibiotic treatments is concern about the effect on microbial ecology (Table 11.5). The normal microflora act as a barrier against colonization by potentially pathogenic bacteria and the control of growth of opportunistic bacteria is called colonization resistance. The normal equilibrium between host and microorganisms may be disturbed by a number of factors, but commonly and essentially by antibiotic therapy. To what extent disturbances occur depends of numerous factors: the spectrum of the antibiotic, the dose, the route of administration, pharmacokinetic and pharmacodynamic properties and in vivo inactivation of the drug .
Clindamycin administration results in major ecological disturbances in intestinal and oro-pharyngeal microflora: the numbers of entero-coccal species increase and those of all anaerobes decrease [39, 51]. A possible complication of clindamycin treatment is pseudomembra-nous colitis, which occurs when antibiotics such as clindamycin, ampicillin and third-generation cephalosporins suppress the normal flora, allowing Clostridium difficile to grow and produce toxins . Rifampicin treatment was shown to lead to a decrease in total aerobic and anaerobic oral bacteria in healthy volunteers .
The emergence of antimicrobial resistance is strongly associated with the clinical use of the antibiotics and a balanced microflora prevents establishment of resistant strains of bacteria . It is well known that oral antibiotics select for resistant bacteria at all body sites where there is a normal flora: skin, conjunctivae, oral cavity, nasopharynx, upper respiratory tract, intestinal tract, and vagina . A therapy administered for a long period, as was recommended in HS treatment , will exert a high pressure for the development of the resistant strains of Propionibacterium acnes, coagulase-negative staphylo-
Table 11.5. Effects of antibiotic administration on the ecological balance of human microflora
- Disturbances in the balance between host and normal flora from the intestinal tract, skin, oropharyngeal tract, and vagina
- Altered colonization resistance (growth control of opportunistic bacteria)
- Overgrowth of pathogenic bacteria or yeasts
- The emergence of antimicrobial resistance in the normal flora
- Possible transfer of resistance to pathogenic bacteria cocci on the skin, Staphylococcus aureus in the nares, streptococci in the oral cavity, and en-terobacteria in the gut .
Topical clindamycin will increase carriage of Propionibacterium acnes and Staphylococcus epidermidis resistant strains on skin and there is a risk of transfer of resistance to other pathogenic bacteria, Staphylococcus aureus and Streptococcus species . The skin and conjunctivae flora from untreated sites will also be affected by transfer of antibiotic .
In conclusion, antibacterial drugs represent an adjuvant treatment in HS. They are not curative but they reduce odor and discharge, and diminish pain. Antibiotics represent a palliative therapy that may control the disease in early stages and can reduce the inflammation before and after surgery  but clinicians should be aware about the downside of taking them.
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