Clinical Knowledge Summaries: Previous version Impetigo

Impetigo
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About this topic

Have I got the right topic?
This guidance covers the treatment of impetigo. This guidance does not cover the management of infected wounds and burns, infected eczema, or cellulitis. There are separate CKS topics on Boils and paronychia, Candida skin, Cellulitis, Dermatitis contact, Eczema atopic, and Fungal (dermatophyte) skin infections. The target audience for this guidance is healthcare professionals working within the NHS in England, and providing first contact or primary health care. Patient information from NHS Direct is intended to be printed and given to people with this condition, and the Shared decision making sections are designed to provide a focus for discussion during the consultation about the treatment options.

Changes
Version 1.0.0, revision planned in 2009. Last revised in May 2006 OctoberDecember 2005 reviewed. Validated in March 2006 and issued in May 2006. This guidance has been reviewed and updated following a full literature review. There have been no major changes to the recommendations. A more detailed evidence section to support the recommendations has been included.

Previous changes
September 2002 written. Validated in October 2002 and issued in December 2002.

Update
New evidence
Evidence-based guidelines No new evidence-based guidelines since 1 March 2007. HTAs (Health Technology Assessments) No new HTAs since 1 March 2007. Economic appraisals No new economic appraisals relevant to England since 1 March 2007. Systematic reviews and meta-analyses No new systematic review or meta-analysis since 1 March 2007. Primary evidence No new high quality randomized controlled trials since 1 March 2007.

New policies
No new national policies or guidelines since 1 March 2007.

New safety alerts

No new safety alerts since 1 March 2007.

Changes in product availability

No changes in product availability since 1 March 2007.

Concise knowledge for clinical scenarios

Which therapy?
Topical fusidic acid is the first-line choice topical antibiotic for small, localised patches of impetigo.

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Clinical Knowledge Summaries: Previous version Impetigo

Topical mupirocin should be reserved for second-line therapy of impetigo if fusidic acid has been ineffective or is not tolerated. Oral flucloxacillin is the first-line choice oral antibiotic if there is extensive disease, lesions refractory to topical treatment, or associated lymphadenopathy or systemic illness. Erythromycin is an alternative oral antibiotic if the patient is hypersensitive to penicillins.

Practical prescribing points

For further information please see the Medicines Compendium (www.medicines.org.uk) or the British National Formulary (www.bnf.org). Crusted skin can be softened and removed by soaking in warm soapy water prior to applying topical treatments. Advise on how to reduce transmission e.g. hand washing, not sharing towels or clothing until lesions have fully cleared. Recommend that children stay away from nursery or school until there is no further crusting or until 48 hours after antibiotic treatment has been started.

Should I refer or investigate?

Referral is rarely necessary. Referral may be indicated if: o There is severe extensive impetigo. o Lesions are unresponsive to oral treatment. o Impetigo recurs frequently. o There are significant blistered lesions. Bacteriological swabs for culture and sensitivity should be obtained before referral is considered. If there is a significant local outbreak (e.g. nursing home, school), it is advisable to involve the local Consultant in Communicable Disease Control.

Follow-up advice
Follow-up is generally not necessary if lesions have healed after therapy. Advise the person to return after 1 week of treatment if lesions are not fully cleared or are worsening (see How should treatment failure be managed?).

Prescriptions
Topical fusidic acid for 7 days Fusidic acid ointment
Age from 1 month onwards Sodium fusidate 2% ointment. Apply to the affected area three times a day for 7 days. Supply 15 grams. NHS Cost 2.23 Licensed use: yes Patient Information: Do not use for more than 7 days unless otherwise instructed.

Fusidic acid cream

Age from 1 month onwards Fusidic acid 2% cream. Apply to the affected area three times a day for 7 days. Supply 15 grams. NHS Cost 2.00 Licensed use: yes Patient Information: Do not use for more than 7 days unless otherwise instructed.

Oral flucloxacillin for 7 days Flucloxacillin syrup: 62.5mg four times a day
Age from 1 month to 1 year 11 months

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Clinical Knowledge Summaries: Previous version Impetigo

Flucloxacillin 125mg/5ml oral solution. Take 2.5ml four times a day for 7 days. Supply 100 ml. NHS Cost 7.41 Licensed use: yes Patient Information: Discard any remaining medicine.

Flucloxacillin syrup: 125mg four times a day

Age from 2 years to 4 years 11 months Flucloxacillin 125mg/5ml oral solution. Take one 5ml spoonful four times a day for 7 days. Supply 200 ml. NHS Cost 14.82 Licensed use: yes Patient Information: Discard any remaining medicine.

Flucloxacillin syrup: 250mg four times a day

Age from 5 years to 11 years 11 months Flucloxacillin 250mg/5ml oral solution. Take one 5ml spoonful four times a day for 7 days. Supply 200 ml. NHS Cost 13.94 Licensed use: yes Patient Information: Discard any remaining medicine.

Flucloxacillin capsules: 250mg four times a day

Age from 12 years onwards Flucloxacillin 250mg capsules. Take one capsule four times a day for 7 days. Supply 28 capsules. NHS Cost 4.06 Licensed use: yes

Flucloxacillin capsules: 500mg four times a day

Age from 12 years onwards Flucloxacillin 500mg capsules. Take one capsule four times a day for 7 days. Supply 28 capsules. NHS Cost 7.59 Licensed use: yes

Oral erythromycin for 7 days (if penicillin allergy) Erythromycin s/f suspension: 125mg four times a day
Age from 1 month to 1 year 11 months Erythromycin ethyl succinate 125mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 7 days. Supply 140 ml. NHS Cost 4.69 Licensed use: yes

Erythromycin s/f suspension: 250mg four times a day

Age from 2 years to 11 years 11 months Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 7 days. Supply 140 ml. NHS Cost 6.18 Licensed use: yes

Erythromycin s/f suspension: 500mg four times a day

Age from 9 years to 11 years 11 months Erythromycin ethyl succinate 500mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 7 days. Supply 140 ml. NHS Cost 9.97 Licensed use: yes

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Clinical Knowledge Summaries: Previous version Impetigo

Erythromycin e/c tablets: 250mg four times a day

Age from 12 years onwards Erythromycin 250mg gastro-resistant tablets. Take one tablet four times a day for 7 days. Supply 28 tablets. NHS Cost 2.19 Licensed use: yes

Erythromycin e/c tablets: 500mg four times a day

Age from 12 years onwards Erythromycin 250mg gastro-resistant tablets. Take two tablets four times a day for 7 days. Supply 56 tablets. NHS Cost 4.38 Licensed use: yes

Drug rationale
Drugs not included
Broad-spectrum antibiotics are not recommended. As the pathogen is known, a narrow spectrum antibiotic active against Staphylococcus aureus is sufficient. Mupirocin remains an essential therapy for the treatment of methicillin-resistant S aureus (MRSA) and prescriptions are not offered for first-line use. Topical antibiotics other than fusidic acid are not recommended in impetigo as the evidence best supports the use of fusidic acid or mupirocin. Topical corticosteroid/antibiotic combinations are not recommended as they may aggravate infection. Topical antifungal/antibiotic combinations are not recommended. Hydrogen peroxide cream is not recommended; this was found to be effective in one small trial, but there is insufficient evidence to recommend routine use [Christensen and Anehus, 1994]. Antibacterial skin cleansers are not recommended. o Antibacterial cleansers have been used to remove crusts and to reduce the spread of infection, but there is no evidence that they have any greater effect than washing with soapy water.

Drugs included
Topical fusidic acid preparations are offered for the treatment of localized superficial infection. o To prevent the development of resistance, topical antibiotic agents should not be used to treat widespread lesions and treatment courses should be limited to 7 days initially (maximum duration 10 days). Oral flucloxacillin is effective against Staphylococcus aureus infection. At least 7 days of treatment is required. Oral erythromycin is also effective against S aureus and is offered for people with penicillin allergy.

Shared decision making

Impetigo is not usually serious, but can spread if not treated. An antibiotic cream for 710 days is the usual treatment for small patches of impetigo. Antibiotic liquid, tablets, or capsules are used if the infection is more widespread. Impetigo is contagious: o Try not to touch patches of impetigo. o Wash your hands if you do touch a patch of impetigo, and after applying antibiotic cream. o Wash the affected areas with soapy water. o Wash the hands after touching a patch of impetigo or after applying antibiotic cream. o Avoid scratching affected areas, and keep fingernails clean and cut short. o Avoid sharing towels, flannels, clothing, and bathwater until the infection has cleared.

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Clinical Knowledge Summaries: Previous version Impetigo

o o

Change towels frequently to stop spread of infection. Children should be kept off school or nursery until there is no more blistering or crusting or until 48 hours after antibiotic treatment has been started.

Detailed knowledge about this topic

Goals and outcome measures
Goals
To To To To To alleviate symptoms and limit the duration of infection reduce the risk of complications reduce contagious spread identify any contributory cause reduce the rate of recurrence

Background information
What is it?
Impetigo is a common, highly contagious bacterial infection of the superficial layers of the epidermis. It is usually due to infection with Staphylococcus aureus or Streptococcus pyogenes, alone or together [Koning et al, 2003]. It is typically classified as either primary or secondary: o Primary impetigo occurs when there is direct bacterial invasion of healthy skin. o Secondary impetigo occurs when infection is secondary to some other underlying skin disease (particularly eczema, scabies) or trauma that disrupts the skin barrier [Koning et al, 2003]. It presents clinically as non-bullous or bullous impetigo: o Non-bullous impetigo is the most common form [George and Rubin, 2003]. The initial lesion is a thin-walled vesicle that rapidly ruptures, leaving a superficial erosion covered with yellowish-brown or honey-coloured crusts. Non-bullous impetigo is usually due to infection with Staphylococcus aureus, but 10% of cases in the UK are due to infection with Streptococcus pyogenes [Watkins, 2005]. Secondary impetigo almost invariably presents as the non-bullous form. o Bullous impetigo is characterized by the formation of larger blisters (bullae) on intact skin that rupture less readily and can persist for several days, and is invariably due to S. aureus [Sladden and Johnston, 2004].

How common is it?

Impetigo occurs most commonly in young children, with peak incidence occurring between 2 and 6 years of age [Sladden and Johnston, 2004]. It is the third most common skin disease in children after eczema and viral warts [Bruijnzeels et al, 1993]. In general practice, 2.8% of infants (04 years) and 1.6% of children (515 years) present each year with impetigo [Koning et al, 2003]. In adults, infections in men predominate and large outbreaks may be seen in confined environments such as barracks. The non-bullous form of impetigo is most common, accounting for nearly three quarters of cases [George and Rubin, 2003]. Bullous impetigo occurs sporadically, but clusters of cases may occur in families and larger outbreaks are occasionally seen in small communities such as nursing homes.

What are the predisposing factors?

Hot humid weather Poor personal hygiene Close physical contact (e.g. participation in contact sports, crowded living conditions) Skin disease or trauma that impair the normal skin barrier:

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Clinical Knowledge Summaries: Previous version Impetigo

o Atopic eczema o Scabies o Fungal skin infections o Staphylococcal carriage o Insect bites o Herpes simplex lesions o Chickenpox lesions o Abrasions, lacerations, wounds o Burns Diabetes mellitus Intravenous drug misuse Immunocompromised (reduced ability to fight infections), e.g. due to: o HIV impetigo is one of the most common complicating bacterial infections o Malignancy o Long-term use of systemic corticosteroids o Chemotherapy o Immunosuppressant therapy o Haemodialysis and peritoneal dialysis

How do I know my patient has it?

History
There may be a history of contact with a person with impetigo (e.g. at school, in the family) skin lesions typically appear 410 days post exposure [Nursing Times, 2004]. Lesions are usually asymptomatic, but occasionally they may be itchy or painful, particularly in bullous impetigo [Sladden and Johnston, 2004]. If impetigo is severe, the person may feel systemically unwell with fever and general malaise.

Examination
In non-bullous impetigo, the following features are characteristic [George and Rubin, 2003; Koning et al, 2003; Sladden and Johnston, 2004]. o The area around the mouth and nose is most commonly affected; other areas around the face and the extremities may also be involved. o In the early stages, thin-walled vesicles or pustules on an erythematous base may be seen. o However, vesicles are seldom seen as they quickly rupture leaving raw irregular lesions with no central healing. o Overlying exudate dries to form thick, yellowish-brown, golden crusts. o Multiple lesions may join together. o Satellite lesions may occur due to autoinoculation. o The crust eventually dries, separates, and disappears leaving a red mark that typically heals without scarring. o Systemic upset is usually absent, but with severe impetigo there may be fever and regional lymphadenopathy. In bullous impetigo, the following features are characteristic [Koning et al, 2003; Johnston, 2004; Sladden and Johnston, 2004]: o The trunk is the area most often affected. o There are flaccid, fluid-filled vesicles and blisters (bullae) that are often at least 12 cm in diameter. o Lesions are often multiple, and spread rapidly. o Thin, flat, brownish crusts form after the lesions rupture. o Lesions extend outwards with central healing, and may give rise to annular lesions. o Systemic signs such as fever and lymphadenopathy are more common than with non-bullous impetigo.

Investigations
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Clinical Knowledge Summaries: Previous version Impetigo

Impetigo is usually a clinical diagnosis, and treatment decisions are rarely based on the results of skin swabs, which cannot reliably differentiate between active infection and asymptomatic colonization [George and Rubin, 2003]. Send swabs of lesion exudate for culture if there is: o Extensive and/or severe infection o Treatment failure with oral antibiotics o Recurrent infections Send swabs for staphylococcal nasal carriage if recurrent facial impetigo. If a person has been in contact with someone with known MRSA (methicillin-resistant Staphylococcus aureus): o Swab the lesion o Ensure local protocols are followed o Contact the local Centre for Communicable Disease Control

What else might it be?

Common differential diagnoses of impetigo include [Koning et al, 2003; Watkins, 2005]: Atopic dermatitis Dermatophytosis (fungal skin infection) Drug eruption Herpes simplex (cold sores) Herpes zoster (shingles) Partial burn or scald Pediculosis Bullous pemphigoid Stevens Johnson syndrome Pemphigus vulgaris Toxic epidermal necrolysis Epidermolysis bullosa hereditaria Porphyria cutanea tarda Syphilis

Other differential diagnoses include:

Complications and prognosis

Complications
The majority of potential complications of impetigo are relatively minor: o Spread to other areas of the body. o Scarring and pigment changes may occur with severe impetigo, but often resolve over time. o Spread to other people lesions are highly contagious and may spread by direct contact through a family, nursery, or class [Sladden and Johnston, 2004]. Occasionally, more serious infectious complications may occur: o Furunculosis o Suppurative lymphadenitis o Cellulitis o Abscess formation o Septicaemia o Staphylococcal toxic shock syndrome or scalded skin syndrome (often considered to be a severe form of bullous impetigo) Non-infectious complications of Streptococcus pyogenes infection include [Koning et al, 2003]: o Guttate psoriasis o Scarlet fever o Post-streptococcal glomerulonephritis very rare (less than 1% of impetigo cases due to streptococcal infection) [George and Rubin, 2003]

Prognosis
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Clinical Knowledge Summaries: Previous version Impetigo

There are very little data on the natural history of impetigo; however, literature suggests that untreated impetigo usually resolves in approximately 23 weeks [Koning et al, 2003; Watkins, 2005]. Nasal carriage of micro-organisms may predispose people to recurrent infection [Sladden and Johnston, 2004].

Management issues
Overview of management
Soften and remove crusting skin lesions by soaking in warm soapy water prior to applying topical treatments. Prescribe topical antibiotics for small, localized patches of impetigo. Prescribe oral antibiotics if lesions are extensive, refractory to topical treatment or there is associated systemic illness. Advise appropriate hygiene measures: o careful hand washing after contact o avoid sharing towels o children should not attend school or nursery until there is no further crusting of lesions or until 48 hours after antibiotic treatment has been started Treat pre-existing skin disorders to reduce the risk of recurrence. Referral may be necessary in severe cases or in impetigo unresponsive to systemic treatment.

What should I advise regarding attendance at nursery, school or work?

People should ensure that lesions have crusted over, or that they have received at least 48 hours of antibiotic treatment, before re-attending [HPA, 1999; George and Rubin, 2003; Nursing Times, 2004]: o If a child attends nursery or school. o If working as a clinician, teacher, or nursery attendant.

What hygiene measures should I recommend?

There are no data available on the effectiveness of hygiene measures, but the following is generally advised with the expectation that this will aid response to other treatments, reduce the risk of recurrence, and reduce the risk of spread to others [HPA, 1999; Nursing Times, 2004]: o Wash the affected areas with soapy water. o Wash the hands after touching a patch of impetigo or after applying antibiotic cream. o Avoid scratching affected areas, and keep fingernails clean and cut short. o Avoid sharing towels, flannels, clothing, and bathwater until the infection has cleared. Disinfecting measures are not routinely recommended as there is no evidence that they are effective at healing impetigo as a sole or supplementing treatment.

Should I prescribe an antibiotic?

If the infection is very mild and the risk of infecting other individuals is low, hygiene measures alone is an option as lesions will usually clear spontaneously within 23 weeks [Koning et al, 2003; Watkins, 2005]. However, antibiotics are usually indicated to eradicate infection, relieve symptoms, and reduce the risk of transmission to others [Sladden and Johnston, 2004; HPA, 2005]. o Topical antibiotics are recommended for small, localized patches of impetigo only. o Oral antibiotics are otherwise recommended, especially if there is extensive infection or associated systemic illness. Expert opinion is divided, but overall it is unnecessary to combine oral and topical antibiotic therapy, as oral therapy alone should be sufficient.

Topical antibiotics
Remove the crusting areas by soaking in soapy water before applying topical antibiotics as this will increase the efficacy of treatment.

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Clinical Knowledge Summaries: Previous version Impetigo

Topical treatment avoids possible adverse effects from taking oral antibiotics. However, topical antibiotics are more likely to lead to antibiotic resistance, and their use should be restricted to treating small, localized lesions [HPA, 2005]. First-line choice is fusidic acid for 7 days, with mupirocin as an alternative. o Trial evidence best supports the use of fusidic acid or mupirocin. o There is no significant difference in their effectiveness at treating impetigo. o They are similar in effectiveness to oral antibiotics for the treatment of localized impetigo. o The Health Protection Agency recommends that, where possible, mupirocin should be reserved for the treatment of MRSA (methicillin-resistant Staphylococcus aureus) [HPA, 2005]. Other topical antibiotic preparations are not recommended as the evidence best supports the use of fusidic acid or mupirocin. Combined topical preparations containing corticosteroids with an antibiotic are not recommended [Watkins, 2005]. If underlying infected eczema is suspected, see the CKS topic on Eczema atopic. Treatment for 7 days is usually adequate, as recommended by the manufacturer and supported in several trials [George and Rubin, 2003; Sladden and Johnston, 2004; BNF 50, 2005].

Oral antibiotics
Flucloxacillin is the first-line choice [BNF 50, 2005]. Erythromycin can be used if there is a history of penicillin allergy. These antibiotics exert their bactericidal effect upon many Gram-positive organisms including beta-lactamase-producing staphylococci and beta-haemolytic streptococci, when used in sufficient doses in skin infections [Jones, 2002]. There is no trial evidence that newer, more broad-spectrum antibiotics offer any clinical advantage. Optimal treatment length is not evident from the literature but commonly 7 days of treatment is prescribed [BNF 50, 2005; HPA, 2005].

What follow-up is necessary?

There is no need to follow-up people routinely. Advise the person to return after 1 week of treatment if lesions are not fully cleared or are worsening (see How should treatment failure be managed?).

How should treatment failure be managed?

Take bacteriological swabs for culture and sensitivity, and treat with appropriate antibiotics according to the results. Consider other diagnoses and treat any underlying skin infection. Consider other predisposing factors, and treat if present (if possible). Encourage continued hygiene measures. If treatment failure occurs after topical antibiotics for 1 week, switch to an oral antibiotic. If treatment failure occurs after oral antibiotics for 1 week, consider continuing oral treatment for a further 1 week.

How should I manage a person with recurrent episodes?

Treat individual episodes with antibiotics as outlined in Should I prescribe an antibiotic? Encourage good personal hygiene. Consider whether the person could be getting re-infected from a close contact (e.g. a family member). Treat any underlying skin condition. Consider other predisposing factors, and treat if present (if possible). Take bacteriological swabs of lesion exudate for culture and sensitivity. Check fasting blood glucose to exclude diabetes mellitus.

When should I refer?

Referral is rarely necessary. Consider referring to a dermatologist if:

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Clinical Knowledge Summaries: Previous version Impetigo

o There is severe extensive impetigo. o Lesions are unresponsive to oral treatment. o Impetigo recurs frequently. o There are significant blistered lesions. If there is a significant local outbreak (e.g. nursing home, school), it is advisable to involve the local Consultant in Communicable Disease Control.

Medicines management
Topical antibiotics
Topical antibiotics should be applied sparingly and only to the affected area [Watkins, 2005]. Do not treat for longer than 10 days and avoid frequent repeat courses of treatment, due to the risk of contact sensitization and encouraging antibiotic resistance.

Oral antibiotics
Flucloxacillin
Common adverse effects include minor gastrointestinal disturbances, less common are rash, urticaria, and purpura. Flucloxacillin has been associated with an increased risk of hepatic disorders, namely hepatitis and cholestatic jaundice: o The Committee on Safety of Medicines (CSM) advises that hepatic reactions may occur up to 2 months after treatment with flucloxacillin has stopped. o Risk factors include treatment for more than 14 days and increasing age. o The dose and route of administration do not seem to affect this risk. Avoid flucloxacillin in people with a history of hypersensitivity to beta-lactam antibiotics (e.g. penicillins, cephalosporins).

Erythromycin
Common adverse effects include gastrointestinal disturbances, especially at higher doses. Erythromycin can increase the plasma levels of certain other drugs (e.g. theophylline, carbamazepine) and can potentiate the effects of warfarin. A dose reduction may be required in these circumstances. If a person is taking additional medication that may interact with erythromycin, an alternative macrolide such as azithromycin or clarithromycin may be used [BNF 50, 2005]. If erythromycin is taken with a statin, there is an increased risk of myopathy. Advise the person to stop the statin whilst erythromycin is being taken.

Supporting evidence
Evidence for antiseptic washes and cleaners in the treatment of impetigo
A Cochrane review (search date to January 2003) of interventions for the treatment of impetigo found little evidence on the effectiveness of disinfecting measures [Koning et al, 2003]. o In a single small study (n = 40) of people with non-bullous impetigo no difference was found between people treated with a disinfectant (hexachlorophene) compared with those treated with placebo. In fact, no cures were achieved in either the disinfectant or placebo groups. o Pooled results from two trials (n = 292) of people with non-bullous placebo found that topical antibiotics were better than disinfecting treatments (OR 1.84, 95% CI 1.03 to 3.29). o No trials of disinfecting measures for the treatment of bullous impetigo were found. o The authors concluded that there is no evidence to support disinfecting measures in the treatment of impetigo, as sole or supplementary treatment.

Evidence for antibiotics in the treatment of impetigo

A Cochrane review (search date to January 2003) of interventions for the treatment of impetigo included 57 randomized trials of 3533 participants [Koning et al, 2003]. The main outcome measure was clinical cure rate after one week of treatment, and the authors came to the following conclusions:

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Clinical Knowledge Summaries: Previous version Impetigo

No topical antibiotic is superior to another. Oral antibiotics are no more effective than topical antibiotics for people with limited disease, but have more gastrointestinal adverse effects than topical antibiotics. o There is insufficient evidence as to whether oral antibiotics are better than topical antibiotics for more serious and extensive forms of impetigo. o Based on the available evidence, no clear preference can be given for betalactamase resistant narrow-spectrum penicillins such as flucloxacillin, broadspectrum penicillins such as amoxicillin plus clavulanic acid, cephalosporins, and macrolides. It should be noted that many of these studies were underpowered, partly due to the fact that many trials included several skin infections, impetigo being only one of them. In addition, most studies were carried out in hospital out-patient clinics rather than in a primary care setting.

o o

Topical antibiotics
Non-bullous impetigo: Topical antibiotics compared with placebo: o Topical antibiotics had better cure rates or more symptom improvement than placebo (n = 365, OR 6.49, 95% CI 3.93 to 10.73). o When analysed individually, mupirocin (OR 5.40, 95% CI 2.79 to 10.45) and fusidic acid (OR 8.65, 95% CI 3.88 to 19.29) were more effective than placebo, but bacitracin was no more effective (OR 3.97, 95% CI 0.15 to 104.18). Topical antibiotics compared to disinfecting treatment: o Pooled results from two trials (n = 292) of people with non-bullous placebo found that topical antibiotics were better than disinfecting treatments (OR 1.84, 95% CI 1.03 to 3.29). Topical antibiotics compared with other topical antibiotics: o No single antibiotic was found to be superior over the other. o Fusidic acid was as effective as mupirocin (n = 440, OR 1.22, 95% CI 0.69 to 2.16). Topical antibiotics compared to oral antibiotics: o There were significantly better cure rates and more improvement with mupirocin than oral erythromycin (n = 581, OR 1.76, 95% CI 1.05 to 2.97). o No difference was found between mupirocin and either oral dicloxacillin, cefalexin or ampicillin. o Fusidic acid was significantly better than oral erythromycin in one small study (n = 36, p = 0.007). Studies were very small and many had large confidence intervals for their results. Topical antibiotics compared with other topical antibiotics: o Fusidic acid was more effective than neomycin/bacitracin (n = 24, OR 55.00, 95% CI 4.30 to 703.43) and chloramphenicol (n = 24, OR 25, 95% CI 2.92 to 213.99). o No difference was found between chloramphenicol and neomycin/bacitracin (n = 24, OR 2.20, 95% CI 0.17 to 28.14). Topical antibiotics compared with oral antibiotics: o Oral erythromycin was more effective than neomycin/bacitracin (n = 24, OR 0.06, 95% CI 0.01 to 0.68) and chloramphenicol (n = 24, OR 0.14, 95% CI 0.02 to 0.96). o No significant difference was found between fusidic acid and oral erythromycin (n = 24, OR 3.57, 95% CI 0.53 to 23.95). Topical antibiotics versus steroids versus antibiotic plus steroids: o The combination of betamethasone and gentamicin cream was significantly more effective than gentamicin alone (n = 52, OR 6.11, 95% CI 1.84 to 20.31). o The comparisons of betamethasone versus gentamicin alone (n = 52, OR 2.97, 95% CI 0.97 to 9.12) or betamethasone plus gentamicin (n = 52, OR 2.06, 95% CI 0.65 to 6.54) did not show significant differences.

Bullous impetigo:

Secondary impetigo:

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[Koning et al, 2003]

Oral antibiotics
Non-bullous impetigo: Many of these trials were small and had large confidence intervals for their results. Oral antibiotics compared with placebo: o Only one trial was identified (n = 38), in which no significant difference was found between phenoxymethylpenicillin and placebo, but the confidence interval was extremely wide (OR 9.26, 95% CI 0.44 to 192.72). Oral antibiotic compared with another oral antibiotic: o Three trials compared different penicillins. In one trial (n = 44), amoxicillin/clavulanic acid was more effective than amoxicillin alone (OR 9.80, 95% CI 1.09 to 88.23). In one trial (n = 42), no difference was found between amoxycillin/clavulanic acid and fleroxacin, a fluoroquinolone antibiotic (OR 1.68 95% CI 0.37 to 7.63). In one trial (n = 166), cloxacillin was more effective than phenoxymethylpenicillin (OR 13.74, 95% CI 4.36 to 43.24). o Five trials compared a macrolide with a penicillin: Pooled results from two trials (n = 79) comparing erythromycin with phenoxymethylpenicillin found that erythromycin was the more effective (OR 8.82, 95% CI 1.49 to 52.01). No differences were found between macrolides and flucloxacillin. o Only one trial was identified that compared different macrolides: In this trial (n = 66) no difference in efficacy was found between azithromycin and erythromycin (OR 1.90, 95% CI 0.62 to 5.83). o Seven trials compared a cephalosporin with another antibiotic: In only one trial was a cephalosporin more effective than the comparator antibiotic. This was a small trial (n = 41) comparing cefuroxime with erythromycin (OR 6.40, 95% CI 1.44 to 28.44). Another trial comparing cefalexin with erythromycin failed to find any difference in efficacy. The comparator antibiotics used in the other trials were phenoxymethylpenicillin (two trials), azithromycin (two trials), amoxycillin/clavulanic acid (one trial), and flucloxacillin (one trial). o Three trials compared different cephalosporins: No significant differences were found (cefalexin compared with cefadroxil or cefdinir, and cefaclor compared with cefdinir). Oral antibiotics with other oral antibiotics: o Only one trial was identified (n = 57), with no difference found between cephalexin and dicloxacillin (OR 3.39, 95% CI 0.62 to 18.49). Oral antibiotics with other oral antibiotics: o Only one trial was identified (n = 10), with no difference found between cefalexin and enoxacin, a fluoroquinolone antibiotic (OR 0.50, 95% CI 0.04 to 6.68).

Bullous impetigo:

Secondary impetigo:

[Koning et al, 2003]

References
NHS staff in England can link, free of charge, from references to the full text journal articles by clicking on [NHS Athens Full-text]. You will need an NHS Athens password to access these resources. Click here for Athens registration. All references with links to [Free Full-text] are freely available online to users in England and Wales. This includes the full text of Department of Health papers and Cochrane Library reviews. 1 BNF 50 (2005) British National Formulary. 50th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version Impetigo

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Bruijnzeels, M.A., Van Suijlekom-Smit, L.W.A., Van der Velden, J. and van der Wouden, J.C. (1993) The child in general practice. Dutch national survey of morbidity and interventions in general practice. Rotterdam: Erasmus University. Christensen, O.B. and Anehus, S. (1994) Hydrogen peroxide cream: an alternative to topical antibiotics in the treatment of impetigo contagiosa. Acta Dermato-Venereologica 74(6), 460462. George, A. and Rubin, G. (2003) A systematic review and meta-analysis of treatments for impetigo. British Journal of General Practice 53(491), 480-487. [Abstract] [Free Full-text] HPA (1999) Impetigo: factsheet for schools - wired for health. Health Protection Agency. www.hpa.org.uk [Accessed: 06/03/2007]. [Free Full-text] HPA (2005) Management of infection guidance for primary care for consultation & local adaptation. Health Protection Agency. www.hpa.org.uk [Accessed: 01/06/2007]. [Free Full-text] Johnston, G.A. (2004) Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants. Expert Review of Antiinfective Therapy 2(3), 439-446. [Abstract] Jones, G.R. (2002) Principles and practice of antibiotic therapy for cellulitis. CPD Journal Acute Medicine 1(2), 44-49. Koning, S., Verhagen, A.P., Van Suijlekom-Smit, L.W.A. et al. (2003) Interventions for impetigo (Cochrane Review). The Cochrane Library. Issue 2. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 06/03/2007]. [Free Full-text] Nursing Times (2004) What you need to know about...impetigo. Nursing Times 100(41), 31. Sladden, M.J. and Johnston, G.A. (2004) Common skin infections in children. British Medical Journal 329(7457), 95-99. Watkins, P. (2005) Impetigo: aetiology, complications and treatment options. Nursing Standard 19(36), 50-54. [Abstract] [NHS Athens Full-text]

Patient information
Patient information from NHS Direct: Impetigo Staphylococcal infections

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Quick Reference Guide

Impetigo Paracetamol and ibuprofen use in children Quick Reference Guides are in Adobe PDF format. To view PDF files, You can download Adobe Reader which is freely available from the Adobe website at www.adobe.co.uk. Quick Reference Guides will open in a new browser window.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.