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Topical mupirocin seems the treatment of choice in systemically well children with impetigo

Three Part Question

In [a systemically well child with impetigo] do [oral or topical antibiotics] offer [better clinical effectiveness and/or less side effects]?

Clinical Scenario

A 3 year old child is brought into the emergency department with a crusty yellow rash on the forearm. She is systemically well and a diagnosis of impetigo is made. You wonder whether oral or topical antibiotics are better.

Search Strategy

Medline 1966-06/99 using the OVID interface.
[({exp impetigo OR impetigo.mp} AND {exp antibiotics OR antibiotic$.mp}) AND maximally sensitive RCT filter) LIMIT to human and English.

Search Outcome

69 papers found of which 60 were irrelevant. The remaining nine papers are shown in the table.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Villiger JW et al,
1986,
England
200 patients with skin infections presenting in general practice. Topical mupirocin vs oral erythromycin or oral flucloxacillinPRCTCure rate86% vs 47% vs 76%Undifferentiated skin infections. No randomisation of oral antibiotics
Goldfarb J et al,
1988,
USA
62 patients with impetigo under 13 years old in a childrens hospital Topical mupirocin vs oral erythromycinPRCTClinical responseMore failures with erythromycinNot blinded No statistical analysis
Rate of responseFaster with mupirocin
Barton LL et al,
1989,
USA
97 patients with impetigo under 16 years old in paediatric outpatients Topical mupirocin vs oral erythromycinPRCTRelapse rate3 times higher in erythromycin groupNot blinded No statistical analysis
Bacterial eradication rate71% vs 65%
Clinical response rate96% vs 90%
Mertz PM et al,
1989,
Puerto Rico
75 patients with impetigo over 6 months old in public health clinics Topical mupirocin vs oral erythromycinPRCTBacterial eradication rateBetter eradication in mupirocin group22 patients (mostly in erythromycin group) "unassessable".
Clinical response rateNo significant difference
Britton JW et al,
1990,
USA
54 patients with impetigo under 14 years old in paediatric outpatients Topical mupirocin vs oral erythromycinPRCTComplianceBetter in mupirocin groupMore severe patients in mupirocin group
Adverse effectsNo significant difference
Clinical response rateNo significant difference
McLinn S,
1990,
Australia
60 patients with impetigo Topical mupirocin vs oral erythromycinPRCTAdverse effects0% vs 13%
Bacterial eradication rate100% for both
Dagan R and Bar-David Y,
1992,
Israel
102 patients with impetigo under 16 years in paediatric outpatients Topical mupirocin vs oral erythromycinPRCTAdverse effectsSignificantly lower in mupirocin group13 patients lost from study
Clinical response rateSignificantly better in mupirocin group
Rice TD et al,
1992,
USA
93 patients with impetigo under 16 years old in paediatric emergency room and primary care clinics Topical mupirocin vs oral erythromycinPRCTClinical response rateNo significant difference10 patients did not complete all outcomes. Some baseline differences between groups
Bacterial eradication rateNo significant difference
Adverse effectsHigher in erythromycin group
Bass JW et al,
1997,
USA
26 children with impetigo with a mean age of 3.8 years Topical mupirocin (7) vs topical bacitracin (9) vs oral cephalexin (10)PRCTClinical response rateBacitracin significantly worse. Mupirocin and cephalexin no significant differenceVery small numbers
Failure rateMore failures with bacitracin. Mupirocin and cephalexin no significant difference

Comment(s)

All the trials indicate that topical mupirocin is as effective as oral erythromycin and has fewer systemic side effects. Only one trial looked at the relative efficacy of oral flucloxacillin.

Clinical Bottom Line

Topical mupirocin is the first treatment of choice in systemically well children with impetigo.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

  1. Villiger JW, Robertson WD, Kanji K et al. A comparison of the new topical antibiotic mupirocin (Bactroban) with oral antibiotics in the treatment of skin infections in general practice. Current Med Res Opinion 1986;10(5):339-345.
  2. Goldfarb J, Crenshaw D, O'Horo J et al. Randomized clinical trial of topical mupirocin versus oral erythromycin for impetigo. Antimicrobial Agents and Chemotherapy 1988;32(12):1780-1783.
  3. Barton LL, Freidman AD, Sharkey AM et al. Impetigo contagiosa III. Comparative efficacy of oral erythromycin and topical mupirocin. Pediatr Dermatol 1989;6(2):134-138.
  4. Mertz PM, Marshall DA, Eaglstein WH et al. Topical mupirocin treatment of impetigo is equal to oral erythromycin therapy. Arch Dermatol 1989;125(8):1069-1073.
  5. Britton JW, Fajardo JE, Krafte-Jacobs B. Comparison of mupirocin and erythromycin in the treatment of impetigo. J Pediatr 1990;117(5):827-829.
  6. McLinn S. A bacteriologically controlled, randomized study comparing the efficacy of 2% mupirocin ointment (Bactroban) with oral erythromycin in the treatment of patients with impetigo. J Am Acad Dermatol 1990;22(5 pt 1):883-885.
  7. Dagan R and Bar-David Y. Double-blind study comparing erythromycin and mupirocin for treatment of impetigo in children. Antimicrobial Agents and Chemotherapy 1992;36(2):287-290.
  8. Rice TD, Duggan AK, DeAngelis C. Cost effectiveness of erythromycin versus mupirocin for the treatment of impetigo in children. Pediatrics 1992;89(2):210-214.
  9. Bass JW, Chan DS, Creamer KM et al. Comparison of oral cephalexin, topical mupirocin and topical bacitracin for treatment of impetigo. Pediatr Infect Dis J 1997;16(7):708-710.