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Cochrane review - Interventions for Impetigo Sander Koning Koning S, Verhagen AP, van Suijlekom-Smit LWA, Morris A, Butler CC, van der Wouden JC. The Cochrane Library, Issue 2, 2003 * Desiderius Erasmus Painting by Hans Holbein,1523 * Impetigo Background Third most common skin disorder in children (after dermatitis/eczema and viral warts) 23 % of children consult GP each year (UK, NL) Rising incidence Treatment mainly by GPs Causative agent: S. aureus (S. pyogenes) Natural course? Complications? * Impetigo Treatment options (1) no treatment, waiting for natural resolution, hygiene measures (2) topical disinfectants (e.g. hexachlorophene, povidone-iodine, chlorhexidine); (3) topical antibiotics (e.g. neomycin, bacitracin, polymyxin B, fusidic acid, mupirocin); (4) systemic antibiotics (e.g. penicillin, (flu)cloxacillin, amoxicillin/clavulanic acid, erythromycin, cephalexin) Bacterial resistance in S. Aureus ! * Interventions for Impetigo Rationale for the review Many options, guidelines vary widely Objectives To assess the effects of treatments for impetigo Types of studies Randomised trials Types of participants People with non-bullous or bullous, primary or secondary impetigo Types of interventions Any treatment, including antibiotics, disinfectants or any other intervention * Interventions for impetigo Search strategy Electronic search - Skin Group Specialised Trials Register (March 2002) - Cochrane Central Register of Controlled Trials (2002) - National Research Register (2002) - MEDLINE (1966 to 2003) - EMBASE (1980 to 2000) - LILACS (2001) Handsearch - Yearbook of Dermatology (1938 - 1966) - Yearbook of Drug Therapy (1949 - 1966) Other - reference lists of articles - contacted pharmaceutical companies. * Interventions for Impetigo Data collection & analysis Abstract reading and selection 2 independent reviewers Full copy reading and selection 2 independent reviewers Quality assessment 2 independent reviewers Data extraction 2 independent reviewers Primary Outcome: (Odds Ratio for) cure after one week of treatment Meta-analysis (pooling) for comparisons that have been studied more than once * Interventions for Impetigo Results Studies identified (abstracts) approx. 700 Full copies read 221 Papers included 56 (57 RCTs) Total evaluable patients 3533 Language of papers English 49 Japanese 3 Korean, Thai, Portuguese, Spanish and Danish 1 each * Interventions for Impetigo Results: description of the 57 included studies 38 different treatments studied 20 oral, and 18 local treatments Studies comparing: Two different oral antibiotics: 25 (Cephalosporines: 16) (Macrolides (erythrom. or azithrom.): 10) A topical vs an oral antibiotic: 22 (Erythromycin, mupirocin, or both: 19) Antiseptic or disinfecting treatments: 2 Placebo-controlled trials: 5 * RESULTS Comparison: Topical antibiotic vs placebo(5 studies) No studies OR (95% CI) Mupirocin 3 5.40 (2.79 - 10.45) Fusidic acid 1 8.65 (3.88 - 19.29) Bacitracin 1 3.97 (0.15 to 104.18) Overall 5 6.49 (3.93 - 10.73). * Comparison: Topical antibiotic versus placebo * Comparison: Topical vs another topical antibiotic (12 studies) No studies OR (95% CI) Fusidic acid with mupirocin 4 1.22 (0.69 to 2.16) All other comparisons were only represented by a single small study without a siginificant difference in results * Comparison: Topical versus another topical antibiotic * Comparison: Topical versus oral antibiotic (16 studies) no studies OR (95% CI) Mupirocin versus Erythromycin 10 1.76 (1.05 to 2.97 ) Dicloxacillin 1 NS Cephalexin 1 NS Ampicillin 1 NS Fusidic acid versus Erythromycin 1 8.38 (1.77 39.69) Cefuroxim 1 NS * Comparison: Topical versus oral antibiotic (16 studies) Mupirocin versus erythromycin, (sensitivity analysis for quality), dicloxacillin * Comparison: Topical antibiotic versus antiseptic (2 studies) Study OR (95% CI) Bacitracin vs hexachlorophene 3.97 (0.15 to 104.18) fusidic acid vs hydrogen peroxide 1.79 (0.99 to 3.25). * Comparison: Oral versus other oral antibiotic (22 studies) cephalosporin vs another antibiotic (7 studies) no differences one cephalosporin vs another cephalosporin (4 studies) no differences macrolide vs penicillin (6 studies) Erythromycin superior to penicillin macrolide vs another macrolide (1 study) no difference penicillin vs other oral antibiotics (4 studies) Amoxicillin+clavulanic acid superior to amoxicillin alone Cloxacillin superior to penicillin * Interventions for impetigo Discussion Many small trials of various quality with inconclusive results. Some large trials of good quality. Few placebo-controlled trials. Antiseptic treatment inadequately studied. * Interventions for impetigo Conclusions and Implications for Practice No evidence for the value of disinfecting measures Topical antibiotics Good evidence that topical mupirocin and fusidic acid are equal to or possibly more effective than oral treatment for people with limited disease. Other topical antibiotics seem less effective. Oral antibiotics No evidence that penicillin is effective. No clear preference for B- lactamase resistant penicillins (cloxacillin, dicloxacillin and flucloxacillin), broad spectrum penicillins (ampicillin, amoxicillin plus clavulanic acid), cephalosporins, and macrolides. * Interventions for impetigo Considerations for treatment Actual presence of bacterial resistance in the region and specific patient population (for erythromycin, fusidic acid, any antibiotic) Other criteria can be decisive - price - (u