Interventions for impetigo

 

Abstract

Background

Impetigo is a common, superficial bacterial skin infection, which is most frequently encountered in children. There is no generally agreed standard therapy, and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants. This is an updated version of the original review published in 2003.

Objectives

To assess the effects of treatments for impetigo, including non-pharmacological interventions and 'waiting for natural resolution'.

Search methods

We updated our searches of the following databases to July 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched online trials registries for ongoing trials, and we handsearched the reference lists of new studies found in the updated search.

Selection criteria

Randomised controlled trials of treatments for non-bullous, bullous, primary, and secondary impetigo.

Data collection and analysis

Two independent authors undertook all steps in data collection. We performed quality assessments and data collection in two separate stages.

Main results

We included 57 trials in the first version of this review. For this update 1 of those trials was excluded and 12 new trials were added. The total number of included trials was, thus, 68, with 5578 participants, reporting on 50 different treatments, including placebo. Most trials were in primary impetigo or did not specify this.

For many of the items that were assessed for risk of bias, most studies did not provide enough information. Fifteen studies reported blinding of participants and outcome assessors.

Topical antibiotic treatment showed better cure rates than placebo (pooled risk ratio (RR) 2. 24, 95% confidence interval (CI) 1.61 to 3.13) in 6 studies with 575 participants. In 4 studies with 440 participants, there was no clear evidence that either of the most commonly studied topical antibiotics (mupirocin and fusidic acid) was more effective than the other (RR 1.03, 95% CI 0.95 to 1.11).

In 10 studies with 581 participants, topical mupirocin was shown to be slightly superior to oral erythromycin (pooled RR 1.07, 95% CI 1.01 to 1.13). There were no significant differences in cure rates from treatment with topical versus other oral antibiotics. There were, however, differences in the outcome from treatment with different oral antibiotics: penicillin was inferior to erythromycin, in 2 studies with 79 participants (pooled RR 1.29, 95% CI 1.07 to 1.56), and cloxacillin, in 2 studies with 166 participants (pooled RR 1.59, 95% CI 1.21 to 2.08).

There was a lack of evidence for the benefit of using disinfectant solutions. When 2 studies with 292 participants were pooled, topical antibiotics were significantly better than disinfecting treatments (RR 1.15, 95% CI 1.01 to 1.32).

The reported number of side-effects was low, and most of these were mild. Side-effects were more common for oral antibiotic treatment compared to topical treatment. Gastrointestinal effects accounted for most of the difference.

Worldwide, bacteria causing impetigo show growing resistance rates for commonly used antibiotics. For a newly developed topical treatment, retapamulin, no resistance has yet been reported.

Authors' conclusions

There is good evidence that topical mupirocin and topical fusidic acid are equally, or more, effective than oral treatment. Due to the lack of studies in people with extensive impetigo, it is unclear if oral antibiotics are superior to topical antibiotics in this group. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. There is a lack of evidence to support disinfection measures to manage impetigo.

 

Plain language summary

Interventions for the skin infection impetigo

Impetigo causes blister-like sores. The sores can fill with pus and form scabs, and scratching can spread the infection. Impetigo is caused by bacteria. It is contagious and usually occurs in children. It is the most common bacterial skin infection presented by children to primary care physicians. Treatment options include topical antibiotics (antibiotic creams), oral antibiotics (antibiotics taken by mouth), and disinfectant solutions. There is no generally agreed standard treatment, and the evidence on what intervention works best is not clear.

We identified 68 randomised controlled trials comparing various treatments for impetigo. Altogether, these studies evaluated 26 oral treatments and 24 topical treatments, including placebo, and results were described for 5708 participants.

Overall, topical antibiotics showed better cure rates than topical placebo.

Two antibiotic creams, mupirocin and fusidic acid, are at least as effective as oral antibiotics where the disease is not extensive. There was no clear evidence that either of these most commonly studied topical antibiotics was more effective than the other.

Topical mupirocin was superior to the oral antibiotic, oral erythromycin.

We found that the oral antibiotic, oral penicillin, is not effective for impetigo, while other oral antibiotics (e.g. erythromycin and cloxacillin) can help.

It is unclear if oral antibiotics are superior to topical antibiotics for people with extensive impetigo.

There is a lack of evidence to suggest that using disinfectant solutions improves impetigo. When 2 studies with 292 participants were pooled, topical antibiotics were significantly better than disinfecting treatments.

Reported side-effects for topical treatments were mild and low in frequency; the treatments sometimes resulted in itching, burning, or staining. Oral antibiotics produced gastrointestinal complaints, such as nausea and diarrhoea, in 2% to 30% of participants, depending upon the specific antibiotic.

Worldwide, bacteria causing impetigo show growing resistance rates for commonly used antibiotics. For a newly developed topical treatment, retapamulin, no resistance has yet been reported.

 

摘要

背景

膿痂疹的治療

膿痂疹是一種常見的細菌性淺層皮膚感染症，最常見於小孩。目前並沒有標準的治療方式，而各種治療方針彼此歧異頗大。治療選項包括許多口服及塗抹的抗生素及消毒劑。

目標

評估治療膿痂疹各種方式的效果，包括等待自然痊癒。

搜尋策略

我們搜尋了the Skin Group Specialised Trials Register (2002年3月), Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2002), the National Research Register (2002), MEDLINE (from 1966 to 2003年1月), EMBASE (from 1980 to 2000年3月) and LILACS (2001年11月). 也搜尋了the Yearbook of Dermatology (1938 – 1966), the Yearbook of Drug Therapy (1949 – 1966), 也找了文章的參考文獻目錄,並與相關藥品公司聯絡。

選擇標準

針於非水皰型及水皰型、原發性及次發性膿痂疹的隨機對照試驗。

資料收集與分析

由2位獨立的審查者完成資料收集的各步驟。我們以2個分離的階段完成品質評估及資料收集。

主要結論

我們的研究包含了57個臨床試驗，包括了3533位受試者，總共有20種口服治療，18種塗抹治療。治癒或進步 針對治癒或進步來評估，塗抹抗生素比安慰劑來得好 (勝算比 (odds radio, OR) 6.49, 95% 信賴區間 (confidence interval, CI) 3.93到10.73), 而塗抹的抗生素彼此並沒有哪一種是特別好的 (mupirocin 比上 fusidic acid的聯合勝算比 (pooled OR) 為1.76, 95% 信賴區間為0.69到2.16) 。而塗抹的mupirocin比口服erythromycin來得有效 (聯合勝算比1.22, 95% 信賴區間 1.05到2.97) 。就治癒率而言，塗抹抗生素及口服抗生素大部分藥物的比較上，並沒有統計學上的差異。而關於口服抗生素間的比較，大多也都沒有統計學上的差異。口服Penicillin比erythromycin及cloxacillin來得差。而且對於 (disinfectants) 消毒劑用來治療膿痂疹的證據非常薄弱。副作用 被報導過的副作用數量並不多。口服抗生素治療比塗抹抗生素引起較多副作用，尤其是胃腸道的副作用。

作者結論

關於膿痂疹自然進程方面的資料相當缺乏。也很少包含安慰對照組的臨床試驗。關於用消毒的方式 (disinfecting measures) 來治療膿痂疹的證據非常薄弱。對於局限性的疾病，塗抹抗生素 (mupirocin與fusidic acid效果相等) 比口服抗生素來得有效，而且證據力相當好。對於廣泛性的膿痂疹，目前並沒清楚口服抗生素是否比塗抹抗生素來得好；而fusidic acid與mupirocin的效果大致相等。跟其他抗生素比起來，penicillin的效果較差。不同抗生素的抗藥性表現不同，而且也應作為選擇抗生素治療的考量之一。

翻譯人

本摘要由馬偕醫院王仁佑翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

對於改善膿痂疹的效果，mupirocin及fusidic acid的乳膏至少與口服抗生素一樣有效；但是penicillin沒有效，而且消毒藥水也不一定有幫助。膿痂疹會導致水泡樣的傷口，而且可能充滿了膿並形成疤痕，而搔抓可能會散布病原。膿痂疹是由細菌所引起，具有傳染性，而且通常發生在小孩。治療方式包括消毒藥水，抗生素乳膏，類固醇/抗生素乳膏，及口服抗生素。在回顧相關的臨床試驗後，發現penicillin對於膿痂疹的治療是無效的，而其他口服抗生素有幫助。然而，針對局限性的病灶，有兩種抗生素乳膏 (mupirocin and fusidic acid) 至少與口服抗性素一樣有效。對於消毒藥水能改善膿痂疹的證據則是非常薄弱。