Interventions to reduce Staphylococcus aureus in the management of atopic eczema

  • Review
  • Intervention

Authors


Abstract

Background

Staphylococcus aureus can cause secondary infection in atopic eczema, and it may promote inflammation in eczema that does not look infected. Many antimicrobial products exist for eczema, but it is unclear if they work or if they promote bacterial resistance.

Objectives

To assess the effects of interventions to reduce Staphylococcus aureus for treating infected or uninfected atopic eczema.

Search methods

We searched the Cochrane Skin Group Specialised Register (March 2008), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 1, 2008), MEDLINE (OVID) (from 2002 to March 2008), EMBASE (OVID) (from 2002 to March 2008), Ongoing trials registers (March 2008). References from trials and reviews were searched, pharmaceutical companies were contacted for unpublished trials. There were no language restrictions.

Selection criteria

Randomised controlled trials (RCTs) of people with atopic eczema who have been treated with a product intended to reduce S. aureus on the skin.

Data collection and analysis

Two people independently performed the study selection, data abstraction and quality assessment.

Main results

We included 21 studies (1018 participants) covering 7 treatment categories. Most studies were poorly reported and study differences limited pooling of results. Adverse effects were especially poorly reported, and only one study reported the emergence of resistant bacterial strains following oral antibiotics. Oral antibiotics were not associated with benefit in non-infected (2 trials, 66 participants) or infected eczema (1 trial, 33 participants). We did not find any benefit for antibacterial soaps (1 trial, 50 participants), or antibacterial bath additives (2 trials, 41 participants), or topical antibiotics/antiseptics (4 studies, 95 participants). Adding antibiotics to topical corticosteroids reduced numbers of Staphylococcus aureus in 4 trials (302 participants), but there was no evidence of any clinical benefit in 9 trials involving 677 participants: betamethasone plus neomycin vs clobetasol (MD 1.2; 95% CI 0.25, 2.15), prednicarbate plus antimicrobial vs prednicarbate (RR 0.64; 95% CI 0.25, 1.68), or betamethasone valerate plus gentamicin vs betamethasone (RR 0.31; 95% CI 0.07, 1.35). One trial (30 participants) showed no significant improvement in eczema for those using silver textiles (RR 2.67; 95% CI 0.98, 7.22), despite using 10 times the amount of topical steroids.

Authors' conclusions

We failed to find clear evidence of benefit for antimicrobial interventions for people with atopic eczema, despite their widespread use. This does not necessarily mean they do not work because the studies were small and poorly reported. Further large studies with long-term outcomes and clearly defined participants are urgently required.

摘要

背景

減少金黃色萄蔔球菌的治療對異位性皮膚炎的影響

金黃色萄蔔球菌會造成異位性皮膚炎患者的次發性感染,同時造成皮膚發炎更加嚴重,雖然看起來不像是感染性疾病。雖然許多抗生素產品已經用在異位性皮膚炎的治療,但是它們是否真的能發揮功效,或是反而會造成抗藥性的產生,仍然存疑。

目標

評估減少金黃色葡萄球菌感染的處理,對於有感染與沒有感染的異位性皮膚炎的效果。

搜尋策略

我們研究了 the Cochrane Skin Group Specialised Register (2008年3月), the Cochrane Central Register of Controlled Trials (Cochrane Library 2008年第一期), MEDLINE (OVID) (2002年至2008年3月), EMBASE (OVID) (2002年至2008年3月) 及Ongoing trials registers (2008年3月) 。試驗或文章的參考文獻也被研讀,並且也接觸藥廠以取得未公開的試驗結果。研究的搜尋並沒有語言的限制。

選擇標準

在異位性皮膚炎患者,使用減少皮膚上的金黃色葡萄球菌產品的隨機對照實驗。

資料收集與分析

由兩個人獨立完成研究的選擇,資料的分析,和品質的評估。

主要結論

我們選取了21個研究 (共1018名參與者), 包含了7種治療種類。多數研究報告不佳,且結果相異性高無法整合。特別是副作用很少被提及,只有一個研究報告在服用抗生素後,造成抗藥性菌株的產生。口服抗生素並沒有在未感染 (2個試驗,66個參與者) 或感染的病人 (1 個試驗,33個參與者) 上被證明有幫助。抗菌皂 (1個試驗,50名病人) ,添加抗菌成份的沐浴乳 (2個試驗,41個病人) ,和外用抗生素/消毒劑 (4個試驗,95個病人) 也沒有發現好處。在4個試驗中,於類固醇藥膏中添加抗生素以減少金黃色葡萄球菌的數量 (包含302個病人) ,但在9個試驗,共677個病人中都沒有證據顯示有任何臨床上的幫助,例如betamethasone加上neomycin比較clobetasol (MD 1.2; 95% CI 0.25, 2.15), prednicarbate加上抗菌劑比較prednicarbate (RR 0.64; 95% CI 0.25, 1.68), 或betamethasone valerate 加上gentamicin比較betamethasone (RR 0.31; 95% CI 0.07, 1.35) 。在一個包含了30名患者的試驗中,那些有使用銀材質的衣物者 (RR 2.67; 95% CI 0.98, 7.22) ,儘管使用10倍量的外用類固醇,對皮膚炎並沒有顯著的幫助。。

作者結論

我們沒有找到明確的證據證實抗菌措施對異位性皮膚炎患者的臨床效益,儘管它們已經廣泛地被使用。但也不能說它們一定沒有幫助,因為研究規模小且報告少。

翻譯人

本摘要由馬偕醫院謝志偉翻譯。

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

總結

進一步大型且長期的研究,並且清楚規範參與者的條件是急切需要的。異位性皮膚炎是一個世界性的大問題,患者常常在皮膚上有許多金黃色葡萄球菌,有時候這些金黃色葡萄球菌可能造成嚴重的次發性感染。即使臨床上沒有感染的跡象,它們也可能讓皮膚炎本身更加嚴重。因此,許多治療都在試著減少金黃色葡萄球菌量,包括口服抗生素、清潔的抗菌肥皂、或是在皮膚炎的治療同時合併抗生素使用。針對此主題進行系統性的回顧乃因為,我們仍然不清楚哪一種治療有臨床的助益,以及廣泛性使用抗菌劑會有造成抗藥性細菌的疑慮。我們回顧了21個大型隨機對照研究,共有1080個參與者,包含了多種抗金黃葡萄球菌的治療,像是:口服抗生素 (3個試驗) ,抗菌皂 (1個試驗) ,外用類固醇加上抗菌劑 (10個試驗) ,抗菌沐浴乳 (2個試驗) ,外用消毒劑/抗生素藥膏 (4個試驗) 和含銀布料 (1個試驗) 。一般說來,這些研究品質不佳,規模太小,以致不能辨別其間重要的差異,即便他們確實存在。這些措施,在短期的濕疹控制上,沒有任何試驗證實有任何明確的效益。但有些試驗證實能減少皮膚表面金黃色葡萄球菌的數量。廣泛使用的外用類固醇加上抗生素,沒有證據證實比單獨使用外用類固醇效果佳。副作用例如皮膚的刺激性並沒有被詳細記錄,只有一個小試驗提到了在口服抗生素組有抗藥性菌株的產生。只有一個小試驗評估了感染性皮膚炎,但也沒有結論。在評估這些報告必須非常小心,因此這些報告沒有顯示好處,也不能說這些治療一定沒有幫助,因為研究規模都很小且報告少。一般的常識是只要被感染的皮膚炎,就先以口服抗生素治療,除非有明確證據證實這樣的做法不對,否則這樣的觀念必須繼續。但由於我們無法由現有的研究中證明,在沒有感染的異位性皮膚炎使用抗菌劑會有好處,因此對這樣的用法也要保持存疑。進一步大型且長期的研究是必要的,來探索對預防異位性皮膚炎復發,使用抗菌劑長期的效益及傷害影響。

Plain language summary

Interventions to reduce Staphylococcus aureus in the management of atopic eczema

Atopic eczema (atopic dermatitis or childhood eczema) is a big problem worldwide. The skin of people with atopic eczema often contains high numbers of a bacterium called Staphylococcus aureus (S. aureus).

Sometimes S. aureus results in an obvious secondary infection. Even when the eczema does not look infected S. aureus may still play a part in promoting skin inflammation. As a result, lots of eczema treatments have been developed to reduce S. aureus, including antibiotics taken by mouth, washing with antibacterial soaps or antibiotics combined with other eczema treatments. We undertook a systematic review on this topic as it is not clear which treatments offer any clinical benefit and because there is some concern that their widespread use may promote bacterial resistance.

Our review included 21 randomised controlled trials involving 1018 participants covering a range of anti-staphylococcal treatments: oral antibiotics (3 trials), antibacterial soaps (1 trial), topical steroids combined with antibacterials (10 trials), antibacterial bath additives (2 trials), topical antiseptic/antibiotics creams (4 trials) and silver impregnated textiles (1 trial). Generally, the quality of the reported studies was poor, and many were too small to identify important differences even if they existed. None of the trials showed any clear benefit in terms of short-term eczema control for any of the interventions tested, although several interventions were associated with decreased numbers of S. aureus on the skin. There was no clear evidence that widely used topical steroid/antibiotic combinations were any better than the topical steroids used alone. Adverse effects like irritation were especially poorly reported and only one study reported on the emergence of resistant bacterial strains in the group treated with oral antibiotics. Only one small inconclusive study evaluated people with clinically infected eczema.

Care should be taken in interpreting the above studies as failure to show benefit in a series of small, poorly reported studies does not mean that the anti-staphylococcal interventions could not be helpful in eczema. It is clinical common sense to treat overtly infected eczema with oral antibiotics, and that practice should continue until good evidence suggests otherwise. However, given that none of the other studies showed clear clinical benefit for anti-staphylococcal interventions in non-infected eczema, their continued use should be questioned in such situations. More studies should be done to look at the long-term possible benefits and harms of such interventions in preventing flares of atopic eczema.

Laički sažetak

Intervencije za smanjenje razine bakterije Staphylococcus aureus u liječenju atopijskog ekcema

Atopijski ekcem (atopijski dermatitis ili ekcem dječje dobi) predstavlja veliki problem širom svijeta. Koža pacijenata oboljelih od atopijskog dermatitisa često ima visok broj bakterija Staphylococcus aureus (S. aureus).

Ponekad S.aureus može uzrokovati nastanak vidljivih sekundarnih infekcija. No čak i kada atopična područja ne djeluju inficirano, S. aureus može imati značajnu ulogu u razvoju upale kože. Stoga su razvijeni brojni načini liječenja dermatitisa u svrhu smanjivanja broja S. aureusa, uključujući oralnu primjenu antibiotika, ispiranje antibakterijskim sredstvima za pranje ili primjenu antibiotika u kombinaciji s drugim lijekovima za liječenje dermatitisa. Budući da nije jasno koji od navedenih načina terapije pruža bilo kakav željen klinički učinak i da postoji bojazan kako bi široka upotreba antibiotika mogla doprinijeti razvoju bakterijske rezistencije, napravljen se Cochrane sustavni pregled literature na tu temu.

Pregled uključuje 21 randomizirano kontrolirano ispitivanje s 1018 ispitanika u kojem je obuhvaćen niz terapija za smanjenje broja stafilokoknih bakterija: oralni antibiotici (3 istraživanja), antibakterijski sapuni (1 istraživanje), topikalni kortikosteroidi u kombinaciji s antibakterijskim sredstvom (10 istraživanja), antibakterijski dodaci kupkama (2 istraživanja), topikalne antiseptičke/antibiotske kreme (4 istraživanja) te odjeća impregnirana srebrom (1 istraživanje). Kvaliteta opisivanja tih istraživanja u znanstvenim radovima općenito je bila slaba, a mnoga su premala da bi omogućila utvrđivanje značajnih razlika u terapijskim pristupima čak i kad bi razlike postojale. Niti jedno od ispitivanja nije pokazalo značajnu prednost određenog terapijskog pristupa u vidu kratkoročne kontrole dermatitisa, iako neki jesu povezani sa smanjenjem broja S. aureusa na koži. Nema niti jasnih dokaza da je raširena primjena topikalnih kombinacija kortikosteroida i antibiotika učinkovitija u odnosu na samostalno primijenjene topikalne kortikosteroide. Neželjeni učinci, kao što su iritacije, su izrazito loše opisani, te je samo u jednoj studiji opisan nastanak rezistentnog bakterijskog soja u grupi ispitanika koji su primali oralne antibiotike. Samo je jedna manja, neuvjerljiva studija procjenjivala ispitanike s klinički inficiranim ekcemom.

Potreban je oprez prilikom tumačenja rezultata ove analize jer nemogućnost da se temeljem niza malih, loše opisanih studija pokaže prednost, ne znači nužno da antistafilokokna terapija ne može biti korisna kod ekcema. Uobičajeno je u kliničkoj praksi liječiti inficirane ekceme oralnim antibioticima, te bi se takva praksa trebala nastaviti ukoliko se temeljem znanstvenih dokaza ne ustanovi drugačije. No, uzevši u obzir da niti jedno istraživanje nije pokazalo jasnu kliničku korist antistafilokoknih mjera kod neinficiranih ekcema, njihova kontinuirana primjena je upitna u takvim situacijama. Potrebno je provesti više ispitivanja u svrhu utvrđivanja rizika i koristi takvih mjera u prevenciji pogoršanja (egzacerbacija) atopijskog dermatitisa.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Maja Kišan
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

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