• 
• 

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 flucloxacillin	PRCT	Cure rate	86% 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 erythromycin	PRCT	Clinical response	More failures with erythromycin	Not blinded No statistical analysis
			Rate of response	Faster with mupirocin
Barton LL et al, 1989, USA	97 patients with impetigo under 16 years old in paediatric outpatients Topical mupirocin vs oral erythromycin	PRCT	Relapse rate	3 times higher in erythromycin group	Not blinded No statistical analysis
			Bacterial eradication rate	71% vs 65%
			Clinical response rate	96% 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 erythromycin	PRCT	Bacterial eradication rate	Better eradication in mupirocin group	22 patients (mostly in erythromycin group) "unassessable".
			Clinical response rate	No significant difference
Britton JW et al, 1990, USA	54 patients with impetigo under 14 years old in paediatric outpatients Topical mupirocin vs oral erythromycin	PRCT	Compliance	Better in mupirocin group	More severe patients in mupirocin group
			Adverse effects	No significant difference
			Clinical response rate	No significant difference
McLinn S, 1990, Australia	60 patients with impetigo Topical mupirocin vs oral erythromycin	PRCT	Adverse effects	0% vs 13%
			Bacterial eradication rate	100% for both
Dagan R and Bar-David Y, 1992, Israel	102 patients with impetigo under 16 years in paediatric outpatients Topical mupirocin vs oral erythromycin	PRCT	Adverse effects	Significantly lower in mupirocin group	13 patients lost from study
			Clinical response rate	Significantly 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 erythromycin	PRCT	Clinical response rate	No significant difference	10 patients did not complete all outcomes. Some baseline differences between groups
			Bacterial eradication rate	No significant difference
			Adverse effects	Higher 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)	PRCT	Clinical response rate	Bacitracin significantly worse. Mupirocin and cephalexin no significant difference	Very small numbers
			Failure rate	More 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.