Topical mupirocin seems the treatment of choice in systemically well children with impetigo
Date First Published:
March 1, 2000
Last Updated:
October 10, 2002
Report by:
Jane McVicar, Clinical Fellow (Manchester Royal Infirmary)
Search checked by:
Vince Choudhery, Manchester Royal Infirmary
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.
Search Details:
[({exp impetigo OR impetigo.mp} AND {exp antibiotics OR antibiotic$.mp}) AND maximally sensitive RCT filter) LIMIT to human and English.
Outcome:
69 papers found of which 60 were irrelevant. The remaining nine papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A comparison of the new topical antibiotic mupirocin (Bactroban) with oral antibiotics in the treatment of skin infections in general practice. Villiger JW, Robertson WD, Kanji K 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 |
| Randomized clinical trial of topical mupirocin versus oral erythromycin for impetigo. Goldfarb J, Crenshaw D, O'Horo 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 | ||||
| Impetigo contagiosa III. Comparative efficacy of oral erythromycin and topical mupirocin. Barton LL, Freidman AD, Sharkey AM 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% | ||||
| Topical mupirocin treatment of impetigo is equal to oral erythromycin therapy. Mertz PM, Marshall DA, Eaglstein WH 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 | ||||
| Comparison of mupirocin and erythromycin in the treatment of impetigo. Britton JW, Fajardo JE, Krafte-Jacobs B. 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 | ||||
| A bacteriologically controlled, randomized study comparing the efficacy of 2% mupirocin ointment (Bactroban) with oral erythromycin in the treatment of patients with impetigo. 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 | ||||
| Double-blind study comparing erythromycin and mupirocin for treatment of impetigo in children. 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 | ||||
| Cost effectiveness of erythromycin versus mupirocin for the treatment of impetigo in children. Rice TD, Duggan AK, DeAngelis C. 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 | ||||
| Comparison of oral cephalexin, topical mupirocin and topical bacitracin for treatment of impetigo. Bass JW, Chan DS, Creamer KM 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 |
Author Commentary:
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.
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:
- 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.
- Goldfarb J, Crenshaw D, O'Horo J et al.. Randomized clinical trial of topical mupirocin versus oral erythromycin for impetigo.
- Barton LL, Freidman AD, Sharkey AM et al.. Impetigo contagiosa III. Comparative efficacy of oral erythromycin and topical mupirocin.
- Mertz PM, Marshall DA, Eaglstein WH et al.. Topical mupirocin treatment of impetigo is equal to oral erythromycin therapy.
- Britton JW, Fajardo JE, Krafte-Jacobs B.. Comparison of mupirocin and erythromycin in the treatment of impetigo.
- 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.
- Dagan R and Bar-David Y.. Double-blind study comparing erythromycin and mupirocin for treatment of impetigo in children.
- Rice TD, Duggan AK, DeAngelis C.. Cost effectiveness of erythromycin versus mupirocin for the treatment of impetigo in children.
- Bass JW, Chan DS, Creamer KM et al.. Comparison of oral cephalexin, topical mupirocin and topical bacitracin for treatment of impetigo.