Spotlight on Pharmacy

Is topical mupirocin safer and more effective than oral antibiotics for treating impetigo?
Bottom line
Topical mupirocin is more effective than oral erythromycin and is as effective as several other oral antibiotics for treating impetigo. There is a lower total incidence of side effects, especially gastrointestinal effects, with topical mupirocin as compared to oral erythromycin. (SOR: A, based on a systematic review.) Current local resistance patterns are an important consideration when prescribing antibiotics for impetigo. (SOR: C, based on accepted guidelines.) treatment. There was a trend toward significant benefit with topical antibiotics versus oral erythromycin (OR 0.48; 95% CI, 0.231.00). When a fourth study comparing topical mupirocin and bacitracin with oral cephalexin was included in the analysis, no significant difference was noted between the topical and oral antibiotic treatment groups (OR 1.20; 95% CI, 0.64 2.26).2 The most recent (2005) guidelines for treating impetigo from the Infectious Diseases Society of America (IDSA) recommend topical mupirocin for treatment of limited impetigo. Oral antimicrobials were recommended for patients with numerous lesions or those not responding to topical treatment.3 Both the Cochrane review and the IDSA guidelines stress the importance of using current local resistance pattern data to guide the decision of which antibiotic to use in treating impetigo. Mupirocin is generally effective against methicillin-resistant S aureus (MRSA), although high-level resistance has been identified.4 EBP
Luke Bloomquist, MD Cody Mead, DO
Carl R. Darnall Army Medical Center Fort Hood, TX
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Army Medical Department or the US Army at large.
REFERENCES

Evidence summary
Impetigo is a common, contagious, superficial bacterial skin infection usually caused by Staphylococcus aureus or Streptococcus pyogenes. Children ages 2 to 5 years are most frequently affected. No standard treatment exists for impetigo and a variety of topical and oral antibiotics are used in clinical practice. A 2004 Cochrane review examined a variety of interventions for impetigo. Ten studies with 581 patients compared topical mupirocin with oral erythromycin; topical mupirocin had significantly better clinical cure rates and greater clinical improvement (OR 1.76; 95% CI, 1.052.97).1 When a meta-analysis of only the 3 highest-quality studies with 197 patients was performed, the advantage of topical mupirocin over oral erythromycin was more pronounced (OR 3.73; 95% CI, 1.3510.34). No significant difference was noted between topical mupirocin and several other commonly prescribed oral antibiotics.1 Eighty of 297 (27%) participants in the erythromycin groups reported gastrointestinal adverse effects versus 17 of 323 (5%) participants in the mupirocin group. Skin adverse effects were more prevalent with mupirocin than erythromycin (7% vs 2%, respectively). The authors did not state whether this difference was statistically significant. Adverse effects for trials comparing other topical and oral antibiotics were not reported.1 In a 2003 systematic review of treatments for impetigo, 3 RCTs including 186 patients compared topical antibiotics (either mupirocin or bacitracin) with oral erythromycin. The primary outcome was clinical cure or improvement 7 to 10 days after starting
14 Evidence-Based Practice / September 2011

1.  Koning S, Verhagen AP, van Suijlekom-Smit LW, Morris A, Butler CC, van der Wouden JC. Interventions for impetigo. Cochrane Database Syst Rev. 2004; (2):CD003261. [LOE 1a] 2.  George A, Rubin G. A systematic review and meta-analysis of treatments for impetigo. Br J Gen Pract. 2003; 53(491):480487. [LOE 1a] 3.  Stevens DL, Bisno AL, Chambers HF, et al; for the Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005; 41(10):13731406. [LOE 3] 4.  Geria AN, Schwartz RA. Impetigo update: new challenges in the era of methicillin resistance. Cutis. 2010; 85(2):6570. [LOE 3]

Evidence-Based Practice learning objectives

1  To become knowledgeable about evidence-based solutions to commonly encountered clinical problems 2  To understand how ground-breaking research is changing the practice of family medicine 3  To become conversant with balanced appraisals of drugs that are marketed to physicians and consumers.