Antibiotic stewardship in skin infections: a cross-sectional analysis of early-career GP’s management of impetigo

Abstract

ObjectiveTo establish the prevalence and associations of systemic antibiotic prescription for impetigo by early-career general practitioners (GPs) (GP registrars in their first 18 months in general practice).DesignA cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study.SettingReCEnT is an ongoing multisite cohort study of Australian registrars’ in-consultation clinical practice across five Australian states.ParticipantsRegistrars participating in ReCEnT from 2010 to 2017.Outcome measuresManagement of impetigo with systemic antibiotics.Results1741 registrars (response rate 96%) provided data from 384 731 problems identified in 246 434 consultations. Impetigo, on first presentation or follow-up, was managed in 930 (0.38%, 95% CI 0.35 to 0.40) consultations and comprised 0.24% (95% CI 0.23 to 0.26) of problems. 683 patients presented with a new diagnosis of impetigo of which 38/683 (5.6%) were not prescribed antibiotics; 239/683 (35.0%) were prescribed solely topical antibiotics; 306/683 (44.8%) solely systemic antibiotics and 100/683 (14.6%) both systemic and topical antibiotics. The most common systemic antibiotic prescribed was cephalexin (53.5%). Variables independently associated with prescription of systemic antibiotics were an inner regional (compared with major city) location (OR 1.82, 95% CI 1.06 to 3.13; p=0.028), seeking in-consultation information or advice (OR 2.17, 95% CI 1.47 to 3.23; p<0.001) and ordering pathology (OR 2.13, 95% CI 1.37 to 3.33; p=0.01).ConclusionsAustralian early-career GPs prescribe systemic antibiotics (the majority broad-spectrum) for a high proportion of initial impetigo presentations. Impetigo guidelines should clearly specify criteria for systemic antibiotic prescription and individual antibiotic choice. The role of non-antibiotic management and topical antiseptics needs to be explored further.

Topical antibiotics in the dermatological clinical practice: Indications, efficacy, and adverse effects

“…However, although international guidelines may seem not to be in agreement upon which topical antibiotic is to be preferred, it is important to underline that topical antimicrobials in impetigo are generally chosen depending on the local bacterial resistance profiles, thus explaining possible different therapeutic choices 7 …”

“…Therefore, despite different antimicrobial molecules being possible treatments for localized impetigo, most guidelines define topical antibiotics as the first choice treatment for localized impetigo, although hydrogen peroxide 1% or povidone‐iodine 10% are preferred to topical antibiotics for impetigo with less than three lesions in the 2017 New Zealand guidelines 7‐9 …”

“…6 Fusidic acid is generally recommended as a second-choice topical antibiotic, although it is in some cases preferred to mupirocin/ retapamulin for impetigo, as illustrated in the 2015 UK guidelines, the 2017 Netherlands guidelines, and the 2017 New Zealand guidelines. [7][8][9] As regards its administration, one of the most common regimens establishes its application on the infected skin three times daily for 7 to 12 days.…”

“…However, although international guidelines may seem not to be in agreement upon which topical antibiotic is to be preferred, it is important to underline that topical antimicrobials in impetigo are generally chosen depending on the local bacterial resistance profiles, thus explaining possible different therapeutic choices. 7 As a matter of fact, no conclusive data are currently available regarding which topical antibiotic works the best for impetigo patients, as several clinical studies demonstrated fusidic acid to be either equivalent or superior to mupirocin and retapamulin. 10,11 Moreover, 57 randomized controlled trials, published together with a whole meta-analysis of 3533 impetigo patients, concluded that mupirocin and fusidic acid are the first-line treatments in impetigo patients.…”

“…12,13 Therefore, despite different antimicrobial molecules being possible treatments for localized impetigo, most guidelines define topical antibiotics as the first choice treatment for localized impetigo, although hydrogen peroxide 1% or povidone-iodine 10% are preferred to topical antibiotics for impetigo with less than three lesions in the 2017 New Zealand guidelines. [7][8][9] In cases of recurrent impetigo, only 2% topical intranasal mupirocin is recommended in S aureus carrier patients to reduce clinical relapses. 5 As illustrated earlier, the most commonly used topical antibiotics in impetigo are also those related to the highest resistance rates, thus Ozenoxacin was reported to be efficient but also safe, as no adverse effect was considered drug-related, and as only one patient revealed systemic absorption, still at extremely low nontoxic concentrations.…”