200 likes | 527 Views
Desiderius Erasmus. Painting byHans Holbein,1523. Impetigo Background . Third most common skin disorder in children (after dermatitis/eczema and viral warts) 2
E N D
1. Cochrane review- Interventions for Impetigo
Sander Koning
Koning S, Verhagen AP, van Suijlekom-Smit LWA, Morris A, Butler CC, van der Wouden JC. The Cochrane Library, Issue 2, 2003
2. Desiderius Erasmus
Painting by
Hans Holbein,1523
3. ImpetigoBackground
Third most common skin disorder in children
(after dermatitis/eczema and viral warts)
2–3 % of children consult GP each year (UK, NL)
Rising incidence
Treatment mainly by GPs
Causative agent: S. aureus (S. pyogenes)
Natural course?
Complications?
4. ImpetigoTreatment options
(1) no treatment, waiting for natural resolution, hygiene measures
(2) topical disinfectants
(e.g. hexachlorophene, povidone-iodine, chlorhexidine);
(3) topical antibiotics
(e.g. neomycin, bacitracin, polymyxin B, fusidic acid, mupirocin);
(4) systemic antibiotics
(e.g. penicillin, (flu)cloxacillin, amoxicillin/clavulanic acid, erythromycin, cephalexin)
Bacterial resistance in S. Aureus !
5. Interventions for ImpetigoRationale for the review
Many options, guidelines vary widely
Objectives
To assess the effects of treatments for impetigo
Types of studies
Randomised trials
Types of participants
People with non-bullous or bullous, primary or secondary impetigo
Types of interventions
Any treatment, including antibiotics, disinfectants or any other intervention
6. Interventions for impetigoSearch strategy
Electronic search- Skin Group Specialised Trials Register (March 2002)- Cochrane Central Register of Controlled Trials (2002)- National Research Register (2002)- MEDLINE (1966 to 2003)- EMBASE (1980 to 2000)- LILACS (2001) Handsearch- Yearbook of Dermatology (1938 - 1966)- Yearbook of Drug Therapy (1949 - 1966)Other- reference lists of articles- contacted pharmaceutical companies.
7. Interventions for ImpetigoData collection & analysis Abstract reading and selection 2 independent reviewers
Full copy reading and selection 2 independent reviewers
Quality assessment 2 independent reviewers
Data extraction 2 independent reviewers
Primary Outcome: (Odds Ratio for) cure after one week of treatment
Meta-analysis (pooling) for comparisons that have been studied more than once
8. Interventions for ImpetigoResults Studies identified (abstracts) approx. 700
Full copies read 221
Papers included 56 (57 RCT’s)
Total evaluable patients 3533
Language of papers
English 49
Japanese 3
Korean, Thai, Portuguese,
Spanish and Danish 1 each
9. Interventions for ImpetigoResults: description of the 57 included studies 38 different treatments studied
20 oral, and 18 local treatments
Studies comparing:
Two different oral antibiotics: 25
(Cephalosporines: 16)
(Macrolides (erythrom. or azithrom.): 10)
A topical vs an oral antibiotic: 22
(Erythromycin, mupirocin, or both: 19)
Antiseptic or disinfecting treatments: 2
Placebo-controlled trials: 5
10. RESULTSComparison:Topical antibiotic vs placebo(5 studies)
No studies OR (95% CI)
Mupirocin 3 5.40 (2.79 - 10.45)
Fusidic acid 1 8.65 (3.88 - 19.29)
Bacitracin 1 3.97 (0.15 to 104.18)
Overall 5 6.49 (3.93 - 10.73).
11. Comparison:Topical antibiotic versus placebo
12. Comparison: Topical vs another topical antibiotic (12 studies)
No studies OR (95% CI)
Fusidic acid with mupirocin 4 1.22 (0.69 to 2.16)
All other comparisons were only represented by a single small study without a siginificant difference in results
13. Comparison: Topical versus another topical antibiotic
14. Comparison: Topical versus oral antibiotic (16 studies) no studies OR (95% CI)
Mupirocin versus
Erythromycin 10 1.76 (1.05 to 2.97 )
Dicloxacillin 1 NS
Cephalexin 1 NS
Ampicillin 1 NS
Fusidic acid versus
Erythromycin 1 8.38 (1.77 – 39.69)
Cefuroxim 1 NS
15. Comparison: Topical versus oral antibiotic (16 studies)
Mupirocin versus erythromycin, (sensitivity analysis for quality), dicloxacillin
16. Comparison: Topical antibiotic versus antiseptic (2 studies)
Study OR (95% CI)
Bacitracin vs hexachlorophene 3.97 (0.15 to 104.18)
fusidic acid vs hydrogen peroxide 1.79 (0.99 to 3.25).
17. Comparison: Oral versus other oral antibiotic (22 studies) cephalosporin vs another antibiotic (7 studies)
no differences
one cephalosporin vs another cephalosporin (4 studies)
no differences
macrolide vs penicillin (6 studies)
Erythromycin superior to penicillin
macrolide vs another macrolide (1 study)
no difference
penicillin vs other oral antibiotics (4 studies)
Amoxicillin+clavulanic acid superior to amoxicillin alone
Cloxacillin superior to penicillin
18. Interventions for impetigoDiscussion
Many small trials of various quality with inconclusive results.
Some large trials of good quality.
Few placebo-controlled trials.
Antiseptic treatment inadequately studied.
19. Interventions for impetigoConclusions and Implications for Practice No evidence for the value of disinfecting measures
Topical antibiotics
Good evidence that topical mupirocin and fusidic acid are equal to or possibly more effective than oral treatment for people with limited disease. Other topical antibiotics seem less effective.
Oral antibiotics
No evidence that penicillin is effective. No clear preference for B-lactamase resistant penicillins (cloxacillin, dicloxacillin and flucloxacillin), broad spectrum penicillins (ampicillin, amoxicillin plus clavulanic acid), cephalosporins, and macrolides.
20. Interventions for impetigo Considerations for treatment
Actual presence of bacterial resistance in the region and specific patient population (for erythromycin, fusidic acid, any antibiotic)
Other criteria can be decisive
- price
- (unnecessary) broadness of spectrum
- wish to “save” a particular antibiotic for a specific goal
(eradication of MRSA, treatment of severe bone infections)
21. Interventions for impetigoImplications for Research
Trials should:
- compare treatments for a specific disease, rather than the effectiveness of a specific antibiotic on a variety of (skin) infections
- use objective outcome measures, instead of subjective judgements such as 'improved', 'satisfactory‘.
Unknown territory:
- mechanisms of bacterial resistance induction
- new antibiotics
- efficacy of disinfecting treatments
- natural course of impetigo