New antimicrobial prescribing guidance for impetigo

NICE is consulting on draft guidance on the treatment of impetigo. The recommendations will form part of NICE and Public Health England’s series of antimicrobial prescribing guidelines, which offer evidence-based prescribing advice to help tackle antimicrobial resistance.

Impetigo is a superficial bacterial infection of the skin that can occur in any age group but is most common in young children. It has two main clinical forms – non-bullous and bullous. Non-bullous impetigo is characterised by thin-walled vesicles or pustules that rupture quickly, forming a golden-brown crust and is caused by Staphylococcus aureus and/or Streptococcus pyogenes. Bullous impetigo is characterised by fluid-filled vesicles and blisters, often with a diameter of over 1cm, which rupture leaving a thin, flat yellow-brown crust; S. aureus is the bacteria responsible for this form.

NICE advises good hygiene measures to reduce the spread of impetigo to other areas of the body or to other people. For patients with localised non-bullous impetigo who are not systemically unwell or at high risk of complications, NICE recommends that a topical antiseptic such as hydrogen peroxide 1% cream should be offered first; a topical antibiotic should only be offered if a topical antiseptic is not suitable or is ineffective. However, a topical or oral antibiotic should be offered to patients with widespread non-bullous impetigo, and an oral antibiotic offered in the case of bullous impetigo, or to those who are systemically unwell or at high risk of complications.

Patients with impetigo should be reassessed if their symptoms worsen rapidly or have not improved after completing a course of treatment. Consideration should be given to alternative diagnoses, such as cellulitis or a deeper soft tissue infection; the patient should be referred to hospital if they have symptoms suggesting a serious illness such as sepsis. Referral should be considered if the patient has bullous impetigo (particularly babies aged one year or younger) and their impetigo recurs frequently or if they are systemically unwell or at high risk of complications.

NICE provides tables to guide antibiotic choice in adults and children; in both patient groups, the topical antibiotic of first choice is fusidic acid 2% and the first-choice oral antibiotic is flucloxacillin. NICE advises against combined treatment using both a topical and an oral antibiotic.

The final guideline is expected to be published in February 2020.

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