International Comparison of Guidelines for Management of Impetigo: A Systematic Review

Context Impetigo is a common superficial skin infection that affects people worldwide and is usually treated with antibiotics; therefore, its management has implications for global antibiotic stewardship.

Objective This systematic review and narrative synthesis compares and contrasts international impetigo management guidelines.

Methods The study was designed and conducted in accordance with the PRISMA statement and registered with PROSPERO: CRD42018117770.

Guidelines for treatment of impetigo that were produced by a national authority; available to primary care physicians; and published since 2008 were included. There was no language restriction. In addition to a comprehensive search strategy, members of the General practice Research on infections Network (GRIN) were contacted to access guidelines not available in Australia. Data extraction from eligible studies was performed independently in duplicate. Details of antiseptic and antibiotic treatment; methicillin-resistant Staphylococcus aureus treatment; and conservative management and preventative measures were tabulated and analysed descriptively.

Results Fifty-one guidelines were included from 42 different countries. All guidelines recommended systemic antibiotics, 78% of these only for widespread lesions or failure of topical antibiotic treatment. The first-line systemic antibiotic treatment was restricted to narrow-spectrum options in 21 (41%) whilst 7 (14%) recommended only broad-spectrum antibiotics first-line. Thirty-four (67%) guidelines included recommendations for topical antibiotic use. Twenty guidelines (39%) did not mention antiseptic treatment for impetigo. Guidelines did not always provide clear indications for different treatment options.

Conclusions Despite potentially equal efficacy to systemic antibiotics, only two-thirds of guidelines include topical antibiotic options. Many fail to include recommendations for non-antibiotic treatments such as antiseptics, preventative measures and conservative management, despite potential for antibiotic-sparing. Provision of clear definitions of disease severity and indications for treatment would enhance the ability of clinicians to adhere to recommendations. Further investigation into the efficacy of topical antiseptics for treating impetigo, and analysis of the evidence underpinning guideline recommendations is warranted. This could potentially encourage non-antibiotic treatment of impetigo, particularly for mild cases.