Don't prescribe antibiotics for non-bullous impetigo, draft NICE guidance advises

Topical antiseptics are preferable to antibiotics for some patients with impetigo, according to provisional new antimicrobial prescribing guidance from NICE.

Impetigo is highly infectious, and treatment should be offered to limit the spread of infection, hasten recovery and limit deterioration. | DR P. MARAZZI/SCIENCE PHOTO LIBRARY
Impetigo is highly infectious, and treatment should be offered to limit the spread of infection, hasten recovery and limit deterioration. | DR P. MARAZZI/SCIENCE PHOTO LIBRARY

For patients with localised, non-bullous impetigo who are not systemically unwell or at risk of complications, draft guidance published this week by NICE recommends offering a topical antiseptic, such as hydrogen peroxide 1% cream. A topical antibiotic can be considered if an antiseptic is not suitable.

If symptoms fail to improve after 5 to 7 days of treatment with a topical antiseptic, patients should be prescribed a topical antibiotic if the condition is still localised. An oral antibiotic can be considered if the impetigo has become widespread, NICE said.

Patients with widespread non-bullous impetigo who are not systemically unwell should be given a topical or oral antibiotic, according to the guidance.

Oral antibiotics are recommended for patients with bullous impetigo, and those who are systemically unwell or at high risk of complications.

The evidence reviewed by NICE suggested that combination treatment with an oral and topical antibiotic was no more effective than a topical antibiotic alone, so combination treatment should not be offered.

Antibiotic choice

When prescribing a topical antibiotic, the guidance says the first-line option in adults should be fusidic acid 2%, with the second choice mupirocin 2%. If oral antibiotics are needed, the first-line option should be flucloxacillin, with clarithromycin as a second choice, or erythromycin in women who are pregnant.

The guidance is open for consultation until 11 September.

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