Loracarbef vs. cefaclor in pediatric skin and skin structure infections

Interventions for impetigo

BACKGROUND

Impetigo is a common, superficial bacterial skin infection, which is most frequently encountered in children. There is no generally agreed standard therapy, and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants. This is an updated version of the original review published in 2003.

OBJECTIVES

To assess the effects of treatments for impetigo, including non-pharmacological interventions and 'waiting for natural resolution'.

SEARCH METHODS

We updated our searches of the following databases to July 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched online trials registries for ongoing trials, and we handsearched the reference lists of new studies found in the updated search.

SELECTION CRITERIA

Randomised controlled trials of treatments for non-bullous, bullous, primary, and secondary impetigo.

DATA COLLECTION AND ANALYSIS

Two independent authors undertook all steps in data collection. We performed quality assessments and data collection in two separate stages.

MAIN RESULTS

We included 57 trials in the first version of this review. For this update 1 of those trials was excluded and 12 new trials were added. The total number of included trials was, thus, 68, with 5578 participants, reporting on 50 different treatments, including placebo. Most trials were in primary impetigo or did not specify this.For many of the items that were assessed for risk of bias, most studies did not provide enough information. Fifteen studies reported blinding of participants and outcome assessors.Topical antibiotic treatment showed better cure rates than placebo (pooled risk ratio (RR) 2. 24, 95% confidence interval (CI) 1.61 to 3.13) in 6 studies with 575 participants. In 4 studies with 440 participants, there was no clear evidence that either of the most commonly studied topical antibiotics (mupirocin and fusidic acid) was more effective than the other (RR 1.03, 95% CI 0.95 to 1.11).In 10 studies with 581 participants, topical mupirocin was shown to be slightly superior to oral erythromycin (pooled RR 1.07, 95% CI 1.01 to 1.13). There were no significant differences in cure rates from treatment with topical versus other oral antibiotics. There were, however, differences in the outcome from treatment with different oral antibiotics: penicillin was inferior to erythromycin, in 2 studies with 79 participants (pooled RR 1.29, 95% CI 1.07 to 1.56), and cloxacillin, in 2 studies with 166 participants (pooled RR 1.59, 95% CI 1.21 to 2.08).There was a lack of evidence for the benefit of using disinfectant solutions. When 2 studies with 292 participants were pooled, topical antibiotics were significantly better than disinfecting treatments (RR 1.15, 95% CI 1.01 to 1.32).The reported number of side-effects was low, and most of these were mild. Side-effects were more common for oral antibiotic treatment compared to topical treatment. Gastrointestinal effects accounted for most of the difference.Worldwide, bacteria causing impetigo show growing resistance rates for commonly used antibiotics. For a newly developed topical treatment, retapamulin, no resistance has yet been reported.

AUTHORS' CONCLUSIONS

There is good evidence that topical mupirocin and topical fusidic acid are equally, or more, effective than oral treatment. Due to the lack of studies in people with extensive impetigo, it is unclear if oral antibiotics are superior to topical antibiotics in this group. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. There is a lack of evidence to support disinfection measures to manage impetigo.

Interventions for cellulitis and erysipelas

BACKGROUND

Cellulitis and erysipelas are now usually considered manifestations of the same condition, a skin infection associated with severe pain and systemic symptoms. A range of antibiotic treatments are suggested in guidelines.

OBJECTIVES

To assess the efficacy and safety of interventions for non-surgically-acquired cellulitis.

SEARCH STRATEGY

In May 2010 we searched for randomised controlled trials in the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and the ongoing trials databases.

SELECTION CRITERIA

We selected randomised controlled trials comparing two or more different interventions for cellulitis.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 25 studies with a total of 2488 participants. Our primary outcome 'symptoms rated by participant or medical practitioner or proportion symptom-free' was commonly reported. No two trials examined the same drugs, therefore we grouped similar types of drugs together.Macrolides/streptogramins were found to be more effective than penicillin antibiotics (Risk ratio (RR) 0.84, 95% CI 0.73 to 0.97). In 3 trials involving 419 people, 2 of these studies used oral macrolide against intravenous (iv) penicillin demonstrating that oral therapies can be more effective than iv therapies (RR 0.85, 95% CI 0.73 to 0.98).Three studies with a total of 88 people comparing a penicillin with a cephalosporin showed no difference in treatment effect (RR 0.99, 95% CI 0.68 to 1.43).Six trials which included 538 people that compared different generations of cephalosporin, showed no difference in treatment effect (RR 1.00, 95% CI 0.94 to1.06).We found only small single studies for duration of antibiotic treatment, intramuscular versus intravenous route, the addition of corticosteroid to antibiotic treatment compared with antibiotic alone, and vibration therapy, so there was insufficient evidence to form conclusions. Only two studies investigated treatments for severe cellulitis and these selected different antibiotics for their comparisons, so we cannot make firm conclusions.

AUTHORS' CONCLUSIONS

We cannot define the best treatment for cellulitis and most recommendations are made on single trials. There is a need for trials to evaluate the efficacy of oral antibiotics against intravenous antibiotics in the community setting as there are service implications for cost and comfort.

Oral β-lactams applied to uncomplicated infections of skin and skin structures

Uncomplicated skin and skin structure infections (uSSSIs) include impetigo, erysipelas, folliculitis, simple abscesses, and cellulitis. Their common bacterial causative agents include Staphylococcus aureus and Streptococcus pyogenes. Current guidelines predate the widespread occurrences of methicillin-resistant S. aureus (MRSA) as a community-acquired pathogen and include dicloxacillin, cephalexin, erythromycin, clindamycin, and amoxicillin/clavulanic acid, all orally, or mupirocin ointment applied topically, for impetigo. For other uSSSI, recommendations are based on the probability of the infection being caused by MRSA. If methicillin-susceptible S. aureus (MSSA) are known or suspected, the oral agents recommended include clindamycin, dicloxacillin, cephalexin, doxycycline, minocycline, and trimethoprim-sulfamethoxazole (SXT). For MRSA, recommended oral agents are linezolid, clindamycin, doxycycline, minocycline, and SXT. Because community-acquired MRSA infections now predominate in patients with abscesses in the United States, agents recommended for MRSA should be used for this indication. Local susceptibility patterns should guide empiric therapy. However, no placebo-controlled trials of uSSSI are available, and the evidence used to generate these recommendations is based on comparative noninferiority studies, often with wide noninferiority margins and confidence intervals. The evidence used in developing current guidelines therefore has significant limitations. Further studies, such as superiority outcome studies, placebo-controlled studies, measurement of time to resolution, or other novel approaches, are needed to resolve these treatment dilemmas. Until such studies are performed, the best surrogate available for predicting clinical outcome is application of pharmacokinetic and pharmacodynamic principles; these describe in vivo drug behavior and allow determination of susceptibility breakpoints for predicting in vivo antimicrobial efficacy via attainment of antimicrobial targets.

Staphylococcal skin infections in children: rational drug therapy recommendations

Staphylococcus aureus remains one of the most common and troublesome of bacteria causing disease in humans, despite the development of effective antibacterials and improvement in hygiene. The organism is responsible for over 70% of all skin and soft tissue infections in children and accounts for up to one-fifth of all visits to pediatric clinics. Skin and soft tissue infections that are predominantly caused by S. aureus include bullous and non-bullous impetigo, folliculitis, furunculosis, carbunculosis, cellulitis, surgical and traumatic wound infections, mastitis, and neonatal omphalitis. Other skin and soft tissue infections may also be caused by S. aureus but are often polymicrobial in origin and require special consideration. These include burns, decubitus ulcers (particularly in the perianal region), puncture wounds of the foot, as well as human and mammalian bites. Treatment of staphylococcal skin infections varies from topical antiseptics to prolonged intravenous antibacterials, depending on severity of the lesions and the health of the child. The treatment of choice for oral antibacterials remains the penicillinase-resistant penicillins such as flucloxacillin. Cefalexin and erythromycin are suitable cost-effective alternatives with broader cover, although care must be taken with the use of macrolides because of development of resistance to multiple families of antibacterials, particularly the lincosamides. Other cephalosporins such as cefadroxil and cefprozil are also effective, can be given once daily and have a better tolerability profile -- while azithromycin has a further advantage of a 3-day course. However, all of these agents are more expensive. Although the antibacterials have been given for 10 days in most clinical trials, there is no evidence that this duration is more effective than a 7-day course. In children requiring intravenous therapy, ceftriaxone has a major advantage over other antibacterials such as sulbactam/ampicillin and cefuroxime in that it can be given once daily and may, therefore, be suitable for outpatient treatment of moderate-to-severe skin infections. Newer-generation cephalosporins and loracarbef are also effective and have a broader spectrum of activity, but do not offer any added benefit and are significantly more expensive. Skin and soft tissue infections due to methicillin-resistant S. aureus (MRSA) are still relatively uncommon in children. Well children with community-acquired MRSA infections can be treated with clindamycin or trimethoprim-sulfamethoxazole (cotrimoxazole), but must be observed closely for potentially severe adverse effects. In severe infections, vancomycin remains the treatment of choice, while intravenous teicoplanin and clindamycin are suitable alternatives. Linezolid and quinupristin/dalfopristin are currently showing great promise for the treatment of multi-resistant Gram-positive infections. While the choice of antibacterial is important, supportive management, including removal of any infected foreign bodies, surgical drainage of walled-off lesions, and regular wound cleaning, play a vital role in ensuring cure.

Interventions for impetigo

BACKGROUND

Impetigo is a common superficial bacterial skin infection, most frequently encountered in children. There is no standard therapy and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants.

OBJECTIVES

To assess the effects of treatments for impetigo, including waiting for natural resolution.

SEARCH STRATEGY

We searched the Skin Group Specialised Trials Register (March 2002), Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2002), the National Research Register (2002), MEDLINE (from 1966 to January 2003), EMBASE (from 1980 to March 2000) and LILACS (November 2001). We handsearched the Yearbook of Dermatology (1938-1966), the Yearbook of Drug Therapy (1949-1966), used reference lists of articles and contacted pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials of treatments for non-bullous and bullous, primary and secondary impetigo.

DATA COLLECTION AND ANALYSIS

All steps in data collection were done by two independent reviewers. We performed quality assessments and data collection in two separate stages.

MAIN RESULTS

We included 57 trials including 3533 participants in total which studied 20 different oral and 18 different topical treatments. CURE OR IMPROVEMENT: Topical antibiotics showed better cure rates than placebo (pooled odds ratio (OR) 6.49, 95% confidence interval (CI) 3.93 to 10.73), and no topical antibiotic was superior (pooled OR of mupirocin versus fusidic acid 1.76, 95% CI 0.69 to 2.16). Topical mupirocin was superior to oral erythromycin (pooled OR 1.22, 95% CI 1.05 to 2.97). In most other comparisons, topical and oral antibiotics did not show significantly different cure rates, nor did most trials comparing oral antibiotics. Penicillin was inferior to erythromycin and cloxacillin and there is little evidence that using disinfectant solutions improves impetigo.

SIDE EFFECTS

The reported number of side effects was low. Oral antibiotic treatment caused more side effects, especially gastrointestinal ones, than topical treatment.

REVIEWERS' CONCLUSIONS

Data on the natural course of impetigo are lacking. Placebo controlled trials are scarce. There is little evidence about the value of disinfecting measures. There is good evidence that topical mupirocin and topical fusidic acid are equally, or more effective than oral treatment for people with limited disease. It is unclear if oral antibiotics are superior to topical antibiotics for people with extensive impetigo. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. Resistance patterns against antibiotics change and should be taken into account in the choice of therapy.

Treatment of bacterial skin and skin structure infections

Bacterial skin and skin structure infections (SSSIs) are among the most frequently seen infectious entities in the community setting and occasionally in the institutional setting. A wide variety of SSSIs exist, with cellulitis, impetigo and folliculitis being the most common. Most SSSIs are caused by aerobic staphylococci and streptococci, with aerobic Gram-negative bacilli and anaerobes being involved in more complicated infections. Systemic therapy with a variety of beta-lactams, macrolides and lincosamides (clindamycin) have been the cornerstone of SSSI therapy for many years. With the exception of mupirocin, topical therapy occupies a small therapeutic niche. Despite the emergence of antimicrobial resistance among the pathogens most commonly associated with SSSIs (for example, Streptococcus pyogenes and macrolides; Staphylococcus aureus and methicillin, vancomycin, penicillin and mupirocin), few treatment failures have been reported. The newest antimicrobials reviewed herein (linezolid, quinupristin/dalfopristin, gatifloxacin, gemifloxacin and moxifloxacin) are not a significant improvement upon older agents in the treatment of SSSIs. Perhaps this assessment will change if the penetrance of the antimicrobial resistance patterns described above reach a critical threshold and clinical failures become more widespread.

Antibiotics in the management of pediatric skin disease

An increasingly large number of antibiotics are available for the treatment of uncomplicated skin and skin structure infections in children. Primary factors in the choice among these agents are the antibiotic resistance profile of the target pathogen(s), and the antibiotic's spectrum of activity, pharmacologic properties, potential adverse reactions and interactions and propensity to select for the emergence of resistant organisms. Based on a consideration of these principles, this article provides a practical guide to the use of antibiotics in the management of common cutaneous infections in the pediatric population.

Study of use of cefdinir versus cephalexin for treatment of skin infections in pediatric patients. The Cefdinir Pediatric Skin Infection Study Group

Three hundred ninety-four patients, aged 6 months to 12 years, entered a multicenter, randomized, controlled, investigator-blind study comparing cefdinir, 7 mg/kg of body weight twice a day, with cephalexin, 10 mg/kg four times a day, each given for 10 days. The most common infections treated were impetigo and secondary infection of preexisting dermatitis. The most common pathogens isolated were Staphylococcus aureus and Streptococcus pyogenes. Two hundred thirty-one patients were microbiologically evaluable. Microbiologic eradication rates were 164 of 165 pathogens (99.4%) in the cefdinir group and 152 of 156 pathogens (97.4%) in the cephalexin group (P = 0.14). Clinical cure rates were 116 of 118 patients (98.3%) in the cefdinir group and 106 of 113 patients (93.8%) in the cephalexin group (P = 0.056). Sixteen percent of cefdinir patients and 11% of cephalexin patients experienced adverse events (P = 0.11), the most common being diarrhea, which affected 8% of the cefdinir group and 4% of the cephalexin group. Cefdinir appears to be an effective and well-tolerated agent for the treatment of uncomplicated skin and skin structure infections in pediatric patients.