Summary of the evidence

This is a summary of the evidence, for full details see the evidence review.

Antimicrobials

Efficacy of topical antibiotics

The following topical antibiotics were shown to be more effective than placebo for the outcome of cure or improvement:

  • mupirocin in adults, young people and children

  • fusidic acid in children

  • ozenoxacin in children.

Efficacy of oral antibiotics

Phenoxymethylpenicillin was not statistically significantly different compared with placebo in children for the outcome of cure or improvement.

Topical antibiotics compared with antiseptics, steroids or antifungals

There were no statistically significant differences in clinical effectiveness of the following comparisons for the outcome of cure or improvement:

  • topical antibiotic (fusidic acid) compared with a topical antiseptic (hydrogen peroxide 1%) in children

  • topical antibiotic (gentamicin) compared with a topical steroid (betamethasone valerate; age not reported)

  • topical antibiotic (gentamicin) plus a topical steroid (betamethasone valerate) compared with a topical steroid (betamethasone valerate; age not reported)

  • topical antibiotic (mupirocin) compared with a topical antifungal (terbinafine) in children.

Safety of antibiotics

There were no statistically significant differences in adverse effects for the following comparisons:

  • topical mupirocin and placebo in adults, young people and children

  • topical fusidic acid and disinfectants in children

  • topical mupirocin and antifungals in children.

No safety or tolerability data were reported for the other comparisons.

The evidence for the efficacy and safety of antimicrobials is based on 1 systematic review and meta-analysis of randomised controlled trials (RCTs; Koning et al. 2012) and 1 pooled-analysis of 2 RCTs (Hebert et al. 2018).

Choice of antibiotics

Topical antibiotics

There were no statistically significant differences in the clinical effectiveness of the following topical antibiotic comparisons for the outcome of cure or improvement:

  • topical mupirocin compared with topical fusidic acid in adults, young people and children

  • topical mupirocin compared with topical neomycin in children and young people

  • topical mupirocin compared with topical polymyxin B plus neomycin (population not reported).

Some differences were seen for cure or improvement for other topical antibiotic comparisons:

  • topical fusidic acid was more effective than topical neomycin plus bacitracin in children

  • topical gentamicin was more effective than topical neomycin in adults, young people and children.

There were no statistically significant differences in adverse effects between topical mupirocin compared with topical polymyxin B plus neomycin (age not reported).

The incidence of skin rash was increased with topical mupirocin compared with topical fusidic acid in adults, young people and children.

No safety or tolerability data were reported for the other comparisons.

Oral antibiotics

There were no statistically significant differences in the clinical effectiveness of the following oral antibiotic comparisons for the outcome of cure or improvement:

  • oral macrolides compared with oral penicillins in adults, young people and children

  • oral erythromycin compared with oral amoxicillin in children

  • oral azithromycin compared with oral erythromycin in adults, young people and children

  • oral cefalexin compared with oral cefadroxil in children and young people

  • oral cefalexin compared with oral erythromycin in children or oral azithromycin in adults

  • oral cefaclor compared with oral azithromycin or oral co-amoxiclav in children

  • oral cefadroxil compared with oral flucloxacillin in adults, young people and children.

Some differences were seen for cure or improvement for other antibiotic comparisons:

  • oral erythromycin was more effective than phenoxymethylpenicillin in children

  • oral co-amoxiclav was more effective than oral amoxicillin in children and young people

  • oral cefalexin was more effective than oral phenoxymethylpenicillin in children.

There were no statistically significant differences in adverse effects for the following oral antibiotic comparisons:

  • oral co-amoxiclav compared with oral amoxicillin in children and young people

  • oral cefalexin compared with oral azithromycin in adults

  • oral cefaclor compared with oral azithromycin in children

  • oral cefaclor compared with co-amoxiclav in children.

Some differences were seen in adverse effects for other oral antibiotic comparisons:

  • there were more incidences of diarrhoea in children taking oral erythromycin compared with oral amoxicillin

  • there were more incidences of stomach ache, rash, fever or vomiting but fewer incidents of diarrhoea in adults, young people and children taking oral cefadroxil compared with oral flucloxacillin.

No safety or tolerability data were reported for the other comparisons.

Dual antibiotics

Oral plus topical antibiotics compared with topical antibiotics

There were no statistically significant differences in the clinical effectiveness of the following antibiotic comparisons in children for the outcome of cure or improvement:

  • oral cefdinir plus topical tetracycline compared with topical tetracycline

  • oral minomycin plus topical tetracycline compared with topical tetracycline

  • oral fosfomycin plus topical tetracycline compared with topical tetracycline.

The evidence for choice of antibiotics is based on 1 systematic review and meta-analysis of RCTs (Koning et al. 2012).

Course length

Shorter course antibiotics compared with longer course antibiotics

A 3-day course of oral co-trimoxazole was not statistically significantly different compared with a 5-day course of oral co-trimoxazole for treatment success in children.

The evidence for course length of antibiotics is based on 1 non-inferiority RCT (Bowen et al. 2014).

Route of administration

Topical antibiotics compared with oral antibiotics

There were no statistically significant differences in the clinical effectiveness of the following antibiotic comparisons for the outcome of cure or improvement:

  • topical mupirocin compared with oral erythromycin in adults, young people and children

  • topical mupirocin compared with oral cefalexin in children with impetigo, or in adults, young people and children with secondary impetigo

  • topical mupirocin compared with oral ampicillin (age not reported)

  • topical fusidic acid compared with oral erythromycin in newborn babies (aged 3 days to 14 days) with bullous impetigo

  • topical chloramphenicol compared with oral erythromycin in newborn babies (aged 3 days to 14 days) with bullous impetigo.

Oral erythromycin was more effective than topical neomycin plus bacitracin for the outcome of cure or improvement in newborn babies (aged 3 days to 14 days) with bullous impetigo.

Topical mupirocin was not statistically significantly different compared with oral cefalexin for adverse effects in children.

Topical mupirocin was associated with fewer gastrointestinal adverse events than oral erythromycin in adults, young people and children.

No safety or tolerability data were reported for the other comparisons.

Intramuscular antibiotics compared with oral antibiotics

Intramuscular ceftriaxone was not statistically significantly different compared with oral cefadroxil for cure in children.

Oral co-amoxiclav was non-inferior to intramuscular benzylpenicillin for treatment success in children.

Intramuscular benzylpenicillin was associated with more adverse events than co-trimoxazole in children.

The evidence for route of administration of antibiotics is based on 1 systematic review and meta-analysis of RCTs (Koning et al. 2012), and 2 RCTs (Al-Samman et al. 2014 and Bowen et al. 2014).

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)