children.3,4 Moreover, impetiginized dermatitis is a frequent disorder also seen in the pediatric dermatologist office.
Non-bullous impetigo accounts for 70% of cases and usually resolves without complications.5 Bullous impetigo lesions are typically large, transparent superficial flaccid blisters. The risk of complications requiring hospital admittance is higher than for non-bullous impetigo.5,6 The cost of hospitalizations related to S. aureus skin infections, including severe impetigo, is estimated at $5 billion annually in the US.7 Approximately 6.9 million topical and 8.2 million oral antibiotic prescriptions annually are dispensed for dermatologic conditions in the US.8,9
Bacterial resistance is reported to many antibiotics prescribed for the treatment of impetigo, including mupirocin, retapamulin, and fusidic acid.10-15
Another more recent therapeutic option is Ozenoxacin cream 1%, which has been developed for the first-line treatment of impetigo in patients from two months and up in the U.S. and Canada and six months in E.U. countries. This bactericidal topical non-fluorinated quinolone has been studied in seventeen clinical trials to date but has not yet been incorporated in published practice guidelines for impetigo treatment.10 Ozenoxacin has been shown to be highly effective against S. pyogenes and S. aureus, including methicillin-susceptible and resistant strains (MRSA).42,43 Additionally, preliminary data show ozenoxacin's capacity to eradicate biofilm-forming MRSA at therapeutic concentrations. Unpublished research on 700 S. aureus and S. pyogenes strains derived from wound infections showed that ozenoxacin is also active against, mupirocin-, fusidic acid-, macrolide-, clindamycin-, and fluoroquinoloneresistant S. aureus and against clarithromycin-, clindamycin, and fusidic acid-resistant Streptococcus pyogenes strains.
Although there are guidelines on the skin and soft tissue infection treatment, currently, an algorithm that specifically addresses the treatment of impetigo is lacking.5,10 An evidencebased impetigo treatment algorithm was developed to fill this gap.
Scope
An international panel of pediatric dermatologists, dermatologists, pediatricians, and pediatric infectious disease specialists developed an evidence-based impetigo treatment algorithm for pediatric and adult populations. The algorithm supports healthcare providers to optimize clinical outcomes for their patients with impetigo. The treatment of other forms of soft tissue infections is beyond the scope of this work.
Non-bullous impetigo accounts for 70% of cases and usually resolves without complications.5 Bullous impetigo lesions are typically large, transparent superficial flaccid blisters. The risk of complications requiring hospital admittance is higher than for non-bullous impetigo.5,6 The cost of hospitalizations related to S. aureus skin infections, including severe impetigo, is estimated at $5 billion annually in the US.7 Approximately 6.9 million topical and 8.2 million oral antibiotic prescriptions annually are dispensed for dermatologic conditions in the US.8,9
Bacterial resistance is reported to many antibiotics prescribed for the treatment of impetigo, including mupirocin, retapamulin, and fusidic acid.10-15
Another more recent therapeutic option is Ozenoxacin cream 1%, which has been developed for the first-line treatment of impetigo in patients from two months and up in the U.S. and Canada and six months in E.U. countries. This bactericidal topical non-fluorinated quinolone has been studied in seventeen clinical trials to date but has not yet been incorporated in published practice guidelines for impetigo treatment.10 Ozenoxacin has been shown to be highly effective against S. pyogenes and S. aureus, including methicillin-susceptible and resistant strains (MRSA).42,43 Additionally, preliminary data show ozenoxacin's capacity to eradicate biofilm-forming MRSA at therapeutic concentrations. Unpublished research on 700 S. aureus and S. pyogenes strains derived from wound infections showed that ozenoxacin is also active against, mupirocin-, fusidic acid-, macrolide-, clindamycin-, and fluoroquinoloneresistant S. aureus and against clarithromycin-, clindamycin, and fusidic acid-resistant Streptococcus pyogenes strains.
Although there are guidelines on the skin and soft tissue infection treatment, currently, an algorithm that specifically addresses the treatment of impetigo is lacking.5,10 An evidencebased impetigo treatment algorithm was developed to fill this gap.
Scope
An international panel of pediatric dermatologists, dermatologists, pediatricians, and pediatric infectious disease specialists developed an evidence-based impetigo treatment algorithm for pediatric and adult populations. The algorithm supports healthcare providers to optimize clinical outcomes for their patients with impetigo. The treatment of other forms of soft tissue infections is beyond the scope of this work.
METHODS
Preliminary Considerations
In February 2020, an international expert panel was convened for a meeting to develop an impetigo treatment algorithm for both pediatric and adult populations. For this purpose, the best available evidence, coupled with the panel opinion, was used. The process used for this project was following a modified Delphi technique, which is used to gain judgment on complex matters or achieve consensus among experts.16,17 The classical Delphi technique can be successfully modified for the development of medical algorithms.16,17
Literature Review
Before the expert panel meeting, a systematic literature review selected present clinical guidelines, algorithms, and evidencebased recommendations describing current practice for impetigo treatment. Literature was selected for clinical relevance, addressing aspects of impetigo management, including clinical efficacy and safety of the treatment, antimicrobial resistance, costs, quality of life effects, and handling and tolerance of the treatment regimens. The systematic review included research studies, clinical guidelines, consensus papers, and reviews published in the English language from 2014 to February 2020. For the literature search, the following terms were used: Impetigo; bullous impetigo; non-bullous impetigo; impetigo pathogenesis and diagnosis; topical and systemic impetigo treatment; adjunctive impetigo treatment; adherence; concordance; efficacy; safety; tolerability; antimicrobial and antibiotic resistance.
Exclusion criteria were: No original data (unless a review article was deemed relevant), not dealing with the clinical management of impetigo, and publication language other than English. The searches yielded a total of 43 papers detected after the exclusion of duplicates (Figure 1).
The Role of the Panel
The panel, consisting of nine members, discussed the proposed design of an algorithm for the prevention, treatment, and maintenance approach for impetigo, developed based on the selected literature from the conducted searches. After presentations on current issues in impetigo diagnosis, treatment, antibiotic resistance, and modified Delphi method, summaries of the literature searches, and the proposed algorithm, the panel worked in small groups, offering their algorithm, editing, and revising it at length. The panel then reconvened into a plenary group to define the algorithm. Reviewing and finetuning, as well as developing and reviewing the manuscript, took place online.
In February 2020, an international expert panel was convened for a meeting to develop an impetigo treatment algorithm for both pediatric and adult populations. For this purpose, the best available evidence, coupled with the panel opinion, was used. The process used for this project was following a modified Delphi technique, which is used to gain judgment on complex matters or achieve consensus among experts.16,17 The classical Delphi technique can be successfully modified for the development of medical algorithms.16,17
Literature Review
Before the expert panel meeting, a systematic literature review selected present clinical guidelines, algorithms, and evidencebased recommendations describing current practice for impetigo treatment. Literature was selected for clinical relevance, addressing aspects of impetigo management, including clinical efficacy and safety of the treatment, antimicrobial resistance, costs, quality of life effects, and handling and tolerance of the treatment regimens. The systematic review included research studies, clinical guidelines, consensus papers, and reviews published in the English language from 2014 to February 2020. For the literature search, the following terms were used: Impetigo; bullous impetigo; non-bullous impetigo; impetigo pathogenesis and diagnosis; topical and systemic impetigo treatment; adjunctive impetigo treatment; adherence; concordance; efficacy; safety; tolerability; antimicrobial and antibiotic resistance.
Exclusion criteria were: No original data (unless a review article was deemed relevant), not dealing with the clinical management of impetigo, and publication language other than English. The searches yielded a total of 43 papers detected after the exclusion of duplicates (Figure 1).
The Role of the Panel
The panel, consisting of nine members, discussed the proposed design of an algorithm for the prevention, treatment, and maintenance approach for impetigo, developed based on the selected literature from the conducted searches. After presentations on current issues in impetigo diagnosis, treatment, antibiotic resistance, and modified Delphi method, summaries of the literature searches, and the proposed algorithm, the panel worked in small groups, offering their algorithm, editing, and revising it at length. The panel then reconvened into a plenary group to define the algorithm. Reviewing and finetuning, as well as developing and reviewing the manuscript, took place online.
RESULTS
The Algorithm
An algorithm is a precise, unambiguous, logical step-by-step method used to solve a problem.18 The function of an algorithm in this context is to standardize and support medical decision making, such as standardizing the selection and use of treatment regimens, thereby improving adherence to evidence-based
An algorithm is a precise, unambiguous, logical step-by-step method used to solve a problem.18 The function of an algorithm in this context is to standardize and support medical decision making, such as standardizing the selection and use of treatment regimens, thereby improving adherence to evidence-based
