Do Antimicrobial Resistance Patterns Matter? An Algorithm for the Treatment of Patients With Impetigo

February 2021 | Volume 20 | Issue 2 | Original Article | 134 | Copyright © February 2021


Published online January 11, 2021

Lawrence A. Schachner MD FAAP FAAD,a Anneke Andriessen PhD,b Latanya T. Benjamin MD FAAP FAAD,c Cristina Claro MD,d Lawrence F. Eichenfield MD FAAP FAAD,e Susanna MR Esposito MD,f Linda Keller MD FAAP,g Leon Kircik MD FAAD,h Pearl C. Kwong MD FAAD,i Catherine McCuaig MD FAADj

aDivision of Pediatric Dermatology, Department of Dermatology & Cutaneous Surgery, Department of Pediatrics, Leonard M. Miller School of Medicine, University of Miami, FL
bRadboud UMC, Nijmegen, and Andriessen Consultants, Malden, The Netherlands
cIntegrated Medicine Science, Florida Atlantic University, Boca Raton, FL
dGrupo Português de Dermatologia Pediátrica, Department of Dermatology, Hospital da Luz Oeiras, Lisabon, Portugal
eDepartments of Dermatology and Pediatrics, University of California, San Diego and Rady Children's Hospital, San Diego, CA
fDepartment of Medicine and Surgery, University of Parma, Parma, Italy
gSouth Miami Hospital, Baptist Hospital, Miami, FL
hIchan School of Medicine at Mount Sinai, New York, NY; Indiana University Medical Center, Indianapolis, IN; Physicians Skin Care, PLLC, Louisville, KY, DermResearch, PLLC, Louisville, KY
iJacksonville, FL
jDivision of Dermatology, Sainte-Justine University Medical Center, Montreal; University of Montreal, Montreal, QC, Canada

USA, for non-MRSA impetigo cases, dicloxacillin or cephalexin, and for MRSA cases, after culture and sensitivity testing, trimethoprim-sulfamethoxazole is mainly used. In Europe, for non-MRSA cases, amoxicillin-clavulanate, clindamycin, or flucloxacillin may be prescribed, and for those with MRSA, mainly clindamycin or vancomycin are recommended.

Oral antibiotics, for seven days, are recommended in widespread or severe bullous impetigo or when the outbreak of impetigo affects several people.5,10 Oral antibiotics are also applicable if the patient has a fever or extensive lymphadenopathy, in which case hospitalization is indicated.10 In those impetigo cases with no MRSA involvement, dicloxacillin, cephalexin, erythromycin, or amoxicillin-clavulanate can be prescribed, and for MRSA suspected or confirmed cases, clindamycin, TMPSMX, tetracycline, telavancin, or daptomycin is recommended (Table 2).10

If the skin has not cleared after the treatment, underlying conditions should be ruled out, and another culture and sensitivity test should be performed.10 In patients who received oral antibiotics, the type of antibiotic should be adjusted. If the skin has not been cleared or exacerbated after three days, hospitalization is to be considered.

DISCUSSION

Antimicrobial resistance has become a worldwide concern. In 2015 the WHO launched the Global Action Plan on Antimicrobial resistances (GAP on AMR), specifically the One Health program, to fight antimicrobial resistance at the human, veterinary and environmental levels. It is being implemented by many countries in the world with specific country-based programs.21

The strategic objectives of the GAP are 1. Improve awareness and understanding of infections and bacterial mechanisms of action and resistance; 2. Strengthen knowledge on AMR through surveillance and research; 3. Reduce the incidence of infection (preventive measures); 4. Optimize the use of antimicrobial medicines: antibiotic stewardship programs, and 5. Ensure sustainable investment for R&D and implementation of control measures.21

To comply with the strategic objectives of the GAP21 the panel discussed trends of antibiotic resistance related to impetigo treatment and agreed that when prescribing antibiotics, it is essential to know the local trends in antibiotic resistance. The panel recognized that doctors need education in antibiotic stewardship principles as, for some of them, it is an unknown field. For the newest treatment of impetigo with topical ozenoxacin, the panel insisted on short-term use (5 days, twice a day) for localized cases of impetigo.

Antibiotic Resistance and Choosing a Treatment
Antimicrobial resistance is a major threat to public health in the world, and resistance to mupirocin and fusidic acid is increasing worldwide.11-15,22-30 Resistance rate varies from country to country, center to center, as it is linked to resistant bacteria and mechanisms of resistance. Due to increasing concerns about emerging resistance to commonly used antibiotics for impetigo, treatment decisions should consider resistance patterns of S. aureus.22-28 MRSA has been shown to cause impetigo.11

Retrospective observational data collected from skin culture isolates annually between 2005 and 2011 from the University of Miami Hospital outpatient dermatology clinic showed 387 S. aureus isolates and that MRSA increased by 17.0% during the last three years.28

Updates in 2016 on trends in S. aureus resistance in the USA demonstrated that resistance to clindamycin is up by seventeen percent and that there is a changing susceptibility of S. aureus in a pediatric population with an increase of 40% in resistance of isolates to Oxacillin.31

Resistance to Mupirocin
Topical mupirocin is used widely to treat skin and soft tissue infections and eradicate MRSA's nasal carriage. The increase in resistance to mupirocin is related to the widespread use of