Ideal Features of Topical Antibiotic Therapy for the Treatment of Impetigo: An Italian Expert Consensus Report.

Current Therapeutic Research 98 (2023) 100690 Contents lists available at ScienceDirect Current Therapeutic Research journal homepage: www.elsevier.com/locate/curtheres Review Article Ideal Features of Topical Antibiotic Therapy for the Treatment of Impetigo: An Italian Expert Consensus Report Iria Neri, MD 1, Michele Miraglia del Giudice, MD 2, Andrea Novelli, MD 3, Giuseppe Ruggiero, MD 4, Giovanni Pappagallo, MD, MPH 5, Luisa Galli, MD 6,7,∗ 1 Dermatology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy Department of Woman and Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy 3 Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Florence, Italy 4 Dermatology Study Group of the Italian Federation Italian of Pediatricians, Rome, Italy 5 School of Clinical Research Methodology, IRCCS Sacro Cuore - Don Calabria Hospital, Negrar di Valpolicella VR, Italy 6 Department of Health Sciences, University of Florence, Florence, Italy 7 Paediatric Infectious Diseases Unit, Meyer Children’s Hospital, Florence, Italy 2 a r t i c l e i n f o Article history: Received 19 May 2022 Accepted 16 December 2022 Key words: antibiotic resistance antibiotic treatment Delphi method impetigo skin infection topical antibiotic a b s t r a c t Background: A group of Italian experts in impetigo medical care sought to define 10 statements to describe the ideal characteristics of the best local antibiotic treatments, and to provide relevant information re- garding their appropriate use and prescription that should be considered in clinical practice for impetigo management. Objective: A group of Italian experts in impetigo medical care sought to define 10 statements to describe the ideal characteristics of the best local antibiotic treatments, and to provide relevant information regarding their appropriate use and prescription that should be considered in clinical practice for impetigo management. Methods: A consensus on ideal features of antibiotic therapy for the treatment of impetigo was appraised by an online Delphi-based method, based on a panel of 61 infectious disease specialists, pediatricians, and dermatologists coordinated by a scientific committee of 5 experts specializing in impetigo management. Results: Full or very high consensus was reached on the 10 statements identified to describe the characteristics of the best hypothetic antibiotic therapy for impetigo together with indications for appropriate antibiotics use. Conclusions: Several criteria have to be considered when selecting topical antibacterial therapy for impetigo. Beyond efficacy and safety, antimicrobial susceptibility and pharmacological characteristics of the agent are essential points. Formulation of the antimicrobial product is fundamental, as well as patient and caregiver preference, to facilitate therapeutic adherence, to achieve the infection control, and to obtain the best benefit from treatment (Curr Ther Res Clin Exp. 2023; 84:XXXXXX). © 2022 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Introduction Impetigo is a common bacterial skin infection that mainly occurs in children from ages 2 to 5 years; however, individuals of any age can be affected by this bacterial condition.1 Recent data indicate 111 million children and up to 140 million people are affected at a given time in developed countries.2 ∗ Address correspondence to: Luisa Galli, Paediatric Infectious Diseases Unit, University Hospital Meyer, Azienda Ospedaliero Universitaria Meyer, Viale Pieraccini 24, Florence IT-50131, Italy E-mail address: luisa.galli@unifi.it (L. Galli). Impetigo is typically due to infection by Staphylococcus aureus, group A beta-hemolytic Streptococcus pyogenes, or less commonly by anaerobic bacteria. These bacteria habitually reside on healthy skin and some of them, such as Strep pyogenes and Staph aureus, may colonize the nasal, axillary, pharyngeal, or perineal areas. Susceptible skin can develop infections due to these bacteria.1 Two types of impetigo have been described: nonbullous (ie, impetigo contagiosa) and bullous. Around 70% of cases are nonbullous impetigo (due to Staph aureus and group A betahaemolytic Streptococcus), which is generally managed in pediatric primary care settings. Nonbullous impetigo is primarily characterized by maculo-papular lesions and subsequently by thin- https://doi.org/10.1016/j.curtheres.2022.100690 0011-393X/© 2022 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) I. Neri, M. Miraglia del Giudice, A. Novelli et al. Current Therapeutic Research 98 (2023) 100690 walled vesicles that break, resulting in erosions on the skin surface with crusts on both intact and damaged skin.1 Bullous impetigo is caused by toxin-producing Staph aureus and its features include fragile and large vesicles and flaccid bullae evolving into erosions with a varnish-like and thin crust. This kind of impetigo is typically localized in intertriginous areas of the trunk and extremities.3 After excoriating an infected area, patients with impetigo can further spread the infection either to themselves or others, especially in crowded places (eg, schools and ambulatory care centers), with higher probability during summer and in low hygiene areas.3 Treatment with antibiotics should be initiated as soon as possible due to the high contagiousness of the disease, the associated discomfort, and bad cosmetic appearance.4 Therapy depends on different parameters, including the extent and site of lesions and the presence of systemic symptoms. Currently, topical and/or systemic antibiotics and topical disinfectants are the main options for the treatment of impetigo.3 Topical antibiotics offer several advantages compared with systemic administration, among them the delivery of high concentrations of the antimicrobial agent to the site of infection and the limited toxicity.5 Unfortunately, the extensive use of several topical antibiotics caused an increase of bacterial resistance in some settings, with a possible reduction of the efficacy of these agents.5 Results from a Cochrane review (analyzing 68 randomized controlled trials) on impetigo treatments showed that topical antibiotics are more effective than placebo and preferable to oral antibiotics for impetigo of limited extension.6 Systemic antibiotics are often used for those patients with more generalized or severe infections, in which topical therapy is not appropriate. When prescribing antibiotics, it is essential to know the antibiotic resistance trends at the local level. The development of new antibiotics represents a current need, considering the increase in multidrug-resistant pathogens, such as methicillin-resistant Staph aureus (MRSA) and mupirocin-re (...truncated)