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How do registrars manage impetigo?

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Evidence for practice – findings from the GP Synergy Research and Evaluation Unit

Impetigo is a highly contagious superficial skin infection caused by Streptococcus pyogenes or Staphylococcus aureus. It most commonly affects children aged 0–9 years. Impetigo is quite a common general practice presentation, but registrars will have had very limited exposure to managing impetigo in hospital practice. Using data recorded by registrars across five Australian states (and the ACT) during their participation in the ReCEnT project, we examined registrars’ experience of managing impetigo.

Impetigo is managed in 0.4% of registrar consultations. Of patients with a new diagnosis of impetigo, 5.6% were not prescribed antibiotics, 35% were prescribed solely topical antibiotics, 45% solely systemic antibiotics, and 15% both systemic and topical antibiotics. The most common systemic antibiotic prescribed was cephalexin (54%). The most frequently prescribed topical antibiotic was mupirocin (97.1%).

Seeking in-consultation information or assistance, ordering pathology, and an inner regional (compared with a major city) practice location were significantly associated with prescribing systemic antibiotics. Patients aged 15–34 years (compared with age 65+) were more likely to be managed with systemic antibiotics.

Registrars’ impetigo management is consistent with generally good adherence to the recommendations of the Australian eTherapeutic Guidelines (noting that eTG recognizes cephalexin may be sometimes prescribed in children rather than the preferred di/flucloxacillin if palatability of liquid formula is an issue for the child). When comparing the rate of systemic antibiotic prescription for impetigo with the Netherlands, however, Australian registrars prescribe more antibiotics than Dutch GPs (60% versus 14% in the Netherlands). Antimicrobial resistance/antimicrobial stewardship are important issues in skin infections as they are in other areas of antibiotic therapeutics.

The reason for the disparity in the Australian and Dutch rates of antibiotic prescription may relate to the wording of the Australian eTG recommendations. The eTG recommendations are for systemic antibiotics for ‘multiple impetigo lesions or recurrent infection’ but do not define ‘multiple’. There may be a case for defining ‘multiple’ to guide GPs’ (including registrars’) impetigo management. Registrars should discuss cases of impetigo with their supervisors including what the supervisor might define as multiple lesions.

See: Heal C, van Driel M, Gorges H, Tapley A, Davis J, Davey A, Holliday E, Ball J, Spike N, FitzGerald K, Magin P. Antibiotic stewardship in skin infections: a cross-sectional analysis of early-career GPs’ management of impetigo. 2019. BMJ Open. 9 e031527.

For further information contact Professor Parker Magin, Director, NSW & ACT Research and Evaluation Unit: parker_magin@gpsynergy.com.au

The ReCEnT project during 2010-19 has been funded by the Australian Government and by the participating Regional Training Providers and Regional Training Organisations (funded by the Australian Government). Since 2016, the ReCEnT project has been hosted by GP Synergy.