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GPs should not prescribe antibiotics for impetigo, says NICE

Antibiotics should not be prescribed to patients with non-bullous impetigo, according to new draft guidance.

The joint guidelines, from NICE and Public Health England (PHE), say that GPs should recommend topical antiseptic instead of antibiotics, with the aim of reducing antimicrobial resistance.

It found that antiseptics, such as hydrogen peroxide 1% cream, were just as effective as topical antibiotics and therefore should be prescribed instead.

However, the guidelines state that GPs can still prescribe an oral antibiotic if the non-bullous impetigo is widespread, or the patient is systematically unwell or at risk of complications.

Non-bullous impetigo is the more common form of skin infection, usually starting with a rash of small, pus-filled blisters, compared to bullous impetigo, which presents with sores and intact blisters, according to the British Skin Foundation.

It is highly infectious and although usually clears up within two to three weeks without treatment, it is usually treated with an antibiotic to prevent the spread of infection and speed up recovery, according to NICE.

A spokesperson from NICE said: ‘NICE now say that topical antiseptics should be offered to people with localised, non-bullous impetigo if they aren’t systemically unwell or at risk of developing any complications.

‘If antiseptic treatment is not suitable, or a person has widespread non-bullous impetigo, a topical antibiotic should be given instead (fusidic acid 2%). An oral antibiotic (flucloxacillin) is also an option for people with widespread non-bullous impetigo and should be given first line if the person has bullous impetigo or if they are systemically unwell or at risk of developing any complications.’

The guidance also included that GPs should not combine a topical and oral antibiotic to treat impetigo, as using both is ‘no more effective’ than using one.

It follows a pledge by the Government to cut antibiotics prescribing by a further 15%.

Readers' comments (22)

  • David Banner

    I’m sure that those impetigo patients subsequently admitted with “sepsis” will be perfectly satisfied that their GP failed to prescribe an antibiotic.

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  • yes - total rubbish

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  • Anything the government orders doctors to do, people will do the exact opposite. If the government ran out of money that’s not doctors fault. Sorry

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  • It's 3 weeks to see a GP keep it that way if its not settled by then -- bingo

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  • NICE the foulest legacy of Nu-Labour

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  • @Holy Smoke Batman
    Absolutely agree. The principle is fine but unless it is funded properly, is not forced to rush things through, not subject to the external biases of big pharma, patient action groups and charities, and unless it represents broad medical views (that should involve GPs particularly- but not the Steve Field gong chasing types of course) then it will not work.
    In the meantime it is what it is. The National Institute of Clinical Excrement.

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  • This is draft guidance out for consultation. This means that those who have registered an interest can comment during the consultation. It is common for recommendations to change as a result of feedback.

    As for the GP representation; you can see the make-up of the guideline development group on the NICE website. There are 2 GPs, one is a Prof of Primary Care but the other appear not to hold any ivory tower links.

    COI I have served on NICE guideline development groups but have no link to the current topic.

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  • Facial impetigo is likely to represent URT carriage of pathogenic Staph/Strep.
    Topical treatment of any kind does nothing to address this.
    The patient remains a risk to themselves and to any contacts.
    Cases of neumonia, sepsis and scarlet fever have increased. Who is researching the impact/harms of not treating?
    Too many agenda guidelines based on too little medical evidence.

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  • and then what about school absence? The HPA advice is exclusion from school until 48 hours after antibiotics commenced, or until lesions have crusted and healed. So parents to keep kids off school for 2-3 weeks under the above guidance - I'm sure that's going to go down well on the school attendance record!

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  • Took Early Retirement

    Good point about school! Good reason for ignoring this trash.

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  • Oh dear. Once again NICE are making everyone's lives more difficult. I'm ardently against antibiotics, but impetigo is an exception. It is highly contagious, prevents education of the next generation, is unsightly and often clears only slowly without treatment. This advice will hardly endear our patients to us!
    Fucidic acid is a complete waste of time.
    Mupirocin should be reserved for more serious infections, including MRSA
    have you tried taking, or persuading a child to take Fluclox? It is revolting and therefore not taken.
    Yes antibiotics catastrophically damage the microbiome.
    Yes antibiotics are soon going to be obsolete and we need to use them responsibly.
    Let's start with viral URTI / ear infections / acne / rosacea and MOST importantly, the farming world!

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  • That nice advice is not very nice.

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  • Until a child dies from sepsis related to impetigo as a focus, then you will know that NICE Guidance will not save you from being struck off for not treating the 'well and obvious' impetigo lesion which could have saved the child. Hind sight they say is great.

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  • i don't this is particularly aimed at GPs as most of them know when and what to use for impetigo. Trouble is most of these cases are now being seen by noctors without our level of experience or training and treat everything regardless and in combinations still. All the recent evidence shows that GPs are reducing their prescribing of antibiotics. Some one has to say whats best to use and when somewhere based on the best evidence available or experts in their fields, otherwise its a free for all. As very few parents would enrol their kids in a research study to see what would be the best way to prevent sepsis one is not going to have much evidence to go on. Fortunately more studies are now being done in children so perhaps the guidelines will improve. Until then its all we have. There is a cohort of GPs who comment on new guidelines and how it effects general practice and NICE are starting to listen to what they have to say. However they don't have control over primary care funding or lack of, as is the case, which is hampering the implementation of lots of these guidelines. they should really be called current reasonable best practice and aspirations rather than guidelines. British farmers have strict rules on the use of antibiotics and also don't want to use them as much as we do. they don't treat UTI in cows, for instance. where they are used, as growth promoters, is a major issue worldwide. perhaps if we ate less pork and chicken and up the price to cover the actual cost of raising farmstock without antibiotics then this would prevent their over usage.

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  • @ Geepjul : so the expertsa at NICE often get it wrong then, and nobody has changed them for new ones?
    And wehre are we supposed to get 1% peroxide?
    And can we use it on patients????
    What about skin discolouration??

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  • The peroxide then needs to be made available to pharmacists who can be trained to sell it to patients for this condition.

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  • More than 80% of the total world antibiotic use is by 2 countries in farming.These reactivate genes for antibiotic resistance that are millions of years old [ found in bacteria buried deep in permafrost long before antibiotic use by mankind], washed down through rivers into oceans and ship's ballasts and multiple ways of spreading. Our use of antibiotics is probably about 0.01 % of world usage.But we still need to be careful, even though we do not make any difference to global AMR genes.

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  • I wonder if they are right.. I often wondered is antibiotics were OTT. I have never used hydrogen peroxide cream. Did not know it was a thing.

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  • DO NOT give antibiotics for anything like impetigo or could be impetigo
    DO give antibiotics for anything like Lyme disease or could be Lyme disease
    DO NOT give a damn

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  • I think this is just reminder type of NICE guidelines, most of us practice same, topical mainly and oral ABx if horrible look. I am not sure about anybody”s experience of Hydrogen peroxide cream 1% in that case. Here is role of robust safety netting if we feel , threshold for aggressive treatment is dropping.

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