BMJ 2002;324:203 ( 26 January )

Primary care

Fusidic acid cream in the treatment of impetigo in general practice: double blind randomised placebo controlled trial

Sander Koning, general practitioner, ^a Lisette W A van Suijlekom-Smit, paediatrician, ^b Jan L Nouwen, infectiologist, ^c Cees M Verduin, medical microbiologist, ^c Roos M D Bernsen, statistician, ^a Arnold P Oranje, dermatologist, ^d Siep Thomas, general practitioner, ^a Johannes C van der Wouden, research coordinator. ^a

^a Department of General Practice, Erasmus University and University Hospital Rotterdam, Room Ff 325, PO Box 1738, 3000 DR Rotterdam, Netherlands, ^b Department of Paediatrics, Erasmus University and University Hospital Rotterdam, ^c Department of Medical Microbiology and Infectious Diseases, Erasmus University and University Hospital Rotterdam, ^d Department of Dermato-venereology, Erasmus University and University Hospital Rotterdam

Correspondence to: J C van der Wouden vanderwouden{at}hag.fgg.eur.nl

Objective: To test the hypothesis that fusidic acid would not increase the treatment effect of disinfecting with povidone-iodine alone in children with impetigo.
Design: Randomised placebo controlled trial.
Setting: General practices in Greater Rotterdam.
Participants: 184 children aged 0-12 years with impetigo.
Main outcome measures: Clinical cure and bacterial cure after one week.
Results: After one week of treatment 55% of the patients in the fusidic acid group were clinically cured compared with 13% in the placebo group (odds ratio 12.6, 95% confidence interval 5.0 to 31.5, number needed to treat 2.3). After two weeks and four weeks the differences in cure rates between the two groups had become smaller. More children in the placebo group were non-compliant (12 v 5) and received extra antibiotic treatment (11 v 3), and more children in the placebo group reported adverse effects (19 v 7). Staphylococcus aureus was found in 96% of the positive cultures; no strains were resistant to fusidic acid.
Conclusions: Fusidic acid is much more effective than placebo (when both are given in combination with povidone-iodine shampoo) in the treatment of impetigo. Because of the low rate of cure and high rate of adverse events in the placebo group, the value of povidone-iodine in impetigo can be questioned.

What is already known on this topic Impetigo is the most common skin infection in children Fusidic acid, which is advocated as topical treatment in several countries, has never been investigated in a placebo controlled study What this study adds In combination with povidone-iodine, treatment with fusidic acid is much more effective than placebo None of the strains of Staphylococcus aureus isolated at baseline showed resistance to fusidic acid The value of treatment with povidone-iodine alone can be questioned

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