Natural history of non-bullous impetigo: a systematic review of time to resolution or improvement without antibiotic treatment

Abstract

Background: Non-bullous impetigo is typically treated with antibiotics. However, the duration of symptoms without their use is not established which hampers informed decision-making about antibiotic use. Aim: To determine the natural history of non-bullous impetigo. Design and Setting: Systematic review. Method: We searched PubMed up to January 2020 and reference lists of articles identified in the search. Eligible studies involved participants with impetigo in either the placebo group of randomised trials or in single-group prognostic studies not using antibiotics and measured time to resolution or improvement. A modified version of a risk of bias assessment for prognostic studies was used. Outcomes were percentage of participants who, at any timepoint, had: i) symptom resolution, ii) symptom improvement, or iii) failed to improve. Adverse event data were also extracted. Results: Seven randomised trials (557 placebo group participants) were identified. At about 7 days, the percentage of participants classified as resolved ranged from 13% to 74% across the studies, whereas the percentage classified as ‘failure to improve’ ranged from 16% to 41%. The rate of adverse effects was low. Incomplete reporting of some details limited assessment of risk of bias. Conclusions: While some uncertainty around the natural history of non-bullous impetigo remains, symptoms resolve in some patients by about 7 days without using antibiotics, with about one-quarter of patients not improving. Immediate antibiotic use may not be mandatory and discussions with patients should include the expected course of untreated impetigo and careful consideration of the benefits and harms of antibiotic use.

Prevalence and determinants of impetigo in Ghana: a cross-sectional study

“…Among individuals with impetigo, antibiotics may be given to reduce the risk of contagious spread within the affected individual and to others, quicken resolution of lesions, and reduce the risk of complications in vulnerable populations. However, non-bullous impetigo in some individuals resolves spontaneously by about 7 days [ 44 ]; this implies antibiotics are not always needed. Informed decision making on antibiotic use in impetigo should balance the benefits of use against the potential risk of development of antibiotic resistance within the context of good antimicrobial stewardship programmes.…”

Mapping the evidence about the natural history of acute infections commonly seen in primary care and managed with antibiotics: a scoping review

“…Of the 40 included reviews, six (15%) aimed to synthesise natural history information [13,21,[24][25][26][27]. Of these, four included participants from cohort and observational studies as well as those from placebo or no treatment arms [13,21,25,26], and two included multiple ARIs [13,21].…”

How can general practitioners reduce antibiotic prescribing in collaboration with their patients?

“…31 Delayed prescribing can be used in conjunction with shared decision making for self-limiting conditions such as ARIs, uncomplicated urinary tract infections, conjunctivitis and skin infections such as non-bullous impetigo. 25,27,32,33 If the option of 'wait and see'/no immediate antibiotics is chosen, patients and GPs may sometimes feel more comfortable if an 'in case' antibiotic prescription is provided, along with safety-netting information about when to use it or re-consult. As shown in Figure 1, as part of this option, it is important that patients are told how long it would normally take for the infection to resolve if antibiotics are not used.…”