Antibiotic stewardship in skin infections: A cross-sectional analysis of early-career GP's management of impetigo

Clare Heal, Hilary Gorges, Mieke L. Van Driel, Amanda Tapley, Josh Davis, Andrew Davey, L. Holliday, Jean Ball, Nashwa Najib, Neil Spike, Kristen Fitzgerald, Parker Magin

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Objective: To establish the prevalence and associations of systemic antibiotic prescription for impetigo by early-career general practitioners (GPs) (GP registrars in their first 18 months in general practice). 

Design: A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. 

Setting: ReCEnT is an ongoing multisite cohort study of Australian registrars' in-consultation clinical practice across five Australian states. 

Participants: Registrars participating in ReCEnT from 2010 to 2017. 

Outcome measures: Management of impetigo with systemic antibiotics. 

Results: 1741 registrars (response rate 96%) provided data from 384 731 problems identified in 246 434 consultations. Impetigo, on first presentation or follow-up, was managed in 930 (0.38%, 95% CI 0.35 to 0.40) consultations and comprised 0.24% (95% CI 0.23 to 0.26) of problems. 683 patients presented with a new diagnosis of impetigo of which 38/683 (5.6%) were not prescribed antibiotics; 239/683 (35.0%) were prescribed solely topical antibiotics; 306/683 (44.8%) solely systemic antibiotics and 100/683 (14.6%) both systemic and topical antibiotics. The most common systemic antibiotic prescribed was cephalexin (53.5%). Variables independently associated with prescription of systemic antibiotics were an inner regional (compared with major city) location (OR 1.82, 95% CI 1.06 to 3.13; p=0.028), seeking in-consultation information or advice (OR 2.17, 95% CI 1.47 to 3.23; p<0.001) and ordering pathology (OR 2.13, 95% CI 1.37 to 3.33; p=0.01). 

Conclusions: Australian early-career GPs prescribe systemic antibiotics (the majority broad-spectrum) for a high proportion of initial impetigo presentations. Impetigo guidelines should clearly specify criteria for systemic antibiotic prescription and individual antibiotic choice. The role of non-antibiotic management and topical antiseptics needs to be explored further.

Original languageEnglish
Article numbere031527
Pages (from-to)1-9
Number of pages9
JournalBMJ Open
Issue number10
Publication statusPublished - Oct 2019


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