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Is NICE’s new impetigo guidance enough to tame contagion-fearing parents?


By Dr Livingstone
GP blogger

03 Sep 2019

A few years ago, something amazing happened in our practice; us GPs all agreed to stop prescribing chloramphenicol ointment for uncomplicated conjunctivitis.

Our rationale was that conjunctivitis is a self-limiting illness and that antibiotic treatment makes very little difference to recovery times – so this was an opportunity to reduce antibiotic prescribing, promote self-help and save appointments.

Reaching this decision and putting it into action involved a scrutiny of the evidence, some heated discussion, the reaching of consensus, written protocols for doctors, nurses and receptionists and a publicity campaign for our patients.

And, yes, we even liaised with local pharmacists so they understood our plan and logic and didn’t inadvertently sabotage the whole thing by continuing to sell topical chloramphenicol, which had recently become OTC, for the uncomplicated cases we were trying to avoid.

Result? Incredibly, patient behaviour gradually changed. What used to be one of the commonest day-duty appointments now rarely present itself. And the only negative was, predictably, one outraged and antibiotic-deprived ‘worst practice ever’ review on our NHS Choices profile.

Now, I’m wondering if we could pull the same stunt again – this time, for impetigo. Because draft NICE guidance suggests that, in simple impetigo, a topical antiseptic such as hydrogen peroxide 1% cream is as effective as the traditional treatment of topical antibiotics.

So, opportunity knocks. Contagion-fearing parents tend to hammer our door down at the first sign of Staph-induced crusting on their treasured progeny. If we could get the message across that antiseptic is as effective as antibiotics, and is available OTC rather than via an appointment-negotiating, time-wasting, hassle-inducing doctor appointment, then this could be another victory in the war on workload and drug-resistance.

The only fly in the antiseptic ointment is the cost: topical hydrogen peroxide seems off-puttingly pricey. So help us out, pharmacists.

As NICE points out, other antiseptics are available that are (probably) equally effective. Give these a push, cut the price and divert the impetiginous away from the GP. And if they insist on an antibiotic, well… chloramphenicol would probably do the trick. I won’t tell if you don’t.

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