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2. Fusidic Acid in Skin and Soft-Tissue Infections

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2. Fusidic Acid in Skin and Soft-Tissue Infections Acta Derm Venereol 2008; Suppl 216: 14–20 2. Fusidic acid in skin and soft-tissue infections Barry H. LONG Topical antibacterial therapy is an important component treatment may subsequently require modification once in managing skin and soft-tissue infections (SSTIs). the culture results become available. Fusidic acid, a narrow-spectrum antibiotic active against Topical antibacterials have a distinct advantage over Staphylococcus aureus, has shown good skin permeabi- systemic agents, in that they can be applied to the af- lity and low allergenic potential. The resistance rate in fected area and therefore high local concentrations of the S. aureus remains low, as shown in a study of Canadian agent may be achieved. With selection of the appropriate hospitals from 1999 to 2005. In treating primary skin agent, interaction with normal flora can be avoided. The infections, including impetigo, fusidic acid cream and ideal topical antibiotic should: ointment provided similar response rates and equal/better • have a selective effect on one (or at least very few) tolerability compared with other topical and oral anti- organisms of the same class, therefore minimizing biotics. Fusidic acid and mupirocin are equally or more the development of cross-resistance to other orga- efficacious than oral treatment in localized impetigo, nisms; and may be similarly efficacious in extensive impetigo, • not cause allergic reactions or potential cross-allergic according to a recent Cochrane review. In clinical prac- reactions with other medications of the same class or tice, mupirocin is often reserved for methicillin-resistant individual components of these, such as preservati- S. aureus infections. Studies of oral fusidic acid forms in ves; SSTI have shown that: tablets are as effective as compara- • be safe, efficacious and ideally penetrate the skin in tor antibiotics; they have fewer side-effects; a suspension sufficiently high concentrations to kill bacteria effic- achieves high cure rates, and is suitable for paediatric iently; use. Fusidic acid, both topical and systemic, is an effective • be available in different formulations in order to meet treatment for SSTI with few adverse reactions. patients' preferences and needs, as this will increase compliance with treatment and thus improve thera- intRoduction peutic outcomes. The obvious limitation to topical antibacterial therapy Superficial skin and soft tissue infections (SSTIs) are is that the infections must be limited or localized in area common presentations in clinical practice. These may and must, for the most part, be superficial. manifest either as primary infections or as secondary Classes of topical antibiotics used for superficial to some other cutaneous problem. Primary SSTIs, such SSTIs are shown in Table I. Fusidic acid is an antibio- as impetigo contagiosa, bullous impetigo, folliculitis, tic that has all of the features listed above for an ideal furuncles, carbuncles and cellulitis, are frequent occur- topical antibacterial treatment. This article reviews the rences, in addition to secondary SSTIs, for example, clinical evidence on the efficacy and safety of fusidic secondarily infected wounds or secondarily infected acid in primary skin infections. A review of the use dermatoses of different types such as atopic dermatitis, of fusidic acid in secondary skin infections appears contact dermatitis, prurigo and neurodermatitis. elsewhere in this supplement (1). The majority of primary and secondary skin infections are caused by either S. aureus or Streptococcus pyo- Table I. Examples of topical antibiotics commonly used for genes. Primary skin infections caused by Gram-negative superficial skin and soft tissue infections organisms are infrequent but may occur in patients who are immunocompromised or diabetic. Chronic wound Generic name Class Mechanism of action infections are more likely to be colonized by Gram- Fusidic acid Fusidanes Inhibits protein synthesis Mupirocin Unique Inhibits protein synthesis negative organisms, although initial colonization is Neomycin Aminoglycoside Inhibits protein synthesis usually by Gram-positive organisms. Gentamicin Aminoglycoside Inhibits protein synthesis Topical antibacterial therapy is an important com- Bacitracin Cyclic polypeptide Inhibits cell wall synthesis ponent of therapeutic management. There are various Polymyxin B Cyclic lipopeptide Increases cell membrane classes of topical antibacterial therapy, both antibiotic permeability Sulfacetamide sodium Sulfonamide Inhibits folic acid synthesis and non-antibiotic, which may have beneficial results on Silver sulfadiazine Sulfonamide Inhibits folic acid synthesis the overall therapeutic outcome. Culture should ideally Silver – inhibits cell wall be carried out and a microbiological diagnosis obtained synthesis Erythromycin Macrolide Inhibits protein synthesis before instituting any form of therapy, but this may Clindamycin Lincosamide Inhibits protein synthesis not be possible in a given clinical situation. Antibiotic Retapamulin Pleuromutilin Inhibits protein synthesis Acta Derm Venereol Suppl 216 © 2008 Acta Dermato-Venereologica. ISSN 0365-8341 doi: 10.2340/00015555-0387 Fusidic acid in skin infections 15 WHY USE FUSIDIC ACID? efficacy, safety and outcome compared with other topical therapies and systemic antibiotics in various Fusidic acid is available in different topical formu- disease states. lations: fusidic acid (Fucidin® cream; LEO Pharma A/S, Ballerup, Denmark) and sodium fusidate (Fuci- din® ointment; LEO Pharma A/S). There are also oral Comparison of fusidic acid cream and ointment formulations in the form of tablets and a suspension. Two studies have compared fusidic acid cream and Following absorption, fusidic acid and sodium fusi- ointment (Table II) (7–8). In a study by Pakrooh (7), date ionize into the same molecule, fusidate; thus, in the use of these 2 formulations was compared in 101 this article the term fusidic acid will be used to refer patients with SSTI, specifically abscess/boil, paro- ® to the therapeutic agents in all Fucidin formulations. nychia and infected wounds. Each preparation was Combinations of fusidic acid with corticosteroids are applied 2 or 3 times a day or once daily if a dressing covered elsewhere in this supplement (1). was applied. S. aureus was the most frequently isolated Fusidic acid has a steroid-like structure but no steroid pathogen. Both preparations were effective treatments, side-effects (2). In topical form, its penetration is time- with mean healing times being similar: 7.7 days for the related and is comparable to glucocorticoids in diseased ointment and 7.9 days for the cream. Both preparations skin (3, 4). The normal skin horny layer offers marked were well tolerated and there were no complaints of resistance to outside agents unless it is damaged or re- side-effects. moved, but fusidic acid does still penetrate intact skin to A larger multicentre study by Baldwin & Cranfield some extent (3, 5). Because of its significant absorption (8), involving 487 patients with skin infections (ab- qualities, topical administration of fusidic acid results in scess/boil, impetigo, paronychia, wounds and burns), much higher local concentrations than can be achieved compared the use of these 2 formulations applied 3 times with systemic administration, even at deeper layers of daily or once daily with a dressing. An excellent or good the epidermis or dermis (6). It is indicated for use in response to treatment was observed in over 90% of pa- the treatment of mild to moderately severe primary and tients, with mean healing times of 7.1 days for patients secondary skin infections caused by sensitive strains of treated with the ointment and 7.7 days for those using S. aureus, Streptococcus species and Corynebacterium the cream. Both preparations were well tolerated: only minutissimum. Fusidic acid has some activity against one patient complained of a mild skin reaction with the other corynebacteria and strains of Clostridium. It is vir- ointment, which was not severe enough to discontinue tually inactive against Gram-negative bacteria because treatment. Subsequent treatment with fusidic acid cream of a difference in cell wall permeability; however, it has elicited no reaction. demonstrated good in vitro activity against strains of Neisseria and Bacteroides. Skin infections Policies designed to limit the development of antibio- tic resistance recommend that, in any therapeutic situa- Further studies using either fusidic acid cream or oint- tion, the optimal antibiotic with the narrowest spectrum ment have shown that there is fast and effective healing should be used. As fusidic acid targets the common of SSTIs (Table II) (9–14). Studies in mainly primary pathogens in skin infection, a broader-spectrum anti- skin infections, such as impetigo, abscesses/boils, biotic should not be necessary. This therefore limits the folliculitis and paronychia, and including a few cases development of antibiotic resistance, cross-resistance of infected wounds and other secondary infections and cross-allergic reactions with other medications. (9, 10, 12–14), have demonstrated response rates of Clinical disease states that would be expected to between 86% and 100%, with treatment duration or respond to the topical use of fusidic acid are impetigo mean healing time varying between 4 and 7.1 days. contagiosa, bullous impetigo, folliculitis, sycosis bar- Adverse events have been infrequent, with most related bae, furuncles, carbuncles, ecthyma, acute paronychia, to
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