Agents used for cutaneous infections and wound care

Generic Name

Bacitracin

  • Pregnancy Category C
Formulations

Bactericidal

  • Ointment TID
Mechanism of Action

Cyclic polypeptide
Inhibits bacterial cell wall synthesis by inhibiting phospholipid receptors involved in peptidoglycan synthesis (complexes with C-55 phenol pyrophosphate in cell wall)

Indication / Spectrum of Activity

Gram positive mainly: 

  1. aureus, S. pneumonia, Neisseria spp, T. pallidum
Side Effects
  • Pruritus, burning
  • Allergic contact dermatitis (0.9%), worse if barrier disruption
  • Anaphylaxis 
  • Co-reacts with Neomycin (as they are usually combined)
  • Cross-reactivity with Polymyxin B
Other
  • In Polysporin ointment, not in the cream
  • Can be combined with Polymyxin B, and neomycin to provide wider spectrum of coverage
  • Inferior to Mupirocin for impetigo and eliminating nasal S. Aureus colonization
  • Frequent allergen in patient with stasis dermatitis or keratoconjunctivitis 
  • Both derived from Bacillus spp, Bolognia

Generic Name

Polymyxin B

  • Pregnancy Category
    • B (Wolverton)
    • C (Bolognia)
Formulations

Bactericidal

  • Ointment, cream, powder (IV, IM)
Mechanism of Action

Cyclic lipopeptide
Increase cell wall permeability through interacting with phospholipid components of the cell membrane

Indication / Spectrum of Activity

Gram negative only:

  • Proteus, Pseudomonas, Serratia, Acinetobacter
Side Effects
  • Rare allergic contact dermatitis
Other
  • Commonly combined with Bacitracin (Polysporin) and Neomycin

Generic Name

Fusidic acid

  • Pregnancy Category C
Formulations
  • 2% cream or ointment
Mechanism of Action

Inhibits protein synthesis (interferes with elongation factor G)

Indication / Spectrum of Activity

Gram positive:

  • S. aureus
Side Effects
  • Allergic contact dermatitis reported
Other
  • Not available in USA
  • Can be combined with topical corticosteroids (Fuci-bet, Fucidin-H)

Generic Name

Neomycin

  • Pregnancy Category 
    • C (Bolognia)
    • D (Wolverton)
Formulations

Bactericidal

  • 0.5% ointment or cream QD-TID
Mechanism of Action

Aminoglycoside

  • Binds 30s subunit of the bacterial ribosome inhibiting protein synthesis (irreversible). 
  • May also inhibit bacterial DNA polymerase
Indication / Spectrum of Activity

Gram negative > Gram positive: E. coli, H. influenza, Klebsiella, Proteus, S. aureus, Serratia

Side Effects
  • Allergic contact dermatitis: 0.09-1.1% in Wolverton; 5-15% in Bolognia: this likely reflects acute vs chronic exposure
  • Co-reacts with bacitracin
  • Oto- & nephro- toxicity if systemic absorption (no more than 1g/day, max 7 days to prevent toxicity)
Other
  • Resistance reported in both gram positive and negative so commonly combined with Bacitracin and Polymyxin B (Neosporin)
  • Cross-reacts with Streptomycin, Kanamycin, Gentamicin, Paromomycin, Spectinomycin and Tobramycin
  • Frequent allergen in patient with stasis dermatitis and leg ulcers 
  • Delayed positive patch test

Generic Name

Gentamicin

  • Pregnancy Category C
Formulations

Bactericidal

  • 0.1% ointment or cream QD-TID
Mechanism of Action

Aminoglycoside

  • Binds 30s subunit of the bacterial ribosome inhibiting protein synthesis (irreversible). 
  • May also inhibit bacterial DNA polymerase
Indication / Spectrum of Activity

Gram negative > Gram positive: E. coli, H. influenza, Klebsiella, Proteus, S. aureus, Serratia

Side Effects
  • Erythema, pruritis, edema, photosensitization 
  • Allergic contact dermatitis rare, but 8% of pts with rosacea have allergic contact dermatitis (possibly sensitized from previous exposure for treatment of ocular rosacea)
  • Neonatal periocular ulcerative dermatitis (eyedrops)
Other
  • Commonly for eye infections
  • Topical Aminoglycosides (gentamicin, tobramycin) can induce translational read-through of nonsense mutations in Hailey-Hailey and Nagashima type palmoplantar keratoderma
  • Risk of developing gentamicin-resistant strains of Pseudomonas when used in heavily colonized areas (leg ulcers)

Generic Name

Mupirocin

  • Pregnancy Category B
Formulations

Bacteriostatic > Bactericidal

  • Cream, 2% ointment, white paraffin TID
Mechanism of Action

Monoxycarbolic acid

  • Inhibits bacterial RNA/protein synthesis via binding of isoleucyl t-RNA synthetase
Indication / Spectrum of Activity

Gram positive (S. aureus, S. epidermis, S. pyogenes, Group B Strep., MRSA)

Side Effects
  • Pain, burning, itching when applied (vehicle)
  • Allergic contact dermatitis very rare
  • If used nasally: headaches, rhinitis, pharyngitis, dysgeusia
  • report of renal toxicity from systemic absorption of vehicle polyethylene glycol (extensive area with decreased skin barrier)
Other
  • Resistance to MRSA & MRSE (3%, mut ileS gene or its transfer through plasmid which encodes a different isoleucyl t-RNA synthetase)
  • Staphylococcal colonization: BID x 5 days for nasal decolonization, prolonged suppression with weekly doses or monthly courses (superior to bacitracin)
  • MRSA in immunocompetent patients with recurrent pyodermas, apply TID combined with dilute bleach baths/chlorohexidine body washes daily 5days/month 
  • Used in Impetigo, folliculitis, impetiginized eczema, burns, lacerations and leg ulcers
  • Derived from pseudomonas

Generic Name

Retapamulin

  • Pregnancy Category B
Formulations

Bacteriostatic

  • 1% ointment BID x 5d
Mechanism of Action

Pleuromutilin

  • Inhibits protein synthesis by 1) binding to L3 site on 50s ribosome 2) inhibiting ribosomal peptidyl transferase & 3) preventing translation by blocking t-RNA binding to the ribosome
Indication / Spectrum of Activity

Gram positive (S. pyogenes, MRSA especially mupirocin resistant), anaerobes

Side Effects
  • Pruritus, paresthesia, irritation, pain 
  • Allergic contact dermatitis (rare)
Other
  • BID x 5 days for impetigo (FDA approved only for MSSA and Streptococcus pyogenes)
  • Cross resistance is uncommon

Generic Name

Ozenoxacin

  • Unknown pregnancy cat.
Formulations

Bacteriostatic

  • 1% Cream BID x 5d
Mechanism of Action

Nonfluorinated quinolone

  • Inhibits bacterial DNA synthesis by inhibiting DNA gyrase A and Topoisomerase IV
Indication / Spectrum of Activity

Gram positive, Gram negative

  • C. acnes, S. aureus, S. pyogenes, even quinolone-resistant bacteria due to dual inhibition of both enzymes
Side Effects
  • Rosacea and seborrheic dermatitis (rare)
Other
  • Non-fluorinated quinolone
  • FDA for Impetigo caused by meth. sensitive S. aureus and Strep pyogenes
  • Faster response than Retapamulin

Generic Name

Silver sulfadiazine

  • Pregnancy Category B
Formulations

Bactericidal

  • 1% cream
  • Daily-BID
Mechanism of Action

Sulfone

  • Binds bacterial DNA, inhibits its replication +
  • Silver interacts with bacterial cell wall & membrane
Indication / Spectrum of Activity

Gram positive, Gram negative (including MRSA & Pseudomonas)

  • Used for thermal burns
Side Effects
  • Overall rare side effects (low toxicity); but include following: 
  • Allergy (to sulfa) 
  • Hemolysis (if G6PD deficiency)
  • Hyperosmolality
  • Methemoglobinemia
  • Argyria (reports in excessive application)
Other
  • Can interfere with topical proteolytic enzymes 
  • Contraindicated in pts with history of sulfonamide hypersensitivity

Generic Name

Mafenide acetate

  • Pregnancy Category B
Formulations
  • Cream
  • Daily-BID
Mechanism of Action

Sulfone

  • Binds bacterial DNA, inhibits its replication +
  • Silver interacts with bacterial cell wall & membrane
Indication / Spectrum of Activity

Antibiotic + antifungal

  • Used in thermal burns
Side Effects
  • Burning, urticaria, facial edema
  • Intense pain upon application
  • Rarely bone marrow suppression, hemolytic anemia in G6PD deficiency
Other
  • Should be used with caution in pts with renal or pulmonary disease due to potential metabolic acidosis 
  • Can be associated with Candida superinfection 

Generic Name

Iodoquinol

  • Pregnancy Category C
Formulations
  • Cream
  • Gel
  • TID-QID
Mechanism of Action
  • Halogenated quinolone; mechanism of action unknown
Indication / Spectrum of Activity
  • MRSA, Pseudomonas, Corynebacterium, C. acnes
  • Dermatophytes, Yeasts (Candida, Malassezia)
Side Effects
  • Avoid with infants and children (neurotoxicity)
Other
  • Systemic form used for amebiasis
  • Good option for nonspecific Intertrigo in adults

Generic Name

Topical Tetracycline

Formulations

Bacteriostatic

  • 3% solution, ointment
Mechanism of Action
  • Inhibit bacterial protein synthesis
Indication / Spectrum of Activity

Gram negative, Gram positive

  • Superficial skin infections
  • Acne
Side Effects
  • Stinging, burning, unpleasant odor
  • Yellow discoloration of skin
Other
  • Not available in US
  • Should not be used by pregnant women, nursing mothers, or children <8 due to permanent discoloration of teeth