Dermatology: Practical and Conceptual Research | Dermatol Pract Concept 2020;10(2):e2020043 1 Dermatology Practical & Conceptual Prevalence and Associations of General Practice Registrars’ Management of Impetigo: A Cross- Sectional Analysis From the Registrar Clinical Encounters in Training (ReCEnT) Study Hilary Gorges,1 Clare Heal,1 Mieke van Driel,2 Amanda Tapley,3 Joshua Davis,4 Andrew Davey,3 Elizabeth Holliday,5 Jean Ball,6 Nashwa Najib,3 Neil Spike,7 Kristen Fitzgerald,8 Parker Magin3 1 Mackay Clinical School, College of Medicine and Dentistry, James Cook University, Mackay, Australia 2 Primary Care & General Practice, Faculty of Medicine, University of Queensland, Australia 3 GP Synergy, Australia 4 Global and Tropical Health Division, Menzies School of Health Research School of Medicine, Darwin, Australia 5 Biostatistics, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia 6 Clinical Research Design and Statistics, Hunter Medical Research Institute, New Lambston Heights, Australia 7 Department of General Practice, The University of Melbourne, Notting Hill, Australia 8 General Practice Training Tasmania Key words: impetigo, prevalence, bacterial, primary care, skin infection Citation: Gorges H, Heal C, van Driel M, Tapley A, Davis J, Davey A, Holliday E, Ball J, Najib N, Spike N, Fitzgerald K, Magin P. Prevalence and associations of general practice registrars’ management of impetigo: a cross-sectional analysis from the Registrar Clinical Encounters in Training (ReCEnT) study. Dermatol Pract Concept. 2020;10(2):e2020043. DOI: https://doi.org/10.5826/dpc.1002a43 Accepted: January 29, 2020; Published: April 3, 2020 Copyright: ©2020 Gorges et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: During the data collection period 2010 to 2015, funding of the ReCEnT study was by the participating educational organizations: General Practice Training Valley to Coast, the Victorian Metropolitan Alliance, General Practice Training Tasmania, Tropical Medicine Training, and Adelaide to Outback GP Training Program. These organizations were funded by the Australian Government. From 2016- 2019, the ReCEnT study was funded by an Australian Government Commissioned Research Grant, and supported by GP Synergy, the general practice Regional Training Organization for New South Wales and the Australian Capital Territory. GP Synergy is funded by the Australian Government. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author: Dr. Hilary Gorges, Mackay Clinical School, College of Medicine and Dentistry, James Cook University, Mackay Base Hospital, Bridge Rd., Mackay QLD 4740 Australia. Email: Hilary.gorges@jcu.edu.au Background: Impetigo is a mild bacterial skin infection of childhood that is usually managed empir- ically in primary care. Objective: To establish the prevalence and associations of impetigo in general practice (GP) registrars’ consultations. Methods: Cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study data. ABSTRACT https://doi.org/10.5826/dpc.1002a43 mailto:Hilary.gorges@jcu.edu.au 2 Research | Dermatol Pract Concept 2020;10(2):e2020043 of 44.5% (interquartile range [IQR] 34%-49.2%), there is a lack of data for non-Aboriginal and Torres Strait Islander Australian populations [2]. The prevalence of impetigo presenting in the general population in Australia is unknown, and its associations are unexplored. The aim of this study is to investigate the preva- lence of impetigo presenting to Australian GP registrars, and the associations and outcomes of these consultations. Methods ReCEnT Project Data were analyzed from the multisite cohort study of Aus- tralian GP registrars’ clinical practice, detailed methodology of which is described elsewhere [10]. Outcome Factor The outcome factor was a problem/diagnosis being “impe- tigo,” defined by the International Classification of Primary Care, second edition classification system [11] as code S84. Independent variables were related to registrar, patient, practice, and consultation. Registrar Variables Registrar variables were age, sex, training term, place of medi- cal qualification (Australia/international), full-time/part-time, and worked at the practice previously. Patient Variables Patient variables were age, sex, Aboriginal/Torres Strait Islander, non–English-speaking background (NESB), prob- lem/diagnosis was new, new to the practice, and new to the registrar. Practice Variables Practice variables were training “region,” rurality/urbanity, practice size (number of GPs), socioeconomic status of area, and routine bulk-billing. Postal codes defined rurality of loca- tion using Australian Standard Geographical Classification-Re- moteness Area classification [12] and the location’s Socioeco- nomic Index for Area Relative Index of Disadvantage [13]. What is known about the topic? Impetigo is a bacterial skin infection, most prevalent in remote Aboriginal communities, with implications for anti- microbial stewardship. What does this paper add? Prevalence of impetigo and associated characteristics in the Australian population, outside of remote Aboriginal com- munities. Introduction Impetigo is a common skin infection [1,2] caused by Staph- ylococcus aureus or Streptococcus pyogenes [2,3]. It is often seen in childhood and is associated with poverty and tropical environments [2] and is most prevalent in remote indigenous Australian children [2]. As a mild disease with good progno- sis and potential for self-resolution [3], impetigo is managed in primary care [3,4], but because of its significant disease burden and highly contagious nature [2,3], empirical anti- biotic treatment is recommended. Skin swabs for bacterial culture are reserved for severe/recurrent disease or empirical treatment failure [5,6]. Thus the management of impetigo has considerable implications for antibiotic stewardship. Previous analysis from the Registrar Clinical Encounters in Training (ReCEnT) study [7] raised questions regarding inter- pretation of Australian guidelines for impetigo management and the subsequent implications for antibiotic stewardship. Characterizing the prevalence of impetigo and its associations is important to optimize and explore management that pro- motes antimicrobial stewardship. Skin conditions are among the most common problems in Australian general practice (GP), managed in 17.4 per 100 encounters, and they account for 11.3% of problems [8]. Despite this frequency, studies have shown that registrars find skin conditions challenging and are not adequately prepared for the dermatology burden in the community [9]. Impe- tigo prevalence in global communities has been measured extensively, and while it is highest in remote Aboriginal and Torres Strait Islander populations, with a median prevalence Results: Impetigo was managed in 0.24% of problems and 0.43% of consultations. Patient variables associated with impetigo presentations were younger age and impetigo as a new problem, while pa- tients with non–English-speaking backgrounds were less likely to present with impetigo. Associated registrar variables were being new to the registrar and practicing in outer regional/remote locations. Compared with all other problems/diagnoses, impetigo more often involved information seeking, or- dering pathology, and prescription of medication, but less often involved follow-up or referral. Conclusions: Impetigo accounts for 0.43 per 100 GP registrar consultations in Australia. Association with outer regional/remote areas may reflect climate and socioeconomic factors that predispose to impetigo. Associated pathology requests may reflect a lack of confidence in GP registrars’ management of impetigo. Cultural differences may exist regarding health-seeking behavior relating to impetigo. ABSTRACT Research | Dermatol Pract Concept 2020;10(2):e2020043 3 Results A total of 1,741 registrars (response rate 96%) contrib- uted 377,980 patient problems over 214,888 consultations. Impetigo was diagnosed in 915 consultations, accounting for 0.24% of all problems and managed in 0.43 per 100 consultations. Characteristics Associated With an Impetigo Diagnosis On multivariable analysis, younger patients (age 0-14, com- pared to 15-34: odds ratio [OR] 7.14, 95% CI 5.75-8.86, P < 0.001) and patients new to the registrar (OR 1.33, 95% CI 1.11-1.60, P = 0.002) were more likely to present with impe- tigo (Table 1). NESB patients were less likely to present with impetigo (OR 0.57, 95% CI 0.36-0.89, P = 0.015). Registrars working in outer regional/remote/very remote areas (OR 1.66, compared to major cities: 95% CI 1.11-2.48, P = 0.014) and male registrars (OR 1.20, 95% CI 1.45-1.01, P = 0.038) were more likely to see patients with impetigo. What Happens Differently During Impetigo Consultations? Impetigo consultations were significantly shorter in duration (14 vs 19 minutes on unadjusted analysis and OR 0.94 per additional minute, 95% CI 0.93-0.96, P < 0.001 on multi- variable analysis) and the registrars were more likely to seek help (OR 2.53, 95% CI 2.13-3.02, P < 0.001) (Table 1). Of those who sought help from supervisors, the highest propor- tion were first-term registrars (70.7%) (Table 2). The most frequent resource type used was electronic; the most com- mon was Therapeutic Guidelines (61.65%) (Tables 2 and 3). Impetigo was more likely to present as a new, rather than existing, problem (OR 2.19, 95% CI 1.74-2.76, P < 0.001). What Outcomes Are Different in Impetigo Consultations? Impetigo consultations were significantly more likely to involve pathology being ordered (OR 2.43, 95% CI 1.93- 3.06, P < 0.001) (Table 1), the majority being skin swabs for bacterial culture (47%) (Table 4). Impetigo consultations were more likely to involve medication prescription (OR 12.8, 95% CI 9.34-17.5, P < 0.001) but less likely to result in follow-up (OR 0.71, 95% CI 0.59-0.86, P = 0.001) or referral (OR 0.11, 95% CI 0.04-0.29, P < 0.0001). Of impetigo con- sultations, 83% did not result in generation of a learning goal. Discussion Prevalence Impetigo accounted for 0.24% of problems seen by Austra- lian GP registrars and was managed in 0.43 per 100 consul- Consultation and Educational Variables Consultation variables included duration, number of diagno- ses/problems, pathology/imaging ordered, specialist referral made, follow-up organized, and medication prescribed. Edu- cational variables included seeking information or assistance and generating learning goals. Statistical Analysis We conducted cross-sectional analysis of data from the ReCEnT cohort study performed on 16 rounds of 6-monthly collected data from 2010-2017, with analysis at the individ- ual problem/diagnosis level. The proportion of registrars’ impetigo problems/diag- noses and the proportion of impetigo consultations were calculated, with 95% confidence intervals (CIs). Impetigo vs Other Problems/Diagnoses To test associations of a problem/diagnosis being impetigo, simple and multiple logistic regression analyses were used within the generalized estimating equations framework, accounting for clustering of patients within registrars. All variables with a P value <0.20 in univariate analysis were included in the multiple regression model. Covariates with P > 0.2 in the multivariable model were tested for removal. Covariates were removed if this did not substantively change the remaining coefficients in the model. To examine 3 separate issues within our research ques- tion, 3 models were built, each with the dependent variable “impetigo problem/diagnosis”: 1. To examine associations of a problem/diagnosis being impetigo (compared with other problems/diagnoses), patient, practice and registrar independent variables were entered in a regression model. 2. To examine in-consultation differences of an impetigo problem/diagnosis compared with other problems/diagno- ses, the above variables were entered in a model along with consultation duration, information/assistance accessed by registrar, and number of problems/diagnoses dealt with in consultation. 3. To examine whether actions from managing impetigo differ from those managing other problems/diagnoses, all variables entered in the previous 2 models were entered in a model along with learning goals generated, follow-up organized, specialist referrals made, and pathology and imaging ordered. Statistical analyses were programmed using STATA 14.0 and SAS v9.4. P values <0.05 were considered statistically significant. Ethics Approval The University of Newcastle Human Research Ethics Com- mittee approved the study (Reference H-2009-0323). 4 Research | Dermatol Pract Concept 2020;10(2):e2020043 Table 2. Resource Type Used for Impetigo Consultations Presented by Training Term Resource Type Used in Impetigo Consultation Term 1 Frequency (%) Term 2 Frequency (%) Term 3 Frequency (%) Total Electronic 113 (52.6) 54 (25.1) 48 (22.3) 215 Supervisor 65 (70.7) 21 (22.8) 6 (6.5) 92 Book 13 (72.2) 3 (16.7) 2 (11.1) 18 Specialist 0 (0) 2 (66.7) 1 (3.3) 3 Other 5 (55.6) 2 (22.2) 2 (22.2) 9 Table 1. Patient, Registrar, and Consultation Characteristics Associated With Impetigo Variable Class Univariate Adjusted OR (95% CI) P OR (95% CI) P Patient variables Patient age group 0-14 years 7.97 (6.64, 9.57) <0.0001 7.14 (5.75, 8.86) <0.0001 35-64 years 0.38 (0.29, 0.50) <0.0001 0.38 (0.28, 0.52) <0.0001 65+ years 0.12 (0.07, 0.20) <0.0001 0.12 (0.07, 0.24) <0.0001 Patient sex Female 0.66 (0.57, 0.76) <0.0001 0.87 (0.74, 1.02) 0.0795 Aboriginal or Torres Strait Islander Yes 2.66 (1.78, 3.98) <0.0001 1.48 (0.96, 2.28) 0.0758 Non–English-speaking background Yes 0.40 (0.27, 0.58) <0.0001 0.57 (0.36, 0.89) 0.0145 Patient/practice status New to practice 1.90 (1.44, 2.50) <0.0001 0.93 (0.67, 1.29) 0.6588 New to registrar 2.11 (1.80, 2.48) <0.0001 1.33 (1.11, 1.60) 0.0018 Registrar variables Registrar sex Female 0.75 (0.64, 0.87) 0.0003 0.83 (0.69, 0.99) 0.0382 Worked at practice previously Yes 0.85 (0.70, 1.03) 0.0992 0.82 (0.66, 1.02) 0.0758 Registrar age 1.01 (1.00, 1.02) 0.1100 1.00 (0.98, 1.01) 0.7376 Practice variables Practice routinely bulk bills Yes 0.66 (0.53, 0.81) <0.0001 0.78 (0.60, 1.01) 0.0622 Rurality Inner regional 1.32 (1.10, 1.58) 0.0024 1.14 (0.91, 1.43) 0.2516 Outer regional remote 1.41 (1.13, 1.77) 0.0029 1.66 (1.11, 2.48) 0.0139 Socioeconomic Index for Area 1.03 (1.00, 1.05) 0.0587 1.02 (0.98, 1.06) 0.2831 Region Region 2 0.40 (0.28, 0.57) <0.0001 0.37 (0.24, 0.56) <0.0001 Region 3 0.84 (0.66, 1.07) 0.1525 0.66 (0.48, 0.90) 0.0080 Region 4 0.65 (0.54, 0.77) <0.0001 0.54 (0.42, 0.68) <0.0001 Region 5 1.47 (1.00, 2.16) 0.0475 0.79 (0.45, 1.39) 0.4087 Region 6 0.49 (0.34, 0.72) 0.0002 0.47 (0.29, 0.78) 0.0032 Consultation variables New problem seen Yes 4.14 (3.36, 5.11) <0.0001 2.19 (1.74, 2.76) <0.0001 Sought help any source Yes 2.68 (2.32, 3.11) <0.0001 2.53 (2.13, 3.02) <0.0001 Consultation duration 0.93 (0.92, 0.94) <0.0001 0.94 (0.93, 0.96) <0.0001 No. of problems 0.44 (0.40, 0.49) <0.0001 0.95 (0.84, 1.07) 0.4079 Consultation outcome variables Pathology ordered Yes 1.13 (0.95, 1.35) 0.1705 2.43 (1.93, 3.06) <0.0001 Follow-up ordered Yes 0.83 (0.72, 0.96) 0.0137 0.71 (0.59, 0.86) 0.0004 Referral ordered Yes 0.03 (0.01, 0.08) <0.0001 0.11 (0.04, 0.29) <0.0001 Medication prescribed Yes 15.7 (12.1, 20.3) <0.0001 12.8 (9.34, 17.5) <0.0001 CI = confidence interval; OR = odds ratio. Research | Dermatol Pract Concept 2020;10(2):e2020043 5 impetigo consultations in our study compared with main- stream GPs. Patients being more likely to present to the registrar with impetigo as a new problem or for the first time reflects impetigo’s acute nature. Patients may be more willing to see registrars for acute issues or perceived minor problems [22]. Consultations for acute conditions are also booked on shorter notice, with the first doctor available, who is usually the registrar [9]. NESB patients were less likely to present with impetigo. One-tenth of GP patients are from NESB [8] and 21% of Australians speak a language other than English at home [23]. Our finding may reflect cultural practices that predispose patients to impetigo; also as impetigo is a mild condition with the potential for self-resolution, this may reflect differ- ent cultural approaches to health-seeking behavior regarding impetigo. Differences in Impetigo Consultations Impetigo consultations were shorter; this is expected as impe- tigo is a common condition with a clinical diagnosis, system- ically well patients [3,4], and clear guidelines available [6]. Registrars are more likely to seek information/assistance for impetigo despite its being a mild disease. First-term regis- trars were more likely to seek help from their supervisor than those in advanced terms, which may reflect initial inadequate preparation for the dermatological disease burden in the community [9], with confidence improving with experience. The most commonly used resources were electronic (Table 2); the Therapeutic Guidelines [6] were most often used (Table 3). In impetigo consultations the majority of registrars (83%) did not generate learning goals, patients were mostly children, and medication was usually prescribed; therefore, registrars may have used this reference for dose checking rather than guidance on diagnosis/management. tations. Finding comparable data regarding the prevalence of impetigo is difficult. The BEACH study grouped impetigo with other “skin problems,” which were seen in 17.4 per 100 consultations [8]. In Aboriginal and Torres Strait Islander communities, impetigo encounters have been recorded as high as 7.5 per 100 consultations [14]. In a Dutch study, yearly impetigo incidence was 4 per 100 patients aged <18 years; however, the proportion of consultations was not measured [15]. Impetigo prevalence in global communities has been measured more extensively, although the majority of data was collected before 2010, with only 3 studies from 2010-2015 (3%) [2]. Impetigo prevalence is highest in remote Aboriginal and Torres Strait Islander populations with a median preva- lence of 44.5% (IQR 34%-49.2%) [2]. A Canadian study of 2 First Nation communities found impetigo prevalence between 1% and 4.2% [16]; in comparison, the median prevalence of impetigo in Africa is 7% (IQR 4.1%-12.3%) [2] and 0.75% in Japan [17]. There is a paucity of prevalence data for North America, China, most European countries and non-Aborigi- nal Australian populations [2,18]. Impetigo Diagnosis Characteristics Registrars working in outer regional/remote areas were more likely to see patients with impetigo. Impetigo is most preva- lent in poorly resourced areas and tropical/arid climates [2]; the regional differences seen in our study may reflect lower income level and more tropical/arid climates [12,19] in Aus- tralian outer regional/remote areas. Most patients with impetigo were <14 years, consistent with impetigo being a childhood disease [1,3]. Registrars see younger patients than do established GPs [8,20]; of registrar consultations, 17% involve patients <14 years [20,21] com- pared with 12% for established GPs [8]. Registrars are also more likely to see new patients, new problems, and acute illnesses [8], which may result in an elevated proportion of Table 3. Electronic Resources Used for Impetigo Consultations Resource Frequency (%) Therapeutic Guidelines 127 (61.65) Royal Children’s Hospital Guidelines 22 (10.68) DermNet NZ 17 (8.25) Australian Medicines Handbook 11 (5.34) Monthly Index of Medical Specialties (MIMS online) 6 (2.91) Murtagh's General Practice 4 (1.94) Other 19 (9.2) Total 206 Table 4. Pathology Ordered for Impetigo Pathology request Frequency (%) Skin swab MC&S 96 (47) Swab MC&S 57 (28) Nose swab MC&S 16 (7.9) Herpes simplex culture 11 (5.4) Viral swab MC&S 4 (2) MC&S 3 (1.5) Other 16 (7.9) Total 203 MC&S = microscopy, culture and sensitivity. 6 Research | Dermatol Pract Concept 2020;10(2):e2020043 6. eTG. electronic Therapeutic Guidelines complete: Impetigo. https://tgldcdp.tg.org.au/viewTopic?topicfile=impetigo&guide lineName=Antibiotic&topicNavigation=navigateTopic#toc_ d1e108. Published 2018. Accessed August 2, 2018. 7. Heal C, Gorges H, van Driel ML, et al. Antibiotic stewardship in skin infections: a cross-sectional analysis of early-career GP’s management of impetigo. BMJ Open. 2019;9(10):e031527. 8. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2015-16. http://purl.library.usyd.edu.au/sup/9781743 325131. Published 2015-2016. Accessed October 24, 2018. 9. Whiting G, Magin P, Morgan S, et al. General practice trainees’ clinical experience of dermatology indicates a need for im- proved education: a cross-sectional analysis from the Registrar Clinical Encounters in Training Study. Australas J Dermatol. 2017;58(4):e199-e206. 10. Morgan S, Magin PJ, Henderson KM, et al. Study protocol: the Registrar Clinical Encounters in Training (ReCEnT) study. BMC Fam Pract. 2012;13:50. 11. Britt H. A new coding tool for computerised clinical systems in primary care—ICPC plus. Aust Fam Physician. 1997;26(Suppl 2): S79-S82. 12. Australian Bureau of Statistics. 1216.0—Australian Standard Geographical Classification (ASGC), 2006. http://www.abs.gov. au/AUSSTATS/abs@.nsf/Latestproducts/1AE106C101420508CA 2571A900170741. Published July 2006. Accessed August 2, 2018. 13. Australian Bureau of Statistics. 2039.0—Information Paper: An Introduction to Socio-Economic Indexes of Areas (SEIFA), 2006. http://www.abs.gov.au/ausstats/abs@.nsf/mf/2039.0/. Published 2006. Accessed August 2, 2018. 14. Thomas DP, Heller RF, Hunt JM. Clinical consultations in an ab- original community-controlled health service: a comparison with general practice. Aust N Z J Public Health. 1998;22(1):86-91. 15. Loadsman MEN, Verheij TJ, van der Velden AW. Impetigo in- cidence and treatment: a retrospective study of Dutch routine primary care data. Fam Pract. 2019;36(4):410-416. 16. Nicolle LE, Postl B, Urias B, Law B, Ling N. Group A streptococcal pharyngeal carriage, pharyngitis, and impetigo in two northern Ca- nadian native communities. Clin Invest Med. 1990;13(3):99-106. 17. Furue M, Yamazaki S, Jimbow K, et al. Prevalence of dermato- logical disorders in Japan: a nationwide, cross-sectional, seasonal, multicenter, hospital-based study. J Dermatol. 2011;38(4):310-320. 18. Romani L, Steer AC, Whitfeld MJ, Kaldor JM. Prevalence of sca- bies and impetigo worldwide: a systematic review. Lancet Infect Dis. 2015;15(8):960-967. 19. Peel MC, Finlayson BL, McMahon TA. Updated world map of the Köppen-Geiger climate classification. Hydrol Earth Syst Sci. 2007;11(5):1633-1644. 20. Simon M, Henderson K, Tapley A, et al. Problems managed by Australian general practice trainees: results from the ReCenT (Registrar Clinical Encounters in Training) study. Educ Prim Care. 2014;25(3):140-148. 21. Freed GL, Spike N, Magin P, Morgan S, Fitzgerald M, Brooks P. The paediatric clinical experiences of general practice registrars. Aust Fam Physician. 2012;41(7):529-533. 22. Bonney A, Phillipson L, Reis S, Jones SC, Iverson D. Patients’ attitudes to general practice registrars: a review of the literature. Educ Prim Care. 2009;20(5):371-378. 23. Australian Bureau of Statistics. 2016 Census: Multicultural. http:// www.abs.gov.au/ausstats/abs@.nsf/lookup/Media%20Release3. Published 2016. Accessed October 31, 2018. Different Outcomes in Impetigo Consultations Impetigo consultations were more likely to involve pathology being ordered, the majority being skin swabs for bacterial culture (Table 4), and medication prescription. As guide- lines advise empirical treatment for impetigo, reserving skin swabs for severe, resistant, or recurrent disease [6], this may demonstrate lack of confidence with treating dermatological conditions. Follow-up and referrals were less likely in impe- tigo consultations, reflecting the mild nature of the disease and preferred management in primary care [3,4]. Strengths and Limitations The strengths of this study are a large sample size of GP regis- trars with a high response rate from across Australia, includ- ing major cities and remote areas. A limitation of the analysis and interpretation of the data is the absence of information regarding the severity of impetigo. We are unable to account for this variable in our interpretation, and low numbers of Aboriginal and Torres Strait Islander patients (4%) means we were underpowered to analyze this variable. Conclusions Impetigo accounts for 0.43 per 100 consultations seen by Australian GP registrars. It is more common in outer regional/ remote/very remote areas and usually presents as a new problem. NESB patients are less likely to present with impe- tigo, which may reflect different cultural approaches to the management of a mild, potentially self-limiting condition. Impetigo was associated with pathology being ordered, which may reflect a lack of confidence in Australian GP registrars when dealing with this presentation. References 1. Sladden MJ, Johnston GA. Common skin infections in children. BMJ. 2004;329(7457):95-99. 2. Bowen AC, Mahe A, Hay RJ, et al. The global epidemiology of impetigo: a systematic review of the population prevalence of impetigo and pyoderma. PLoS One. 2015;10(8):e0136789. 3. WHO. Epidemiology and management of common skin diseases in children in developing countries. http://www.who.int/maternal_ child_adolescent/documents/fch_cah_05_12/en/. Published 2005. Accessed August 2, 2018. 4. Shallcross LJ, Petersen I, Rosenthal J, Johnson AM, Freemantle N, Hayward AC. Use of primary care data for detecting impe- tigo trends, United Kingdom, 1995-2010. Emerg Infect Dis. 2013;19(10):1646-1648. 5. Bowen A. The Australian Healthy Skin Consortium. National Healthy Skin Guideline: for the Prevention, Treatment and Public Health Control of Impetigo, Scabies, Crusted Scabies and Tinea for Indigenous Populations and Communities in Australia. https://rhdaction.org/resources/national-healthy-skin-guideline- prevention-treatment-and-public-health-control-impetigo. Pub- lished 2018. Accessed August 2, 2018. https://tgldcdp.tg.org.au/viewTopic?topicfile=impetigo&guidelineName=Antibiotic&topicNavigation=navigateTopic#toc_d1e108 https://tgldcdp.tg.org.au/viewTopic?topicfile=impetigo&guidelineName=Antibiotic&topicNavigation=navigateTopic#toc_d1e108 https://tgldcdp.tg.org.au/viewTopic?topicfile=impetigo&guidelineName=Antibiotic&topicNavigation=navigateTopic#toc_d1e108 http://purl.library.usyd.edu.au/sup/9781743325131 http://purl.library.usyd.edu.au/sup/9781743325131 http://www.abs.gov.au/AUSSTATS/abs http://www.abs.gov.au/AUSSTATS/abs http://www.abs.gov.au/ausstats/abs http://www.abs.gov.au/ausstats/abs http://www.abs.gov.au/ausstats/abs http://www.who.int/maternal_child_adolescent/documents/fch_cah_05_12/en/ http://www.who.int/maternal_child_adolescent/documents/fch_cah_05_12/en/ https://rhdaction.org/resources/national-healthy-skin-guideline-prevention-treatment-and-public-health-control-impetigo https://rhdaction.org/resources/national-healthy-skin-guideline-prevention-treatment-and-public-health-control-impetigo