Mupirocin

Mupirocin, sold under the brand name Bactroban among others, is a topical antibiotic useful against superficial skin infections such as impetigo or folliculitis. It may also be used to get rid of methicillin-resistant S. aureus (MRSA) when present in the nose without symptoms. Due to concerns of developing resistance, use for greater than ten days is not recommended. It is used as a cream or ointment applied to the skin. Mupirocin, sold under the brand name Bactroban among others, is a topical antibiotic useful against superficial skin infections such as impetigo or folliculitis. It may also be used to get rid of methicillin-resistant S. aureus (MRSA) when present in the nose without symptoms. Due to concerns of developing resistance, use for greater than ten days is not recommended. It is used as a cream or ointment applied to the skin. Common side effects include itchiness and rash at the site of application, headache, and nausea. Long term use may result in increased growth of fungi. Use during pregnancy and breastfeeding appears to be safe. Mupirocin is in the carboxylic acid class of medications. It works by blocking a bacteria's ability to make protein, which usually results in bacterial death. Mupirocin was initially isolated in 1971 from Pseudomonas fluorescens. It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system. The wholesale cost in the developing world is about US$2.10 for a 15 g tube. In the United States, a course of treatment costs $25 to $50. In 2016 it was the 199th most prescribed medication in the United States with more than 2 million prescriptions. Mupirocin is used as a topical treatment for bacterial skin infections, for example, furuncle, impetigo, open wounds, which are typically due to infection by Staphylococcus aureus or Streptococcus pyogenes. It is also useful in the treatment of superficial methicillin-resistant Staphylococcus aureus (MRSA) infections. Mupirocin is inactive for most anaerobic bacteria, mycobacteria, mycoplasma, chlamydia, yeast and fungi. Intranasal mupirocin before surgery is effective for prevention of post-operative wound infection with Staphylcoccus aureus and preventative intranasal or catheter-site treatment is effective for reducing the risk of catheter site infection in persons treated with chronic peritoneal dialysis. Shortly after the clinical use of mupirocin began, strains of Staphylococcus aureus that were resistant to mupirocin emerged, with nares clearance rates of less than 30% success. Two distinct populations of mupirocin-resistant S. aureus were isolated. One strain possessed low-level resistance, MuL, (MIC = 8–256 mg/L) and another possessed high-level resistance, MuH, (MIC > 256 mg/L). Resistance in the MuL strains is probably due to mutations in the organism's wild-type isoleucyl-tRNA synthetase. In E. coli IleRS, a single amino acid mutation was shown to alter mupirocin resistance. MuH is linked to the acquisition of a separate Ile synthetase gene, MupA. Mupirocin is not a viable antibiotic against MuH strains. Other antibiotic agents, such as azelaic acid, nitrofurazone, silver sulfadiazine, and ramoplanin have been shown to be effective against MuH strains. Most strains of Cutibacterium acnes, a causative agent in the skin disease acne vulgaris, are naturally resistant to mupirocin. The mechanism of action of mupirocin differs from other clinical antibiotics, rendering cross-resistance to other antibiotics unlikely. However, the MupA gene may co-transfer with other antibacterial resistance genes. This has been observed already with resistance genes for triclosan, tetracycline, and trimethoprim. It may also result in overgrowth of non-susceptible organisms. Mupirocin reversibly binds to the isoleucyl t-RNA synthetase in Staphylococcus aureus and Streptococcus, resulting in inhibition of protein synthesis. DNA and cell wall formation are also negatively impacted to a lesser degree. The inhibition of RNA synthesis was shown to be a protective mechanism in response to a lack of one amino acid, isoleucine. In vivo studies in E. coli demonstrated that pseudomonic acid inhibits isoleucine t-RNA synthetase. This mechanism of action is shared with furanomycin, an analog of isoleucine.