Baciguent, Neosporin (combination), Polysporin (combination)
Evidence Grade A — Regulatory approved. 4059 published studies. 40 registered clinical trials.
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Bacitracin is one of the most familiar topical antibiotics in the world — it is a key ingredient in household first-aid products like Neosporin and Polysporin. Applied to minor cuts, scrapes, and burns, it kills bacteria on the skin's surface to help prevent infection. An injectable form exists but is almost never used because of severe kidney toxicity.
4,059 published studies: 1394 human, 1227 animal, 437 in-vitro, 134 reviews
Bacitracin is marketed as Baciguent (topical) and BACiiM (injection), and is a component of Neosporin and Polysporin. Approved in 1948, it is one of the oldest peptide antibiotics still in widespread use.
Topical bacitracin is available over the counter and is applied to minor cuts, scrapes, and burns to prevent infection. Its systemic use is limited to rare situations where no alternatives exist, due to severe nephrotoxicity. There has been growing discussion in wound care about whether routine topical antibiotic use on minor wounds provides meaningful benefit over simple petroleum jelly in keeping wounds moist, and about the risk of contact allergic dermatitis with repeated bacitracin use.
Bacitracin disrupts bacterial cell wall construction at a different point than vancomycin. It binds to a lipid carrier molecule (undecaprenyl pyrophosphate) that acts as a shuttle, carrying cell wall building blocks across the bacterial membrane. By trapping this shuttle in its used form, bacitracin prevents it from being recycled for another round of delivery. Without this carrier, the bacterium cannot transport new cell wall components to where they are needed, and wall construction stops. This mechanism requires zinc as a cofactor.
Bacitracin has been in use since 1948, long before modern clinical trial standards were established, so its evidence base is largely historical rather than built on large randomised trials. Its effectiveness as a topical antibiotic for minor wounds is generally accepted, though there is growing debate in wound care about whether topical antibiotics provide meaningful benefit over simply keeping wounds moist with plain petroleum jelly. A notable concern is allergic contact dermatitis — skin allergy testing data suggests bacitracin is one of the more common contact allergens, particularly in people with chronic wounds. The injectable form carries a boxed warning for kidney toxicity. Research into next-generation bacitracin variants with activity against resistant bacteria (including vancomycin-resistant organisms) has shown early promise in laboratory studies.
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Health Canada Market Authorisation
Corticotropin is marketed as H.P. Acthar Gel (currently ANI Pharmaceuticals). It carries approximately 19 FDA-labelled indications including infantile spasms (its strongest evidence base), nephrotic syndrome, multiple sclerosis relapses, and rheumatic disorders. Acthar Gel has been at the centre of major pricing and legal controversies. The price rose from approximately $40 per vial in 2001 to over $40,000, driven by successive acquisitions and orphan-like positioning despite broad labelling. The former manufacturer Mallinckrodt agreed to a $260 million settlement over antitrust concerns. Clinically, the strongest evidence supports its use in infantile spasms, where it is considered a first-line treatment. For most other indications, debate continues over whether it offers meaningful advantages over far less expensive oral corticosteroids.
Enfuvirtide is marketed as Fuzeon (approved March 2003). It requires twice-daily subcutaneous injections, and injection-site reactions occur in nearly all patients (98%). In clinical trials (TORO-1 and TORO-2), enfuvirtide combined with an optimised background regimen achieved significantly greater viral suppression than background regimen alone in treatment-experienced patients. Enfuvirtide represented a major advance when HIV drug resistance was a more pressing clinical challenge, but its use has declined substantially with the arrival of more convenient oral antiretrovirals. The twice-daily injection burden, injection-site reactions, high cost, and complex manufacturing (it is one of the largest synthetic peptides manufactured at scale) have limited its role to a last-resort option for patients with highly resistant HIV.
Vancomycin is marketed as Vancocin and Firvanq (approved 1958, with oral solution Firvanq approved 2018). It is the standard treatment for serious MRSA infections (bloodstream infections, endocarditis, pneumonia, bone infections) and is first-line for severe C. difficile colitis. Vancomycin requires therapeutic drug monitoring — blood levels must be checked regularly to ensure the dose is effective without causing kidney damage or hearing loss. The rise of vancomycin-resistant enterococci (VRE) and occasional vancomycin-intermediate S. aureus (VISA) strains represent ongoing challenges. Despite being nearly 70 years old, vancomycin remains irreplaceable for many serious infections, though newer alternatives like daptomycin and the lipoglycopeptides offer advantages in specific settings.
