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Impetigo medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

The mainstay of therapy for impetigo is antimicrobial therapy. Topical therapy is preferred unless there is an indication for systemic therapy.[1][2]Empiric therapy for mild disease includes either Mupirocin or Retapamulin applied topically. Empiric therapy for numerous lesions or poststreptococcoal glomerulonephritis includes either Dicloxacillin, Amoxicillin-Clavulanate, or Cephalexin. Penicillin is the drug of choice for impetigo caused by Streptococcus. Patients with impetigo caused by Methicillin-resistant Staphylococcus aureus are treated with either Doxycycline, Clindamycin, or Sulfamethoxazole-Trimethoprim. Non-bullous impetigo is self resolving and usually takes 1-2 weeks.[3][4]

Medical Therapy

  • Topical therapy is preferred for patients with small amount of lesions and without any bullae[1][5]; but oral therapy is also accepted.[6]
  • Non-medical therapy involves washing the lesions and the rest of the body with soap and water, and letting the impetigo dry in the air.
  • Hand-washing and daily bathing is considered a method to prevent impetigo in children.[7]
  • It is very important to remove the crusts before applying ointment, as the bacteria that cause the disease are located underneath them.
  • The recommended duration of therapy is 7 days but will depend on the clinical response.


▸ Click on the following categories to expand treatment regimens.

Bullous Impetigo

  ▸  Adults

  ▸  Children

Non-Bullous Impetigo

  ▸  Adults

  ▸  Children

Bullous Impetigo – Adults†
High suspicion for MRSA
Preferred Regimen
▸ Vancomycin 15 mg/kg IV q12h
OR
▸ Linezolid 600 mg PO q12h
OR
▸ Clindamycin 300-450 mg PO q8h
Alternative Regimen
▸ Doxycycline 100 mg PO q12h
OR
▸ Minocycline 100 mg PO q12h
OR
▸ TMP/SMZ 160/800 mg (1-2 tablets) PO q12h
† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[9]
Low suspicion for MRSA
Preferred Regimen
▸ Dicloxacillin 250 mg PO q6h
OR
▸ Cephalexin 250 mg PO q6h
Alternative Regimen
▸ Erythromycin‡ 250 mg PO q6h
† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[9]
‡ Most S. aureus and Streptococci may be resistant against erythromycin
Bullous Impetigo – Children†
High suspicion for MRSA
Preferred Regimen
▸ Vancomycin 10 mg/kg IV q6h
OR
▸ Linezolid 10 mg/kg PO q12h
OR
▸ Clindamycin 10-20 mg/kg/day PO divided in 3 doses
Alternative Regimen
▸ TMP/SMZ‡ 8-12 mg/kg/day PO divided in 2 doses
† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[9]
‡ TMP/SMZ dose is based on the TMP component.
Low suspicion for MRSA
Preferred Regimen
▸ Dicloxacillin 12 mg/kg/day PO divided q6h
OR
▸ Cephalexin 25 mg /kg/day PO divided q6h
Alternative Regimen
▸ Erythromycin‡ 40 mg/ kg/day divided PO q6h
† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[9]
‡ Most S. aureus and Streptococci may be resistant against erythromycin
Non-Bullous Impetigo – Adults†
Topical Regimen
▸ Mupirocin 2% apply to lesions q8h x 7 days
OR
▸Fusidic acid 2% apply to lesions q8h x 7 days
OR
▸ Retapamulin 1% apply to lesions q12h x 5 days
Preferred Oral Regimen
▸ Dicloxacillin 250 mg PO q6h
OR
▸ Cephalexin 250 mg PO q6h
Alternative Oral Regimen
▸ Erythromycin‡ 250 mg PO q6h
† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[9]
‡ Most S. aureus and Streptococci may be resistant against erythromycin
Non-Bullous Impetigo – Children†
Topical Regimen
▸ Mupirocin 2% apply to lesions q8h x 7 days
OR
▸Fusidic acid 2% apply to lesions q8h x 7 days
OR
▸ Retapamulin 1% apply to lesions q12h x 5 days
Preferred Oral Regimen
▸ Dicloxacillin 12 mg/kg/day PO divided q6h
OR
▸ Cephalexin 25 mg /kg/day PO divided q6h
Alternative Oral Regimen
▸ Erythromycin‡ 40 mg/ kg/day divided PO q6h
† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[9]
‡ Most S. aureus and Streptococci may be resistant against erythromycin


Antimicrobial regimen

  • 1.1 Empiric antimicrobial therapy (covering methicillin-susceptible Staphylococcus aureus and β-hemolytic streptococci)
  • 1.1.1 Limited number of lesions
  • Preferred regimen (1): Mupirocin topically bid for 5 days
  • Preferred regimen (2): Retapamulin topically bid for 5 days
  • 1.1.2 Numerous lesions or outbreaks of post streptococcal glomerulonephritis
  • Preferred regimen (3): Cephalexin 250 mg PO qid for 7 days
  • Alternative regimen (1): (for penicillin-allergic patients) Doxycycline 100 mg PO bid for 7 days
  • Alternative regimen (2): (for penicillin-allergic patients) Clindamycin 300–400 mg PO qid for 7 days
  • 1.2 Culture-directed antimicrobial therapy
  • 1.2.1 Streptococcus alone
  • Preferred regimen: Penicillin V 250–500 mg PO qid for 7 days
  • Alternative regimen (1): (for penicillin-allergic patients) Erythromycin 250 mg PO qid for 7 days
  • Alternative regimen (2): (for penicillin-allergic patients) Clindamycin 300–400 mg PO qid for 7 days
  • 1.2.2 Methicillin-resistant Staphylococcus aureus
  • Preferred regimen (1): Doxycycline 100 mg PO bid for 7 days
  • Preferred regimen (2): Clindamycin 300–450 mg PO qid for 7 days
  • 2. Impetigo, pediatric
  • 2.1 Empiric antimicrobial therapy (covering methicillin-susceptible Staphylococcus aureus and β-hemolytic streptococci)
  • 2.1.1 Limited number of lesions
  • Preferred regimen (1): Mupirocin topically bid for 5 days
  • Preferred regimen (2): Retapamulin topically bid for 5 days
  • 2.1.2 Numerous lesions or outbreaks of poststreptococcal glomerulonephritis
  • Preferred regimen (2): Cephalexin 25–50 mg/kg/day PO tid–qid for 7 days
  • Alternative regimen (1): (for penicillin-allergic patients) Clindamycin 25–30 mg/kg/day PO tid for 7 days
  • 2.2 Culture-directed antimicrobial therapy
  • 2.2.1 Streptococcus alone
  • Preferred regimen: Penicillin V 60,000–100,000 U/kg PO qid for 7 days
  • Alternative regimen (1): (for penicillin-allergic patients) Erythromycin 40 mg/kg/day PO tid–qid for 7 days
  • Alternative regimen (2): (for penicillin-allergic patients) Clindamycin 20 mg/kg/day PO tid for 7 days
  • 2.2.2 Methicillin-resistant Staphylococcus aureus
  • Preferred regimen (1): Clindamycin 25–30 mg/kg/day PO tid for 7 days

References

  1. ↑ 1.0 1.1 Rhody C (2000). “Bacterial infections of the skin”. Prim Care. 27 (2): 459–73. PMID 10815055.
  2. ↑ Brown J, Shriner DL, Schwartz RA, Janniger CK (2003). “Impetigo: an update”. Int J Dermatol. 42 (4): 251–5. PMID 12694487.
  3. ↑ Cole C, Gazewood J (2007). “Diagnosis and treatment of impetigo”. Am Fam Physician. 75 (6): 859–64. PMID 17390597.
  4. ↑ Koning S, van der Sande R, Verhagen AP, van Suijlekom-Smit LW, Morris AD, Butler CC; et al. (2012). “Interventions for impetigo”. Cochrane Database Syst Rev. 1: CD003261. doi:10.1002/14651858.CD003261.pub3. PMID 22258953.
  5. ↑ Sander Koning, Renske van der Sande, Arianne P. Verhagen, Lisette W. A. van Suijlekom-Smit, Andrew D. Morris, Christopher C. Butler, Marjolein Berger & Johannes C. van der Wouden (2012). “Interventions for impetigo”. The Cochrane database of systematic reviews. 1: CD003261. doi:10.1002/14651858.CD003261.pub3. PMID 22258953.
  6. ↑ Ranti S. Bolaji, Tushar S. Dabade, Cheryl J. Gustafson, Scott A. Davis, Daniel P. Krowchuk & Steven R. Feldman (2012). “Treatment of impetigo: oral antibiotics most commonly prescribed”. Journal of drugs in dermatology : JDD. 11 (4): 489–494. PMID 22453587. Unknown parameter |month= ignored (help)
  7. ↑ Stephen P. Luby, Mubina Agboatwalla, Daniel R. Feikin, John Painter, Ward Billhimer, Arshad Altaf & Robert M. Hoekstra (2005). “Effect of handwashing on child health: a randomised controlled trial”. Lancet. 366 (9481): 225–233. doi:10.1016/S0140-6736(05)66912-7. PMID 16023513. Unknown parameter |month= ignored (help)
  8. ↑ Pereira LB (2014). “Impetigo – review”. An Bras Dermatol. 89 (2): 293–9. PMC 4008061. PMID 24770507.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ; et al. (2005). “Practice guidelines for the diagnosis and management of skin and soft-tissue infections”. Clin Infect Dis. 41 (10): 1373–406. doi:10.1086/497143. PMID 16231249.
  10. ↑ Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ; et al. (2011). “Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children”. Clin Infect Dis. 52 (3): e18–55. doi:10.1093/cid/ciq146. PMID 21208910.
  11. ↑ Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). “Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America”. Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.


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