Impetigo medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

• The treatment of impetigo depends on the location, number of lesions and the type (bullous or non-bullous). Antibiotic therapy could be administered topically or orally.

Medical Therapy

• Topical therapy is preferred for patients with small amount of lesions and without any bullae; but oral therapy is also accepted.

• Oral regimens are used for patients with several lesions and patients with bullous impetigo.

• 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.

• 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 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 ‡ 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 ‡ 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 ‡ 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 ‡ 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 ‡ Most S. aureus and Streptococci may be resistant against erythromycin

Antimicrobial regimen

• 1. Impetigo, adult

• 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 (1): Dicloxacillin 250 mg PO qid for 7 days

• Preferred regimen (2): Amoxicillin-Clavulanate 875/125 mg PO bid for 7 days

• 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

• Alternative regimen (3): (for penicillin-allergic patients) Sulfamethoxazole-Trimethoprim 1–2 double-strength tablets PO bid 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

• Preferred regimen (3): Sulfamethoxazole-Trimethoprim 1–2 double-strength tablets PO bid 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 (1): Amoxicillin-Clavulanate 25 mg/kg/day of amoxicillin component PO bid for 7 days

• 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

• Alternative regimen (2): (for penicillin-allergic patients) Sulfamethoxazole-Trimethoprim 8–12 mg/kg/day PO bid 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

• Preferred regimen (2): Sulfamethoxazole-Trimethoprim 8–12 mg/kg/day PO bid for 7 days