Impetigo medical therapy

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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.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.

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.

• Indications for systemic therapy include:
  • Involvement of deeper layers
  • Pharyngitis
  • Lymphadenopathy
  • Widespread infection
  • Infection around the oral cavity or the scalp

▸ 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