Impetigo medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{‪Impetigo‬}}
{{‪Impetigo‬}}
{{CMG}}
{{CMG}}; {{AE}} {{USAMA}}


==Overview==
==Overview==
Topical or oral [[antibiotic]]s are usually prescribed.
The mainstay of therapy for impetigo is antimicrobial therapy. Topical therapy is preferred unless there is an indication for systemic therapy.<ref name="pmid10815055">{{cite journal| author=Rhody C| title=Bacterial infections of the skin. | journal=Prim Care | year= 2000 | volume= 27 | issue= 2 | pages= 459-73 | pmid=10815055 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10815055  }} </ref><ref name="pmid12694487">{{cite journal| author=Brown J, Shriner DL, Schwartz RA, Janniger CK| title=Impetigo: an update. | journal=Int J Dermatol | year= 2003 | volume= 42 | issue= 4 | pages= 251-5 | pmid=12694487 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12694487  }} </ref>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.<ref name="pmid17390597">{{cite journal| author=Cole C, Gazewood J| title=Diagnosis and treatment of impetigo. | journal=Am Fam Physician | year= 2007 | volume= 75 | issue= 6 | pages= 859-64 | pmid=17390597 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17390597  }} </ref><ref name="pmid22258953">{{cite journal| author=Koning S, van der Sande R, Verhagen AP, van Suijlekom-Smit LW, Morris AD, Butler CC et al.| title=Interventions for impetigo. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 1 | issue=  | pages= CD003261 | pmid=22258953 | doi=10.1002/14651858.CD003261.pub3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22258953  }} </ref>


==Medical Therapy==
==Medical Therapy==
Treatment may involve washing with soap and water and letting the impetigo dry in the air.
* [[Topical]] therapy is preferred for patients with small amount of [[lesions]] and without any bullae<ref name="pmid10815055">{{cite journal| author=Rhody C| title=Bacterial infections of the skin. | journal=Prim Care | year= 2000 | volume= 27 | issue= 2 | pages= 459-73 | pmid=10815055 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10815055  }} </ref><ref>{{Cite journal
| author = [[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]]
| title = Interventions for impetigo
| journal = [[The Cochrane database of systematic reviews]]
| volume = 1
| pages = CD003261
| year = 2012
| month =
| doi = 10.1002/14651858.CD003261.pub3
| pmid = 22258953
}}</ref>; but [[oral]] therapy is also accepted.<ref>{{Cite journal
| author = [[Ranti S. Bolaji]], [[Tushar S. Dabade]], [[Cheryl J. Gustafson]], [[Scott A. Davis]], [[Daniel P. Krowchuk]] & [[Steven R. Feldman]]
| title = Treatment of impetigo: oral antibiotics most commonly prescribed
| journal = [[Journal of drugs in dermatology : JDD]]
| volume = 11
| issue = 4
| pages = 489–494
| year = 2012
| month = April
| pmid = 22453587
}}</ref>


Many general practitioners choose to treat impetigo with bactericidal ointment, such as [[fusidic acid]] (Fucidin) or [[mupirocin]] (Bactroban), but in more severe cases oral antibiotics, such as [[flucloxacillin]] (e.g. Floxapen) or [[erythromycin]] (e.g. Erythrocin) or [[Dicloxacillin]] are necessary.
* [[Oral]] regimens are used for patients with several [[lesions]] and patients with bullous [[impetigo]].


It is ''very'' important to remove the crusts before applying ointment, because the [[bacteria]] that cause the disease live underneath them.
* 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.
 
* [[Handwashing|Hand-washing]] and daily bathing is considered a method to prevent impetigo in children.<ref>{{Cite journal
| author = [[Stephen P. Luby]], [[Mubina Agboatwalla]], [[Daniel R. Feikin]], [[John Painter]], [[Ward Billhimer]], [[Arshad Altaf]] & [[Robert M. Hoekstra]]
| title = Effect of handwashing on child health: a randomised controlled trial
| journal = [[Lancet]]
| volume = 366
| issue = 9481
| pages = 225–233
| year = 2005
| month = July
| doi = 10.1016/S0140-6736(05)66912-7
| pmid = 16023513
}}</ref>
 
* 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:<ref name="pmid24770507">{{cite journal| author=Pereira LB| title=Impetigo - review. | journal=An Bras Dermatol | year= 2014 | volume= 89 | issue= 2 | pages= 293-9 | pmid=24770507 | doi= | pmc=4008061 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24770507  }} </ref>
**Involvement of deeper layers
**[[Pharyngitis]]
**[[Lymphadenopathy]]
**Widespread [[infection]]
**[[Infection]] around the oral cavity or the scalp
 
 
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
 
{|
| valign=top |
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Bullous Impetigo'''
</font>
</div>
 
<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adults'''
</font>
</div>
 
<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Children'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Non-Bullous Impetigo'''
</font>
</div>
 
<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adults'''
</font>
</div>
 
<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Children'''
</font>
</div>
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Bullous Impetigo - Adults†}}
|-
| style="padding: 0 5px; font-size: 90%; background: #4479BA; font-weight: bold; font-style: italic;" align=center |{{fontcolor|#FFF| High suspicion for MRSA}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg IV q12h''''' <br> OR <br> ▸ '''''[[Linezolid]] 600 mg PO q12h'''''<br> OR <br> ▸ '''''[[Clindamycin]] 300-450 mg PO q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Doxycycline]] 100 mg PO q12h'''''<br> OR <br> ▸ '''''[[Minocycline]] 100 mg PO q12h'''''<br> OR <br> ▸ '''''[[TMP/SMZ]] 160/800 mg (1-2 tablets) PO q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | <small>† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name="pmid16231249">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ et al.| title=Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal=Clin Infect Dis | year= 2005 | volume= 41 | issue= 10 | pages= 1373-406 | pmid=16231249 | doi=10.1086/497143 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16231249  }} </ref></small>
|-
| style="padding: 0 5px; font-size: 90%; background: #4479BA; font-weight: bold; font-style: italic;" align=center |{{fontcolor|#FFF| Low suspicion for MRSA}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dicloxacillin]] 250 mg PO q6h''''' <br> OR <br> ▸ '''''[[Cephalexin]] 250 mg PO q6h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Erythromycin]]‡ 250 mg PO q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | <small>† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name="pmid16231249">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ et al.| title=Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal=Clin Infect Dis | year= 2005 | volume= 41 | issue= 10 | pages= 1373-406 | pmid=16231249 | doi=10.1086/497143 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16231249  }} </ref><br> ‡ Most S. aureus and Streptococci may be resistant against erythromycin</small>
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Bullous Impetigo - Children†}}
|-
| style="padding: 0 5px; font-size: 90%; background: #4479BA; font-weight: bold; font-style: italic;" align=center |{{fontcolor|#FFF| High suspicion for MRSA}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 10 mg/kg IV q6h''''' <br> OR <br> ▸ '''''[[Linezolid]] 10 mg/kg PO q12h'''''<br> OR <br> ▸ '''''[[Clindamycin]] 10-20 mg/kg/day PO divided in 3 doses'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[TMP/SMZ]]‡ 8-12 mg/kg/day PO divided in 2 doses'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | <small>† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name="pmid16231249">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ et al.| title=Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal=Clin Infect Dis | year= 2005 | volume= 41 | issue= 10 | pages= 1373-406 | pmid=16231249 | doi=10.1086/497143 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16231249  }} </ref><br> ‡ TMP/SMZ dose is based on the TMP component.</small>
|-
| style="padding: 0 5px; font-size: 90%; background: #4479BA; font-weight: bold; font-style: italic;" align=center |{{fontcolor|#FFF| Low suspicion for MRSA}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dicloxacillin]] 12 mg/kg/day PO divided q6h''''' <br> OR <br> ▸ '''''[[Cephalexin]] 25 mg /kg/day PO divided q6h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Erythromycin]]‡ 40 mg/ kg/day divided PO q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | <small>† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name="pmid16231249">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ et al.| title=Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal=Clin Infect Dis | year= 2005 | volume= 41 | issue= 10 | pages= 1373-406 | pmid=16231249 | doi=10.1086/497143 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16231249  }} </ref> <br> ‡ Most S. aureus and Streptococci may be resistant against erythromycin</small>
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Non-Bullous Impetigo - Adults†}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Topical Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Mupirocin]] 2% apply to lesions q8h x 7 days''''' <br> OR <br> ▸'''''[[Fusidic acid]] 2% apply to lesions q8h x 7 days''''' <br> OR <br> ▸ '''''[[Retapamulin]] 1% apply to lesions q12h x 5 days'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Oral Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dicloxacillin]] 250 mg PO q6h''''' <br> OR <br> ▸ '''''[[Cephalexin]] 250 mg PO q6h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Oral Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Erythromycin]]‡ 250 mg PO q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | <small>† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name="pmid16231249">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ et al.| title=Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal=Clin Infect Dis | year= 2005 | volume= 41 | issue= 10 | pages= 1373-406 | pmid=16231249 | doi=10.1086/497143 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16231249  }} </ref> <br> ‡ Most S. aureus and Streptococci may be resistant against erythromycin</small>
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Non-Bullous Impetigo - Children†}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Topical Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Mupirocin]] 2% apply to lesions q8h x 7 days''''' <br> OR <br> ▸'''''[[Fusidic acid]] 2% apply to lesions q8h x 7 days''''' <br> OR <br> ▸ '''''[[Retapamulin]] 1% apply to lesions q12h x 5 days'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Oral Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dicloxacillin]] 12 mg/kg/day PO divided q6h''''' <br> OR <br> ▸ '''''[[Cephalexin]] 25 mg /kg/day PO divided q6h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Oral Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Erythromycin]]‡ 40 mg/ kg/day divided PO q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | <small>† Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name="pmid16231249">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ et al.| title=Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal=Clin Infect Dis | year= 2005 | volume= 41 | issue= 10 | pages= 1373-406 | pmid=16231249 | doi=10.1086/497143 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16231249  }} </ref> <br> ‡ Most S. aureus and Streptococci may be resistant against erythromycin</small>
|-
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<br>
 
==Antimicrobial regimen==
*1. '''Impetigo, adult'''<ref name="pmid21208910">{{cite journal| author=Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ et al.| title=Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 3 | pages= e18-55 | pmid=21208910 | doi=10.1093/cid/ciq146 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21208910  }} </ref><ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref>
:*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


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 22:21, 29 July 2020

Impetigo Microchapters

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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.[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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