eMedicine Specialties > Dermatology > Bacterial Infections
Impetigo: Treatment & Medication
Updated: Sep 8, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
Antibiotics are the mainstay of therapy, and the chosen agent must provide coverage against both Staphylococcus aureus and Streptococcus pyogenes. Community-acquired methicillin-resistant S aureus (MRSA) infection most commonly manifests as folliculitis or abscess, rather than impetigo; thus, beta-lactam drugs remain an appropriate initial empiric choice in the treatment of impetigo.
Topical antibiotics are used in patients with small or few lesions, applied to affected areas twice or thrice daily for 7-10 days.
Mupirocin ointment has been used for both the lesions and to clear chronic nasal carriers. It has been shown to be superior to topical polymyxin B and neomycin14,15 and equally effective compared with oral cephalexin. Both mupirocin and oral cephalexin are superior to bacitracin.16 Unfortunately, S aureus and MRSA resistance to mupirocin has emerged at estimated rates ranging from 5-10%.14 An experimental drug (TD1414 2% cream) is currently being evaluated in a phase 2, randomized, single-blind (investigator), active control (mupirocin 2% cream), safety/efficacy study in patients with impetigo and secondarily infected traumatic lesions. Results are expected by June 2009.17
Retapamulin was approved by the US Food and Drug Administration (FDA) in 2007 for the topical treatment of impetigo in adults and children older than 9 months caused by S pyogenes and methicillin-susceptible S aureus.18 Retapamulin has an excellent spectrum of activity, surpassing the bacterial spectrum of mupirocin.14,19 It has been shown to preserve its activity against bacteria that were resistant to multiple antibiotic drugs, such as methicillin, erythromycin, fusidic acid, mupirocin, azithromycin, and levofloxacin.20 In more than 1900 patients evaluated in several comparative studies, retapamulin has demonstrated to be as effective as topical fusidic acid and oral cephalexin, with a low rate of adverse events.14 In another study, retapamulin 1% ointment showed more efficacy than fusidic acid 2% ointment for the treatment of impetigo.21
Further, a randomized, double-blind, multicenter study to evaluate the safety and efficacy of topical retapamulin 1% ointment, compared with oral linezolid in the treatment of secondarily-infected traumatic lesions and impetigo caused by MRSA in subjects of aged 2 months and older, is currently being conducted Results are expected by August 2010.22
Topical sodium fusidate (fusidic acid), currently not available in the United States, has been recognized as first-line of therapy in Europe and other parts of the world.3,23 High resistance rates have been reported with the use of fusidic acid, ranging from 32.5-50%.3,21,24,25,26
Other topical antibiotics that have reported some benefit for the treatment of impetigo include the following:
- Clindamycin (cream, lotion, and foam) is useful in several MRSA infections.27,28
- Gentamicin ointment or cream has been used in many countries for some gram-positive infections by Staphylococcus species, including impetigo and pyoderma. Its use is precluded by the potential development of ear and kidney toxicity.14,27
- Hydrogen peroxide 1% cream, available in many countries, has demonstrated comparable bactericidal activity but longer duration of action than hydrogen peroxide 1% aqueous solution in vitro. It is applied 2-3 times a day on the affected area for a maximum of 3 weeks. Although the potential for sensitization is low, hypersensitivity reactions have been reported to other ingredients in the commercially available product.27,29
- Tetracycline has been used for localized impetigo, although it is not widely prescribed because of the potential risk of skin photosensitivity reactions.1,27
Drugs such as sulfanilamide, nitrofurazone, and silver sulfadiazine, widely used for the treatment of burns, are not used by dermatologists for the treatment of impetigo. Because of their antibacterial spectrum and proven efficacy and tolerability, these drugs may need to be considered in the future for the treatment of impetigo and other community-acquired skin infections.14,27
Oral antibiotics remain appropriate for many patients with impetigo. For empiric antibiotic therapy, a cephalosporin, semisynthetic penicillin, or beta-lactam/beta-lactamase inhibitor is recommended. If bacterial cultures reveal MRSA and the patient is not improving, tetracyclines, trimethoprim/sulfamethoxazole (Bactrim), clindamycin, or linezolid are effective oral antibiotics.
Gentle debridement of lesional crusts using antibacterial soap and a washcloth is also recommended. Good hygiene with antibacterial washes, such as chlorhexidine, may prevent the spread of impetigo and prevent recurrences, but the efficacy of this has not been proven.
A clinical guideline summary from the Infectious Diseases Society of America, Practice guidelines for the diagnosis and management of skin and soft-tissue infections, may be helpful.30
Consultations
Consult a nephrologist if signs and symptoms of acute glomerulonephritis develop.
Medication
The goals of pharmacotherapy for impetigo are to reduce morbidity, to prevent complications, and to prevent spread to other individuals.
Antibiotics
Mupirocin applied topically has been shown to be effective for localized impetigo, but resistance has emerged. Retapamulin is a new option.23,31 Bacitracin is no longer the preferred topical antibiotic because it causes frequent allergic skin reactions and occasional/rare anaphylaxis.27
The advantages of topical antibiotics include low risk of systemic adverse events, higher concentration of the antibiotic when applied to the affected area, smaller amount of drug is used, lack of effect on intestinal florae, and low cost, while the disadvantages include the potential production of irritant and allergic contact dermatitis, decreased penetration in the affected area, potential rapid appearance of bacterial resistance, potential alteration of cutaneous florae, and potential systemic absorption and consequent toxic effects.27
Systemic antibiotic treatment is indicated for most cutaneous infections, although abscesses may respond to drainage alone. A cephalosporin, semisynthetic penicillin, or beta-lactam/beta-lactamase inhibitor combination is generally suitable for first-line therapy. MRSA should be suspected in cases of spontaneous abscess or cellulitis and in lesions that do not resolve with traditional antimicrobial therapy, in which case alternative antibiotics should be considered. These include trimethoprim/sulfamethoxazole, tetracycline, clindamycin, fluoroquinolones, and linezolid.
Mupirocin (Bactroban)
DOC for localized disease; inhibits bacterial growth by inhibiting RNA and protein synthesis.
Adult
Apply thin film to affected area 3-5 times/d for 7-14 d; cleanse lesions prior to application
Recurrent disease: Apply to nostrils twice/d for 5 d monthly
Pediatric
Apply as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Prolonged use may result in growth of nonsusceptible organisms; use with caution over large surface areas, especially in the setting of moderate-to-severe renal disease, due to polyethylene glycol absorption, which is excreted by the kidneys
Retapamulin (Altabax)
Topical antibiotic available as a 1% ointment. First of new antibiotic class called pleuromutilins. Inhibits protein synthesis by binding to 50S subunit on ribosome. Indicated for impetigo caused by S aureus or S pyogenes.
Adult
Apply thin layer to affected area bid for 5 d to a total area of <100 cm2; affected area should be covered with sterile dressing after application
Pediatric
Approved for patients 9 mo or older; apply as in adults; total area of treatment should be <2% of total BSA in patients aged 9 mo to 18 y
None known
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause irritation at application site (1.4%); avoid application to eye area; keep out of reach of children
Dicloxacillin (Dycill, Dynapen)
Binds to one or more penicillin-binding proteins, which, in turn, inhibits synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci. May use to initiate therapy when S aureus infection is suspected.
Adult
125-500 mg PO q6h; not to exceed 2 g/d
Pediatric
Neonates: 4-8 mg/kg PO q6h
<40 kg: 12.5-50 mg/kg/d PO divided q6h
>40 kg: 125-500 mg PO q6h
May decrease effects of anticoagulants and oral contraceptives; probenecid and disulfiram may increase penicillin levels; concomitant penicillin and aminoglycoside therapy reported to result in inactivation of aminoglycoside both in vivo and in vitro; penicillins may alter intestinal florae, which, in turn, alters enterohepatic circulation of combination contraceptives, possibly resulting in unintended pregnancies
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor PT in patients taking anticoagulant medications; toxicity may increase in patients with renal impairment
Cephalexin (Keflex)
First-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin florae; used for skin infections or prophylaxis in minor procedures.
Adult
250 mg PO q6h or 500 mg PO bid for 7-14 d; not to exceed 4 g/d
Pediatric
25-50 mg/kg/d PO divided q12h for 7-14 d; not to exceed 3 g/d
Probenecid may increase effect of cephalosporins; tetracyclines may decrease effect of cephalosporins with concurrent use; coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Clindamycin (Cleocin)
Effective for skin infections; binds to the 50S ribosomal subunit, interfering with protein synthesis. Can also be used for impetigo prophylaxis.
Adult
Prophylaxis: 150 mg/d PO for 3 mo
Treatment: 150-300 mg PO q6h for 7-10 d
Pediatric
10-30 mg/kg/d PO divided q6-8h or 25-40 mg/kg/d IV/IM divided q6-8h
May potentiate effects of botulinum toxins and other neuromuscular blockers
Documented hypersensitivity, history of antibiotic-associated colitis, caution in liver or renal disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in setting of hepatic or renal disease; associated with Clostridium difficile colitis
Erythromycin (E.E.S., E-Mycin, Ery-Tab)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. Resistance is prevalent. In children, age, weight, and severity of infection determine proper dosage. When twice-daily dosing is desired, half the total daily dose may be taken q12h.
Adult
250 mg erythromycin stearate/base PO q6h or 500 mg q12h for 10 d; increase to 4 g/d depending on severity of infection; 250 mg of erythromycin stearate/base is equivalent to 400 mg of E.E.S.
Pediatric
30-50 mg/kg/d PO divided q6-8h for 7-14 d; double dose for severe infection
Coadministration may increase toxicity of carbamazepine, cyclosporine, digoxin, HMG-CoA reductase inhibitors (statins), and theophylline; may potentiate anticoagulant effects of warfarin; drugs metabolized by cytochrome P450 may demonstrate increased toxicity when administered with erythromycin
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; common adverse GI effects include nausea, vomiting, abdominal pain, diarrhea, and anorexia
Rifampin (Rifadin, Rimactane)
Inhibits DNA-dependent RNA polymerase. Used in combination with other antibiotics so that resistance to rifampin does not occur; can also be used to treat nasal carriers of S aureus.
Adult
300–600 mg PO bid for 10 d; take 1 h ac or 2 h pc
Nasal carriers: 600 mg/d PO for 5-10 d
Pediatric
15 mg/kg/d divided q12h for 5-10 d
Induces hepatic enzymes and may decrease levels of benzodiazepines, cyclosporine, oral contraceptives, HMG-CoA reductase inhibitors, and other drugs metabolized in the liver
May increase acetaminophen toxicity; induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin
Blood pressure may increase with coadministration of enalapril; coadministration with isoniazid or pyrazinamide may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution in hepatic dysfunction; obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Trimethoprim-sulfamethoxazole (Bactrim, Septra)
Selectively inhibits bacterial dihydrofolate reductase. Has good susceptibility against community-acquired MRSA but is not effective against S pyogenes.
Adult
1 DS tab PO tid for 10 d
Pediatric
8-10 mg/kg/d PO q12h (based on trimethoprim)
Inhibits hepatic metabolism of other drugs (use with caution with warfarin and other drugs metabolized by the liver); may increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity to this or any sulfa drug
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Decrease dose in patients with liver or kidney dysfunction; do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Dosage adjustments (adult adjustments)
CrCl 80-50 mL/min: Recommended IV dose q18h
CrCl 50-10 mL/min: Recommended IV dose q24h
CrCl <10 mL/min: Not recommended
HD: 4-5 mg/kg after HD
During peritoneal dialysis: 0.16-0.8 g q48h
Discontinue at first appearance of rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly persons, anticonvulsant therapy, or malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Levofloxacin (Levaquin)
Inhibits DNA gyrase and topoisomerase IV for bactericidal activity. Use as an alternative for MRSA infection.
Adult
500 mg/d PO for 7-14 d; take 1 h ac or 2 h pc
Pediatric
Not recommended
May prolong QT interval if used with antiarrhythmic drugs or TCAs; antacids may reduce serum levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Decrease dose in patients with renal dysfunction; rapid infusions may cause hypotension; fluoroquinolones cause arthropathy and osteochondrosis in juvenile animal laboratory studies (not routinely recommended or used in children <18 y without extreme caution); photosensitivity and seizures (latter especially if also taking NSAIDs) have occurred with this class of medication
Interacts with oral hypoglycemic agents; avoid coadministration with QT-prolonging agents (including class Ia and III antiarrhythmics, erythromycin, cisapride, antipsychotics, and cyclic antidepressants); avoid taking with antacids, zinc, iron, didanosine, or sucralfate; adverse neurologic effects reported (eg, dizziness); musculoskeletal problems (eg, tendinitis, tendon rupture); patient should stay well hydrated
Ciprofloxacin (Cipro)
Inhibits DNA gyrase and topoisomerase IV for bactericidal activity. Use as an alternative for MRSA infection.
Adult
500 mg PO bid for 10 d; take 1 h ac or 2 h pc
Pediatric
20-30 mg/kg/d PO divided q12h
Inhibits hepatic metabolism (monitor levels of clozapine, warfarin, and theophylline); can lead to increased caffeine levels; probenecid decreases excretion
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Decrease dose in patients with renal dysfunction; rapid infusions may cause hypotension; fluoroquinolones cause arthropathy and osteochondrosis in juvenile animal laboratory studies (not routinely recommended or used in children <18 y without extreme caution); photosensitivity and seizures (latter especially if also taking NSAIDs) have occurred with this class of medication
Interacts with oral hypoglycemic agents; avoid coadministration with QT-prolonging agents (including class Ia and III antiarrhythmics, erythromycin, cisapride, antipsychotics, and cyclic antidepressants); avoid taking with antacids, zinc, iron, didanosine, or sucralfate; adverse neurologic effects reported (eg, dizziness); musculoskeletal problems (eg, tendinitis, tendon rupture); patient should stay well hydrated
Linezolid (Zyvox)
Binds to the 50S ribosomal subunit, interfering with protein synthesis; used for MRSA or complicated skin infections
Adult
Uncomplicated infection: 400 mg PO bid for 10-14 d
Complicated infections: 600 mg PO bid for 10-28 d
Pediatric
20-30 mg/kg/d PO divided q8-12h for 10-14 d
Has mild MAOI properties (use with caution in patients taking MAOIs or TCAs and in patients with liver or renal dysfunction
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid large quantities of tyramine-containing foods; monitor CBC count qwk because of risk of myelosuppression
Antihistamines
If pruritus is significant, antihistamines can be prescribed to possibly help minimize scratching. Avoidance of trauma to the skin may prevent or limit the spread of impetigo by autoinoculation.
Loratadine (Claritin)
Nonsedating and selectively inhibits peripheral histamine H1 receptors.
Adult
10 mg/d PO
Pediatric
<2 years: Not established
2-6 years: 5 mg/d PO
>6 years: Administer as in adults
Cimetidine, erythromycin, and ketoconazole may increase levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Starting dose of 10 mg q48h in patients with liver impairment or renal insufficiency (CrCl <30 mL/min)
Desloratadine (Clarinex)
Long-acting tricyclic histamine antagonist selective for H1 receptor. Relieves nasal congestion and systemic effects of seasonal allergy. Major metabolite of loratadine, which, after ingestion, is metabolized extensively to active metabolite 3-hydroxydesloratadine.
Adult
5 mg/d PO
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Data limited; erythromycin and ketoconazole increase desloratadine and 3-hydroxydesloratadine plasma concentrations, but no increase in clinically relevant adverse effects, including QTc, was observed
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Decrease dose in hepatic impairment; rarely causes pharyngitis or dry mouth
Cetirizine (Zyrtec)
Long-acting selective histamine H1 receptor antagonist.
Adult
5-10 mg/d PO
Pediatric
6 months to 2 years: 2.5 mg/d PO
2-5 years: 2.5-5 mg/d PO
6-11 years: 5-10 mg/d PO
May increase risk of CNS depression when used with other CNS depressants
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause somnolence
Hydroxyzine (Atarax, Vistaril)
Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS. Often administered before sleep because of sedating properties.
Adult
25-100 mg PO q6-8h prn for pruritus
Pediatric
<6 years: 2 mg/kg/d PO divided q6-8h prn
6-12 years: 12.5-25 mg PO q6-8h prn
CNS depression may increase with alcohol or other CNS depressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause drowsiness
More on Impetigo |
| Overview: Impetigo |
| Differential Diagnoses & Workup: Impetigo |
 Treatment & Medication: Impetigo |
| Follow-up: Impetigo |
| Multimedia: Impetigo |
| References |
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References
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Further Reading
Keywords
impetigo, impetigo contagiosa, Fox impetigo, impetigo bullosa, impetigo contagiosa bullosa, impetigo neonatorum
