eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Impetigo: Treatment & Medication

Author: Lisa S Lewis, MD, Consulting Staff, Division of Emergency Medicine, Children's Hospital Medical Center of Cincinnati
Coauthor(s): Allan D Friedman, MD, MPH, Chairman, Division of General Pediatrics, Dept of Pediatrics, Professor of Pediatrics, Virginia Commonwealth University, VCUH Health System
Contributor Information and Disclosures

Updated: Apr 27, 2009

Treatment

Medical Care

Treatment of impetigo may involve local wound care along with topical or systemic antibiotic therapy.

  • Local wound care: Cleansing, removal of the honey-colored crusts, and frequent application of wet dressings to areas affected by lesions are recommended.
  • Topical antibiotic treatment: Topical antibiotic therapy is considered the treatment of choice for individuals with uncomplicated localized impetigo. Mupirocin has been found to clear 52-68% of patients with methicillin-resistant S aureus (MRSA) colonization. Retapamulin ointment is in a new class of topical antimicrobials and is indicated for treatment of localized impetigo in children older than 9 months. It has demonstrated excellent activity in vitro against mupirocin-resistant S aureus.2
  • Systemic antibiotic treatment
    • Persons with infections that are widespread, complicated, or are associated with systemic manifestations are usually treated with antibiotics that have gram-positive bacterial coverage.
    • Systemic therapy is also recommended if multiple incidents of pyoderma occur within daycare, family, or athletic team settings.
    • Beta-lactamase resistant antibiotics (eg, cephalosporins, amoxicillin-clavulanate, cloxacillin, dicloxacillin) are recommended. Cephalexin appears to be the drug of choice for oral antimicrobial therapy in children.
    • Recently, community-acquired MRSA infections have reached epidemic proportions.3  If MRSA is suspected, alternative antibiotics include vancomycin, trimethoprim/sulfamethoxazole, and clindamycin.
    • Erythromycin and clindamycin are alternatives in patients with penicillin hypersensitivity. Macrolide resistance has been increasing in the United States. Thus, avoid treatment of impetigo with erythromycin in geographic regions that are known to have a high resistance rate. Group A beta hemolytic streptococci (GABHS) and S aureus resistance to clindamycin has also been reported.

Medication

Topical antibiotics, systemic antibiotics, or a combination are effective therapies for impetigo. Empiric bacterial coverage is aimed at eradicating S aureus and group A beta hemolytic streptococci (GABHS).

Topical antibiotics

Topical antibiotic treatment with mupirocin is the treatment of choice for uncomplicated localized pyoderma, although S aureus resistance to mupirocin has been increasing.4


Mupirocin (Bactroban)

Naturally occurring antibiotic produced by fermentation of Pseudomonas fluorescens. Mechanism of action of mupirocin is via inhibition of bacterial protein synthesis.

Adult

Apply to affected areas tid for 7-10 d

Pediatric

Administer as in adults

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


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 Streptococcus pyogenes.

Adult

Apply topically to affected site bid for 5 d

Pediatric

<9 months: Not established
>9 months: Apply as in adults

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 irritation or pruritus at application site (1.4%); avoid application to eye area; keep out of reach of children

Systemic antibiotics

Systemic antibiotic treatment is indicated for widespread or complicated pyoderma.


Cephalexin (Biocef, Keflex, Keftab)

First-generation cephalosporin antibiotic commonly used to treat impetigo and other skin infections. As with other cephalosporins, mechanism of action is through inhibition of cell wall synthesis.

Adult

500 mg PO q6h

Pediatric

25-50 mg/kg/d PO divided tid/qid

Coadministration with aminoglycosides increases nephrotoxic potential

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dosage with renal insufficiency; caution in patients sensitive to penicillin


Amoxicillin and clavulanate (Augmentin)

Oral antibiotic combining broad-spectrum antibiotic amoxicillin with beta-lactamase inhibitor clavulanate. Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase producing bacteria. For children >3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Adult

500 mg PO q12h or 250 mg PO q8h

Pediatric

20-45 mg/kg/d PO divided bid/tid
<3 months: 125 mg/5 mL PO susp based on amoxicillin; 30 mg/kg/d divided bid for 7 d
>3 months: If using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO q12h; if using 125 mg/5 mL or 250 mg/5 mL susp, 40 mg/kg/d PO q8h for 7 d
>40 kg: Administer as in adults

Coadministration with warfarin or heparin increases risk of bleeding; avoid combination with allopurinol, which results in increased incidence of rash

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Because chewable tab contain phenylalanine, do not administer to patients with PKU


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 staphylococcal infection is suspected.

Adult

125-500 mg PO q6h, administer 1 h ac or 2 h pc

Pediatric

25 mg/kg/d PO divided q6h, administer 1 h ac or 2 h pc

Decreases efficacy of oral contraceptives; may decrease effects of anticoagulants; probenecid and disulfiram may increase penicillin levels

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 who are renally impaired


Erythromycin (E.E.S., E-Mycin, Eryc)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double dose.

Adult

250-500 mg (stearate/base) PO q6h

Pediatric

30-50 mg/kg/d (stearate/base) PO divided q6-8h

Potent inhibitor of CYP450-3A4; coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

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; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs


Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Adult

150-450 mg PO q6h

Pediatric

10-30 mg/kg/d PO divided q6-8h

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile


Cloxacillin (Cloxapen)

For treatment of infections caused by penicillinase-producing staphylococci.

Adult

250-500 mg PO q6h

Pediatric

50-100 mg/kg/d PO divided q6h

Decreases efficacy of oral contraceptives; may decrease effects of anticoagulants; probenecid and disulfiram may increase penicillin levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in patients with impaired renal function

More on Impetigo

Overview: Impetigo
Differential Diagnoses & Workup: Impetigo
Treatment & Medication: Impetigo
Follow-up: Impetigo
Multimedia: Impetigo
References
Further Reading
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Further Reading

  • The Infectious Diseases Society of America have established practice guidelines for the diagnosis and management of skin and soft-tissue infections. 5

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Keywords

impetigo, impetigo contagiosa, impetigo bullosa, streptococcal impetigo, staphylococcal impetigo, nonbullous impetigo, bullous impetigo, crusted tetter, pyoderma, group A beta hemolytic streptococci, GABHS, Staphylococcus aureus, varicella, acute poststreptococcal glomerulonephritis, APSGN, scarlet fever, osteomyelitis, septic arthritis, pneumonia, septicemia, guttate psoriases, rheumatic fever, treatment, diagnosis, lymphadenopathy

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Contributor Information and Disclosures

Author

Lisa S Lewis, MD, Consulting Staff, Division of Emergency Medicine, Children's Hospital Medical Center of Cincinnati
Lisa S Lewis, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Allan D Friedman, MD, MPH, Chairman, Division of General Pediatrics, Dept of Pediatrics, Professor of Pediatrics, Virginia Commonwealth University, VCUH Health System
Allan D Friedman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Glenn J Fennelly, MD, MPH, Director, Division of Pediatric Infectious Diseases, Jacobi Medical Center; Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine
Glenn J Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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