Impetigo Empiric Therapy

Updated: Mar 07, 2023
  • Author: Chinelo N Animalu, MD, MPH, FIDSA; Chief Editor: Thomas E Herchline, MD  more...
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Empiric Therapy Regimens

Empiric therapeutic regimens for impetigo are outlined below, including those for localized, uncomplicated impetigo and those for widespread, or complicated, impetigo.

Impetigo is a contagious, superficial bacterial infection commonly seen in children. Treatment typically involves local wound care along with topical or systemic antibiotic therapy with activity against beta-hemolytic streptococci and Staphylococcus aureus.

Topical therapy is preferred for localized, uncomplicated nonbullous or bullous impetigo. [1] Systemic antibiotics are used for widespread infections, complicated infections, outbreaks of poststreptococcal glomerulonephritis, or multiple incidents that have occurred within the home, daycare, or athletic-team settings. The duration of therapy should be based on clinical improvement; however, a 7-day regimen is recommended. [2] As S aureus isolates from impetigo are usually methicillin-susceptible, cephalexin, amoxicillin-clavulanate, or dicloxacillin is usually recommended. Trimethoprim-sulfamethoxazole, clindamycin, or doxycycline is recommended for confirmed or highly suspected MRSA impetigo.

The Infectious Diseases Society of America (IDSA) published 2014 guidelines for the treatment of impetigo (see Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America). [2]

Localized, uncomplicated impetigo

Localized, uncomplicated impetigo is treated as follows:

  • Topical wound cleansing
  • Ozenoxacin cream 1% thin layer BID for 5 days  [3, 4]   or
  • Mupirocin 2% cream/ointment applied topically BID for 5 days or
  • Retapamulin 1% ointment applied topically BID for 5 days if ozenoxacin cream not tolerated  [5]

Widespread (complicated) impetigo  [6, 7] ref2} [8]

Widespread (complicated) impetigo is treated as follows:

  • Cephalexin 250 mg PO QID for 7 days in adults or 25 mg/kg/day in 4 divided doses for 7 days in children or
  • Dicloxacillin 250 mg PO QID for 7 days in adults/children >40 kg or 25 mg/kg/day PO divided QID for 7 days in patients < 40 kg or
  • Amoxicillin-clavulanate 875 mg/125 mg PO BID for 7 days in adults or 25 mg amoxicillin/kg/day PO divided BID in children for 7 days

Penicilins tend to be the most common first-line systemic antibiotics, with 2nd generation cephalosporins and macrolides being common second-liine antibiotics. [9]  

​Widespread (complicated) impetigo with confirmed MRSA  [2]

Widespread (complicated) impetigo with confirmed MRSA is treated as follows:

  • Clindamycin 300 mg PO QID for 7 days in adults or 10-20 mg/kg/dose PO TID for 7 days in children  or
  • Trimethoprim-sulfamethoxazole 160 mg PO BID for 7 days in adults or 8-12 mg TMP/kg/d PO BID for 7 days in infants >2 months or
  • Doxycycline 100 mg PO BID for 7 days in patients >45 kg or 2 mg/kg/dose PO BID for 7 days in patients < 45 kg and >8 years [6]