From the Guidelines
Impetigo should be treated with either topical mupirocin or retapamulin twice daily for 5 days, as recommended by the most recent and highest quality study 1.
Treatment Options
- For mild cases, topical antibiotics such as mupirocin or retapamulin are effective 1.
- For more extensive impetigo, oral antibiotics such as cephalexin or dicloxacillin may be recommended 1.
Key Considerations
- Treatment without culture or gram stain is reasonable in typical cases 1.
- Oral therapy is recommended for patients with numerous lesions or in outbreaks affecting several people to help decrease transmission of infection 1.
- It is essential to avoid sharing towels or personal items, keep fingernails short to prevent scratching, and cover lesions if possible to reduce transmission.
Antibiotic Options
- Mupirocin or retapamulin are recommended for topical treatment 1.
- Cephalexin or dicloxacillin are recommended for oral treatment 1.
- Alternative options include amoxicillin-clavulanate or clindamycin for penicillin-allergic patients 1.
Prevention of Complications
- Treatment is essential to prevent complications like cellulitis or, rarely, post-streptococcal glomerulonephritis 1.
- Systemic antimicrobials should be used for infections during outbreaks of poststreptococcal glomerulonephritis to help eliminate nephritogenic strains of Streptococcus pyogenes from the community 1.
From the FDA Drug Label
Mupirocin ointment, 2% is indicated for the topical treatment of impetigo due to: Staphylococcus aureus and Streptococcus pyogenes. The efficacy of topical mupirocin ointment in impetigo was tested in two studies. In the first, patients with impetigo were randomized to receive either mupirocin ointment or vehicle placebo t.i. d. for 8 to 12 days. Clinical efficacy rates at end of therapy in the evaluable populations (adults and pediatric patients included) were 71% for mupirocin ointment (n=49) and 35% for vehicle placebo (n=51). Treatment of impetigo can be done with mupirocin ointment, 2% as it is indicated for the topical treatment of impetigo due to Staphylococcus aureus and Streptococcus pyogenes 2.
- Clinical efficacy rates of mupirocin ointment in treating impetigo were 71% in one study and 93% in another study 2.
- Mupirocin ointment can be used in both adults and pediatric patients 2.
From the Research
Treatment Options for Impetigo
- Topical antibiotics such as mupirocin, retapamulin, and fusidic acid are effective in treating impetigo 3, 4, 5
- Oral antibiotic therapy can be used for impetigo with large bullae or when topical therapy is impractical, with options including amoxicillin/clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, minocycline, trimethoprim/sulfamethoxazole, and macrolides 3, 6
- Natural therapies such as tea tree oil, olive, garlic, and coconut oils, and Manuka honey have been anecdotally successful, but lack sufficient evidence to recommend or dismiss them as treatment options 3
Comparison of Topical Antibiotics
- Topical mupirocin and fusidic acid are equally effective, with no clear evidence that one is more effective than the other 4
- Retapamulin is an effective alternative, but may entail higher cost 5
- Ozenoxacin is also an effective alternative, but may entail higher cost 5
Antimicrobial Stewardship
- Antimicrobial stewardship is critical to optimize patient outcomes and to prevent the development of resistance 7
- Healthcare providers should be aware of local resistance patterns in impetigo to help guide therapy 7
- The use of newer safe and effective topical antibiotic alternatives as a first-line treatment should be an important step in antimicrobial stewardship 7
Treatment Considerations
- Treatment considerations have changed with the increasing prevalence of antibiotic-resistant bacteria, with methicillin-resistant S. aureus, macrolide-resistant streptococcus, and mupirocin-resistant streptococcus all documented 3
- Penicillin is not a recommended treatment option due to its inferior efficacy compared to other antibiotics 3, 4