What is the first line treatment for impetigo in a neonate?

First-Line Treatment for Impetigo in Neonates

For impetigo in neonates, intravenous vancomycin is the recommended first-line treatment, as outlined in the Infectious Diseases Society of America (IDSA) guidelines for MRSA infections. 1

Diagnosis and Clinical Presentation

Impetigo in neonates presents as:

• Localized pustular lesions
• Honey-colored crusts (in nonbullous impetigo)
• Flaccid bullae that may rupture (in bullous impetigo)

Treatment Algorithm

Mild, Localized Disease

• For full-term neonates with very limited disease: Topical mupirocin may be adequate 1
• Apply twice daily for 5 days 2

More Extensive Disease or Premature/Low Birth Weight Infants

1. First-line therapy: Intravenous vancomycin 1

   • Dosing as outlined in the Red Book
   • This is essential to exclude bacteremia which can be life-threatening in neonates

2. Alternative agents (for non-endovascular infections):

   • Clindamycin 1
   • Linezolid 1

Rationale for Aggressive Treatment in Neonates

Neonatal impetigo requires more aggressive treatment than in older children for several reasons:

• Neonates have immature immune systems
• Higher risk of bacteremia and systemic spread
• Potential for serious complications including sepsis

Important Considerations

• Bacterial cultures: Should be obtained before initiating therapy to guide subsequent treatment
• Duration of therapy: Typically 7-14 days depending on clinical response
• Monitoring: Close follow-up is essential to ensure resolution and detect complications early

Cautions and Pitfalls

1. Do not use oral penicillin alone - It is not effective for impetigo treatment 2

2. Avoid doxycycline and minocycline in neonates due to potential adverse effects on bone and teeth development 1

3. Be vigilant for signs of systemic infection - Fever, lethargy, poor feeding may indicate progression to bacteremia

4. Differentiate from neonatal pustulosis - Which may present similarly but has different management requirements

5. Consider MRSA coverage - Given the increasing prevalence of methicillin-resistant Staphylococcus aureus in community settings

The aggressive approach to neonatal impetigo is warranted given the potentially serious consequences of untreated or inadequately treated infection in this vulnerable population.