What are the treatment and prevention options for recurrent impetigo?

Treatment and Prevention of Recurrent Impetigo

For recurrent impetigo infections, a 5-day decolonization regimen with intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items such as towels, sheets, and clothes is strongly recommended. 1

Treatment Approach for Recurrent Impetigo

Initial Treatment

1. Drainage and Culture

   • Recurrent abscesses should be drained and cultured early 2
   • After obtaining cultures, treat with a 5-10 day course of antibiotics active against the identified pathogen 2

2. Antibiotic Selection

   • For localized lesions:

     • Topical mupirocin 2% ointment applied 2-3 times daily for 5-7 days 1, 3
     • Clinical efficacy rates with mupirocin are 71-93%, significantly higher than placebo (35%) 3

   • For extensive or multiple lesions:

     • MSSA infections: Dicloxacillin or cephalexin for 7 days 1
     • MRSA infections: Doxycycline, clindamycin, or trimethoprim-sulfamethoxazole 1
     • Standard duration of oral antibiotic therapy is 7 days 1

3. Treatment Monitoring

   • Evaluate clinical response within 48-72 hours 1
   • If no improvement within 3-5 days, obtain bacterial culture and sensitivity testing and consider alternative antibiotics 1

Prevention Strategy for Recurrent Infections

Decolonization Protocol

1. 5-day decolonization regimen:
   • Intranasal mupirocin twice daily
   • Daily chlorhexidine washes
   • Daily decontamination of personal items (towels, sheets, clothes) 2, 1

Hygiene Measures

• Keep draining wounds covered with clean, dry bandages
• Regular handwashing
• Avoid sharing personal items that contact skin
• Daily change of clothing that contacts affected areas
• Regular cleaning of high-touch surfaces 1

Special Considerations

Antibiotic Resistance

• Be aware of increasing prevalence of antibiotic-resistant bacteria:
  • Methicillin-resistant S. aureus (MRSA)
  • Macrolide-resistant streptococcus
  • Mupirocin-resistant streptococcus 4

Evaluation for Underlying Conditions

• Adult patients with recurrent infections should be evaluated for neutrophil disorders 2
• Consider investigating for other predisposing factors that may contribute to recurrent infections

Pitfalls to Avoid

• Failing to consider MRSA as the causative organism in recalcitrant impetigo
• Using penicillin, which has been shown to be inferior to other antibiotics for impetigo
• Inadequate duration of therapy
• Relying solely on topical therapy for extensive disease
• Not addressing underlying conditions that may predispose to recurrent infection 1

Expected Outcomes

• With appropriate treatment, impetigo typically resolves within 7-10 days 1
• Treatment significantly shortens the duration of impetigo compared to no treatment 1
• Complications are rare, with poststreptococcal glomerulonephritis being the most serious but occurring in less than 1 case per 1,000 population per year 1

By implementing this comprehensive treatment and prevention strategy, most patients with recurrent impetigo can achieve successful resolution of their condition and prevent future recurrences.