What is the next step for a 6-year-old patient with a skin infection if mupirocin (mupirocin) is not effective?

Next Steps After Mupirocin Failure in a 6-Year-Old with Skin Infection

If mupirocin treatment fails in a 6-year-old with a skin infection, the next step should be a combination approach of chlorhexidine body washes and diluted bleach baths, along with an appropriate oral antibiotic based on the likely pathogen. 1

Assessment of Mupirocin Failure

When mupirocin fails to resolve a skin infection in a child, consider:

• Duration of treatment (should be 3-5 days before reassessment) 2
• Proper application technique (small amount applied three times daily) 2
• Possibility of resistant organisms or non-bacterial etiology
• Deeper infection than initially assessed

Next Treatment Steps

1. Topical Antiseptic Measures

• Chlorhexidine body washes: Daily application for 5-14 days 1, 3
• Diluted bleach baths: Concentration of 1 teaspoon per gallon of bath water (1/4 cup per 1/4 tub) for 15 minutes, twice weekly for up to 3 months 1
  • Caution: Provide clear instructions to prevent skin irritation from improper dilution

2. Oral Antibiotic Therapy

For a 6-year-old with presumed MRSA skin infection:

• First-line: Trimethoprim-sulfamethoxazole (TMP-SMX) dosed at 5 mg/kg (based on trimethoprim component) twice daily 3
• Alternative options:
  • Clindamycin (if local resistance patterns permit)
  • Amoxicillin-clavulanate 875/125 mg twice daily (adjusted for pediatric dosing) 3

For presumed streptococcal infection:

• First-line: Amoxicillin or cephalexin (weight-based dosing)

3. Additional Hygiene Measures

• Cover draining wounds with clean dressings
• Regular handwashing
• Avoid sharing personal items (towels, clothing, bedding)
• Launder clothing, towels, and bedding in hot water 3
• Clean high-touch surfaces regularly

Duration of Treatment

• Oral antibiotics: 5-10 days for uncomplicated skin infections 3
• Continue topical antiseptic measures for at least 2 weeks

When to Consider Hospitalization

Hospitalization should be considered if:

• Evidence of deeper or necrotizing infection
• Systemic symptoms (fever, altered mental status)
• Hemodynamic instability
• Immunocompromised status
• Poor adherence to outpatient therapy 1

Common Pitfalls to Avoid

1. Failure to identify colonization sites: Check interdigital toe spaces for fissuring, scaling, or maceration that may harbor pathogens 1

2. Inadequate decolonization: Treating only the patient without addressing household contacts may lead to reinfection 1

3. Overuse of antibiotics: Using oral antibiotics without appropriate topical measures may lead to resistance

4. Inadequate follow-up: Patients should be reassessed within 3-5 days if not improving 2

5. Hexachlorophene use in young children: Should not be used in infants under 2 months due to risk of neurological complications 1

By implementing this comprehensive approach, most skin infections that have failed mupirocin therapy can be effectively managed in the outpatient setting.