What are alternative treatments for pediatric impetigo if mupirocin (Bactroban) is ineffective?

Alternative Treatments for Pediatric Impetigo When Mupirocin Fails

For pediatric impetigo that is refractory to mupirocin treatment, oral antibiotics such as clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), or cephalexin should be initiated as the next step in management. 1

Assessment of Treatment Failure

• Consider possible mupirocin resistance, which has been increasingly documented, especially in areas with high MRSA prevalence 1
• Obtain cultures if treatment failure occurs or MRSA is suspected to guide appropriate antibiotic selection 1
• Rule out deeper infection or alternative diagnosis if clinical presentation is atypical 1

Recommended Oral Antibiotic Options

For Presumed Methicillin-Susceptible S. aureus (MSSA):

• Cephalexin: 25 mg/kg/day in 4 divided doses for children 1, 2
• Amoxicillin-clavulanate: 25 mg/kg/day of amoxicillin component in 2 divided doses for children 1
• Dicloxacillin: 12 mg/kg/day in 4 divided doses for children 1

For Suspected or Confirmed MRSA:

• Clindamycin: 10-20 mg/kg/day in 3 divided doses for children 3, 1
• TMP-SMX: 8-12 mg/kg/day (based on trimethoprim component) in 2 divided doses for children 3, 1
• Doxycycline: 100 mg twice daily (only for children ≥8 years of age) 3, 1

Treatment Algorithm Based on Extent of Disease

For Limited Lesions:

• Consider alternative topical agent like retapamulin if available 1
• If topical therapy fails, transition to appropriate oral antibiotic based on suspected pathogen 1, 4

For Extensive Disease:

• Oral antibiotics are preferred over topical treatment 1, 5
• For children with extensive impetigo, oral clindamycin is an effective option if MRSA is suspected 3, 1
• If the patient is stable without ongoing bacteremia, empirical therapy with clindamycin 10–13 mg/kg/dose IV every 6–8 hours is recommended if clindamycin resistance rate is low (<10%) 3

Special Considerations

• Tetracyclines (including doxycycline) should not be used in children <8 years of age 3, 1
• Penicillin alone is not effective for impetigo as it lacks adequate coverage against S. aureus 1, 6
• Macrolides (e.g., erythromycin) may have increasing resistance rates and should be used with caution 1, 5
• For treatment failure with oral antibiotics, consider hospitalization with IV antibiotics such as vancomycin for MRSA 3
• Linezolid can be considered for children with MRSA resistant to clindamycin (30 mg/kg/day in 3 doses for children <12 years and 20 mg/kg/day in 2 doses for children ≥12 years) 3, 1

Duration of Treatment and Follow-up

• Oral antibiotics should typically be continued for 5-10 days 3, 1
• Re-evaluate if no improvement after 48-72 hours of therapy 1
• For recurrent impetigo, consider decolonization strategies for S. aureus carriers 1

Topical mupirocin has traditionally been effective for localized impetigo 7, but with increasing resistance rates, oral antibiotics have become necessary for treatment failures. The choice between MSSA-targeted and MRSA-targeted therapy should be guided by local resistance patterns and, when available, culture results 1, 4.