What is the drug of choice for impetigo (impetigo contagiosa) in pediatric patients?

Drug of Choice for Impetigo in Pediatric Patients

Topical mupirocin 2% ointment applied three times daily for 5-7 days is the first-line treatment for localized impetigo in pediatric patients. 1, 2

First-Line Treatment

• Mupirocin 2% topical ointment is recommended for minor skin infections such as impetigo in children, with application three times daily for 5-7 days 3, 1
• Clinical efficacy rates for mupirocin in pediatric patients with impetigo are high (78-96%), significantly better than placebo (36%) 2
• Mupirocin has demonstrated comparable or superior efficacy to oral erythromycin in treating pediatric impetigo with fewer side effects 2, 4
• Retapamulin 1% ointment applied twice daily for 5 days is an effective alternative for limited impetigo 1

When to Use Oral Antibiotics

Oral antibiotics should be used in the following situations:

• When impetigo is extensive or involves multiple sites 3, 1, 5
• When topical therapy is impractical 1, 5
• When treatment with topical antibiotics has failed 1, 5
• When systemic symptoms are present 1

Recommended Oral Antibiotic Options

For oral therapy when indicated, options include:

• For methicillin-susceptible S. aureus (MSSA):

  • Cephalexin: 25 mg/kg/day in 4 divided doses for children 1, 5
  • Dicloxacillin: 12 mg/kg/day in 4 divided doses for children 5
  • Amoxicillin-clavulanate: 25 mg/kg/day of amoxicillin component in 2 divided doses 5

• For methicillin-resistant S. aureus (MRSA) or when MRSA is suspected:

  • Clindamycin: 10-20 mg/kg/day in 3 divided doses 3, 1, 5
  • Trimethoprim-sulfamethoxazole (TMP-SMX): 8-12 mg/kg/day (based on trimethoprim component) in 2 divided doses 3, 5
  • Note: Tetracyclines (doxycycline, minocycline) should NOT be used in children under 8 years of age 3, 1, 5

Duration of Treatment

• Topical antibiotics should be used for 5-7 days 1, 5
• Oral antibiotics should be used for 5-10 days 3, 5
• Re-evaluation is recommended if no improvement after 48-72 hours of therapy 1, 5

Important Clinical Considerations

• Cultures should be obtained if there is treatment failure, MRSA is suspected, or in cases of recurrent infections 1, 5
• Penicillin alone is not effective for impetigo as it lacks adequate coverage against S. aureus 1, 5
• Mupirocin has shown clinical efficacy against MRSA, but bacterial culture is recommended to rule out resistance 6
• Keep draining wounds covered with clean, dry bandages to prevent spread 3
• Maintain good personal hygiene with regular bathing and cleaning of hands 3
• Avoid reusing or sharing personal items that have contacted infected skin 3

Common Pitfalls and Caveats

• Topical mupirocin is not formulated for use on mucosal surfaces 2
• Prolonged use of topical antibiotics may result in overgrowth of nonsusceptible organisms, including fungi 2
• Rising resistance rates to mupirocin represent a growing concern in some regions 6, 7
• If impetigo has not improved in 3 to 5 days, consider switching to oral antibiotics or obtaining cultures to guide therapy 5, 2
• For hospitalized children with complicated skin infections, IV vancomycin or clindamycin may be needed 3