What is the recommended treatment for impetigo in adults in Australia?

Treatment of Impetigo in Adults in Australia

For impetigo in adults in Australia, topical mupirocin 2% ointment applied three times daily for 5-7 days is the first-line treatment for localized disease, while oral antibiotics are recommended for extensive disease or when topical therapy is impractical. 1, 2

First-Line Treatment Options

• Localized impetigo: Apply topical mupirocin 2% ointment three times daily for 5-7 days 1, 2
• Alternative topical option: Fusidic acid applied to affected area 3-4 times daily 3, 4
• Topical antibiotics are effective and may be superior to oral antibiotics for limited disease 4

Second-Line Treatment Options (Oral Antibiotics)

Oral antibiotics should be used when:

• Impetigo is extensive or involves multiple sites 1, 2
• Topical therapy is impractical 1, 2
• Treatment with topical antibiotics has failed 1, 2
• Systemic symptoms are present 1, 2

For Methicillin-Susceptible S. aureus (MSSA):

• Dicloxacillin 250 mg four times daily 1, 2
• Cephalexin 250-500 mg four times daily 5, 1

For Methicillin-Resistant S. aureus (MRSA):

• Clindamycin 300-450 mg three times daily 5, 1
• Trimethoprim-sulfamethoxazole (TMP-SMX) 5, 1
• Doxycycline 5, 1

Treatment Duration

• Topical antibiotics: 5-7 days 1, 2
• Oral antibiotics: 5-10 days 2
• Re-evaluate if no improvement after 48-72 hours of therapy 2

Special Considerations for Australian Context

• In remote Australian settings, topical antibiotics are increasingly avoided due to rising antimicrobial resistance, with preference for oral or injectable antibiotics 6
• Oral erythromycin has better cure rates than penicillin (RR, 1.07; 95% CI, 1.01-1.13) 5
• Cloxacillin shows better cure rates than penicillin (RR, 1.59; 95% CI, 1.21-2.08) 5

Diagnostic Approach

• Diagnosis is typically clinical based on the characteristic honey-colored crusted lesions 7
• Cultures should be obtained if there is treatment failure, MRSA is suspected, or in cases of recurrent infections 1, 2

Prevention of Spread

• Lesions should be kept covered with clean, dry bandages 2
• Maintain good personal hygiene to prevent spread 2
• Systemic antimicrobials should be used during outbreaks of poststreptococcal glomerulonephritis to eliminate nephritogenic strains of S. pyogenes 5

Common Pitfalls and Caveats

• Penicillin alone is not effective for impetigo as it lacks adequate coverage against S. aureus 1
• If impetigo is not responding to appropriate therapy, consider alternative diagnoses 1
• Topical disinfectants are not useful in the treatment of impetigo 4

Treatment Algorithm

1. Assess extent: Determine if impetigo is localized or extensive
2. For localized disease: Start with topical mupirocin 2% ointment three times daily for 5-7 days 1, 2
3. For extensive disease: Use oral antibiotics active against both S. aureus and streptococci 5, 1
4. For suspected MRSA: Consider clindamycin, TMP-SMX, or doxycycline 5, 1
5. For treatment failure: Obtain cultures and adjust therapy based on susceptibility results 1, 2