Recommended Treatment for Pediatric Impetigo
For children with minor, localized impetigo, topical mupirocin 2% ointment applied three times daily for 5-7 days is the first-line treatment, while extensive disease requires oral antibiotics such as cephalexin (25-50 mg/kg/day divided into 4 doses) or dicloxacillin, with clindamycin or trimethoprim-sulfamethoxazole reserved for suspected MRSA. 1, 2, 3
Initial Assessment and Treatment Selection
For localized disease (few lesions):
- Start with topical mupirocin 2% ointment applied three times daily for 5-7 days 1, 3, 4
- Topical therapy is superior to oral antibiotics for limited lesions, with fewer side effects and excellent cure rates (RR 2.24 vs placebo) 5
- Alternative topical option is retapamulin if mupirocin is unavailable 6, 2
For extensive disease (multiple lesions, widespread involvement):
- Oral antibiotics are required when topical therapy is impractical 1, 2, 4
- First-line oral options for presumed methicillin-susceptible S. aureus:
MRSA Coverage Considerations
When to suspect MRSA:
- High local MRSA prevalence (>10% resistance rate) 1, 2
- Treatment failure with standard antibiotics 6, 2
- Known MRSA exposure or previous MRSA infection 1, 2
Oral antibiotics for suspected/confirmed MRSA:
- Clindamycin: 10-20 mg/kg/day divided into 3 doses for 7 days (preferred if local resistance <10%) 1, 6, 2
- Trimethoprim-sulfamethoxazole: 8-12 mg/kg/day (trimethoprim component) divided into 2 doses for 7 days 1, 6, 2
- Doxycycline: 2-4 mg/kg/day divided into 2 doses for 7 days (only for children ≥8 years) 1, 6, 2
Critical Pitfalls to Avoid
Do not use penicillin alone - it lacks adequate coverage against S. aureus and has inferior cure rates compared to other antibiotics (RR 1.29-1.59 for treatment failure) 6, 5
Avoid tetracyclines (including doxycycline) in children <8 years due to risk of permanent dental staining 1, 6, 2
Do not use topical disinfectants - they are inferior to antibiotics and not recommended for impetigo treatment 1, 5
Be aware of erythromycin resistance - macrolides have increasing resistance rates and should be used with caution 6, 2, 4
Treatment Failure Protocol
If no improvement after 3-5 days of topical mupirocin:
- Switch to oral antibiotics (cephalexin, dicloxacillin, or amoxicillin-clavulanate) 6, 2
- Consider mupirocin resistance, which is increasingly documented 6
- Obtain bacterial cultures to guide therapy 1, 6
If oral antibiotics fail:
- Consider MRSA and switch to clindamycin or TMP-SMX 6, 2
- Obtain cultures for susceptibility testing 1, 6
- For severe cases requiring hospitalization, use IV vancomycin (children) or IV clindamycin 10-13 mg/kg/dose every 6-8 hours if clindamycin resistance is <10% 1, 6
Treatment Duration and Monitoring
Standard treatment duration is 5-10 days for both topical and oral antibiotics 1, 6, 2
Reassess at 48-72 hours if no clinical improvement to rule out deeper infection or alternative diagnosis 6
Prevention of Spread
Keep draining wounds covered with clean, dry bandages 1, 2
Maintain good hand hygiene with soap and water or alcohol-based gel, particularly after touching infected skin 1, 2
Avoid sharing personal items (razors, linens, towels) that contact infected skin 1, 2
Evaluate symptomatic contacts for evidence of S. aureus infection and treat as needed 1
Special Populations
For recurrent impetigo:
- Evaluate for nasal carriage of S. aureus 7
- Consider decolonization strategies after treating active infection 1, 6
- Nasal mupirocin may be used for decolonization in carriers 1
During outbreaks of poststreptococcal glomerulonephritis:
- Use systemic antimicrobials to eliminate nephritogenic strains 2
For pregnant patients: