What is the treatment for a 3-year-old (YOM) child weighing 17 kilograms with facial lesions consistent with impetigo?

Treatment of Impetigo in a 3-Year-Old Child (17 kg)

For this 3-year-old child with facial impetigo, initiate treatment with mupirocin 2% topical ointment applied three times daily for 5-7 days. 1, 2

First-Line Topical Therapy

• Mupirocin 2% ointment is the gold standard treatment for localized impetigo in children, applied three times daily to affected lesions for 5-7 days 1, 2
• This topical approach is FDA-approved for impetigo caused by Staphylococcus aureus and Streptococcus pyogenes, the two primary pathogens 2
• Topical antibiotics demonstrate superior cure rates compared to placebo (risk ratio 2.24) and cause fewer side effects than oral therapy 3
• Retapamulin 1% ointment twice daily for 5 days is an alternative if mupirocin is unavailable 4

When to Escalate to Oral Antibiotics

Switch to systemic therapy if:

• No improvement after 48-72 hours of topical treatment 4
• Multiple lesions are present across extensive body surface areas 1
• Systemic symptoms develop (fever, malaise, lymphadenopathy) 4
• The child cannot tolerate or comply with topical application 5

Oral Antibiotic Options (If Needed)

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

• Cephalexin 25-50 mg/kg/day divided into 3-4 doses (for this 17 kg child: approximately 425-850 mg/day total, divided) 5
• Dicloxacillin is an alternative but requires four-times-daily dosing 5

For suspected community-acquired MRSA (CA-MRSA):

• Clindamycin 10-13 mg/kg/dose every 6-8 hours (for this 17 kg child: 170-221 mg per dose) if local resistance rates are <10% 1
• Trimethoprim-sulfamethoxazole (TMP-SMX) is an alternative for MRSA but must be combined with a beta-lactam (like amoxicillin) to cover streptococcal species 1

Duration: 5-10 days of oral therapy, adjusted based on clinical response 1

Critical Pitfalls to Avoid

• Never use penicillin alone - it lacks adequate coverage against S. aureus and shows inferior cure rates compared to other antibiotics 4, 3, 6
• Do not use tetracyclines (doxycycline, minocycline) in this 3-year-old child - they are contraindicated in children under 8 years of age due to tooth discoloration risk 1, 4
• Avoid rifampin as monotherapy or adjunctive therapy for skin infections 1, 4
• Do not use topical disinfectants (like povidone-iodine or chlorhexidine) as primary treatment - they are inferior to antibiotics 1, 3
• Avoid bacitracin and neomycin - they are considerably less effective than mupirocin 4

Special Considerations for Facial Lesions

• Facial impetigo is typically caused by S. aureus or S. pyogenes, both covered by mupirocin 2, 5
• The characteristic honey-colored crusts on the face suggest nonbullous impetigo, which responds well to topical therapy 5
• Avoid contact with eyes when applying topical ointment to facial lesions 2
• Lesions should improve within 3-5 days; if not, contact the provider for reassessment 2

Hygiene and Infection Control Measures

• Keep draining wounds covered with clean, dry bandages 1
• Maintain good hand hygiene with soap and water or alcohol-based gel, especially after touching infected skin 1
• Avoid sharing personal items (towels, linens) that contact infected skin 1
• Evaluate household contacts for signs of infection 1

Emerging Resistance Patterns

• Community-acquired MRSA is increasingly recognized as a cause of impetigo, particularly in areas with high prevalence 1, 5
• Macrolide resistance (erythromycin) is rising, making it a less reliable choice 5, 7
• Mupirocin and fusidic acid demonstrate equivalent efficacy and both cover methicillin-susceptible organisms 3, 6
• If MRSA is suspected based on local epidemiology or treatment failure, empirical coverage should be considered 1