What is the first-line management for in-hospital impetigo?

First-Line Management of In-Hospital Impetigo

For hospitalized children with impetigo, mupirocin 2% topical ointment applied three times daily for 5-7 days is the first-line treatment. 1, 2, 3

Initial Treatment Approach

Topical Therapy as First-Line

• Mupirocin 2% ointment applied three times daily for 5-7 days is the gold standard for localized impetigo, with clinical efficacy rates of 71-93% in controlled trials 2, 4
• The IDSA specifically recommends mupirocin 2% topical ointment for children with minor skin infections such as impetigo 1
• Retapamulin 1% ointment applied twice daily for 5 days is an effective alternative if mupirocin is unavailable 2, 3
• Avoid bacitracin and neomycin as they are considerably less effective 2

When to Escalate to Systemic Antibiotics

Switch to oral antibiotics if there is no improvement after 48-72 hours of topical therapy or if any of the following are present: 2, 3

• Extensive disease involving multiple body sites
• Systemic symptoms (fever, malaise, lymphadenopathy)
• Signs of systemic inflammatory response
• Immunocompromised status 1

Oral Antibiotic Selection for In-Hospital Cases

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

• Dicloxacillin 250 mg four times daily for adults (weight-adjusted for children) 2, 3
• Cephalexin 250-500 mg four times daily for adults is an alternative 2, 3
• Duration: 5-10 days 3

For Suspected or Confirmed MRSA:

Given the in-hospital setting, MRSA coverage should be strongly considered, particularly if the patient has risk factors including: 1

• Long-stay care facility residence
• Hospitalization within preceding 30 days
• Current hospitalization >16 days
• Recent antibiotic exposure (beta-lactams, carbapenems, quinolones)
• Age ≥75 years
• Charlson score >5 points

Recommended MRSA-active agents: 1, 2, 3

• Clindamycin 600 mg IV or PO three times daily for adults (10-13 mg/kg/dose IV every 6-8 hours for children, only if local clindamycin resistance rate is <10%) 1
• Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily for adults 2, 3
• Linezolid 600 mg PO/IV twice daily for children >12 years; 10 mg/kg/dose PO/IV every 8 hours for children <12 years 1

Critical Pitfalls to Avoid

• Never use penicillin alone—it lacks adequate coverage against S. aureus 2, 3
• Never use rifampin as monotherapy or adjunctive therapy for skin infections 1, 2
• Tetracyclines (doxycycline, minocycline) are contraindicated in children <8 years of age 1, 2, 3

Pediatric-Specific Considerations

• For hospitalized children with complicated SSTI, vancomycin is recommended as first-line IV therapy 1
• Clindamycin is an option for stable children without ongoing bacteremia if local resistance rates are low 1
• All oral antibiotic dosing must be weight-adjusted for children 3

Infection Control Measures

In the hospital setting, implement strict contact precautions: 1

• Keep draining wounds covered with clean, dry bandages
• Maintain hand hygiene with soap and water or alcohol-based gel after touching infected skin
• Evaluate contacts for evidence of S. aureus infection
• Consider nasal and topical body decolonization of symptomatic contacts following treatment of active infection

Culture Guidance

Obtain cultures from purulent lesions in the following situations: 1, 3

• Treatment failure after 48-72 hours
• Suspected MRSA
• Severe local infection or signs of systemic illness
• Concern for a cluster or outbreak in the hospital setting