What is the appropriate management for a neonate presenting with a significant size and number of pustules?

Management of Significant Neonatal Pustulosis

For a neonate presenting with significant size and number of pustules, immediate assessment for systemic illness is mandatory, with empiric parenteral antibiotics required for extensive disease or any signs of sepsis, while localized pustulosis in well-appearing full-term neonates can be managed with topical mupirocin alone. 1, 2

Immediate Clinical Assessment

The critical first step is distinguishing between benign transient pustulosis and potentially life-threatening infectious causes:

• Perform rapid bedside diagnostics immediately: Tzanck smear (most important first test), Gram stain, and potassium hydroxide (KOH) preparation should be performed on pustule contents before initiating therapy 3, 4
• Assess for systemic signs: Fever, poor feeding, lethargy, irritability, or loss of alertness indicate sepsis and mandate immediate hospitalization and parenteral antibiotics 1, 5
• Recognize that absence of vesicular rash does not exclude herpes simplex virus (HSV) - only 60% of neonates with CNS or disseminated HSV disease present with vesicular rash 1

Risk Stratification and Treatment Thresholds

Extensive Disease Requiring Parenteral Antibiotics:

• Any neonate with systemic signs or symptoms 2
• Premature infants with pustulosis (regardless of extent) 2
• Neonates with risk factors: central lines, prolonged antibiotics, recent surgery 2
• Rapidly spreading pustules or underlying bony involvement 5

Localized Disease Amenable to Topical Therapy:

• Full-term infants ≤30 days with localized pustulosis and no systemic signs can receive topical mupirocin 2-3 times daily with close monitoring 2

Empiric Antibiotic Therapy

For neonates requiring systemic treatment:

Age 8-28 Days with Suspected Sepsis:

• Amphotericin B 0.5-1 mg/kg/day IV if disseminated cutaneous candidiasis is suspected in premature/low birth weight infants 1
• Ampicillin 150 mg/kg/day IV divided every 8 hours PLUS either ceftazidime 150 mg/kg/day IV divided every 8 hours OR gentamicin 4 mg/kg IV every 24 hours for bacterial sepsis 1

Suspected Staphylococcal/Streptococcal Infection:

• Nafcillin or oxacillin 50 mg/kg/dose IV every 6 hours 5
• Vancomycin for MRSA: Initial dose 15 mg/kg, followed by 10 mg/kg every 12 hours in first week of life, then every 8 hours up to 1 month of age, infused over 60 minutes 6
• Avoid TMP-SMX in immediate neonatal period due to kernicterus risk 2
• Cefalexin is contraindicated in neonates (birth to 28 days) 5

Essential Diagnostic Workup

For Extensive Disease or Systemic Illness:

• Blood cultures 2
• Lumbar puncture with CSF PCR for HSV DNA (diagnostic test of choice for HSV encephalitis) 1
• Culture specimens from blood, skin vesicles, mouth/nasopharynx, eyes, urine, stool if HSV suspected 1
• Dilated retinal examination and imaging of genitourinary tract, liver, spleen if sterile body fluid cultures persistently positive for Candida 7

Bedside Diagnostics:

• Tzanck smear: Detects multinucleated giant cells (HSV) and differentiates eosinophils (benign) from neutrophils (infectious) 3
• Gram stain: Identifies bacterial pathogens 3, 4
• KOH preparation: Detects fungal elements 3, 4

Specific Infectious Considerations

Candidiasis in High-Risk Neonates:

• Amphotericin B deoxycholate 1 mg/kg/day for invasive candidiasis 7
• Liposomal amphotericin B 2.5-7 mg/kg/day is an alternative with better safety profile 7
• Fluconazole 12 mg/kg daily is reasonable alternative if urinary tract involvement excluded 7
• Treatment duration: 3 weeks minimum 7
• Catheter removal is strongly recommended 7

HSV Infection:

• Grouped vesicles on erythematous base appearing at 10-11 days of age are characteristic 1
• Initiate acyclovir immediately if HSV suspected while awaiting confirmatory testing 1

Local Wound Care

• Gently cleanse pustules with antimicrobial solution without rupturing initially 5
• Pierce pustules at base with sterile needle if drainage needed, apply gentle pressure with sterile gauze 5
• Avoid deroofing blisters or pustules 5
• Apply nonadherent dressing as needed 5

Critical Pitfalls to Avoid

• Never delay antibiotics for imaging or extensive workup in systemically ill neonates 5
• Do not use high-potency topical corticosteroids on infant facial skin due to systemic absorption risk and HPA axis suppression 1
• Neonates under 2 weeks can deteriorate rapidly from localized infection to sepsis - maintain high index of suspicion 5
• Monitor premature infants especially closely as they require immediate escalation to systemic antibiotics with any clinical change 2
• In nurseries with high invasive candidiasis rates (>12%), consider fluconazole prophylaxis 3-6 mg/kg twice weekly for neonates <1000g 7