What is the recommended treatment and dosage of Mupirocin for a patient with a bacterial skin infection, such as impetigo, or nasal colonization with Methicillin-resistant Staphylococcus aureus (MRSA)?

Mupirocin Treatment for Bacterial Skin Infections and MRSA Decolonization

For impetigo and localized bacterial skin infections, apply mupirocin 2% ointment three times daily for up to 10 days; for MRSA nasal decolonization, apply intranasally twice daily for 5-10 days. 1

Dosing for Skin Infections (Impetigo, Secondarily Infected Wounds)

• Apply a small amount of mupirocin 2% ointment with a cotton swab or gauze pad to the affected area three times daily 1
• Maximum treatment duration is 10 days 1
• Cover the treated area with gauze dressing if desired 1
• Re-evaluate patients not showing clinical response within 3-5 days 1
• Expected outcomes: >90% bacterial eradication and >80% clinical cure or marked improvement 2, 3

Critical Limitation for Abscesses

• For furuncles (boils) and carbuncles, incision and drainage is the PRIMARY treatment—mupirocin alone is insufficient 4, 5
• Systemic antibiotics are indicated if extensive surrounding cellulitis or fever is present 4
• Mupirocin may serve as adjunctive therapy after drainage 5

Dosing for MRSA Nasal Decolonization

• Apply intranasal mupirocin 2% twice daily for 5-10 days 4, 5
• The 10-dose regimen (twice daily for 5 days) is superior to 6-dose regimens, maintaining decolonization for at least 4 weeks post-treatment (89.5% vs 68.0% success, p=0.016) 6
• For surgical prophylaxis in MRSA carriers, start at least 48 hours before surgery and continue for 5-7 days total 5

Enhanced Decolonization Protocol for Recurrent Infections

When simple hygiene measures fail, combine the following for 5-14 days: 4, 5

• Intranasal mupirocin twice daily 4
• Daily chlorhexidine body washes 4, 5
• Daily decontamination of personal items (towels, sheets, clothes) 4
• Dilute bleach baths (¼-½ cup per full bath) as an alternative to chlorhexidine 4

Monthly Suppressive Therapy for Recurrent Furunculosis

• Apply intranasal mupirocin twice daily for the first 5 days of each month—reduces recurrences by approximately 50% 5
• Alternative: clindamycin 150 mg daily for 3 months decreases subsequent infections by approximately 80% 5

Important Contraindications and Precautions

Do NOT Use Mupirocin For:

• Intranasal, ophthalmic, or other mucosal surfaces (except the specific intranasal formulation for decolonization) 1
• Extensive infections requiring systemic therapy 5
• Patients with moderate or severe renal impairment when treating large open wounds (polyethylene glycol absorption risk) 1
• Known hypersensitivity to mupirocin 1

Avoid Concurrent Application

• Do not apply mupirocin concurrently with other lotions, creams, or ointments 1

Monitor for Resistance

• High-level mupirocin resistance (MIC >512 µg/mL) is associated with treatment failure 5
• Increased mupirocin use predisposes to resistance, with rates as high as 81% reported in some settings 7
• Prolonged or indiscriminate use should be avoided 5
• Resistance is strongly associated with previous mupirocin exposure 7

When Systemic Antibiotics Are Required Instead

Switch to or add systemic antibiotics for: 4, 5

• Fever or systemic signs of infection (SIRS) 4
• Extensive cellulitis surrounding the infection 4
• Deep soft tissue infections 5
• Immunocompromised patients with significant infections 4
• No clinical improvement within 5 days of topical therapy 4
• Complicated skin and soft tissue infections requiring hospitalization 5

Specific Systemic Regimens for Severe Infections

• For cellulitis with MRSA risk factors (penetrating trauma, known MRSA colonization, injection drug use, purulent drainage, or SIRS): vancomycin or another agent effective against both MRSA and streptococci 4
• Duration: minimum 5 days, extended if not improved 4

Practical Application Pearls

• For lower extremity cellulitis, examine interdigital toe spaces—treating fissuring or maceration reduces recurrence risk 4
• Elevation of affected area and treatment of predisposing factors (edema, underlying skin disorders) are essential adjuncts 4
• Household contacts should be evaluated; symptomatic contacts require treatment, and asymptomatic contacts may benefit from decolonization 4
• Environmental hygiene: focus on high-touch surfaces (counters, doorknobs, bathtubs, toilet seats) 4

Common Pitfalls to Avoid

• Do not use mupirocin as monotherapy for abscesses—drainage is mandatory 4, 5
• Do not continue beyond 10 days without reassessment 1
• Avoid eye contact; rinse well with water if accidental contact occurs 1
• Discontinue if severe local irritation or sensitization develops 1
• One randomized trial showed intranasal mupirocin alone (without body decolonization) did NOT reduce subsequent skin infections in military MRSA carriers 4—emphasizing the need for comprehensive decolonization protocols when indicated

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