Impetigo

Treat a typical superficial, crusted eruption as impetigo on clinical grounds. Nonbullous impetigo commonly follows minor cutaneous trauma and affects the face or extremities; bullous impetigo produces flaccid bullae from toxin-producing S. aureus. ScienceDirect+1ScienceDirectSkin Microflora and Bacterial Infections of the Skin - ScienceDirect.comIDSASkin and Soft Tissue Infections - IDSA Do not use morphology to choose staphylococcal versus streptococcal coverage in nonbullous disease: physical examination cannot reliably make that distinction. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC

Identify ecthyma as a management-changing branch. IDSA recommends an oral antimicrobial for ecthyma rather than topical therapy. IDSAIDSASkin and Soft Tissue Infections - IDSA In a patient with a lesion that is not clinically typical, obtain a bacterial specimen and broaden the diagnostic assessment rather than repeatedly prescribing topical antibiotics.

Escalate from lesion-limited management to oral therapy when lesions are numerous or when several people are affected in an outbreak; this choice is intended to reduce transmission as well as treat the individual. IDSAIDSASkin and Soft Tissue Infections - IDSA Bullous and nonbullous forms can otherwise be treated with either topical or oral antimicrobials. Oxford Academic+1Oxford AcademicPractice Guidelines for the Diagnosis and Management of Skin and ...IDSASkin and Soft Tissue Infections - IDSA

For impetigo or ecthyma, collect Gram stain and culture from lesion pus or exudate when pathogen identification is needed; IDSA recommends this approach to identify S. aureus and/or beta-hemolytic streptococci. IDSAIDSASkin and Soft Tissue Infections - IDSA In a classic, limited presentation, empiric therapy without microbiology is reasonable. IDSAIDSASkin and Soft Tissue Infections - IDSA CDC similarly notes that laboratory testing is not routinely performed, although culture or Gram stain of exudate or pus can identify the bacterial cause. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC

Obtain culture before changing therapy in questionable lesions, recurrent disease, treatment nonresponse, or clustered cases in which susceptibility data may guide management and outbreak control. Culture is also useful in outbreaks of poststreptococcal glomerulonephritis to identify nephritogenic group A streptococcal strains. ScienceDirect+1ScienceDirectCommunicable Disease - an overview | ScienceDirect TopicsPubMedSummary of Evidence - Topical Antibiotics for Impetigo: A Review of the Clinical Effectiveness and Guidelines - NCBI Bookshelf A negative or nondiagnostic superficial sample should prompt reconsideration of the diagnosis rather than automatic escalation of antibiotic spectrum.

Interpret a culture in the clinical context: nonbullous impetigo may involve S. aureus, group A streptococci, or both, whereas bullous impetigo is associated with toxin-producing S. aureus. ScienceDirect+1ScienceDirectCommunicable Disease - an overview | ScienceDirect TopicsIDSASkin and Soft Tissue Infections - IDSA Initial antimicrobial selection should cover both group A streptococci and S. aureus unless microbiology supports a narrower directed regimen. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC

For limited bullous or nonbullous impetigo, prescribe mupirocin or retapamulin topically twice daily for 5 days. IDSAIDSASkin and Soft Tissue Infections - IDSA Mupirocin ointment 2% has been evaluated in randomized impetigo trials. dailymed nlm nihdailymed nlm nihMUPIROCIN OINTMENT USP, 2% - DailyMed Topical therapy limits systemic exposure and, for localized nonbullous disease, can be as effective as oral antibiotic treatment with minimal systemic adverse-effect risk from lower absorption. WHOWHO[PDF] Essential Medicines List Antibiotic Book

Use an oral antimicrobial when lesions are numerous or during outbreaks, and use oral therapy for ecthyma. IDSAIDSASkin and Soft Tissue Infections - IDSA The oral regimen should be active against both S. aureus and group A streptococci. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC In pediatric bullous impetigo, cephalexin or clindamycin is listed as recommended oral treatment. publications aappublications aapSkin and Soft-Tissue Infections - AAP Publications Select an oral agent using patient allergy history, local susceptibility information, and culture results when obtained.

Do not extend or broaden treatment solely because lesions are initially widespread if culture and clinical response support the chosen regimen. Conversely, failure of a topical course should trigger reassessment of adherence, lesion diagnosis, bacterial culture, and the need for oral treatment rather than serial empiric topical substitutions. Resistance to mupirocin and fusidic acid has been reported and is a stewardship concern. PubMed+1PubMedNon-bullous Impetigo: Incidence, Prevalence, and Treatment in the Pediatric Primary Care Setting in ItalyPubMedOzenoxacin 1% in Pediatric and Adult Patients with Impetigo: A Meta-Analysis of Randomized Trials

Cover all lesions to reduce spread to other people and to other body sites. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC Reinforce hand hygiene and avoidance of lesion manipulation, because direct contact and excoriation facilitate transmission and autoinoculation. ScienceDirect+1ScienceDirectCommunicable Disease - an overview | ScienceDirect TopicsCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC This is especially important when lesions are on exposed areas, which commonly include the face and extremities. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC

Instruct households to wash clothing, linens, and towels used by the affected person daily and not share them before washing. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC After laundering, these items are safe for use by others. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC In schools, daycare settings, and workplace clusters, pair these measures with oral treatment when an outbreak affects several people. IDSAIDSASkin and Soft Tissue Infections - IDSA

Patients may return to school or work at least 12 hours after beginning antibiotic treatment if lesions are covered. CDCCDCClinical Guidance for Group A Streptococcal Impetigo | Group A Strep | CDC This timing rule applies alongside—not instead of—ongoing lesion coverage and hygiene.