Impetigo - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  --
Last review: 15/03/2016  
Next review: 05/12/2019  
Clinical Guideline
ID: 2254 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.




Preferred option



Reserve topical antibiotics for very localised lesions to reduce the risk of resistance 1C, 4B+
Reserve mupirocin for MRSA decolonisation 1C

Fusidic acid cream
Topical TDS
5 days3A+


For extensive, severe, or bullous impetigo, use oral antibiotics 1C

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin
Adult:500mg QDS
Child 1mth- 1yr: 62.5-125mg
Child 2-9years: 125-250mg
Child 10-17yrs: 250-500mg
All QDS 7 days 2C

Clarithromycin electronic Medicines Compendium information on Clarithromycin
Adult: 250-500mg BD
Child 1mth- 11yrs
Weight up to 8kg:7.5mg/kg
Weight 8-11kg: 62.5mg
Weight 12-19kg:125mg
Weight 20-29kg: 187mg
Weight 30-40kg: 250mg
Child 12-17yrs; 250mg
All BD 7 days.

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  6. 1,A+
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. Co-Amoxiclav (Amoxicillin-Clavulanate), quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  9. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  10. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.
  11. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic tablets are similar cost. In children erythromycin may be preferable as clarithromycin syrup is twice the cost.
  12. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.


Record: 2254
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:


Target patient group:
Target professional group(s): Primary Care Doctors
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.

Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.

Study design


Good recent systematic review of studies


One or more rigorous studies, not combined


One or more prospective studies


One or more retrospective studies


Formal combination of expert opinion


Informal opinion, other information


Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

  1. Public Health England and the British Infection Association recommend that topical antibiotics are reserved only for treatment of very localised lesions because fusidic acid is an antibiotic that is also used systemically. There are concerns that widespread use of topical fusidic acid will lead to increased resistance, rendering systemic fusidic acid (used for severe staphylococcal infections such as osteomyelitis or systemic MRSA) ineffective. If a topical antibiotic is used, a short course (such as 5 days) reduces exposure and the risk of resistance. Since few agents are effective against MRSA, mupirocin should be reserved for such cases.
  2. 2. Public Health England and the British Infection Association recommend flucloxacillin for first-line treatment of impetigo because it is a narrow-spectrum antibiotic that is effective against Gram positive organisms, including beta-lactamase producing Staphylococcus aureus, and it demonstrates suitable pharmacokinetics, with good diffusion into skin and soft tissues. Clarithromycin is recommended for people with penicillin allergy because it is also active against most staphylococcal and streptococcal species.
  3. 3. Koning S, Verhagen AP, van Suijlekom-Smit LWA, Morris AD, Butler C, van der Wouden JC. Interventions for impetigo. Cochrane Database of Systematic Reviews. 2003. Issue 2. Accessed 23.09.14. RATIONALE: Many RCTs identified by this Cochrane review were of poor methodological quality. Pooled data from four RCTs found no difference in cure rates between topical mupirocin and topical fusidic acid (OR 1.22, 95% CI 0.69 to 2.16). Most RCTs that compared topical compared with oral antibiotics used mupirocin. However, mupirocin is reserved for MRSA and should not be used first-line for impetigo. Topical fusidic acid was significantly better than oral erythromycin in one study, but no difference was seen between fusidic acid and oral cefuroxime in a different arm of the same study. Topical bacitracin was significantly worse than oral cefalexin in one small study, but there was no difference between bacitracin and erythromycin or penicillin in two other studies. The results of one non-blinded RCT suggested that topical fusidic acid was more effective than topical hydrogen peroxide, but this did not quite reach statistical significance.
  4. 4. Public Health England and the British Infection Association recommend that topical retapamulin or polymixin are reserved for use in areas where there are rising rates of resistance to fusidic acid. Polymixin (contains bacitracin) has less robust RCT evidence than fusidic acid. Although topical retapamulin has been demonstrated to be non-inferior to topical fusidic acid for the treatment of impetigo in one randomized controlled trial, it is more expensive and there are less safety data available (it is a black triangle drug).
  5. Denton M, O’Connell B, Bernard P, Jarlier V, Williams Z, Santerre Henriksen A. The EPISA study: antimicrobial susceptibility of Staphylococcus aureus causing primary or secondary skin and soft tissue infections in the community in France, the UK, and Ireland. J Antimicrob Chemother 2008;61:586-588. RATIONALE: Of S. aureus isolates from the UK, only 75.6% were susceptible to fusidic acid. A diagnosis of impetigo was associated with reduced fusidic acid susceptibility.

Document history

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