Impetigo in Neonates and Children

• Diagnostics
• Definitions
• Initial empirical antimicrobial management
• Non-antimicrobial management
• Re-assessment and further treatment

Impetigo is a superficial skin infection which is usually mild and uncomplicated. If cellulitis is present follow LTHT guideline for cellulitis in children.

Diagnostics

For neonates and children with a presumed diagnosis of impetigo the following diagnostic tests should be taken to confirm diagnosis:

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Definitions

Non-bullous impetigo

Non-bullous lesions originate as small vesicles (<1cm), which rapidly burst leaving gold crusting. These lesions are usually asymptomatic, but may itch. Systemic features are uncommon unless the infection is widespread. It has been further categorized as primary, or secondary to underlying causes e.g. atopic eczema, scabies, or head lice.

Localised – no clinical features of extensive or widespread impetigo
Widespread - extensive area of skin involvement

Bullous impetigo or impetigo in people who are systemically unwell or at high risk of complications

Bullous impetigo can affect any area of the skin including the axillae, necks folds and nappy areas. Lesions originate as flaccid, fluid filled blisters often over 1cm diameter. These easily burst leaving flat, weepy, red, often annular, areas often with golden crusts. They are often multiple and painful (sometimes significantly so) and have a tendency to spread rapidly. Systematic features such as fever, lethargy and regional lymphadenopathy may be present. They can look similar to a cigarette burn. Swelling of lymph nodes draining affected skin areas is common. It is more common and often more extensive in those with a tendency to dry skin / eczema and can commonly complicate other skin conditions.

Initial empirical antimicrobial management

Most common organisms: Staphylococcus aureus and beta haemolytic Streptococci, such as Streptococcus pyogenes

Localised non-bullous impetigo

For neonates/children not systemically unwell or at high risk of complications:

• Consider hydrogen peroxide 1% cream (dose information in table below)
  Although other topical antiseptics are available NICE found no evidence for using them to treat impetigo
• If hydrogen peroxide 1% cream is unsuitable offer a short course of a topical antibiotic

Widespread non-bullous impetigo

For neonates/children not systemically unwell or at high risk of complications:

• Offer a short course of a topical or oral antibiotic (see table below)
• Take into account:
  • that topical and oral antibiotics are both effective at treating impetigo
  • the preferences of the patient and parent(s)/carer(s) including practicalities of administration and potential adverse effects
  • previous use of topical antibiotics as antimicrobial resistance can develop rapidly with extended or repeated use

Bullous impetigo or impetigo in people who are systemically unwell or at high risk of complications

Offer a short course of an oral antibiotic (see table below).

Antimicrobial information

• See BNF for Children for appropriate use and dosing in specific populations, e.g. hepatic impairment, renal impairment, pregnancy and breastfeeding
• Licensing for use in infants varies between products, see individual summaries of product characteristics for more details, dosing in some age ranges may be ‘off-label’
• A 5-day course is appropriate for most people with impetigo but can be increased to 7 days based on clinical judgement, depending on severity and number of lesions
• Extended or recurrent use of antimicrobials can increase the risk of developing resistance, ensure antimicrobial choice appropriate
• Do not offer combination treatment with a topical and an oral antibiotic to treat impetigo

Table 1: Antimicrobial information

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Non-antimicrobial management

• Offer advice regarding appropriate hygiene measures (e.g. not sharing towels, bathing separately, careful attention to hand hygiene, no contact sports until lesions fully healed) to reduce spread of impetigo to other areas of the body as well as other people
• Advise absenteeism from nursery/school for child until lesions no longer wet/weepy/sore/painful
• A clean cloth soaked in boiled and cooled water (tepid) can be applied as a compress to moist areas for 5-10 minutes several times a day and then any crusts can be gently wiped off
• Antibacterial products can be used to wash e.g. Dermol® products (can be used on eczematous skin) or Hibiscrub® (avoid if skin eczematised as significant irritation/stinging is likely)

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Re-assessment and further treatment

Advise parent(s) or carer(s) to seek medical help if symptoms rapidly or significantly worsen at any time, or if they have not improved after completing the course of treatment.

When re-assessing neonates or children with impetigo, take account of:

• other possible diagnoses e.g. herpes simplex, scabies, fungal, eczema
• any symptoms or signs suggestive of a more serious illness or condition e.g. cellulitis
• previous antibiotic use, which may have led to resistant bacteria

For neonates/children with impetigo that is worsening or has not improved after treatment with hydrogen peroxide 1% cream offer:

• a short course of a topical antibiotic if the impetigo remains localised (see table) or
• a short course of a topical antibiotic or oral antibiotic if the impetigo has become widespread (see table)

For neonates/children with impetigo that is worsening or has not improved after treatment with a course of topical antibiotics:

• offer a short course of an oral antibiotic (see table) and
• consider sending a skin swab for microbiological testing

For neonates/children with impetigo that is worsening or has not improved after treatment with a course of oral antibiotics: send a skin swab for microbiological testing and consider alternative oral antibiotic therapy (see table).

If patient has recurrent episodes then send a skin swab for microbiological testing and consider taking nasal swab and commencing appropriate treatment.

For any patient where swabs are sent for microbiological testing: Review the choice of antibiotic when results are available and change according to results if symptoms are not improving using a narrow spectrum antibiotic if possible.

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