Impetigo in Children and Neonates - Guideline for the Treatment of

Publication: 16/07/2012  --
Last review: 23/05/2017  
Next review: 01/05/2020  
Clinical Guideline
CURRENT 
ID: 2787 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

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.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

Guideline for the Treatment of Impetigo in Children and Neonates

Summary
Impetigo in Children and Neonates

Impetigo is a superficial skin infection which is usually mild and uncomplicated. If cellulitis is present follow LTHT guideline for cellulitis in children (GL1610).

Diagnosis
Diagnosis is made clinically and swabs should be sent to microbiology for confirmation of bacterial growth and sensitivities. Treatment is determined by severity:

  • Limited impetigo = no clinical features of extensive impetigo.
  • Extensive impetigo = extensive area of skin involvement (multiple lesions with at least one >3cm diameter) AND / OR signs of systemic infection (fever >38oC, off food/vomiting, tachycardia, malaise)
  • Always consider / exclude an additional background dermatological problem e.g. eczema, scabies, head lice etc.

Investigation

1. Check if previous microbiology results are available.

2. Skin swabs for culture are recommended if:

  • Diagnosis is uncertain (also send viral swabs in appropriate viral culture medium for Herpes Simplex and Varicella/zoster virus PCR)
  • Impetigo is extensive
  • Impetigo is recurrent (also check nasal swabs and skin swabs from any areas of broken/inflamed skin from close contacts)
  • There is no improvement following a seven-day course of initial treatment (topical or systemic).
  • Infection develops in a neonate
  • Infection develops in an inpatient or within one month of recent hospital admission
  • Infection develops in an immune-compromised inpatient

Non-Antimicrobial Management – to be recommended in all cases

  • Optimise hygiene practices (e.g. not sharing towels, bathing separately, careful attention to hand hygiene, avoiding contact sports until lesions are fully healed).
  • Absenteeism from nursery / school for young children until all wet or weepy areas have started healing, dried out, have crusted over and are no longer painful/sore.
  • A clean cloth soaked in tepid (boiled) water can be applied as a compress to moist areas for 5-10 minutes several times a day and any crusts then gently wiped off.
  • Antibacterial product to wash e.g. Dermol products (can be used on eczematous skin), Hibiscrub (avoid if skin eczematised as significant irritation/stinging is likely).

Empirical (initial) antimicrobial treatment

Limited infection without systemic symptoms
Topical

  • Hydrogen peroxide 1% cream applied 2-3 times daily for 1 week
  • Failure with Hydrogen peroxide cream: Fusidic acid 2% cream/ointment applied 3-4 times daily (be aware of possible Fusidic acid resistance)
  • Treat any associated dry skin or eczema appropriately with ointment based emollients and topical steroids (do not start topical steroids without appropriate antibiotic or antibacterial cover).
  • Wash hands immediately after applying topical treatment
  • If symptoms have not improved after 7 days check previous swab result, repeat swabs for microbiology +/- virology and consider systemic treatment and exclude additional dermatological problem e.g. head lice, scabies etc.

Systemic

  • Not recommended

Extensive infection without systemic upset/symptoms

Topical

  • As per management of limited infection.

AND

Systemic (unless known methicillin resistant Staphylococcus aureus (MRSA) colonisation/infection – see below)

  • First line if no Pencillin allergy – Oral Flucloxacillin electronic Medicines Compendium information on Flucloxacillin dose according to weight / age:
    • Neonate under 7 days           25mg / kg BD
    • Neonate 7-20 days                 25mg / kg TDS
    • Neonate 21-28 days              25mg / kg QDS
    • Child 1 month–2 years          62.5–125 mg QDS
    • Child 2–10 years                    125–250 mg QDS
    • Child 10 –18 years                 250–500 mg QDS
  • First line if Penicillin allergic – Oral Clarithromycin electronic Medicines Compendium information on Clarithromycin , dose according to weight / age:
    • Neonate                     7.5 mg/kg BD
    • Child 1 month–11 years
      • Body-weight <8kg           7.5 mg/kg BD
      • Body-weight 8–11 kg      62.5 mg BD
      • Body-weight 12–19 kg   125 mg BD
      • Body-weight 20–29 kg   187.5 mg BD
      • Body-weight 30–40 kg    250 mg BD
    • Child 12–18 years                          250 mg BD
    • Directed (targeted) antimicrobial therapy
      If swabs have been taken, use directed therapy section of full guideline to direct therapy.
      Known MRSA infection and extensive impetigo – Discuss systemic therapy with microbiology.

      Duration of therapy – 7 days

Extensive infection with systemic upset/symptoms

Refer urgently to Secondary Care Dermatology or Paediatric Medicine for consideration of inpatient treatment with IV antibiotic therapy (see below)

Specialist Dermatology Secondary Care referral is recommended if:

  • The diagnosis is uncertain.
  • Extensive impetigo, not responding to regimen recommended.
  • Recurrent infections.
  • There is significant associated atopic dermatitis or eczema herpeticum or other skin pathology is suspected.
  • Systemic upset e.g. pyrexia, malaise, dehydration – refer urgently to on call dermatologist

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Background

Impetigo is a superficial skin infection usually caused by Staphylococcus aureus and less often group A Beta-haemolytic Streptococci or both. It usually arises on a background of minor skin breaks or secondary to an underlying skin problem - Impetigo can complicate herpes simplex virus lesions, varicella/shingles, fungal, scabetic and head lice infections as well as eczema and other less common dermatoses.

Infection is usually mild, but can occasionally be extensive. It is a common problem in childhood with an annual incidence of around 2.8% in children up to 4 years of age, and 1.6% in children 5–15 years of age in the UK 1.

Non-bullous and bullous forms occur (see diagnosis section). This distinction does not affect the approach to therapy. Non-bullous impetigo is the most common form and most commonly affects the perioral area and nose. As this is a common site for herpetic cold sores, always consider that local impetigo may be complicating underlying herpetic infection i.e. both infections may be present at the same time.

In most cases, impetigo is self-limiting however it can cause psychological distress and there may be complications associated with disseminated impetigo in rare cases 2.

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Clinical Diagnosis

Non-bullous impetigo (also known as impetigo contagiosa or crusted impetigo)

Non-bullous lesions originate as small vesicles, 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.

Non-bullous impetigo with vesicles, pustules, and sharply demarcated regions of honey-colored crusts*
*source: http://www.dermnetnz.org/bacterial/impetigo.html

Bullous impetigo
Bullous impetigo can affect any area of the skin including the axillae, necks folds and nappy areas and is most commonly seen in neonates. Lesions originate as flaccid, fluid filled blisters. 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 common3.

Bullous impetigo with circumscribed lesions with a thin collarette of scale**
**source: http://emedicine.medscape.com/article/965254-overview#showall

The initial approach to therapy should be determined by severity, rather than the type of impetigo described above, however, bullous impetigo is more likely to be associated with systemic symptoms and be categorized as extensive.

N.B Recurrent impetigo is considered a relapse of impetigo within 8 weeks after initial clinical resolution. [Evidence level D]

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Investigation

Most cases of impetigo can be managed without microbiological investigation, but treatment decisions may be influenced by the results of previous skin swabs, particularly if a child has suffered relapsing/recurrent infection or has secondary bullous impetigo due to another underlying skin problem such as eczema, for example

When treatment failure has occurred or infection develops in hospital (or following recent admission), the risk of resistant pathogens is higher, justifying microbiological investigation. In extensive infection, attempting to gain knowledge of the causative organism can be justified on the basis of ensuring that empirical therapy is correct. Immuno-compromised patients may have atypical presentation and are at risk of more severe manifestations.

Recommendations:

1. Check previous microbiology results to see if the child has been infected or colonised with methicillin-resistant (MRSA) or fusidic acid-resistant Staphylococcus aureus in the past. [Evidence level D]

2. Skin swabs for culture should be sent if:

  • diagnosis is uncertain (also send samples for Herpes Simplex and Varicella/zoster virus PCR)
  • impetigo is extensive
  • impetigo is recurrent (also check nasal swabs and skin swabs from any areas of broken/inflamed skin from close contacts)
  • there is no improvement following a seven-day course of initial treatment (topical or systemic).
  • infection develops in an inpatient or following recent admission (<1month)
  • infection develops in an immune-compromised inpatient.
  • the patient has previously been MRSA positive
    [Evidence level C/D]

3. Nasal swabs to identify staphylococcal carriage can be considered in children suffering recurrent infection (see “Treatment failure” section) and close household contacts but there is no evidence that this is beneficial.

A small case control study showed an association between nasal colonisation with S. aureus among close contacts of patients with atopic dermatitis and severity of the condition, however no such study has been done for impetigo4. The role of screening for S. aureus carriage in the patient and close household contacts has been recommended, but efficacy has not been assessed5. Nasal colonisation with S. aureus was not associated with serious staphylococcal infection in one recent US study 6. However, this investigation confirmed a 25% colonisation rate and found that 40% of households had colonised individuals 6.

4. Viral swab: When herpetic lesions are suspected, vesicular fluid can be processed by PCR for herpes simplex virus and varicella/zoster virus (swabs need to be sent in appropriate viral culture medium). Note that when herpetic lesions are significantly secondarily infected with S. aureus, viral swabs may be negative even when underlying herpetic infections is present.

5. MRSA colonised patients should be managed according to the MRSA policy (684) as well as therapy recommended herein. [Evidence level D]

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Treatment
Non-Antimicrobial Treatment

Recommendations:

  • Optimize hygiene practices while lesions are present (for example: not sharing towels, bathing separately, careful attention to hand hygiene, avoiding contact sports until lesions are fully healed).
  • Absenteeism from nursery/school for young children advised until all sores have started healing and crusted over.
  • A clean dressing soaked in tepid (boiled) water can be applied as a compress to moist areas for 5-10 minutes several times a day and then wipe off the crusts gently.
  • Wash hands after handling infected skin or clothing/items or products in contact with infected skin.
    [Evidence level B/D]

Towel sharing and sports participation have been identified as independent risk factors for serious skin and soft tissue infection in a recent detail US study 6 but there is no strong evidence base for the rest of these recommendations, which represent collective experience, “common sense” or common practice.

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Empirical Antimicrobial Treatment

Treatment depends on the extent and severity of the infection.

Recommendations:

1. Topical treatment, continued for 7-10 days, should be used for both extensive and limited infection. [Evidence level C]

- Hydrogen peroxide 1% cream (applied two to three times daily) is first line therapy for limited impetigo. [Evidence level B]

- Fusidic acid 2% cream or ointment applied three to four times daily should be used as first line therapy for extensive impetigo or as second line therapy for limited infection if hydrogen peroxide has failed. [Evidence level A]

- Polymyxin B/bacitracin is also indicated for impetigo (applied two to three times daily) but evidence for use is lacking.

- Antimicrobial emollient wash products (such as those containing chlorhexidine, benzalkonium chloride or triclosan) may be considered for those with extensive infection or background skin condition, however, contact stinging/irritation may occur. Chlorhexidine is not recommended for babies or young children.

2. Oral treatment if non-Penicillin allergic: Flucloxacillin electronic Medicines Compendium information on Flucloxacillin for extensive disease in those who are NOT known to be colonised or previously infected with MRSA:

  • First line if no Pencillin allergy - Flucloxacillin electronic Medicines Compendium information on Flucloxacillin , dose according to weight / age:
    • Neonate under 7 days           25mg / kg BD
    • Neonate 7-20 days                 25mg / kg TDS
    • Neonate 21-28 days               25mg / kg QDS
    • Child 1 month–2 years          62.5–125 mg QDS
    • Child 2–10 years                     125–250 mg QDS
    • Child 10 –18 years                 250–500 mg QDS

[Evidence level B]

3. Oral treatment if Penicillin allergic: Clarithromycin electronic Medicines Compendium information on Clarithromycin , dose according to weight / age.

  • Neonate                                                   7.5 mg/kg BD
  • Child 1 month–11 years
    • Body-weight <8kg                     7.5 mg/kg BD
    • Body-weight 8–11 kg               62.5 mg BD
    • Body-weight 12–19 kg             125 mg BD
    • Body-weight 20–29 kg             187.5 mg BD
    • Body-weight 30–40 kg              250 mg BD
  • Child 12–18 years                                   250 mg BD

[Evidence level B]

4. Inpatient care and IV antibiotic therapy

- If inpatient care is warranted, contact isolation is recommended.

- Inpatient care is required for patients with impetigo who have extensive infection with systemic symptoms (tachycardia, hypotension, pyrexia, dehydration) or for infants at risk of sepsis and/or dehydration due to skin loss.

- Inpatient care is also required if there is associated toxic shock syndrome (Staphylococcal Scalded Skin Syndrome). Consider toxic shock syndrome (skin becomes extremely painful, peeling occurs at the site of redness/crusting but also at other areas e.g. flexures, peri-ocular areas and angles of the mouth with or without systemic symptoms).

- Skin swabs from involved areas and nasal swabs should be sent for microbiology, viral swabs for virology and fungal scrapings for mycology if fungal infection is suspected.

- Intravenous antibiotics ( Flucloxacillin electronic Medicines Compendium information on Flucloxacillin or Clarithromycin electronic Medicines Compendium information on Clarithromycin at appropriate doses) should be commenced in conjunction with intravenous antiviral medication if there is any suspicion of associated herpetic infection.

- If there is any suspicion of additional viral infection e.g. herpes simplex, after swabs have been taken, IV Aciclovir should also be given at appropriate doses.

- Appropriate fluid monitoring and replacement and pain relief are essential. Fluid is given at a volume and rate similar to standard volume replacement for burns. Pain is often severe and appropriate analgesia is very important.

- With regard to topical therapy, after swabs have been taken, a light emollient ointment such as mix of 50:50 liquid paraffin: white soft paraffin should be regularly applied to raw/crusted areas. Eczematised areas can be treated with appropriate strength topical steroid ointment provided that antibiotics have already been commenced and there is no suspicion of herpetic infection.

Evidence review

The rationale for treatment is to speed resolution (and thus reduce soreness / symptoms), to reduce the spread of infection to others and to improve appearance (lesions can be unsightly, particularly on the face).

Antimicrobial therapy can be applied either topically and/or administered systemically.

Topicals

There are two main options for topical therapy of impetigo: antimicrobials and antiseptics (sometimes also called “disinfectants” in the literature). Two different antiseptics, hydrogen peroxide and hexachlorophane were included in the Cochrane review 3. In a review of data from three randomised controlled trials (RCTs), hydrogen peroxide was slightly less effective than fusidic acid but the difference was not statistically significantly different 7. However, the authors of the Cochrane review found the blinding in this study to be inadequate. Hydrogen peroxide has the advantage of not selecting for and having activity against fusidic acid resistant staphylococci. For these reasons, hydrogen peroxide is recommended as first line for limited infection.

Topical antibiotics produce better cure rates than placebo 31. Mupirocin and fusidic acid have similar clinical efficacy 31. There is good evidence that topical fusidic acid and mupirocin are at least as effective as some systemic antimicrobials (e.g. Erythromycin electronic Medicines Compendium information on Erythromycin) 3. Topical therapy has the advantage of easier localised administration and lack of systemic side effects such as antibiotic associated diarrhoea.

Fusidic acid has been reported to have high resistance rates and it is recommended that its use is restricted in order to limit the rising levels of resistance 8 9. Mupirocin resistance is also increasing with use and this agent is the mainstay of MRSA topical “decolonisation” therapy in LTHT. Mupirocin is not therefore recommended for routine use in impetigo. Fusidic acid was superior to hydrogen peroxide in RCTs, but not significantly so, however, because of methodological concerns, fusidic acid is recommended as first line therapy for extensive impetigo.

A newer topical antibiotic, retapamulin 1% has been shown to be equivalent in efficacy to fusidic acid in a comparative RCT 10. This product is not currently available at LTHT and is more expensive than fusidic acid without offering additional clinical benefit.

Antimicrobial wash products may be considered for those with extensive infection or background skin condition, however, there is a lack of evidence to suggest that disinfectant solutions improve impetigo. However, contact stinging/irritation may be significant, particularly if there is background eczema. When 2 studies with 292 participants were evaluated, topical antibiotics were significantly better than disinfecting treatments.3 Chlorhexidine and triclosan are preferred when an antiseptic with persistent activity is desirable, however a moist environment appears necessary for antibacterial activity.

Systemic treatment

Systemic anti-microbials do not offer any advantage over topical therapy for non-severe disease and are therefore not recommended 31. It is established practice to use systemic antimicrobial therapy for severe infection and, from a practical perspective, they are also used for extensive infection. Penicillin is ineffective 3, probably because this infection is predominantly caused by Staphylococcus aureus, which is usually resistant to penicillin, and is not therefore recommended. Flucloxacillin electronic Medicines Compendium information on Flucloxacillin is a narrow spectrum agent that is effective against susceptible Staphylococcus aureus strains and has a low propensity to cause Clostridium difficile infection (CDI) or gastrointestinal side effects and therefore the preferred systemic agent. Macrolides (e.g. Clarithromycin electronic Medicines Compendium information on Clarithromycin ) have less predictable activity against Staphylococcus aureus, a worse side effect profile (usually diarrhoea and other gastrointestinal side effects) and are therefore only recommended for the truly penicillin allergic child. A lack of evidence of superiority, unnecessarily broad spectrum and CDI risk mean that oral cephalosporins and co-amoxiclav are not recommended for impetigo.

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Directed Antimicrobial Treatment (when microbiology results are known)

Recommendation:

1. Microbiology results need only influence treatment if patients are not responding clinically to current therapy. [Evidence level D]

2. For extensive impetigo caused by methicillin resistant Staphylococcus aureus (MRSA) systemic therapy should be guided by susceptibility, but may include agents like co-trimoxazole, linezolid and clindamycin. [Evidence level D]

3. First line therapy for limited MRSA-positive impetigo is topical fusidic acid 2% cream or ointment applied three times daily, provided the isolate is susceptible. [Evidence level D]

4. The usual topical agents should be effective against impetigo caused by Group A streptococci. [Evidence level B]

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Duration of Treatment

Recommendation: The usual duration of therapy is seven days.
[Evidence level C]

Topical treatment with antimicrobials should not be used for longer than 7-10 days due to the risk of developing resistance and sensitivity reactions. Although antimicrobials have been given for 10 days in most clinical trials, there is no evidence that this duration is more effective than a 7-day course. If lesions have not responded within this time frame see treatment failure section.

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Switch to oral agent(s)
N/A

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Treatment Failure

Recommendations:

Dermatological referral is suggested in the following situations:

  • The diagnosis is uncertain.
  • There is extensive disease with or without systemic features.
  • Any systemic features
  • Lesions are resistant to maximal treatment.
  • There are recurrent infections (a relapse of impetigo within 8 weeks after clinical resolution). [Evidence level D] 11

Note: It is common to have impetigo superimposed on other conditions such as eczema or other infections e.g. scabies, herpetic, fungal or head lice infection. Always consider this as a reason for poor response.

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Provenance

Record: 2787
Objective:

Aims

  • To standardize and improve the diagnosis and management of impetigo in children and neonates and harmonize recommendations for primary and secondary care.

Objectives

  1. To provide evidence-based recommendations for appropriate diagnosis and investigation of impetigo in children and neonates
  2. To provide evidence-based recommendations for appropriate non-antimicrobial management of impetigo in children and neonates
  3. To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of impetigo in children and neonates
  4. To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  5. To advise in the event of antimicrobial allergy.
  6. To set out criteria for referral to specialists.
Clinical condition:

Impetigo

Target patient group: Children and neonates with impetigo
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

Evidence levels:

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (Where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

References:

  1. George A, Rubin G. A systematic review and meta-analysis of treatments for impetigo. Br J Gen Pract 2003;53(491):480-7.
  2. Cole C, Gazewood J. Diagnosis and treatment of impetigo. American family physician 2007;75(6):859-64.
  3. Koning S, Verhagen AP, van Suijlekom-Smit LW, Morris A, Butler CC, van der Wouden JC. Interventions for impetigo. Cochrane database of systematic reviews (Online) 2004(2):CD003261. Updated 2012.
  4. Chiu LS, Chow VC, Ling JM, Hon KL. Staphylococcus aureus carriage in the anterior nares of close contacts of patients with atopic dermatitis. Arch Dermatol 2010;146(7):748-52.
  5. Johnston GA. Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants. Expert Rev Anti Infect Ther 2004;2(3):439-46.
  6. Miller M, Cook HA, Furuya EY, Bhat M, Lee MH, Vavagiakis P, et al. Staphylococcus aureus in the community: colonization versus infection. PLoS One 2009;4(8):e6708.
  7. Christensen OB, Anehus S. Hydrogen peroxide cream: an alternative to topical antibiotics in the treatment of impetigo contagiosa. Acta Derm Venereol 1994;74(6):460-2.
  8. Denton M, O'Connell B, Bernard P, Jarlier V, Williams Z, Henriksen AS. 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(3):586-8.
  9. Stoddart B, Collyns T, Denton M. Fusidic acid cream for impetigo. Problem may be clinically important. Bmj 2002;324(7350):1394.
  10. Oranje AP, Chosidow O, Sacchidanand S, Todd G, Singh K, Scangarella N, et al. Topical retapamulin ointment, 1%, versus sodium fusidate ointment, 2%, for impetigo: a randomized, observer-blinded, noninferiority study. Dermatology 2007;215(4):331-40.
  11. Summary NCK. Imptetigo manageemnt 

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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