Impetigo in Children and Neonates - Guideline for the Treatment of
|Last review: 23/05/2017|
|Next review: 01/05/2020|
|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.
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
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).
1. Check if previous microbiology results are available.
2. Skin swabs for culture are recommended if:
Non-Antimicrobial Management – to be recommended in all cases
Empirical (initial) antimicrobial treatment
Limited infection without systemic symptoms
Extensive infection without systemic upset/symptoms
Systemic (unless known methicillin resistant Staphylococcus aureus (MRSA) colonisation/infection – see below)
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:
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*
Bullous impetigo with circumscribed lesions with a thin collarette of scale**
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]
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.
|Empirical Antimicrobial Treatment|
Treatment depends on the extent and severity of the infection.
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 for extensive disease in those who are NOT known to be colonised or previously infected with MRSA:
[Evidence level B]
3. Oral treatment if Penicillin allergic: Clarithromycin , dose according to weight / age.
[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 or 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.
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.
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 ) 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 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 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 ) 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.
|Directed Antimicrobial Treatment (when microbiology results are known)|
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]
|Duration of Treatment|
Recommendation: The usual duration of therapy is seven days.
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.
|Switch to oral agent(s)|
Dermatological referral is suggested in the following situations:
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.
|Target patient group:||Children and neonates with impetigo|
|Target professional group(s):||Secondary Care Doctors
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)
- George A, Rubin G. A systematic review and meta-analysis of treatments for impetigo. Br J Gen Pract 2003;53(491):480-7.
- Cole C, Gazewood J. Diagnosis and treatment of impetigo. American family physician 2007;75(6):859-64.
- 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.
- 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.
- Johnston GA. Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants. Expert Rev Anti Infect Ther 2004;2(3):439-46.
- 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.
- 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.
- 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.
- Stoddart B, Collyns T, Denton M. Fusidic acid cream for impetigo. Problem may be clinically important. Bmj 2002;324(7350):1394.
- 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.
- Summary NCK. Imptetigo manageemnt
Improving Antimicrobial Prescribing Group
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