What is the preferred treatment for bullous impetigo?

1.

Elsevier ClinicalKey Clinical Overview

Treatment Topical or oral antibiotics are acceptable treatments for impetigo; cure rates do not significantly differ Topical antibiotics are preferable in patients with localized disease Oral antibiotics The National Institute for Health and Care Excellence has also published antimicrobial prescribing guidelines for impetigo Mupirocin Retapamulin Fusidic acid (no longer available in the United States) Ozenoxacin Recommended in the following situations: Numerous lesions Outbreak affecting several people (eg, day care, family, athletic team) Ecthyma In a community where there are outbreaks of poststreptococcal glomerulonephritis Infectious Diseases Society of America recommends: Antibiotics active against methicillin-sensitive Staphylococcus aureus (unless a culture has been done and only streptococci are isolated) Dicloxacillin Cephalexin Streptococcal impetigo: penicillin Suspected or confirmed MRSA infection: doxycycline, clindamycin, or sulfamethoxazole-trimethoprim

Synopsis Impetigo is a highly contagious infectious disease that affects the superficial epidermis most commonly in children aged 2 to 5 years, although it can occur in any age group Nonbullous impetigo is caused by Staphylococcus aureus and/or Streptococcus pyogenes Bullous impetigo is always caused by Staphylococcus aureus Diagnosis is determined by history and physical examination; cultures are advisable if identification of causative agent is essential (eg, persistent or recurrent infection) Topical mupirocin is treatment of choice in patients with localized disease Oral antibiotics are recommended for patients with extensive skin lesions, outbreaks affecting multiple people, patients with ecthyma, or outbreaks associated with poststreptococcal glomerulonephritis Children and adults should stay home from school or work for 1 to 2 days after antimicrobial therapy starts No participation in contact or collision sports or in activities requiring shared equipment for 3 days after antimicrobial therapy starts Acute poststreptococcal glomerulonephritis is the most serious complication in patients with streptococcal impetigo; it affects up to 5% of patients

2.

Bolognia, Jean, MCMichael, Amy (2024). In Goldman-Cecil Medicine (pp. 2738). DOI: 10.1016/B978-0-323-93038-3.00408-1

Although mild cases of impetigo usually respond to topical 2% mupirocin three times daily, 1% retapamulin twice daily, or ozenoxacin 1% twice daily,more severe impetigo and ecthyma require oral antibiotics that coverS. aureus(e.g., dicloxacillin, 250mg orally [PO] four times daily, or cephalexin, 250mg PO four times daily). Compared with furuncles and abscesses, impetigo is less often due to methicillin-resistantS. aureus(MRSA).

3.

Kroshinsky, Daniela (2024). In Goldman-Cecil Medicine (pp. 2712). DOI: 10.1016/B978-0-323-93038-3.00406-8

Gentle washing is recommended to remove any crusts. Limited cases can be treated with topical 2% mupirocin ointment. Oral antibiotics (e.g., dicloxacillin 500mg four times daily or cephalexin 500mg three times daily) for 7 days are indicated for extensive disease and for patients who do not respond to topical antibiotics.

4.

Elsevier ClinicalKey Drug Monograph

Content last updated: January 3, 2024.

Indications And Dosage **For the treatment of impetigo and other skin and skin structure infections due to susceptible strains of S. aureus or S. pyogenes** **for the treatment of impetigo** Topical dosage (ointment) Adults: Apply a thin layer to the affected area(s) 3 times daily. The area(s) may be covered with a sterile gauze dressing. Therapy is usually continued for 1 to 2 weeks. If a response is not evident within 3 to 5 days, the infection should be reevaluated. Infants, Children, and Adolescents 2 months to 17 years: Apply a thin layer to the affected area(s) 3 times daily. The area(s) may be covered with a sterile gauze dressing. Therapy is usually continued for 1 to 2 weeks. If a response is not evident within 3 to 5 days, the infection should be reevaluated. **for the treatment of secondarily infected traumatic skin lesions (up to 10 cm in length or 100 cm2 in area)** Topical dosage (cream) Adults: Apply a thin layer to the affected area(s) 3 times daily for 10 days. If a response is not evident within 3 to 5 days, the infection should be reevaluated. Infants, Children, and Adolescents 3 months to 17 years: Apply a thin layer to the affected area(s) 3 times daily for 10 days. If a response is not evident within 3 to 5 days, the infection should be reevaluated. **for the treatment of impetigo** Topical dosage (ointment) Adults: Apply a thin layer to the affected area(s) 3 times daily. The area(s) may be covered with a sterile gauze dressing. Therapy is usually continued for 1 to 2 weeks. If a response is not evident within 3 to 5 days, the infection should be reevaluated. Infants, Children, and Adolescents 2 months to 17 years: Apply a thin layer to the affected area(s) 3 times daily. The area(s) may be covered with a sterile gauze dressing. Therapy is usually continued for 1 to 2 weeks.

5.

Elsevier ClinicalKey Drug Class Overview

Content last updated: January 1, 2012.

Cephalexin can be used for the treatment of impetigo in adults and children. Skin and soft tissue infections due to methicillin-sensitive _S. aureus_ (MSSA) can be treated with cefazolin or cephalexin in penicillin-allergic patients; however, if the patient has a history of immediate-type hypersensitivity to beta-lactam antibiotics, do not use first-generation cephalosporins. Cephalexin can serve as a first-line treatment for mild to moderate diabetic foot infections. In a randomized trial of 56 patients with mild to moderate diabetic foot infections, cephalexin had similar clinical cure rates to clindamycin with rates of 78% and 72% in clindamycin and cephalexin groups, respectively[39175]. [49858]

6.

Food and Drug Administration (DailyMed).

Publish date: September 1, 2023.

Clinical Studies 14 CLINICAL STUDIES The safety and efficacy of Xepi (ozenoxacin) for the treatment of impetigo was evaluated in two multi-center, randomized, double-blind placebo controlled clinical trials (Trial 1, (NCT01397461) and Trial 2, (NCT02090764)). Seven-hundred twenty-three (723) subjects two months of age and older with an affected body surface area of up to 100 cm 2, and not exceeding 2% for subjects aged 2 months to 11 years were randomized to Xepi (ozenoxacin) or placebo. Subjects applied Xepi (ozenoxacin) or placebo twice daily for 5 days. Subjects with underlying skin disease (e.g., preexisting eczematous dermatitis), skin trauma, clinical evidence of secondary infection, or systemic signs and symptoms of infection (such as fever), were excluded from these studies. Overall clinical success was defined as no need for additional antimicrobial therapy of the baseline affected area(s) and absence/reduction in clinical signs and symptoms assessed at the end of therapy (Day 6-7), as follows: absence of exudates/pus, crusting, tissue warmth, and pain; and erythema/inflammation, tissue edema, and itching assessed as less than mild in Trial 1; and absence of blistering, exudates/pus, crusting, and itching/pain, and mild or improved erythema/inflammation in Trial 2. Table 2 below presents the results for clinical response at the end of therapy. Table 2 Clinical Response at End of Therapy in Trial 1 and Trial 2 in All Randomized Subjects Trial 1 Trial 2 Xepi (ozenoxacin) Placebo Xepi (ozenoxacin) Placebo (N = 155) n (%) (N = 156) n (%) (N = 206) n (%) (N = 206) n (%) a The success rates for Xepi (ozenoxacin) were significantly different than placebo in Study 1 and Study 2 (p = 0.002 and p = 0.001).

Indications And Usage 1 INDICATIONS AND USAGE Xepi (ozenoxacin)™ is indicated for the topical treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes in adult and pediatric patients 2 months of age and older [see Clinical Studies (14) ]. Xepi (ozenoxacin) is a quinolone antimicrobial indicated for the topical treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes in adult and pediatric patients 2 months of age and older ( 1 ).

7.

Food and Drug Administration (DailyMed).

Publish date: June 1, 2023.

Clinical Studies 14 CLINICAL STUDIES Altabax (retapamulin) was evaluated in a placebo-controlled trial that enrolled adult and pediatric subjects aged 9 months and older for treatment of impetigo up to 100 cm 2 in total area (up to 10 lesions) or a total body surface area not exceeding 2%. The majority of subjects enrolled (164/210, 78%) were under the age of 13. The trial was a double-blind, randomized, multi-center, parallel-group comparison of the safety of Altabax (retapamulin) and placebo ointment, both applied twice daily for 5 days. Subjects were randomized to Altabax (retapamulin) or placebo (2:1). Subjects with underlying skin disease (e.g., pre-existing eczematous dermatitis) or skin trauma, with clinical evidence of secondary infection, were excluded from these trials. In addition, subjects with any systemic signs and symptoms of infection (such as fever) were excluded from the trial. Clinical success was defined as the absence of treated lesions, or treated lesions had become dry without crusts with or without erythema compared with baseline, or had improved (defined as a decline in the size of the affected area, number of lesions or both) such that no further antimicrobial therapy was required. The intent-to-treat clinical (ITTC) population consisted of all randomized subjects who took at least 1 dose of trial medication. The clinical per protocol (PPC) population included all ITTC subjects who satisfied the inclusion/exclusion criteria and subsequently adhered to the protocol. The intent-to-treat bacteriological (ITTB) population consisted of all randomized subjects who took at least 1 dose of trial medication and had a pathogen identified at trial entry. The bacteriological per protocol (PPB) population included all ITTB subjects who satisfied the inclusion/exclusion criteria and subsequently adhered to the protocol. Table 4 presents the results for clinical response at end of therapy (2 days after treatment) and follow-up (9 days after treatment), by analysis population. Table