Impetigo - Antibiotic Prescribing

Comments from Expert Advisory Group

Impetigo in children is highly contagious
Do not offer combination topical and oral antibiotics
As resistance is increasing reserve topical antibiotics for very localised lesions (≤ 3 lesions). Prior to application of topical antibiotics soak off crusts with petroleum jelly (Vaseline^®) and gently remove with a warm, damp facecloth to increase absorption
HPSC update on group A Streptococcus
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staphylococcus aureus and is associated with persistent recurrent pustules and carbuncles or cellulitis. Send swabs for culture in these clinical scenarios. On rare occasions it causes more severe invasive infections, even in otherwise fit people. Risk factors include: nursing homes, contact sports, sharing equipment, poor hygiene and eczema

Non-bullous vs Bullous Impetigo

Image: Non-Bullous Impetigo

Image: Bullous Impetigo

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Perioral honey-coloured crusts in impetigo

Image Source: Dermnet

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Widespread bullous impetigo over the back

Image Source: Dermnet

Drug	Children’s Dose	Adult Dose	Duration	Notes
1st choice option
Flucloxacillin	See flucloxacillin dosing table for children	500mg every 6 hours	5-7 days	Avoid in penicillin allergy To optimise absorption, take on an empty stomach (either 1 hour before food or 2 hours after food).
2nd choice options
Cefalexin	See cefalexin dosing table for children	500mg every 12 hours	5-7 days	Cephalosporins should not be used in severe penicillin allergy.
Clarithromycin	See clarithromycin dosing table for children	250mg every 12 hours (can be increased if necessary in severe infection to 500mg every 12 hours)	5-7 days	Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy.
1st choice option in pregnant, penicillin allergic patients
Clindamycin		300mg every 6 hours	5-7 days	Caution: risk of C. difficile.
Topical Treatment for Non-Bullous Impetigo (Reserve for very localised lesions – ≤3 lesions)
Fusidic Acid	Topically to affected areas every 8 hours		5-7 days

Contact school/child care facilities to determine how long a child should stay away (usual guidance is to stay home until lesions have crusted over, or until 24 hours after patients have started treatment, however some establishments may have their own guidance)
Keep sores, blisters and crusty patches clean and dry
Encourage patient and household contacts to wash hands regularly
Wash flannels, sheets and towels at a high temperature
Wash or wipe down toys with detergent and warm water if children have impetigo

We recommend patients use the following links to get further information about managing impetigo:

Dosing in children quick reference dosage/weight guide
Clarithromycin and other macrolides warning
Penicillin allergy – tips on prescribing in penicillin allergy
Renal impairment dosing table
Safety in Pregnancy and Lactation
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed November 2022