Treatment of Impetigo in the Pediatric Population: Consensus and Future Directions

March 2020 | Volume 19 | Issue 3 | Original Article | 281 | Copyright © March 2020


Published online February 10, 2020

Lawrence A. Schachner , Antonio Torrelo , Ayman Grada , Giuseppe Micali , Pearl C. Kwong , Gwenolyn B. Scott , Latanya Benjamin , Mercedes E. Gonzalez , Anneke Andriessen , Thomas Eberlein , Lawrence F. Eichenfield

aDivision of Pediatric Dermatology, The Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery; Department of Pediatrics, Leonard M. Miller School of Medicine, University of Miami, FL bDepartment of Dermatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain cDepartment of Dermatology, Boston University School of Medicine, Boston, MA dDermatology Clinic, University of Catania, Catania, Italy eAffiliated with Wolfson Children’s Hospital, Jacksonville, FL fDivision of Pediatric Infectious Disease (Pediatrics), University of Miami Miller School of Medicine, Miami, FL gPediatric Dermatology, Florida Atlantic University, Boca Raton, FL hThe Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Leonard M. Miller School of Medicine, University of Miami; Pediatric Dermatology of Miami, Miami, FL iRadboud UMC Nijmegen, Andriessen Consultants, Malden, The Netherlands jWCC Wound Competence Centre, Linz, Austria kDepartments of Dermatology and Pediatrics, University of California, San Diego and Rady Children's Hospital, San Diego, CA

Abstract
Background: Impetigo is a common contagious superficial bacterial skin infection. Treatment of localized lesions can be achieved through topical antibiotics. Oral antibiotics are reserved for extensive disease. Increasing antimicrobial resistance to existing therapies have raised concerns. Antimicrobial stewardship, achieved through the responsible use of antibiotics, is an important measure to re-duce bacterial resistance. This review highlights treatment options for impetigo and shares consensus statements to help guide the management of impetigo in the pediatric population.
Objective: An expert panel of dermatologists and pediatricians convened in February 2019 to establish evidence-based consensus on the management of impetigo in the pediatric patient population.
Methods: The consensus was created in accordance with the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument. Prior to the consensus meeting, a systematic literature review was conducted, with the selected literature deemed clinically relevant to the consensus statements. Statements were further refined and assessed systematically following established standards. The consensus process consisted of a modified Delphi approach. The consensus was established through a minimal 75% “agree” rate.
Results: Thirteen consensus statements were developed addressing clinical challenges, existing treatment options and their limita-tions, and new therapeutic alternatives.
Conclusion: Bacterial resistance to antimicrobials commonly used in treating impetigo has been reported. Antimicrobial stewardship is critical to optimize patient outcomes and to prevent the development of resistance. Healthcare providers should be aware of local resistance patterns in impetigo to help guide therapy. The use of newer safe and effective topical antibiotic alternatives as a first-line treatment should be an important step in antimicrobial stewardship.

J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4679

INTRODUCTION

Impetigo is a very common, highly contagious superficial bacterial skin infection caused primarily by Staphylococcus aureus (S. aureus), less frequently by Streptococcus pyogenes (S. pyogenes) or both organisms.1 Group A S. pyogenes remains a common cause of non-bullous impetigo in developing countries. Impetigo occurs most frequently in children aged 2 to 5 years but may affect younger and older children as well as adults.2 More than 3 million cases of impetigo are reported in the United States each year. It is the third most common skin disorder in children and the most common skin infection in young children presenting in general practice in western Europe.2 The global median childhood prevalence is estimated to be 12.3% with a peak in tropical, low-income settings.3 The