Impetigo Antibiotic Stewardship and the Need for Treatment Alternatives
November 2026 | Volume 25 | Issue 11 | 1003 | Copyright © November 2026
Published online October 29, 2026
Lawrence Schachner MD FAAD FAAPa, Anneke Andriessen PhDb, Latanya Benjamin MD FAAD FAAPc, Mercedes E. Gonzalez MD FAADd, Adelaide Hebert MD FAADe, Leon Kircik MD FAADf, Pearl Kwong MD FAAD FAAPg, Peter Lio MD FAADh, Ayleen Pinera-Llano MD FAAPi, Antonio Torrelo MDj, Vanja Adzovic PharmDk, Nanette Silverberg MD FAAD FAAPl
aDermatology and Pediatrics, Pediatric Dermatology, University of Miami School of Medicine, Miami, FL
bRBC consultants, Anneke Andriessen & Co BV, Malden, The Netherlands
cYoung Skin MD, Florida Atlantic University, Parkland, FL
dPediatric Skin Research, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
eDepartment of Dermatology and Pediatrics, McGovern Medical School, and Children's Memorial Hermann Hospital, Houston, TX
fIcahn School of Medicine at Mount Sinai, New York, NY; Indiana University Medical Center, Indianapolis, IN; Physicians Skin Care, PLLC, Louisville, KY; DermResearch, PLLC, Louisville, KY
gSuncoast Skin Solutions Inc and Principal Investigator Apex Clinical Trials, Jacksonville, FL
hDermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
iKings Bay Pediatrics, Miami FL, Nicklaus Children's Hospital, Miami, FL, Baptist Hospital Miami FL, South Miami Hospital, Miami FL
jDepartment of Dermatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
kBlue Quill Communications, Toronto, Canada
lDepartment of Pediatric and Adolescent Dermatology, St. Luke's-Roosevelt and Beth Israel Medical Centers, New York, NY
Abstract
Background: Impetigo is a highly contagious bacterial skin infection, primarily caused by Staphylococcus aureus and, less frequently, Streptococcus pyogenes. Although typically self-limiting, treatment is recommended to reduce symptom burden, limit transmission, and prevent complications. Increasing antimicrobial resistance to commonly used topical antibiotics presents a growing challenge, highlighting the need to develop new topical antibiotics and incorporate antibiotic stewardship principles into impetigo management.
Methods: A structured literature review was conducted to evaluate the clinical efficacy, safety, and antimicrobial resistance associated with topical treatments for impetigo. An international panel of dermatologists, including pediatric dermatologists and a pediatrician, convened in February 2026 to review the evidence and provide clinical insights on stewardship-informed management strategies.
Results: Topical antibiotics remain first-line therapy for localized uncomplicated impetigo. However, resistance to topical antibiotics commonly used to treat impetigo (eg, mupirocin, fusidic acid, and retapamulin) has been widely reported. Antibiotic stewardship is an essential component of impetigo management and promotes the use of the right antibiotic for the right duration. Topical ozenoxacin, which acts against organisms resistant to other topical agents and has a low capacity for developing resistance, may help address existing gaps and support stewardship-informed care.
Conclusions: Impetigo represents an important opportunity for antimicrobial stewardship in dermatology. Consideration of local trends in antibiotic resistance, antibiotic-sparing strategies, and use of novel agents may help optimize management and address current limitations in care.
INTRODUCTION
Increasing rates of antimicrobial resistance in clinical practice underscore the importance of antibiotic stewardship in improving patient outcomes.1 While stewardship efforts have largely focused on systemic infections, superficial skin infections such as impetigo represent an important opportunity to optimize antibiotic prescribing.
Impetigo is 1 of the most common bacterial skin infections, with over 3 million cases reported in the United States every year.1,2 Although most common in children aged 2-5 years, impetigo can occur across all age groups.3 Impetigo is primarily caused by Staphylococcus aureus (S. aureus) and less frequently by both S. aureus and Streptococcus pyogenes (S. pyogenes) or just S. pyogenes. Both S. aureus and S. pyogenes cause the
