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Impetigo
- 2. DEFINITION S and FACTS Highly contagious Superficial bacterial infection Hot, humid weather Two classifications Primary Secondary Pyoderma and impetigo contagiosa Impetiginization
- 3. EPIDEMIOLOGY GREATER THAN 162 MILLION CASES TROPICAL, RESOURCE- POOR COUNTRIES NOT A REPORTABLE DISEASE
- 4. Microbiology Staphylococcus aureus Streptococcus pyrogens
- 7. POTENTIAL COMPLICATIONS Poststreptococcal Glomerulonephritis Complication of streptococcal impetigo Common findings Rheumatic Fever Countries with high rates of acute rheumatic fever Potential sequalae
- 8. PREVENTIO N • Avoid direct skin-to-skin contact with others • Resist urge to touch or scratch sores • No sharing of towels, personal items, or toys. • Keep sores clean and covered • Wash hands • Separate laundry • Disinfect surfaces • Trim nails • Apply an anti-itch medication
- 9. TREATMENT Mild cases: 1. Gentle cleansing 2. Antibiotic ointment More severe cases: Systemic antibiotics
- 13. Bowen, A. C., Mahé, A., Hay, R. J., Andrews, R. M., Steer, A. C., Tong, S. Y., & Carapetis, J. R. (2015). The global epidemiology of impetigo: A systematic review of the population prevalence of impetigo and pyoderma. Plos One,10(8). doi:10.1371/journal.pone.0136789 Sahraoui, S. (2013, June 21). Impetigo in Children and Adolescents. Retrieved from https://www.uspharmacist.com/article/impetigo-in-children-and-adolescents American Academy of Dermatology. (2018). Impetigo, 10 tips to prevent spreading the infection. Retrieved from https://www.aad.org/public/diseases/contagious-skin-diseases/impetigo#tips References Baddour, L. M. (2019). Impetigo, UpToDate. Retrieved June 12, 2019, from http://www.uptodate.com/contents/impetigo
Editor's Notes
- Impetigo is a contagious superficial bacterial infection observed most frequently in children between the ages of two to five years old, however it can occur in older children and adults. Is most common in hot, humid weather and is easily spread among individuals in close contact; risk factors include poverty, crowding, poor hygiene, and underlying scabies. The two classifications are primary and secondary. Primary is direct bacterial invasion of previously normal skin or secondary which is infection at sites of minor skin trauma such as abrasions, minor trauma, and insect bites, or underlying conditions such as eczema . Pyoderma and impetigo contagiosa are common names for primary impetigo where impetiginization is referred to secondary impetigo.
- global population of children suffering from impetigo at any one time to be in excess of 162 million, predominantly in tropical, resource-poor contexts. Impetigo is an not a reportable disease and in conjunction with scabies, comprises a major childhood dermatological condition with potential lifelong consequences if untreated.
- The principal pathogen of impetigo is S. aureus and streptococcus pyrogens, Currently S. aureus is more common than the beta-hemolytic streptooccus pathogen. Methicillin-resistant S. aureus is detected in some cases of impetigo. A Gram stain and culture of pus or exudate is recommended to identify whether S. aureus and/or a beta-hemolytic Streptococcus is the cause. However, treatment may be initiated without these studies in patients with typical clinical presentations [
- Initially the infection starts with one or more sores that are often itchy. The sores quickly burst and the skin can be red or raw where the sores have broken open. The sores begin to crust over and form a thick honey-colored crust. The skin heals without scarring unless scratching cuts are deep into the skin. Glands near the sores may be enlarged. It can spread to other parts of the body where this process begins again which is why treatment is so important. Impetigo usually affects the face and extremities what have been associated with trauma such as mosquito bites and scratches. The skin infection resolves within 2 weeks when left untreated, and often heals without scarring. Multiple lesions may be develop but normally remain well localized. Systemic manifestations are usually minimal and include weakness, fever and diarrhea. This form is caused by staph bacteria that produce a toxin that causes a break between the top layer (epidermis) and the lower levels of skin forming a blister. (The medical term for blister is bulla.) Blisters can appear in various skin areas, especially the buttocks, though these blisters are fragile and often break and leave red, raw skin with a ragged edge. No prior trauma is needed for these blisters to appear. Ecthyma is an ulcerative form of impetigo in which the lesions extend through the epidermis and deep into the dermis. They consist of "punched-out" ulcers covered with yellow crust surrounded by raised violaceous margins and is caused by Group A streptococcus .
- The diagnosis of impetigo often can be made on the basis of clinical manifestations. A complete blood count is often performed because leukocytosis is common. The key clinical findings of non-bullous impetigo, bullous impetigo, and ecthyma include: 1)Non-bullous is the most common form occurring in about 70% of cases, caused by both staph and strep bacteria. MRSA is usually associated with non-bullous form. Initially the infection starts with one or more sores that are often itchy. The sores quickly burst and the skin can be red or raw where the sores have broken open. The sores begin to crust over and form a thick honey-colored crust. The skin heals without scarring unless scratching cuts are deep into the skin. Glands near the sores may be enlarged. It can spread to other parts of the body where this process begins again which is why treatment is so important. Impetigo usually affects the face and extremities what have been associated with trauma such as mosquito bites and scratches. The skin infection resolves within 2 weeks when left untreated and resolves within 2 weeks when left untreated, and often heals without scarring. Multiple lesions may be develop but normally remain well localized. Systemic manifestations are usually minimal and include weakness, fever and diarrhea. Bullous impetigo – Flaccid, fluid-filled bullae that rupture and leave a thin brown crust; often located on the trunk This form is caused by staph bacteria that produce a toxin that causes a break between the top layer (epidermis) and the lower levels of skin forming a blister. (The medical term for blister is bulla.) Blisters can appear in various skin areas, especially the buttocks, though these blisters are fragile and often break and leave red, raw skin with a ragged edge. No prior trauma is needed for these blisters to appear. Ecthyma is an ulcerative form of impetigo in which the lesions extend through the epidermis and deep into the dermis. They consist of "punched-out" ulcers covered with yellow crust surrounded by raised violaceous margins and is caused by Group A streptococcus .
- Poststreptococcal glomerulonephritis — Poststreptococcal glomerulonephritis is a potential complication of streptococcal impetigo that most often occurs within one to two weeks following infection [10]. Common clinical findings include edema, hypertension, fever, and hematuria
- Due to the ease of transmission of impetigo it is imperative that proper infection control practices take place. Preventing the spread of impetigo is crucial due to it’s highly contagious nature. Strategies that we should educate the parents or adult patient include: AVOIDING DIRECT SKIN TO SKIN CONTACT, RESISTING THE URGE TO SCRATCH OR TOUCH SORES, DO NOT SHARE ANY ITEMS SUCH AS TOWELS, TOYS, OR OTHER PERSONAL ITEMS, KEEP SORES CLEAN AND COVERED, WASH HANDS AFTER TREATING SORES, AFTER USING TOILET AND WHEN HANDS ARE SOILED, WAS THE INFECTED PATIENTS LAUNDRY SEPARATLY IN HOT WATER, DISINFECT AREAS OF THE HOME SUCH AS COUNTER TOPS, DOORKNOBS AND OTHER SURFACES THEY MAY HAVE TOUCHED. TRIM NAILS SHORT TO PREVENT SKIN DAMAGE, IF ITCHING IS UNBEARABLE, APPLY ANTI-ITCH MEDICATION
- Mild cases can be handled by gentle cleansing, removing crusts, and applying the prescription-strength antibiotic ointment mupirocin ( Bactroban). More severe or widespread cases, especially of bullous impetigo, may require oral antibiotic medication for impetigo. impetigo may resolve spontaneously, antimicrobial treatment is indicated to relieve symptoms, prevent formation of new lesions, and prevent complications, such as cellulitis.
- Treatment of impetigo is important for reducing spread of infection, more rapid relief of discomfort, and improving the overall cosmetic appearance [29]. Bullous and non-bullous impetigo can be treated with either topical or oral therapy. Topical therapy is used for patients with limited skin involvement, whereas oral therapy is recommended for patients with numerous lesions. Mupirocin and retapamulin are the first-line topical agents recommended. Mupirocin is applied 3x daily where retapamulin is twic daily. Unlike impetigo, ecthyma should always be treated with oral therapy. In healthcare settings, contact precautions to avoid spread of impetigo are indicated until 24 hours after the start of antibiotic therapy. The benefits of topical therapy includes fewer side effects and lower risk for bacterial resistance when compared to systemic antibiotics. Although the components of over-the-counter triple antibiotic ointments (consisting of bacitracin-neomycin-polymyxin B) have some activity against the organisms causing impetigo, they may not be as effective for treatment. Therefore, treatment of impetigo with these agents is not recommended. Cultures results guide the practitioner to make the appropriate choice of antibiotics to prescribe. The first-line antibiotics includes amoxicillin-clavulanate (Augmentin), , Cefuroxime (Ceftin), cephalexin (Keflex), doxycycline and erythromycin. A 7 day course of oral antibiotics is recommended.
- Diligent handwashing is crucial to prevent the spread of impetigo. Improvement of the condition should be noted within a single course of appropriate antibiotic treatment. If lesions fail to respond it could be related to the possibility of resistant pathogens or an incorrect diagnosis. Once a child has been on an effective antibiotic for 24 hours, they can return to school but need to co er draining lesions.