NICE NG153

NICE NG153 (February 2020) is NICE’s antimicrobial prescribing guideline for Impetigo. Impetigo is a contagious superficial skin infection, common in toddlers, and more likely on skin broken by Atopic Dermatitis. The guideline starts with hygiene: advise parents on measures that stop it spreading to other parts of the body and to other people. It sits alongside NICE NG190, which covers infected eczema. Telling the two apart in practice is a judgement call (see Infected Eczema).

NICE [defines] NICE NG153 NICE NG153 [treats] Impetigo Atopic Dermatitis [relates] Impetigo NICE NG153 [relates] NICE NG190

Stepwise treatment. For localised non-bullous impetigo in a child who is not systemically unwell, NICE says to consider Hydrogen Peroxide Cream 1% two or three times daily for 5 days. NICE found no evidence for other antiseptics. If peroxide is unsuitable (e.g. near the eyes) or fails, use Fusidic Acid 2% three times daily for 5 days, or Mupirocin 2% if fusidic acid resistance is suspected. Widespread non-bullous impetigo can be treated with either a topical or an oral antibiotic. Bullous impetigo, or impetigo in a child who is unwell or at high risk, needs oral antibiotics. Topical and oral antibiotics should not be combined.

Hydrogen Peroxide Cream [treats] Impetigo Fusidic Acid [treats] Impetigo Mupirocin [treats] Impetigo NICE NG153 [opposes] Antimicrobial Resistance

Toddler doses (under-18 table). The first oral choice is Flucloxacillin for 5 days: 62.5–125 mg four times daily from 1 month to 1 year, and 125–250 mg four times daily at 2–9 years. Clarithromycin is used for penicillin allergy, or if the flucloxacillin liquid is unpalatable and the child cannot swallow capsules. It is weight-banded, e.g. 62.5 mg twice daily at 8–11 kg and 125 mg twice daily at 12–19 kg. A 5-day course can be extended to 7 days for severe or extensive lesions. Mupirocin licences in infants vary between products. NICE warns that extended or repeated fusidic acid or mupirocin use increases resistance.

Flucloxacillin [treats] Impetigo Clarithromycin [treats] Impetigo

Reassessment and referral. Reassess if the child worsens or has not improved after a course. Consider herpes simplex (Eczema Herpeticum in a child with eczema) and Cellulitis. Swab after a failed topical or oral course. For frequent recurrences, swab, take a nasal swab and consider decolonisation. Refer to hospital for signs of serious illness or for widespread impetigo in an immunocompromised child. Consider specialist advice for bullous impetigo, especially in babies aged 1 year and under.

Eczema Herpeticum [relates] Impetigo NICE NG153 [precedes] When to Refer

Connections

• Impetigo — governing prescribing guideline, source: NICE NG153
• NICE NG190 — companion guideline for infected eczema, source: NICE
• Hydrogen Peroxide Cream — first-line for localised non-bullous impetigo, source: NICE NG153
• Fusidic Acid — first-choice topical antibiotic, 5 days, source: NICE NG153
• Mupirocin — alternative if fusidic acid resistance, source: NICE NG153
• Flucloxacillin — first-choice oral; 2–9 y 125–250 mg QDS, source: NICE NG153
• Clarithromycin — penicillin allergy or unpalatable flucloxacillin, source: NICE NG153
• Antimicrobial Resistance — no topical+oral combination; limit repeat courses, source: NICE NG153
• Cellulitis — reassessment differential and referral trigger, source: NICE NG153