A 6-year-old child presents with honey-crusted lesions on the face and exposed areas of the body. Gram stain shows Gram-positive cocci in clusters. What is the drug of choice for non-bullous impetigo?

Question

Accepted Answer

B. Cloxacillin. ## Drug of Choice for Non-Bullous Impetigo

**Key Point:** Non-bullous impetigo (most common form, ~70% of cases) is caused by *Staphylococcus aureus* and/or *Streptococcus pyogenes*. First-line treatment is a **β-lactamase-resistant penicillin** (antistaphylococcal penicillin).

### First-Line Agents

| Agent | Route | Dosing | Notes |
| --- | --- | --- | --- |
| **Cloxacillin** | Oral | 250–500 mg QID | First-line oral agent in India; excellent S. aureus coverage |
| **Flucloxacillin** | Oral | 250–500 mg QID | Equivalent to cloxacillin; used in some regions |
| **Amoxicillin-clavulanate** | Oral | 375–625 mg TDS | Alternative if β-lactamase production suspected |
| **IV Nafcillin/Oxacillin** | IV | 1–2 g QID | Reserved for severe/systemic cases |

**High-Yield:** Cloxacillin is the **preferred oral agent** for impetigo in India and most South Asian guidelines because:
- Excellent oral bioavailability
- High tissue penetration
- Cost-effective
- Covers both MSSA and MRSA-susceptible strains

### Why Not Cephalosporins or Macrolides?

**Clinical Pearl:** Ceftriaxone (3rd-generation cephalosporin) is **overkill** for localized impetigo and is reserved for systemic/invasive infections. Erythromycin has high resistance rates (>30% in many regions) and is no longer recommended as monotherapy.

**Mnemonic:** **BIPP** = **B**-lactamase-resistant **I**-**P**enicillin for **P**yoderma (impetigo).

### Topical Alternative

For **localized, non-bullous impetigo** (limited to <5 lesions, no systemic signs), **mupirocin 2% ointment** applied TDS for 7–10 days is equally effective and preferred to avoid systemic antibiotic overuse. However, for widespread disease, oral cloxacillin remains standard.

[cite:Park 26e Ch 6]

Answer

A. Flucloxacillin

Answer

C. Erythromycin

Answer

D. Ceftriaxone

A 6-year-old child presents with honey-crusted lesions on the face and exposed areas of the body. Gram stain shows Gram-positive cocci in clusters. What is the drug of choice for non-bullous impetigo?

Explanation

Drug of Choice for Non-Bullous Impetigo

First-Line Agents

Why Not Cephalosporins or Macrolides?

Topical Alternative

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Agent	Route	Dosing	Notes
Cloxacillin	Oral	250–500 mg QID	First-line oral agent in India; excellent S. aureus coverage
Flucloxacillin	Oral	250–500 mg QID	Equivalent to cloxacillin; used in some regions
Amoxicillin-clavulanate	Oral	375–625 mg TDS	Alternative if β-lactamase production suspected
IV Nafcillin/Oxacillin	IV	1–2 g QID	Reserved for severe/systemic cases