## 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]
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