A 5-year-old boy, with no other significant medical history, presented to the emergency department and was seen by a dermatologist. The patient presented with lesions initially on the nasal region and later the rest of the face and some lesions on the rest of the body of approximately 2 weeks’ duration. Suspecting impetigo, he had been treated unsuccessfully with topical mupirocin and subsequently with oral amoxicillin. On examination (Fig. 1), there were multiple eroded plaques, some with yellowish decostration, on the face and abdomen. The lesions were mildly pruritic. There was no fever or other systemic symptoms. Bacterial cultures were taken from the lesion, nares, axillary and inguinal folds on suspicion of bullous impetigo. The lesional and nasal cultures were positive for Staphylococcus aureus. The antibiogram showed that it was specifically methicillin-resistant S. aureus (MRSA) and was sensible to tetracyclines, clindamycin, vancomycin and linezolid. Treatment was started with oral clindamycin 15mg/kg/day and topical clindamycin twice daily in the nose. After one week of treatment, the lesions were in the resolution phase. The patient had no recurrences at 6 months follow-up.
Impetigo is a superficial bacterial infection of the skin, common in children and highly contagious. Epidemiologically, it mainly affects children aged 2–5 years, especially in warm and humid climates. It is transmitted by direct contact with infected persons or contaminated objects.1 Clinically, there are two main forms: non-blistering and blistering impetigo. Non-blistering impetigo is more common and is caused by S.aureus or Streptococcus pyogenes. It appears as small red lesions that develop into pustules that rupture to form honey-coloured crusts. Bullous impetigo, mainly caused by S. aureus, is characterised by fluid-filled vesicles that rupture, leaving an erosive base.2 Diagnosis is clinical, based on the appearance of the skin lesions, but in some cases, cultures may be taken if initial treatment fails or if there are clustered outbreaks.1,2 Treatment is based on careful cleansing of the lesions and the use of antibiotics. In mild cases, topical antibiotics such as mupirocin are used. For more widespread or severe infections, systemic antibiotics such as dicloxacillin or cephalexin are prescribed. However, in recent years there has been an increase in multidrug-resistant infections, including MSRA, mainly due to excessive and inappropriate use of antibiotics.3,4 To combat this threat, rational antibiotic treatment, where possible guided by antibiograms, and adequate patient adherence are essential. In cases of MSRA, other treatments can be used, both topical (such as ozenoxacin or retapamulin) and systemic (such as clindamycin, co-trimoxazole or even linezolid, vancomycin or daptomycin in severe cases).4 Adopting these practices will help reduce the incidence of multidrug-resistant infections and preserve the effectiveness of antibiotics for future generations.
AuthorshipAll authors had access to the data and played a role in writing this manuscript.
Authors’ contributions- -
Miguel Mansilla-Polo and Daniel Martín-Torregrosa managed clinical treatment and procedures, contributing to the development of this paper.
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Miguel Mansilla-Polo supervised the work.
Oral and written consent was obtained to publish this image.
EthicsProcedures followed here were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983. We have not use patients’ names, initials, or hospital numbers.
FundingNo specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.
Conflict of interestThe authors have declared no conflicts of interest.
