IMPETIGO

Shinta Trilaksmi D
Sri Ningsih Lubis
Yuliana Sakti DA
Meylina Uji N
Noviarina Kurniawati
 Overview
Contagious skin infection, localized in
epidermis
Staphylococcus, Streptococcus, or both
With or without wound initiating
Most found in children
2 main forms :
I. Crusted/contagious/superficial honey-
colored crust
I. Bullous bulla
 Crusted Impetigo
Most form of impetigo in Indonesia
Etiology: Staphylococcus, Streptococcus, or
both
Indonesia Staphylococcus aureus
Clinical manifestation:
Macula
Pustule
Vesicle
Crust
Symptoms: itching, fever, malaise (rare)
Pathognomonic: dirty honey-colored crust
 The Process of Rational
Treatment
I. Define patients problems
II. Specify the therapeutic objective
III.Verify the suitability of your P-treatment
IV. Start the treatment
V. Give information, instructions and
warnings
VI. Treatment monitoring
I. Define The Patients Problem

Skin lesion (macula, vesicle, pustule,

crust)
 II. Specify The Treatments
Objectives

S. aureus toxins and Eradicate

ability to invade the
epidermis the agent

Inflammation

Fasten
Skin lesion
(macula, vesicle, the lesion
pustule, crust) healing
 III. Verify The Suitability of Your
P-Treatment
P-Treatment:
Advices and information
Non pharmacologic treatment
Pharmacologic treatment
Referral for treatment
 Advices and Information
Improve general hygiene
Daily bath w/ soap and water
Prevent spread
Avoid contact with non infected person and avoid
sharing of towels, sheets, etc.
Child must not return to day care or school until 24-
72 hr after initiation of antibiotic treatment
Have the patient keep the fingernails short and
recommend avoiding scratching the lesions
 Non Pharmacologic Treatment
Crust removal
Achieved by softening crusts w/ a wet cloth compress
Enhances the penetration of antibacterial oint or
creams
Preventive measures
Daily cleaning of the lesions w/ an antiseptic soap and
water
Prompt attention to minor wounds by keeping them
clean and applying topical antibiotic
Ecthyma
Improve nutritional status and treat underlying
conditions
 Pharmacologic Treatment
Therapeutic ladder of impetigo:
Topical antibiotic
Systemic antibiotic
 Topical Antibiotics
Small lesion
Bacitracin, mupirocin, fusidic acid
 Systemic Antibiotics
Combination w/ topical antibiotics
Wide lesion (>5), systemic infection
symptoms (fever, cough), recurrent lesion,
possibility of nephritogenic infection agent
Penicillinase-resistant penicillin, 1st
generation cephalosporin (mild penicillin
hypersensitivity), vancomycin (severe
hypersensitivity to penicillin, MRSA)
 Drugs Efficacy Safety Suitability Cost
TOPICAL Pharmacokinetic: Efek samping: Kontraindikasi: - +
Bacitracin, Poor absorption Iritasi (jarang) Dosage form:
mupirocin, Pharmacodynamic Topikal (ointment)
fusidic acid Menghambat
sintesis
dinding sel
bakteri
(bakterisidal
lokal)

SISTEMIK Pharmacokinetic: Efek samping: Kontraindikasi: - +

Penicillin Absorbsi dari usus Scr umum non- Dosage form:
resisten- bgs toksik i.v, oral, i.m
penicillinase Dipengaruhi Alergi
(methicillin, makan Skin rash
nafcillin, Tahan asam Syok anafilaksis
isoxazolil Distribusi luas (jrg)
penicillin/oxac Pharmacodynamic Met nefritis
illin) : inters.
Menghambat Naf
sintesis neutropenia
dinding bakteri
 Cephalospor pharmacokinet Efek samping: Kontraindikasi: ++
in generasi 1 ic: Scr umum non- Gagal ginjal
(cephalexin, Ekskresi ginjal toksik Dosage form:
cephadroxil, tinggi Alergi Oral, i.v, i.m
cephazolin) Pharmacodyn Nefrotoksik
amic:
Menghambat
sintesis
dinding
bakteri

Vancomycin pharmacokinet Efek samping: Kontraindikasi: ?

ic: Red man/red Gagal ginjal
Absorbsi oral neck Dosage form:
jelek syndrome i.v
Distribusi luas Minor: iritasi,
(i.v) demam,
Pharmacodyn menggigil,
amic: ototoksik,
Menghambat nefrotoksik
sintesis
dinding sel
Drug of Choice Rationality

Topical Antibiotics
Immediate acting
Minimal side effects
 Topical Antibiotics
Already proven to be effective against S.
aureus:
Bacitracin
Mupirocin Effective against
Gram positive bacteria
Fusidic acid Beta lactamase-
resistant
 Comparison
Efficacy Safety Suitability Cost

Bacitracin Pharmacokinetic: Side effect: Dosage form : 4,62

Poor absorption via Hypersensitivity - Ointment
skin (minimal (rare) 500 unit/g
systemic side - Solution
effect) 100-200
Pharmacodynamic : unit/mL
Inhibit bacterial wall saline
synthesis - Combination
More effective than w/ neomycin
penicillin G Kontraindikasi :
Mupirocin Karakteristik : Sediaan ointmen Dosage form : 4,38
(TN :Asam Aktif melawan kokus yang - ointment
Psudomona Gram positf, baik mengandung 2%
t A, yang sensitive polietilen - krim 2%
Bactroban) maupun resisten glikol dapat - nasal
dengan methicillin menyebabka ointment
(MRSA) n iritasi Kontraindikasi:
Farmakokinetik : mukosa dan Sensitivitas
Sulit diserap dari kulit luka terbuka terhadap
yang masih intak Lebih jarang : mupirocin
Didegradasi dengan Pruritus,
cepat setelah kemerahan,
diabsorpsi, eritema, kulit
sehingga kadar kering,dizzin
dalam plasma ess, sakit
sangat kecil kepala, rasa
Pharmacodynamic : terbakar,
Mengahambat sintesis rasa
dinding sel, DNA, tertusuk,
dan protein bakteri nyeri.
Bakteriostatik pada Keamanan pada
dosis rendah, kehamilan
baktericidal pada dan fetus
dosis tinggi manusia
Lebih manjur jika belum
dibandingkan ditentukan
sediaan penicillin
topikal
Asam fusidat Karakteristik : Jarang Dosage form : 2,74
(TN:Fusidi Aktif melawan infeksi menyebabka - krim asam
n, Leo) stafilokokus pada n reaksi fusidat 2%
kulit; infeksi hipersensitiv - oint 2%
stafilokokus yang itas Na-fusidat
resisten-penicillin;
infeksi
stafilokokus pada
mata tapi tidak
untuk MRSA
Farmakokinetik :
Penetrasi tinggi pada
kulit oleh karena
struktur seperti
steroid
Pharmacodynamic :
menghambat sintesis
protein bakteri
 P-Drug
Fusidic acid
Minimal side effect, no founded
contraindication, cost effective
2005: most of staphylococcus is resistant
to bacitracin
mupirocin save the best for last
 Referral
Not indicated
 P-Formulary
Preparation: ointment/cream
Pharmacologic name: fusidic acid or
sodium fusidate
Dosage and frequency: 2% fusidic acid or
sodium fusidic in 15 gr ointment, 3-4 dd
Duration: 7-10 days
Mechanism: inhibit bacterial protein
synthesis
IV. Start The Treatment
V. Give information, instructions
and warnings
Informations (about the disease)
Instructions
Non pharmacologic (mentioned above)
Pharmacologic (about the drug: effect, side
effect, dosage schedule, etc.)
Warnings (do not share stuff, do not
scratch, etc.)
 VI. Treatment monitoring
Improvement (treatment is effective)
Side effect (+) dosage modification
No improvement 3-5days return