NUR 602 Module 3 Milestone One Example

Milestone One: A Pharmacotherapy Plan for Impetigo in a 4-Year-Old, From Ointment to Weight-Based Oral Therapy

[Student Name]

Southern New Hampshire University

NUR 602: Advanced Pharmacology Across the Life Span

Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: A Pharmacotherapy Plan for Impetigo in a 4-Year-Old, From Ointment to Weight-Based Oral Therapy

Impetigo is one of the most common skin infections of early childhood, and its treatment looks simple. The choices hidden inside it are not: whether a cream is enough, which oral drug covers the likely organisms, how to turn a milligram-per-kilogram range into a volume a parent can measure and how resistance should change the plan. This milestone drafts a pharmacotherapy plan for one preschool child. It argues that limited impetigo in a young child should be treated topically, that oral therapy should be reserved for spread and chosen for coverage of Staphylococcus aureus, and that every dose should be written as an exact volume.

Patient Presentation

Mason is 4 years old and weighs 17 kg. He attends preschool three days a week. His mother reports sores under his nose that began as small blisters, broke and formed honey-colored crusts over four days. On examination there are four crusted lesions, the largest 1.5 cm, around the nares and upper lip, with no fever, no regional lymph node enlargement and no signs of deeper infection. He has mild eczema on both elbows, no drug allergies and no antibiotic courses in the past year. His younger sister has no lesions. The presentation fits nonbullous impetigo, and a clinical diagnosis is reasonable without culture at this stage (Stevens et al., 2014).

Pharmacotherapy Goals

The goals are clinical cure within about a week, prevention of spread to his sister and classmates, return to preschool as soon as he is no longer contagious and avoidance of unnecessary systemic antibiotic exposure. A measurable goal is that no new lesions appear after 48 hours of treatment and existing lesions are dry and healing by day 5.

Topical First: Evidence and Choice

For a small number of lesions, topical antibiotics are the treatment of choice. A Cochrane review of 68 trials found that topical antibiotics produced higher cure rates than placebo and that topical mupirocin was slightly more effective than oral erythromycin, with no clear difference between mupirocin and fusidic acid (Koning et al., 2012). The Infectious Diseases Society of America recommends mupirocin or retapamulin twice daily for 5 days for limited disease (Stevens et al., 2014). A newer agent, ozenoxacin 1% cream, achieved clinical success in 54.4% of patients after 5 days compared with 37.9% with vehicle in a trial that enrolled patients from 2 months of age (Rosen et al., 2018).

For Mason, mupirocin 2% ointment is the first choice because it is inexpensive, familiar and effective for localized disease. His mother should wash the crusts gently with soap and water, pat them dry and apply a thin layer twice daily for 5 days, washing her hands before and after. Topical treatment avoids the diarrhea and rash that oral antibiotics commonly cause in young children and limits selection pressure on his gut flora.

When the Infection Spreads: Oral Therapy

Seven days later Mason returns. The original lesions have improved, but six new ones have appeared on his forearm, and his sister has two lesions on her chin. Numerous lesions and spread within a household are the situations in which the guideline recommends oral therapy. Because Staphylococcus aureus causes most cases and most isolates remain methicillin susceptible, the guideline recommends an oral agent active against it, such as cephalexin or dicloxacillin, for 7 days (Stevens et al., 2014). A swab for culture and susceptibility should be taken now, because the lesions persisted despite topical therapy and resistance to mupirocin has been rising (Bangert et al., 2012).

Cephalexin is the practical choice for a 4-year-old: it comes as a palatable suspension, while dicloxacillin is available only as capsules and tastes bitter. Table 1 shows how the weight-based range becomes a measured dose.

Table 1. Weight-Based Cephalexin Dosing for a 17-kg Child

Note. Dose range from Stevens et al. (2014). Volume rounded to the nearest 0.5 mL so it can be measured with an oral syringe.

Resistance and the Culture Result

If the culture grows methicillin-resistant S. aureus, cephalexin will not work, and the guideline lists clindamycin or trimethoprim-sulfamethoxazole as oral options (Stevens et al., 2014). Clindamycin is a reasonable pediatric choice where local resistance to it is low, although the suspension tastes poor and diarrhea is common. Trimethoprim-sulfamethoxazole does not reliably cover group A streptococcus, so it should not be used alone if streptococci are also present. Doxycycline is avoided at his age for routine skin infection. The plan should therefore read: start cephalexin today, review the culture in 48 to 72 hours and change agents only if the organism or its susceptibility requires it. The value of local resistance data is that it sets the starting drug; the value of the culture is that it corrects the choice for this child.

Education, Monitoring and Prevention

Mason's mother should give each dose with the oral syringe, finish all 7 days even when the sores look better and call if he develops a rash, bloody diarrhea, fever or spreading redness. Nails should be kept short, towels and washcloths not shared and his eczema treated, since broken skin invites reinfection. His sister needs her own assessment and treatment. Many child care policies allow return 24 hours after antibiotic treatment begins, provided lesions can be covered. Follow-up by phone at 48 hours should confirm no new lesions, and a visit at the end of treatment should confirm healing.

Conclusion

For a 4-year-old with a few crusted lesions, a 5-day course of topical mupirocin is effective and spares him systemic exposure. When the infection spreads, a 7-day course of cephalexin at 4.5 mL three times daily covers the most likely organism, and a culture taken at that point lets the plan change if resistance is present. The next milestone can extend this plan with cost, adherence and follow-up data.

References

Bangert, S., Levy, M., & Hebert, A. A. (2012). Bacterial resistance and impetigo treatment trends: A review. Pediatric Dermatology, 29(3), 243-248. https://doi.org/10.1111/j.1525-1470.2011.01700.x

Koning, S., van der Sande, R., Verhagen, A. P., van Suijlekom-Smit, L. W., Morris, A. D., Butler, C. C., Berger, M., & van der Wouden, J. C. (2012). Interventions for impetigo. Cochrane Database of Systematic Reviews, 2012(1), Article CD003261. https://doi.org/10.1002/14651858.CD003261.pub3

Rosen, T., Albareda, N., Rosenberg, N., Alonso, F. G., Roth, S., Zsolt, I., & Hebert, A. A. (2018). Efficacy and safety of ozenoxacin cream for treatment of adult and pediatric patients with impetigo: A randomized clinical trial. JAMA Dermatology, 154(7), 806-813. https://doi.org/10.1001/jamadermatol.2018.1103

Stevens, D. L., Bisno, A. L., Chambers, H. F., Dellinger, E. P., Goldstein, E. J. C., Gorbach, S. L., Hirschmann, J. V., Kaplan, S. L., Montoya, J. G., & Wade, J. C. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 59(2), e10-e52. https://doi.org/10.1093/cid/ciu296