Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A three-year-old otherwise well-child is in for a sick visit. Her caregivers report that the child has been well, with the exception of a number of small, new skin lesions on the chin and arms, present for about 3 days. The child will occasionally rub the lesions, but doesn't complain about pain, has no fever or other symptoms.
Exam is consistent with non-bullous impetigo with approximately six lesions, all less than 2 to 3 centimeters in diameter, scattered over the chin and both arms. The child is in no acute distress and age-appropriately resists the exam. Which of the following is the preferred treatment option?
A: Topical bacitracin, polymyxin, and neomycin cream.
B: Mupirocin ointment.
C: Oral trimethoprim-sulfamethoxazole.
D: Triamcinolone cream.
The correct answer is B: Mupirocin ointment. First, where do we start? Let's figure out what kind of a question this is. Since we're given a clinical scenario and the diagnosis, we're being asked for a treatment option. Clearly, this is a plan/intervention question. A bit of background information: non-bullous impetigo is a common superficial skin infection, most often seen in children ages 2 to 5 years.
The condition starts with papules that then evolve into pustules over a few days. The term non-bullous is used because there aren't the larger vesicles or blisters that would meet the criteria for the bullous form of the disease. The bullous form of the disease, often the lesions are quite widely distributed on the trunk and extremities as well as the face. So back to non-bullous impetigo, which is what this child has.
The next stage involves breaking down of the pustules to form a thick, adherent, crusting lesion. Lesions are typically a golden- or honey-colored and most commonly on the face and arms. Sometimes it will be just a single lesion. Although multiple lesions are certainly possible and usually on skin areas that are open and not covered by clothing. This diagnosis is made clinically, usually without cultures, and the reason for this is the concept of organisms are really quite predictable.
Two major organisms far and away: number one will be Strep pyogenes. That's number one for the non-bullous form. Staph aureus can also be a contributor and is actually more commonly found in the bullous form of the disease. Most of you who are coming to the NP role have been RNs in the acute care setting. And the acute care setting, so that also includes, I'm going to put the emergency department in there.
There is a tendency to think that the vast majority of skin infections have Staph aureus, perhaps even MRSA, as the causative organism. But in the outpatient setting, many conditions of the skin that are infectious in nature are actually caused by streptococcus species. This really changes the game plan on how you're going to treat this infection. And keep in mind on the NP board, what you're going to see is the correct answer that would be best evidence, in an otherwise well-child, living in the community who probably picked this bug up from one of her friends. Didn't get it in the ICU, didn't pick it up in the emergency room, or the medical floor, that type of thing.
Therefore, you're most likely going to see infection caused by non-resistant forms of bacteria rather than resistant forms. With this as a background, let's take a look at the question and the possible responses.
A three-year-old otherwise well-child is in for a sick visit. Her caregivers report that she's been well with the exception of a number of small, tiny, crusted lesions on the chin and arms present for about 3 days. The child will occasionally rub the lesions, but doesn't complain about pain, has no fever or other symptoms. Exam is consistent with non-bullous impetigo, with about six lesions in total, all less than 2 to 3 centimeters in diameter, scattered over the chin and both arms. The child is in no acute distress and age-appropriately resists the exam. Which of the following is the preferred treatment option?
A: Topical bacitracin, polymyxin, and neomycin cream.
This is not correct. You might be more familiar with this product under the trade name of Neosporin and it's been on the market for literally decades now. Well, while Neosporin is commonly used as a first aid product to prevent infection in minor wounds, its spectrum of antibacterial activity in Neosporin is insufficient against the organisms that typically cause non-bullous impetigo.
Option B: Mupirocin ointment. This is, of course, the correct answer For localized impetigo, with relatively few lesions as is described here, topical therapy has been demonstrated to work just as well as oral antimicrobial therapy, with fewer adverse effects. Keep in mind, the little ones will often get diarrhea from oral antibiotics, even at a higher rate than adults tend to do, and they certainly can develop genital candidiasis with antibiotic use.
One more time, just like the adults do. There's also a rule in pharmacology that says, ‘Treat locally rather than systemically whenever possible.’ Now, in the bullous form of impetigo, you do usually need to go to an oral antibiotic, mostly because the lesions are really quite widespread over the body. But another point I want to make here. I've heard people mention that questions like this come up on boards and wonder if this is a question about whether to use an ointment versus a cream, because the Neosporin mentioned was a cream.
The mupirocin or Bactroban is mentioned as an ointment. No, no, no, no. This is a question about the most effective bacterial agent and not about cream versus ointment. It also is a question about what's the appropriate route, because you'll see our next option talks about using a systemic antibiotic. Now, granted, ointment will have a better ability, in all likelihood, to penetrate the crust on the lesion.
But the ointment versus cream part is not all that germane to this question. Option C: Oral trimethoprim-sulfamethoxazole, that is of course known by trade name Bactrim. This is incorrect, due in part to what I just mentioned. This child has superficial, localized infection and it's going to respond quite nicely to the topical mupirocin. As I mentioned, with bullous impetigo or with treatment failure with topical therapy for impetigo, systemic antibiotics are used and the choices can include a penicillin, a cephalosporin, or trimethoprim-sulfamethoxazole.
The box is an option D: Triamcinolone cream. Triamcinolone, of course, is corticosteroid. Corticosteroids play no role in the treatment of impetigo; it's a bacterial infection that requires an antibacterial agent. Key takeaway: whenever choosing an antibacterial agent, you need to back up your clinical decision with a broad and deep knowledge base that includes information on route of administration of the antibacterial; whether it needs to be topical, oral, parenteral; as well as matching the pathogens with the appropriate, predicted-to-be effective agent.
Keeping these key points in mind, you'll be able to choose the best product for your patients and therefore have the best success on the NP boards.
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