What are the treatment options for pediatric cellulitis?

From the Guidelines

Pediatric cellulitis should be treated with antibiotics active against streptococci, with a recommended duration of 5 days, but extended if the infection has not improved within this time period 1.

Key Considerations

• The choice of antibiotic should be based on the severity of the infection and the presence of systemic symptoms.
• For mild cases without systemic symptoms, oral antibiotics such as penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin are suitable options 1.
• In areas with high MRSA prevalence, trimethoprim-sulfamethoxazole or clindamycin may be preferred 1.
• For moderate to severe infections, hospitalization for intravenous antibiotics may be necessary, typically using cefazolin, clindamycin, or vancomycin for MRSA concerns 1.

Supportive Care

• Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended 1.
• Warm compresses and pain management can also be beneficial.
• Parents should monitor for signs of worsening infection, such as spreading redness, increasing pain, fever, or red streaking, which warrant immediate medical attention.

Duration of Treatment

• The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period 1.
• Treatment should continue until complete resolution of symptoms, typically 7-10 days, though longer courses may be needed for severe cases.

From the FDA Drug Label

1. 2 Pediatric Patients Based on the amoxicillin component, amoxicillin and clavulanate potassium should be dosed as follows: Patients Aged 12 weeks (3 months) and Older: See dosing regimens provided in Table 1. Table 1: Dosing in Patients Aged 12 weeks (3 months) and Older INFECTION | DOSING REGIMEN Otitis media, sinusitis, lower respiratory tract infections, and more severe infections | 45 mg/kg/day every 12 hours Less severe infections | 25 mg/kg/day every 12 hours

The recommended dose of amoxicillin and clavulanate potassium for pediatric patients with cellulitis is not explicitly stated in the provided drug label. However, based on the dosing regimens for other infections, the dose for cellulitis would likely be similar to that for more severe infections, which is 45 mg/kg/day every 12 hours 2.

• Key considerations:
  • The dose should be based on the amoxicillin component.
  • The every 12 hours regimen is recommended as it is associated with significantly less diarrhea.
  • Patients weighing 40 kg or more should be dosed according to adult recommendations.
• Important note: The provided drug label does not explicitly address the treatment of cellulitis in pediatric patients, and the recommended dose is based on extrapolation from other infections.

From the Research

Pediatric Cellulitis Treatment Overview

• The treatment of pediatric cellulitis often involves the use of antibiotics, with the choice of antibiotic and route of administration depending on the severity and location of the infection 3.
• First-generation cephalosporins, such as cephalexin, are commonly used to treat noncomplicated, nonfacial cellulitis in children 3, 4.
• The use of oral antibiotics, such as cephalexin, has been shown to be effective in treating noncomplicated cellulitis and requires fewer visits and less time in the emergency department compared to intravenous treatment 3.

Antibiotic Choices and Treatment Duration

• The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics is sufficient 4.
• The optimal time to clinical reassessment is between 2 and 4 days, but this must be interpreted with caution due to considerable heterogeneity and small number of included studies 5.
• Treatment failure was variably defined with an overall failure rate of 12% (95%CI 9-16%) 5.

Combination Therapy and Anti-Inflammatory Agents

• The addition of oral nonsteroidal anti-inflammatory (NSAI) therapy to antibiotic treatment has been shown to hasten the resolution of cellulitis-related inflammation 6.
• Patients receiving supplemental anti-inflammatory treatment experienced complete resolution of cellulitis in 4 to 5 days or less, while 24.2% of patients treated with antibiotic alone required 6 to 7 days, and 6.1% required 7 days or more 6.

Clinical Decision Making and Standardization of Care

• A study achieved consensus on important features for treatment and disposition of children with uncomplicated cellulitis in both emergency and inpatient contexts, which has the potential to aid in decision making and improve standardization of clinical practice 7.
• Emergency medicine providers ranked features such as fevers/chills, lymphangitis, and functional impairment as considerations for initiating intravenous antibiotics, while hospital medicine providers ranked features such as stability and reduction of erythematous margins as important when deciding on readiness for oral antibiotics 7.