What is the recommended treatment for pediatric cellulitis?

Treatment of Pediatric Cellulitis

For pediatric cellulitis, the recommended first-line treatment is based on distinguishing between purulent and non-purulent infections, with non-purulent cellulitis typically requiring beta-lactam antibiotics targeting streptococci, while purulent infections may require coverage for methicillin-resistant Staphylococcus aureus (MRSA). 1

Classification and Initial Assessment

Non-purulent Cellulitis

• Defined as cellulitis with no purulent drainage or exudate and no associated abscess
• Most commonly caused by beta-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus (MSSA)

Purulent Cellulitis

• Defined as cellulitis associated with purulent drainage or exudate
• More likely to be caused by Staphylococcus aureus, including CA-MRSA

Outpatient Treatment Options

For Non-purulent Cellulitis:

• First-line therapy: Beta-lactam antibiotics 2, 1
  • Cephalexin 50-100 mg/kg/day divided QID (max 500 mg QID)
  • Dicloxacillin 25-50 mg/kg/day divided QID (max 500 mg QID)
  • Amoxicillin-clavulanate 45 mg/kg/day divided BID (max 875/125 mg BID)
• Duration: 5-10 days, typically 5-6 days is sufficient for uncomplicated cases 1, 3

For Purulent Cellulitis:

• Empirical coverage for CA-MRSA is recommended pending culture results 2
• Options include:
  • Clindamycin 10-13 mg/kg/dose PO TID (max 450 mg TID) 2
  • TMP-SMX for children >2 months (dosing based on TMP component: 8-12 mg/kg/day divided BID) 2
  • Doxycycline for children >8 years (2-4 mg/kg/day divided BID, max 100 mg BID) 2
  • Linezolid (for children <12 years: 10 mg/kg PO q8h; ≥12 years: 600 mg PO BID) 2, 4

Inpatient Treatment

Indications for Hospitalization:

• Systemic toxicity (fever, tachycardia, hypotension)
• Rapid progression of infection
• Failure to improve on oral antibiotics after 24-48 hours
• Periorbital cellulitis with signs of orbital involvement
• Immunocompromised state
• Inability to tolerate oral medications

Inpatient Antibiotic Options:

• For non-purulent cellulitis:

  • Cefazolin 100 mg/kg/day divided q8h (max 6 g/day) 2, 5

• For purulent cellulitis or suspected MRSA:

  • Vancomycin 15 mg/kg/dose IV q6h for children 2
  • Clindamycin 10-13 mg/kg/dose IV q6-8h (max 900 mg q8h) if local MRSA resistance is low (<10%) 2
  • Linezolid (for children <12 years: 10 mg/kg IV q8h; ≥12 years: 600 mg IV BID) 2, 4

• Duration of IV therapy: Continue until clinical improvement (typically 2-3 days), then transition to oral therapy to complete 7-14 days total 1

Special Considerations

Abscess Management

• For cutaneous abscesses, incision and drainage is the primary treatment 2
• Antibiotics are indicated for abscesses with:
  • Severe or extensive disease
  • Rapid progression with associated cellulitis
  • Signs of systemic illness
  • Immunosuppression
  • Extremes of age
  • Difficult-to-drain locations (face, hand, genitalia)
  • Lack of response to drainage alone 2

Periorbital Cellulitis

• Requires close monitoring and possibly imaging if orbital involvement is suspected
• Daily follow-up for outpatient cases until improvement is noted
• Hospitalization if no improvement within 24-48 hours on oral therapy 1

Prevention of Recurrence

• Keep draining wounds covered with clean, dry bandages
• Maintain good personal hygiene with regular handwashing
• Avoid sharing personal items that contact skin
• For recurrent infections, consider decolonization strategies 2

Common Pitfalls to Avoid

1. Failing to distinguish between periorbital and orbital cellulitis, which require different management approaches 1

2. Inadequate follow-up for outpatient cases - monitor daily until improvement 1

3. Overuse of broad-spectrum antibiotics for typical non-purulent cellulitis 1, 6

4. Delaying surgical drainage for abscesses, which is the primary treatment 2

5. Inadequate duration of therapy or premature discontinuation before clinical improvement 1

The treatment of pediatric cellulitis requires careful assessment of the type of infection, consideration of local resistance patterns, and appropriate antibiotic selection based on likely pathogens. With prompt and appropriate therapy, most children recover quickly from cellulitis 7.