What is the initial approach to treating staph (Staphylococcus) infections in pediatric (peds) patients?

Treatment of Staphylococcal Infections in Pediatric Patients

For pediatric patients with staphylococcal infections, treatment should be based on the type and severity of infection, with appropriate antimicrobial therapy selected according to suspected methicillin susceptibility and proper drainage of purulent collections. 1, 2

Initial Assessment and Classification

• Determine whether the infection is:
  • Superficial (impetigo, folliculitis) vs. deep (abscess, cellulitis)
  • Localized vs. spreading
  • Purulent (abscess, furuncle) vs. non-purulent (cellulitis)
  • Mild, moderate, or severe

Treatment Algorithm

1. Minor Skin Infections (Impetigo, Minor Secondarily Infected Lesions)

• First-line treatment: Mupirocin 2% topical ointment 1
• Apply to affected areas 2-3 times daily for 5-10 days

2. Purulent Skin Infections (Abscesses, Furuncles)

• Primary treatment: Incision and drainage (I&D) 1, 2, 3

  • Essential for abscesses >5 cm in diameter
  • Cultures from abscesses are recommended, especially if:
    • Patient requires antibiotic therapy
    • Severe local infection or systemic illness is present
    • Patient has not responded to initial treatment
    • Concern for outbreak exists 1

• Antimicrobial therapy (based on severity):

  • Mild infections (<5 cm) after adequate I&D: Antimicrobial therapy may not be necessary 3
  • Moderate infections or those with systemic symptoms:
    • First-line: Clindamycin 10-13 mg/kg/dose PO every 6-8 hours (if local resistance <10%) 1
    • Alternatives:
      • TMP-SMX (if coverage for β-hemolytic streptococci is not needed) 1
      • TMP-SMX plus β-lactam (e.g., amoxicillin) if streptococcal coverage is desired 1
      • Linezolid for children >12 years: 600 mg PO twice daily; for children <12 years: 10 mg/kg/dose PO every 8 hours 1

3. Non-purulent Skin Infections (Cellulitis, Erysipelas)

• First-line: β-lactam antibiotic (covers streptococci and MSSA)
  • Cephalexin or dicloxacillin 4
• If MRSA suspected (based on local prevalence or risk factors):
  • Clindamycin (if local resistance <10%) 1
  • Linezolid 1, 5

4. Complicated/Severe Skin and Soft Tissue Infections (cSSTI)

• Hospitalization criteria:

  • Lesions >5 cm in diameter 3
  • Rapid progression
  • Signs of systemic illness
  • Immunocompromised host

• First-line intravenous therapy:

  • Vancomycin 15 mg/kg/dose IV every 6 hours 1

• Alternatives:

  • Clindamycin 10-13 mg/kg/dose IV every 6-8 hours (if local resistance <10%) 1
  • Linezolid: For children >12 years: 600 mg IV/PO twice daily; for children <12 years: 10 mg/kg/dose IV/PO every 8 hours 1, 5
  • Daptomycin 6-10 mg/kg/dose IV once daily (limited pediatric data) 1

• Duration: 7-14 days, individualized based on clinical response 1

Special Considerations

Methicillin-Resistant S. aureus (MRSA)

• Consider empiric MRSA coverage if:
  • Local MRSA prevalence is high
  • Previous MRSA infection or colonization
  • Failure of initial β-lactam therapy
  • Severe or rapidly progressing infection 6

Important Caveats and Pitfalls

1. Avoid tetracyclines in children <8 years of age due to dental staining 1

2. Do not use rifampin as monotherapy for treatment of skin infections 1

3. Drainage is critical - failure to adequately drain purulent collections is a common cause of treatment failure 2, 3

4. Monitor for treatment failure:

   • Persistent fever beyond 48-72 hours
   • Expanding erythema or induration
   • Development of new lesions 1

5. For recurrent infections:

   • Implement decolonization strategies:
     • Nasal mupirocin twice daily for 5-10 days 1, 2
     • Chlorhexidine body washes for 5-14 days 1, 2
   • Address household contacts:
     • Evaluate symptomatic contacts 1
     • Consider decolonization of household members 1
   • Emphasize hygiene measures:
     • Cover draining wounds 1
     • Regular handwashing 1
     • Avoid sharing personal items 1
     • Clean high-touch surfaces 1

By following this structured approach to treating staphylococcal infections in pediatric patients, clinicians can effectively manage these common infections while minimizing complications and reducing the risk of recurrence.