What is the recommended treatment for cellulitis (bacterial skin infection) in children caused by bug bites?

Treatment of Cellulitis in Children from Bug Bites

For children with cellulitis resulting from bug bites, first-line treatment should include an oral antibiotic active against beta-hemolytic streptococci, such as amoxicillin, dicloxacillin, or cephalexin for 5 days, with extension if no improvement is seen. 1

Pathogen Considerations and Antibiotic Selection

• Cellulitis is primarily caused by beta-hemolytic streptococci, with Staphylococcus aureus less frequently involved unless associated with penetrating trauma or an underlying abscess 1, 2
• For typical non-purulent cellulitis in children, recommended oral antibiotics include:
  • Penicillin or amoxicillin (targeting streptococci) 3, 1
  • Dicloxacillin or cephalexin (providing coverage for both streptococci and methicillin-sensitive S. aureus) 1, 4
• For penicillin-allergic children, clindamycin or erythromycin are appropriate alternatives 1, 4
• Tetracyclines should not be used in children under 8 years of age 3

Treatment Duration and Administration

• A 5-day course of antimicrobial therapy is sufficient for uncomplicated cellulitis if clinical improvement occurs 3, 1
• Treatment should be extended if no improvement is seen after 5 days 1
• When using amoxicillin-clavulanate suspension for children:
  • Keep refrigerated and shake well before using
  • Use a dosing spoon or medicine dropper
  • Administer with meals or snacks to reduce gastrointestinal upset 5

MRSA Considerations

• MRSA is an unusual cause of typical cellulitis in children 3
• Consider MRSA coverage only in specific circumstances:
  • Penetrating trauma
  • Evidence of MRSA infection elsewhere
  • Purulent drainage
  • Lack of response to beta-lactam therapy
  • Systemic toxicity 3, 1
• If MRSA coverage is needed, options include:
  • Clindamycin alone (if local resistance rates are low, <10%) 3
  • Trimethoprim-sulfamethoxazole (TMP-SMX) plus a beta-lactam (e.g., amoxicillin) 3, 4
  • Linezolid for children >12 years (10 mg/kg/dose PO every 8 hours for children <12 years) 3

Hospitalization Criteria

• Most children with uncomplicated cellulitis can be treated as outpatients 6
• Consider hospitalization for:
  • Systemic symptoms (high fever, hypotension)
  • Rapidly spreading infection
  • Failure to improve with oral antibiotics
  • Very young age
  • Immunocompromised status
  • Facial or periorbital involvement 3, 6
• For hospitalized children with complicated skin infections:
  • Vancomycin is recommended as first-line therapy 3
  • Clindamycin (10-13 mg/kg/dose IV every 6-8 hours) is an option if local resistance rates are low 3

Adjunctive Measures

• Elevate the affected area to promote drainage of edema and reduce inflammation 1
• For minor skin infections associated with bug bites, mupirocin 2% topical ointment may be effective 3
• Treat predisposing conditions that may lead to recurrence 1, 7

Common Pitfalls to Avoid

• Failing to differentiate between purulent and non-purulent cellulitis, which affects treatment choices 3
• Unnecessarily prescribing MRSA coverage for typical non-purulent cellulitis 3, 1
• Not elevating the affected area, which can delay improvement 1
• Inadequate treatment duration when clinical improvement is not evident after 5 days 1
• Not addressing underlying conditions that may predispose to recurrence 1, 7

Prevention of Recurrence

• Identify and treat predisposing conditions 1, 7
• For children with frequent recurrences despite addressing underlying factors, prophylactic antibiotics may be considered 1