What is the treatment for Staphylococcal (Staph) scalded skin syndrome (SSSS)?

Treatment of Staphylococcal Scalded Skin Syndrome (SSSS)

Immediate empiric treatment with intravenous anti-staphylococcal beta-lactam antibiotics—specifically nafcillin, oxacillin, or flucloxacillin—is essential for SSSS, as this is a pediatric emergency requiring prompt intervention to reduce morbidity and mortality. 1, 2

Initial Antibiotic Selection

First-Line Therapy (Methicillin-Susceptible S. aureus)

• Nafcillin or oxacillin IV should be initiated immediately as first-line empiric therapy 1, 2
• Dosing for oxacillin: 100 mg/kg/day IV divided every 4-6 hours for severe infections in children <40 kg 3
• For neonates and premature infants: 25 mg/kg/day IM or IV 3
• Flucloxacillin is an acceptable alternative in regions where it is available 1, 4

Penicillin-Allergic Patients

• Clarithromycin or cefuroxime may be used for patients with penicillin allergy 1
• Cefazolin can be considered if the allergy is not type 1 hypersensitivity 5

MRSA Coverage Indications

Vancomycin should be used in the following specific scenarios 1, 2:

• Patient is critically ill or not improving on beta-lactam therapy

• Communities with high prevalence of methicillin-resistant S. aureus (MRSA)

• Confirmed MRSA infection on culture

• Vancomycin dosing: 15 mg/kg/dose IV every 6 hours for children 5

• Linezolid is an alternative MRSA-active agent: 10 mg/kg/dose PO/IV every 8 hours for children <12 years (not to exceed 600 mg/dose) 5, 2

Adjunctive Antibiotic Therapy

• Clindamycin should be considered as adjunctive therapy to stop exotoxin production at the bacterial ribosome level 2
• Clindamycin dosing: 10-13 mg/kg/dose IV every 6-8 hours (to administer 40 mg/kg/day) 5
• Important caveat: Recent data shows inducible clindamycin resistance (36% of isolates) rather than constitutive resistance, and clindamycin does not improve length of stay compared to beta-lactams alone 6

Supportive Care Measures

Fluid Management

• Ringer's solution should be administered to balance fluid loss from skin exfoliation 2
• Maintenance fluid therapy must account for ongoing transepidermal water loss from denuded skin 2

Topical Management

• Cotrimoxazole (sulfamethoxazole-trimethoprim) topical application can be applied to affected skin surfaces 2
• Mupirocin 2% topical ointment is recommended for localized minor staphylococcal skin infections 5, 4

Medications to Avoid

• Drugs that reduce renal function should be avoided given the risk of fluid and electrolyte imbalances 2

Duration of Therapy

• Continue antibiotic therapy for at least 48 hours after the patient becomes afebrile, asymptomatic, and cultures are negative 3
• In severe staphylococcal infections, therapy should continue for at least 14 days 3
• Treatment duration should be guided by clinical response, with most SSSS cases requiring 7-14 days of therapy 5

Diagnostic Work-Up Considerations

Essential Testing

• Aerobic cultures from skin lesions (blister fluid, erosions, or primary infection site) should be obtained 1, 4
• Nasal swabs from the patient and immediate family members to identify asymptomatic carriers 4

Testing That Can Be Reduced

• Blood cultures are rarely positive for S. aureus in SSSS (0% positivity in one cohort) and do not improve diagnostic precision 6
• Complete blood counts and chemistry panels do not improve outcomes and can be minimized 6
• The diagnosis is primarily clinical based on tender erythroderma, bullae, positive Nikolsky sign, periorificial crusting, and absence of mucosal involvement 1

Key Clinical Pitfalls

• Do not delay antibiotic initiation waiting for culture results—SSSS is a clinical diagnosis requiring immediate empiric treatment 1
• Most SSSS isolates are resistant to penicillin but sensitive to penicillinase-resistant penicillins 2
• Adult SSSS has >60% mortality compared to 4% in children, so maintain high suspicion in adults with predisposing factors 7
• Tetracyclines should not be used in children <8 years of age 5
• Recent data suggests beta-lactams alone may be superior to clindamycin-containing regimens, as clindamycin did not reduce length of stay and inducible resistance is common 6