What is the best treatment for skin infections in pediatric patients?

Treatment of Skin Infections in Pediatric Patients

For minor skin infections like impetigo in children, topical mupirocin 2% ointment applied three times daily is the first-line treatment, while hospitalized children with complicated skin and soft tissue infections require intravenous vancomycin or clindamycin depending on local MRSA resistance rates. 1

Minor Skin Infections (Impetigo and Localized Infections)

First-Line Topical Therapy

• Mupirocin 2% topical ointment is the treatment of choice for children with minor skin infections including impetigo and secondarily infected skin lesions (eczema, ulcers, lacerations) 1, 2
• Apply three times daily for 8-12 days 2
• Clinical efficacy rates reach 71-93% in pediatric patients, with pathogen eradication rates of 94-100% 2
• Superior to vehicle placebo and comparable to oral erythromycin, with fewer adverse effects 2, 3

Alternative Topical Options

• Fusidic acid (where available) shows equivalent efficacy to mupirocin 1, 4
• Retapamulin is an FDA-approved alternative for MSSA and Streptococcus pyogenes (but not MRSA) 5, 6

When to Use Oral Antibiotics for Minor Infections

Oral therapy is indicated for multiple lesions or household outbreaks 1, 5:

• First-line oral agents: Dicloxacillin, cefalexin (cephalexin), or amoxicillin-clavulanate 1, 7
• If penicillin allergic: First-generation cephalosporin (if not type 1 hypersensitivity), clindamycin, or erythromycin (if susceptibility confirmed) 1, 7
• Avoid: Oral penicillin alone (inferior cure rates compared to cloxacillin or erythromycin) 1

Hospitalized Children with Complicated Skin and Soft Tissue Infections

Empirical Intravenous Therapy

Vancomycin is the recommended first-line agent for hospitalized children with complicated skin and soft tissue infections 1, 8:

• Dosing: 15 mg/kg/dose IV every 6 hours 8
• Use when patient is critically ill, not improving on beta-lactam therapy, or in communities with high MRSA prevalence 8

Alternative for Stable Patients in Low MRSA Settings

Clindamycin can be used empirically ONLY if local clindamycin resistance rates are <10% 1, 8:

• Dosing: 10-13 mg/kg/dose IV every 6-8 hours (to deliver 40 mg/kg/day) 1
• Patient must be stable without ongoing bacteremia or intravascular infection 1, 8
• Transition to oral therapy if strain is susceptible 1

Additional MRSA-Active Options

• Linezolid: 10 mg/kg/dose PO/IV every 8 hours for children <12 years; 600 mg PO/IV twice daily for children ≥12 years 1, 8
• Shows better treatment success than vancomycin in some meta-analyses (OR 1.40), though with increased thrombocytopenia and nausea 1

Severe Infections and Special Considerations

Adjunctive Clindamycin for Toxin-Mediated Disease

Add clindamycin to beta-lactam therapy for 8, 7:

• Staphylococcal scalded skin syndrome (SSSS)
• Necrotizing fasciitis
• Toxic shock syndrome
• Rationale: Suppresses exotoxin production at the ribosomal level 8, 7

Abscess Management

• Incision and drainage is the primary treatment 1
• Culture wound contents for pathogen identification and susceptibility testing 1
• Empirical antibiotics pending culture: trimethoprim-sulfamethoxazole, doxycycline (if ≥8 years old), or clindamycin for suspected MRSA 1
• Do not use trimethoprim-sulfamethoxazole alone for cellulitis due to intrinsic Group A Streptococcus resistance 1

Critical Age-Related Contraindications

Tetracyclines (including doxycycline) must not be used in children <8 years of age 1, 8

Treatment Duration and Follow-Up

• Most uncomplicated skin infections: 7-14 days guided by clinical response 8
• Impetigo with topical mupirocin: 8-12 days 2
• Complicated bacteremia: 4-6 weeks depending on extent of infection 1

Recurrent Infections: Decolonization Strategies

Consider decolonization only after optimizing wound care and hygiene measures fail 1:

• Nasal mupirocin twice daily for 5-10 days 1
• Plus topical chlorhexidine for 5-14 days OR dilute bleach baths (1 teaspoon per gallon of water, 15 minutes twice weekly for 3 months) 1
• Evaluate and treat symptomatic household contacts 1

Common Pitfalls to Avoid

• Do not use oral penicillin alone for impetigo—inferior to cloxacillin or erythromycin 1
• Do not use clindamycin empirically if local resistance rates exceed 10% 1, 8
• Do not use trimethoprim-sulfamethoxazole as monotherapy for cellulitis 1
• Do not prescribe tetracyclines to children under 8 years 1, 8
• Obtain cultures before starting antibiotics in hospitalized patients, those with severe infection, or treatment failures 1