What is the treatment for recurrent Staphylococcus (Staph) skin infections in children?

Treatment for Recurrent Staph Skin Infections in Children

The cornerstone of managing recurrent staphylococcal skin infections in children is a stepwise approach starting with hygiene education and wound care, escalating to decolonization strategies (intranasal mupirocin combined with dilute bleach baths) only after initial measures fail, while reserving systemic antibiotics for active infections rather than prevention. 1

Initial Management: Hygiene and Wound Care

All children with recurrent staph skin infections must receive preventive education as the first-line intervention: 1

• Keep all draining wounds covered with clean, dry bandages at all times 1
• Maintain rigorous hand hygiene with soap and water or alcohol-based sanitizer, especially after touching infected skin or wound dressings 1
• Avoid sharing personal items including razors, towels, linens, and clothing that contact skin 1
• Regular bathing should be emphasized as part of daily routine 1

Environmental Decontamination Measures

When recurrent infections persist despite personal hygiene, implement household cleaning protocols: 1

• Focus on high-touch surfaces that contact bare skin daily: countertops, doorknobs, bathtubs, toilet seats 1
• Use standard commercial cleaners according to manufacturer instructions for routine surface cleaning 1
• Launder clothing, towels, and bedding thoroughly to eliminate fomite transmission 1

Decolonization Strategies: When and How

Decolonization should only be considered after optimizing hygiene measures have failed to prevent recurrent infections. 1 The IDSA guidelines are clear that this is not first-line therapy but reserved for specific scenarios.

Indications for Decolonization:

• Patient develops recurrent SSTI despite optimized wound care and hygiene 1
• Ongoing transmission among household members despite hygiene interventions 1

Recommended Decolonization Regimens:

The most effective evidence-based regimen combines intranasal mupirocin with dilute bleach baths: 1, 2

• Intranasal mupirocin 2% applied twice daily for 5-10 days 1
• PLUS dilute bleach baths: 1 teaspoon bleach per gallon of water (or ¼ cup per ¼ tub/13 gallons), soaking for 15 minutes twice weekly for 3 months 1

This combination achieved 71% eradication at 4 months in a randomized trial, significantly better than education alone (48%) or mupirocin alone (56%). 2 The bleach concentration must be carefully explained to families to avoid skin irritation from inadequate dilution. 1

Alternative decolonization option (less effective):

• Mupirocin alone twice daily for 5-10 days, repeated monthly for up to 1 year, reduces recurrences by approximately 50% 1

Chlorhexidine body washes (4% solution for 5-14 days) can be substituted for bleach baths but show similar efficacy to mupirocin alone 1, 2

Role of Systemic Antibiotics

Oral antibiotics are NOT routinely recommended for decolonization and should only treat active infections. 1 This is a critical pitfall—many clinicians inappropriately prescribe prolonged suppressive antibiotics.

When Systemic Antibiotics May Be Considered:

Only in patients with continued infections despite topical decolonization measures 1

If prescribed for decolonization (not active infection):

• Rifampin-based combination (with TMP-SMX or doxycycline) for short courses (5-10 days) to minimize resistance development 1
• Never use rifampin monotherapy due to rapid resistance emergence 1
• Clindamycin 150 mg daily for 3 months decreased recurrent furunculosis by 80% in older studies of susceptible S. aureus, but this is only appropriate if local clindamycin resistance is <10% 1

Treatment of Active Infections:

For minor active skin infections (impetigo, small abscesses):

• Mupirocin 2% topical ointment three times daily for 5-7 days 1, 3, 4
• Incision and drainage alone is adequate for abscesses <5 cm diameter without systemic antibiotics 5

For more extensive infections requiring oral antibiotics:

• Cephalexin 25-50 mg/kg/day divided into 3-4 doses for 7 days (covers both staph and strep) 3
• Clindamycin 20-30 mg/kg/day divided into 3 doses if penicillin allergy AND local clindamycin resistance <10% 3
• Avoid tetracyclines in children <8 years of age 1, 6, 3

Household Contact Management

When household transmission is suspected: 1

• Evaluate all household contacts for signs of active infection 1
• Treat symptomatic contacts for their active infections first 1
• Consider decolonization of asymptomatic household contacts only after treating active infections and implementing hygiene measures 1
• Apply the same mupirocin plus bleach bath regimen to colonized household members 1

Role of Cultures

Screening cultures are NOT routinely recommended: 1

• Do not obtain pre-decolonization cultures if at least one prior infection was documented as MRSA 1
• Do not perform surveillance cultures after decolonization in the absence of active infection 1
• Culture active infections to guide antibiotic therapy, especially if MRSA is suspected or the child is not improving 1

Critical Pitfalls to Avoid

• Do not use systemic antibiotics as primary decolonization strategy—this promotes resistance without proven benefit for preventing recurrent infections 1
• Do not skip hygiene education—even the most aggressive decolonization fails without proper wound care and environmental cleaning 1
• Do not use TMP-SMX monotherapy for active impetigo due to inadequate streptococcal coverage 3
• Ensure proper bleach dilution instructions—concentrated bleach causes skin irritation and poor adherence 1
• Do not prescribe tetracyclines to children under 8 years 1, 6, 3
• Recognize that high recurrence rates (36% at 4 months) occur even with optimal decolonization, suggesting factors beyond colonization drive reinfection 2

Special Considerations for MRSA

In communities with high MRSA prevalence (>10% resistance): 1, 3

• Empiric clindamycin may be appropriate for active infections if local clindamycin resistance remains <10% 1, 3
• Vancomycin 15 mg/kg/dose IV every 6 hours for hospitalized children with severe infections 6
• Linezolid (10 mg/kg/dose every 8 hours for children <12 years) as alternative for MRSA 1, 6

The evidence consistently shows that recurrent staph infections require a hierarchical approach: start with education, add environmental measures, then consider decolonization, while reserving antibiotics strictly for active infections rather than prevention. 1