What is the treatment for pediatric (ped) cellulitis?

From the Guidelines

For pediatric patients with cellulitis, a 5- to 6-day course of antibiotics active against streptococci, such as cephalexin or clindamycin, is recommended, particularly for patients able to self-monitor and who have close follow-up with primary care 1.

Key Considerations

• The choice of antibiotic should consider local resistance patterns and be adjusted based on culture results if obtained.
• For mild cases without systemic symptoms, oral antibiotics are appropriate.
• Alternatives include clindamycin (10-30 mg/kg/day divided every 6-8 hours) or amoxicillin-clavulanate (45 mg/kg/day divided every 12 hours).
• If MRSA is suspected, consider trimethoprim-sulfamethoxazole (8-12 mg/kg/day of trimethoprim component divided twice daily) or clindamycin.

Treatment Duration

• Treatment duration typically ranges from 5-10 days depending on clinical response, with improvement expected within 48-72 hours of starting appropriate antibiotics.

Supportive Care

• Supportive care includes elevation of the affected area, warm compresses, and pain management.
• Parents should monitor for spreading redness, increasing pain, fever, or lethargy, which warrant immediate medical attention.

Hospitalization

• For moderate to severe infections, hospitalization for intravenous antibiotics may be necessary, typically with cefazolin (100 mg/kg/day divided every 8 hours) or clindamycin (40 mg/kg/day divided every 6-8 hours).

Key Points

• The 2021 guideline from the American College of Physicians recommends a 5- to 6-day course of antibiotics for nonpurulent cellulitis 1.
• The IDSA guideline recommends that patients should receive antibiotics for uncomplicated cellulitis but that clinicians should consider extending treatment if the infection has not improved after 5 days 1.

From the FDA Drug Label

In pediatric patients, a total daily dosage of 25 to 50 mg/kg (approximately 10 to 20 mg/lb) of body weight, divided into 3 or 4 equal doses, is effective for most mild to moderately severe infections. Total daily dosage may be increased to 100 mg/kg (45 mg/lb) of body weight for severe infections The recommended dosage of cefazolin for pediatric patients with cellulitis is 25 to 50 mg/kg per day, divided into 3 or 4 equal doses, which can be increased to 100 mg/kg per day for severe infections 2.

• The dosage should be adjusted based on the severity of the infection and the patient's weight.
• The medication should be administered every 6 to 8 hours.
• It is essential to follow the recommended dosage and administration guidelines to ensure effective treatment and minimize potential side effects.

From the Research

Cellulitis Treatment in Pediatrics

• Cellulitis is a common skin and soft-tissue infection that is usually caused by streptococci bacteria or, less commonly, Staphylococcus aureus 3.
• The goal of treatment is to use the antibiotic with the narrowest spectrum for the shortest duration necessary to provide clinical improvement 3.
• Noncomplicated, nonfacial cellulitis is most commonly treated using first-generation cephalosporins, with oral antibiotics being effective and requiring fewer visits and less time in the ED compared to intravenous treatment 4.
• The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient 5.

Antibiotic Administration and Disposition

• Features such as fevers/chills, lymphangitis, and functional impairment are considered important when deciding on the initial antibiotic route and disposition for children with uncomplicated cellulitis 6.
• Stability, rather than reduction, of erythematous margins is sufficient to consider transition and de-escalation of therapy at less than 24 hours if all other clinical improvement criteria are met 6.
• The use of broad-spectrum antibiotics, including dual/triple therapy and MRSA active antibiotics, can be decreased with the implementation of a clinical practice guideline (CPG) for pediatric preseptal cellulitis 7.

Clinical Practice Guidelines

• Implementing a CPG for pediatric preseptal cellulitis can lead to a decrease in the use of broad-spectrum antibiotics and resource utilization, including blood testing and imaging 7.
• A multifaceted strategy that includes buy-in from key stakeholders, education of frontline providers, and stakeholder check-ins can be effective in implementing a CPG and improving antibiotic use 7.