What is the treatment for pediatric gram-positive cocci skin abscesses?

Treatment of Pediatric Gram-Positive Cocci Skin Abscess

Incision and drainage is the primary and often sufficient treatment for simple pediatric skin abscesses caused by gram-positive cocci, with antibiotics reserved for specific high-risk situations. 1

Primary Treatment Approach

Incision and Drainage (I&D)

• I&D alone is adequate for most simple, uncomplicated abscesses without requiring adjunctive antibiotic therapy 1
• Cure rates of 85-90% are achieved with drainage alone, regardless of whether antibiotics are used 1
• Wound packing after drainage is not necessary and can be safely omitted, avoiding additional pain and anxiety 2
• For small furuncles, moist heat application may be sufficient to promote drainage 1

When Antibiotics ARE Indicated

Add antibiotic therapy if any of the following conditions are present: 1

• Systemic signs of infection (fever, hypotension, oliguria, decreased mental alertness) 1
• Multiple abscesses or satellite lesions 1
• Extensive surrounding cellulitis (erythema extending significantly beyond abscess borders) 1
• Abscess diameter >5 cm (significant predictor of treatment failure without antibiotics) 3
• Immunocompromised patients 1
• Difficult-to-drain locations (face, hand, genitalia) 1
• Rapid progression despite adequate drainage 1
• Age extremes (very young infants) 1
• Associated septic phlebitis or bacteremia 1

Antibiotic Selection for Outpatient Management

First-Line Oral Options for CA-MRSA Coverage

For children ≥8 years old: 1

• Clindamycin 10-13 mg/kg/dose PO every 6-8 hours (preferred if local resistance <10%) 1
• TMP-SMX (trimethoprim-sulfamethoxazole) 1
• Doxycycline or minocycline (can be used safely in children ≥2 years for <2 weeks duration) 1

For children <8 years old: 1

• Clindamycin 10-13 mg/kg/dose PO every 6-8 hours 1
• TMP-SMX (but NOT as monotherapy if streptococcal infection possible) 1

Important caveat: Tetracyclines (doxycycline, minocycline) should not be used in children <8 years of age 1

Coverage Considerations

• For purulent abscesses: Empiric CA-MRSA coverage is appropriate given the rising prevalence (76-86% of cultured specimens) 3, 4, 5
• For non-purulent cellulitis without abscess: β-lactam antibiotics (e.g., cephalexin) targeting streptococci may be sufficient, with modification to MRSA-active therapy if no clinical response 1
• If both streptococcal and MRSA coverage desired: Clindamycin alone OR TMP-SMX/tetracycline combined with a β-lactam (e.g., amoxicillin) 1

Duration of Therapy

• 5-10 days for most uncomplicated cases 1
• Individualize based on clinical response, but typically 7-14 days 1

Inpatient Management for Complicated Cases

Indications for Hospitalization

• Systemic toxicity or signs of organ dysfunction 1
• Failed outpatient management 1
• Deep soft-tissue involvement, surgical/traumatic wound infection, or major abscesses 1
• Need for IV antibiotics or surgical debridement 1

IV Antibiotic Options

For hospitalized children with complicated SSTI: 1

• Vancomycin (first-line for hospitalized children) 1
• Clindamycin 10-13 mg/kg/dose IV every 6-8 hours (40 mg/kg/day) if patient stable without bacteremia and local clindamycin resistance <10% 1
• Linezolid:
  • Children <12 years: 10 mg/kg/dose PO/IV every 8 hours 1, 6
  • Children ≥12 years: 600 mg PO/IV every 12 hours 1, 6

Duration: 7-14 days, adjusted based on clinical response 1

Special Considerations

Minor Superficial Infections

• Impetigo and secondarily infected lesions: Topical mupirocin 2% ointment may be sufficient 1
• Impetigo is highly contagious and predominantly affects children, commonly caused by β-hemolytic Streptococcus and/or S. aureus 1

Neonates and Young Infants

• Pre-term neonates <7 days (gestational age <34 weeks): Linezolid 10 mg/kg every 12 hours initially, consider increasing to every 8 hours if suboptimal response 6
• All neonates by 7 days of life: Linezolid 10 mg/kg every 8 hours 6

What NOT to Do

• Do NOT use rifampin as monotherapy or adjunctive therapy for SSTI 1
• Do NOT use TMP-SMX alone for non-purulent cellulitis due to poor streptococcal coverage 1
• Do NOT routinely prescribe antibiotics for simple abscesses <5 cm in immunocompetent children after adequate I&D 3

Key Clinical Pitfalls

• Initial antibiotic choice before culture results: Studies show that only 7% of children received an effective antibiotic before culture results, yet this did not significantly predict hospitalization when adequate drainage was performed 3
• Abscess size matters: Lesions >5 cm are significant predictors of hospitalization and may benefit more from adjunctive antibiotics 3
• Wound packing is unnecessary: Modern evidence supports omitting packing after I&D, which reduces pain and anxiety without compromising outcomes 2
• Local resistance patterns: Clindamycin should only be used empirically if local inducible clindamycin resistance rates are low (<10%) 1