What are the guidelines for pediatric skin and soft tissue infections?

From the Guidelines

For pediatric skin and soft tissue infections, first-line treatment for mild impetigo includes topical mupirocin or retapamulin applied three times daily for 5-7 days, as recommended by the Infectious Diseases Society of America 1.

Treatment Guidelines

For more extensive impetigo, oral cephalexin (25-50 mg/kg/day divided every 6-8 hours) or clindamycin (10-30 mg/kg/day divided every 6-8 hours) for 7 days is recommended.

• For cellulitis, oral cephalexin is first-line therapy for mild cases,
• while more severe infections require intravenous cefazolin (100 mg/kg/day divided every 8 hours) or clindamycin (30-40 mg/kg/day divided every 6-8 hours) if MRSA is suspected, as per the guidelines 1.

MRSA Infections

Abscesses require incision and drainage as the primary treatment, with antibiotics added for surrounding cellulitis, fever, or extensive disease.

• For MRSA infections, clindamycin, trimethoprim-sulfamethoxazole (8-12 mg/kg/day of trimethoprim component divided twice daily), or linezolid may be used, as suggested by the studies 1.

Duration of Therapy

Duration of therapy typically ranges from 5-10 days depending on severity and clinical response.

• Wound care is essential, including keeping the area clean and covered with sterile dressings changed daily, as emphasized in the guidelines 1.

Hospitalization

Children with extensive infection, systemic symptoms, or immunocompromise should be evaluated for possible hospitalization, as recommended by the Infectious Diseases Society of America 1. These recommendations target the most common pathogens in pediatric skin infections—Staphylococcus aureus and Streptococcus pyogenes—while considering the increasing prevalence of community-acquired MRSA in many regions, as noted in the studies 1.

From the FDA Drug Label

Pediatric Patients (for children who are able to swallow capsules): Serious infections – 8 to 16 mg/kg/day (4 to 8 mg/lb/day) divided into three or four equal doses. More severe infections – 16 to 20 mg/kg/day (8 to 10 mg/lb/day) divided into three or four equal doses. Skin and skin structure infections caused by Staphylococcus aureus and/or Streptococcus pyogenes

For pediatric skin and soft tissue infections, the dosage of clindamycin is:

• 8 to 16 mg/kg/day for serious infections
• 16 to 20 mg/kg/day for more severe infections Cephalexin is also indicated for the treatment of skin and skin structure infections caused by Staphylococcus aureus and/or Streptococcus pyogenes 2, 2, 3.

From the Research

Skin and Soft Tissue Infections in Pediatrics

• Skin and soft tissue infections are common in pediatrics, ranging from mild conditions like impetigo to severe forms such as necrotizing dermohypodermitis 4.
• The main pathogens involved in these infections are Staphylococcus aureus and group A beta-hemolytic streptococci, but enteric organisms also play a role, especially in nosocomial infections 5.

Treatment Guidelines

• For limited impetigo and furonculosis, topical treatments are preferred, with mupirocine and fucidic acid being the two topical antibiotics used preferentially 4.
• For uncomplicated superficial skin infections justifying an oral antibiotic, amoxicillin-clavulanate offers the best guarantee of efficiency 4.
• In case of allergy, a first-generation cephalosporin, a macrolide (if the susceptibility of the strain was checked), or pristinamycine (after 6 years of age) are acceptable alternatives 4.
• For dermohypodermitis, the bacterial antibiotic of choice remains amoxicillin-clavulanate through the IV route, to be active against S. pyogenes, S. aureus, and anaerobic bacteria 4.
• For toxinic syndromes and necrotizing fascitis, clindamycin should be added to a beta-lactam because of its action on protein synthesis, particularly reducing toxin production 4, 6.

Antibiotic Selection

• The French Pediatric Infectious Disease Group recommends the use of amoxicillin + clavulanate as the first-line antibiotic in most children suffering from severe skin infections requiring antibiotic treatment 6.
• In patients presenting with toxinic symptoms and signs, the adjunction of an antibiotic with antitoxin properties, such as clindamycin, should be considered 6.
• Empiric treatment of skin and soft-tissue infections with either clindamycin or trimethoprim/sulfamethoxazole maximizes the probability that the antibiotic will be active when community-associated methicillin-resistant S. aureus (CA-MRSA) prevalence is >10% 7.

Management in Emergency Department

• Skin and soft-tissue infections are among the most common conditions seen in children in the emergency department, with emergency department visits for these infections more than doubling between 1993 and 2005 8.
• The emergence of CA-MRSA has created controversy regarding treatment regimens for skin and soft-tissue infections, emphasizing the need for evidence-based management 8.