Antibiotics for Mild Superficial Cat Scratch in Healthy, Immunized Child
For a mild superficial cat scratch in a healthy, immunized child, antibiotics are NOT routinely recommended, as the majority of uncomplicated cat scratch disease cases resolve spontaneously without antimicrobial therapy. 1, 2, 3
When to Withhold Antibiotics
- Simple superficial scratches in immunocompetent children do not require prophylactic antibiotics, as cat scratch disease is typically self-limiting and resolves within 2-4 months without treatment 1, 2, 4
- The natural course involves spontaneous resolution of lymphadenopathy within 1-6 months in most cases 5
- Treatment should focus on thorough wound cleansing with sterile normal saline to remove debris 6
High-Risk Features Requiring Antibiotic Prophylaxis
Prophylactic antibiotics ARE indicated if any of the following features are present:
- Deep puncture wounds (not superficial scratches) 6, 7
- Wounds on hands, feet, face, or near joints 6, 7
- Immunocompromised status 6, 7
- Wounds presenting >8-12 hours after injury with early signs of infection 7
First-Line Antibiotic When Treatment IS Needed
If the scratch meets high-risk criteria, amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days is the first-line prophylactic choice, providing optimal coverage against Pasteurella multocida and polymicrobial flora 6, 7
Treatment for Established Cat Scratch Disease
If the child develops classic cat scratch disease (regional lymphadenopathy 3 weeks post-scratch), azithromycin is the recommended treatment:
- For children <45 kg: 10 mg/kg on day 1, then 5 mg/kg daily for 4 additional days 5, 6
- For children ≥45 kg: 500 mg on day 1, then 250 mg daily for 4 additional days 5, 6
- Azithromycin accelerates lymph node regression by 80% at 30 days compared to placebo (P = 0.02) 5
Critical Pitfalls to Avoid
- Do NOT use first-generation cephalosporins, penicillinase-resistant penicillins, or clindamycin as monotherapy for cat scratches, as they have poor or absent activity against Pasteurella multocida 7
- Do NOT confuse simple superficial scratches with deep puncture wounds or bites, which have much higher infection rates (10-20% for scratches vs 30-50% for bites) 6
- Verify tetanus immunization status and update if needed 6
When to Treat Despite Mild Presentation
Consider azithromycin treatment even for mild cat scratch disease if:
- Lymph nodes are suppurating (occurs in ~10% of cases) 5
- Extranodal disease develops (CNS, liver, spleen, bone involvement in ≤2% of cases) 5
- Symptoms persist beyond expected timeframe or worsen 8
- Patient requires faster resolution for quality of life reasons 5