What antibiotics are recommended for pediatric patients with sutured wounds?

Antibiotic Management for Pediatric Sutured Wounds

Most simple, clean sutured wounds in children do not require prophylactic antibiotics, as infection rates are extremely low (approximately 1%) when proper wound care is performed. 1

When Antibiotics Are NOT Indicated

• Clean, simple lacerations without contamination do not require antibiotics, regardless of whether sutures are placed 1
• Wounds with minimal systemic signs (temperature <38.5°C, WBC <12,000 cells/µL, pulse <100 beats/minute) and <5 cm of surrounding erythema do not need antibiotics 2
• Simple intraoral lacerations in children generally do not warrant routine antibiotic prophylaxis unless large enough to require suturing 3

High-Risk Wounds Requiring Antibiotics

Antibiotics are indicated for 3-5 days in the following high-risk pediatric wounds: 1

• Immunocompromised patients 1
• Significant contamination (soil, fecal matter, animal tissue) 1, 4
• Moderate to severe injuries 1
• Penetration of periosteum or joint capsule 1
• Wounds with preexisting or resultant edema 1
• Human or animal bites to the hand 1, 5

First-Line Antibiotic Selection

For High-Risk Clean Wounds

Amoxicillin-clavulanate 875/125 mg twice daily orally for 3-5 days is the first-line choice, providing coverage against both aerobic and anaerobic bacteria 1

Pediatric dosing for amoxicillin-clavulanate: 6

• Children ≥3 months and <40 kg: 45 mg/kg/day divided every 12 hours for more severe infections, or 25 mg/kg/day divided every 12 hours for less severe infections
• Children ≥40 kg: Use adult dosing (875/125 mg twice daily)
• Infants <3 months: 30 mg/kg/day divided every 12 hours

For Animal or Human Bites

Amoxicillin-clavulanate remains first-line due to coverage of Pasteurella species (dog/cat bites) and Eikenella corrodens (human bites) 2, 5

Alternative Regimens for Penicillin Allergy

• Clindamycin 8-16 mg/kg/day divided into 3-4 doses for serious infections 7
• For contaminated wounds in penicillin-allergic patients, consider clindamycin plus an aminoglycoside or fluoroquinolone (though fluoroquinolones should be avoided in young children when possible) 2

Contaminated/Dirty Wounds (Therapeutic Antibiotics)

For Class III (contaminated) or Class IV (dirty-infected) wounds, therapeutic antibiotics are required, not just prophylaxis: 4

First-Line Regimen

• First-generation cephalosporin (cefazolin) for Staphylococcus aureus and streptococci coverage 1, 4
• Add aminoglycoside (gentamicin) for severe injuries with gram-negative risk 1, 4
• Add penicillin for soil contamination or ischemic tissue (Clostridium coverage) 1, 4

Duration

• 3 days for less severe contaminated wounds 1, 4
• 5 days for more severe wounds with significant contamination 1, 4
• 48-72 hours for high-velocity gunshot wounds 2

Surgical Site Infections

If infection develops postoperatively with systemic signs (temperature >38.5°C, heart rate >110 bpm, or erythema >5 cm beyond wound margins), a short course of 24-48 hours of antibiotics is indicated along with opening the suture line: 2

Clean Procedures (Trunk/Extremity)

• Cefazolin, cefalexin, or cloxacillin for staphylococcal/streptococcal coverage 2

Contaminated Procedures (Intestinal/Genitourinary)

• Single-drug regimens: Piperacillin-tazobactam, ertapenem, or other carbapenems 2
• Combination regimens: Ceftriaxone plus metronidazole 2

Critical Timing Considerations

Antibiotics must be started as soon as possible when indicated: 1, 4

• For surgical wounds requiring prophylaxis, administer within 60 minutes before incision 2, 1
• Delaying antibiotics beyond 3 hours significantly increases infection risk in contaminated wounds 1, 4
• For established infections, the most important therapy is opening the incision and evacuating infected material; antibiotics are adjunctive 2

Common Pitfalls to Avoid

• Do not use prophylactic antibiotics for simple clean wounds - this increases antibiotic resistance without benefit 2, 1
• Do not substitute two 250/125 mg tablets for one 500/125 mg amoxicillin-clavulanate tablet - they contain different amounts of clavulanic acid 6
• Do not use prophylactic dosing for contaminated wounds - therapeutic dosing is required 4
• Do not extend antibiotic therapy beyond 5 days unnecessarily - this increases resistance risk 4
• Do not forget tetanus prophylaxis in all significant soft tissue injuries 5
• Recognize that polymicrobial infection is the rule in trauma, with 50% being mixed aerobic and anaerobic bacteria 5