Treatment of Boils (Furuncles) in Pediatric Patients
For simple boils in children, incision and drainage alone is likely adequate without antibiotics, but when antibiotics are indicated, oral clindamycin (10-13 mg/kg/dose every 6-8 hours, not to exceed 40 mg/kg/day) or TMP-SMX (trimethoprim 4-6 mg/kg/dose every 12 hours) are the preferred first-line agents for community-acquired MRSA coverage. 1
When Antibiotics Are Indicated
The IDSA guidelines specify that antibiotics should be added to incision and drainage for boils when any of the following conditions exist: 1
- Severe or extensive disease (involving multiple sites of infection) or rapid progression with associated cellulitis
- Signs and symptoms of systemic illness (fever, tachycardia, hypotension)
- Associated comorbidities or immunosuppression (diabetes, HIV/AIDS, malignancy)
- Extremes of age (very young infants or elderly)
- Abscess in difficult-to-drain locations (face, hand, genitalia)
- Associated septic phlebitis
- Lack of response to incision and drainage alone
Recommended Antibiotic Regimens
First-Line Oral Options for Purulent Skin Infections (Including Boils):
Clindamycin is the most versatile option as it covers both CA-MRSA and β-hemolytic streptococci: 1
- Pediatric dose: 10-13 mg/kg/dose PO every 6-8 hours
- Maximum daily dose: 40 mg/kg/day
- Duration: Typically 7-10 days
- Caveat: Clostridium difficile-associated disease may occur more frequently compared with other oral agents 1
TMP-SMX (Trimethoprim-Sulfamethoxazole): 1
- Pediatric dose: Trimethoprim 4-6 mg/kg/dose, sulfamethoxazole 20-30 mg/kg/dose PO every 12 hours
- Important limitation: TMP-SMX is pregnancy category C/D and not recommended for children <2 months of age 1
- Coverage gap: Activity against β-hemolytic streptococci is not well-defined, so consider adding coverage if streptococcal infection is suspected 1
Alternative Options (for children ≥8 years):
Doxycycline: 1
- Pediatric dose (<45 kg): 2 mg/kg/dose PO every 12 hours
- Contraindication: Not recommended for children under 8 years of age (pregnancy category D) 1
Minocycline: 1
- Pediatric dose: 4 mg/kg PO once, then 2 mg/kg/dose PO every 12 hours
- Same age restriction as doxycycline 1
When Streptococcal Coverage Is Also Needed:
If there is concern for both CA-MRSA and β-hemolytic streptococci (such as with surrounding cellulitis), clindamycin is preferred as it covers both organisms. 1 The clinical significance of inducible clindamycin resistance is unclear for mild infections, but its presence should preclude clindamycin use for more serious infections. 1
Critical Considerations
Incision and Drainage Remains Primary Treatment:
For simple abscesses or boils, incision and drainage is likely adequate without antimicrobial therapy. 1 Antibiotics are adjunctive and should not replace proper surgical drainage when indicated.
MRSA Considerations:
Community-acquired MRSA (CA-MRSA) is now a common cause of skin and soft tissue infections in children. 1 The recommended oral agents (clindamycin, TMP-SMX, doxycycline, minocycline) all have good in vitro activity against CA-MRSA. 1
Avoid These Agents:
- Rifampin should not be used as monotherapy due to rapid resistance development 1
- Linezolid (10 mg/kg/dose PO every 8 hours, not to exceed 600 mg/dose) is FDA-approved for SSTI but is not superior to less expensive alternatives 1
Common Pitfalls to Avoid
Prescribing antibiotics without adequate drainage: Antibiotics alone are often insufficient for boils that require drainage 1
Using TMP-SMX as sole therapy when streptococcal infection is possible: TMP-SMX has uncertain activity against β-hemolytic streptococci 1
Prescribing tetracyclines to young children: Doxycycline and minocycline are contraindicated in children <8 years due to effects on developing teeth and bones 1
Ignoring local resistance patterns: Clindamycin resistance is increasing in certain geographic areas among S. aureus infections 1
Using β-lactam antibiotics (like amoxicillin) for suspected MRSA: These are ineffective against methicillin-resistant organisms 1