What antibiotics are recommended for a pediatric patient with an infected wound?

Antibiotic Selection for Pediatric Infected Wounds

For pediatric patients with infected wounds, amoxicillin-clavulanate is the first-line antibiotic choice for mild to moderate infections, with clindamycin or cephalexin as alternatives. 1

Severity Assessment and Initial Approach

The treatment strategy depends critically on infection severity and whether the wound requires drainage:

• Simple abscesses: Incision and drainage is the primary treatment; antibiotics may not provide significant additional benefit for small, adequately drained lesions 1
• Mild infections: Oral antibiotics are appropriate for outpatient management 1
• Complicated infections: Hospitalization with IV antibiotics is required for deeper soft-tissue infections, surgical/traumatic wound infections, major abscesses, or signs of systemic toxicity 1

First-Line Oral Antibiotic Regimens

For Mild to Moderate Infections

Amoxicillin-clavulanate is the WHO-designated first-choice antibiotic for skin and soft tissue infections 1:

• Dosing for children ≥3 months: 45 mg/kg/day (of amoxicillin component) divided every 12 hours for more severe infections, or 25 mg/kg/day every 12 hours for less severe infections 2
• Neonates and infants <3 months: 30 mg/kg/day divided every 12 hours 2
• Children ≥40 kg: Use adult dosing (500 mg/125 mg every 8 hours or 875 mg/125 mg every 12 hours) 2

This combination provides excellent coverage against Staphylococcus aureus and Streptococcus pyogenes, the primary pathogens in pediatric wound infections 3, 4

Alternative First-Line Options

Cephalexin (cefalexin): Also designated as first-choice by WHO 1

• Dosing: 75-100 mg/kg/day divided into 3-4 doses 1

Cloxacillin: First-choice option, particularly for anti-staphylococcal coverage 1

MRSA Coverage (When Indicated)

If community-acquired MRSA is suspected or confirmed, adjust therapy accordingly:

Outpatient Oral Options

• Clindamycin: 30-40 mg/kg/day divided into 3-4 doses (only if local clindamycin resistance is <10%) 1
• Trimethoprim-sulfamethoxazole (TMP-SMX): Effective for MRSA but lacks streptococcal coverage; combine with a β-lactam (e.g., amoxicillin) if streptococcal coverage is needed 1
• Linezolid:
  • Children <12 years: 10 mg/kg/dose every 8 hours
  • Children ≥12 years: 600 mg every 12 hours 1

Important Pediatric Contraindications

Tetracyclines (doxycycline, minocycline) should NOT be used in children <8 years of age due to risk of tooth discoloration and bone growth effects 1

Hospitalized Patients with Complicated Infections

For children requiring hospitalization with complicated skin and soft tissue infections:

IV Vancomycin is the recommended first-line agent 1:

• Dosing: 40-60 mg/kg/day divided every 6-8 hours (or dosed to achieve AUC/MIC ratio >400) 1

Alternative IV regimen if patient is stable without bacteremia:

• Clindamycin: 10-13 mg/kg/dose IV every 6-8 hours (40 mg/kg/day total), only if local clindamycin resistance is low (<10%), with transition to oral therapy if strain is susceptible 1
• Linezolid: Same dosing as oral formulation 1

Special Wound Types

Animal Bites

• Oral: Amoxicillin-clavulanate 1
• IV: Ampicillin-sulbactam or piperacillin-tazobactam 1

Human Bites

• First-line: Amoxicillin-clavulanate or ampicillin-sulbactam 1
• Alternatives: Carbapenems for severe cases or multidrug-resistant bacteria 1

Surgical/Traumatic Wound Infections

Treatment depends on anatomic location:

• Trunk/extremity (away from axilla/perineum): Cefazolin, cephalexin, or anti-staphylococcal penicillins 1
• Axilla/perineum: Ceftriaxone or fluoroquinolone plus metronidazole (note: fluoroquinolones should be avoided in young children when possible) 1

Duration of Therapy

• Typical course: 7-14 days, individualized based on clinical response 1
• Minimum for streptococcal infections: 10 days 5

Critical Pitfalls to Avoid

1. Do not use fluoroquinolones or doxycycline in young children unless absolutely necessary, as these are generally avoided in pediatric populations 1

2. Obtain cultures before antibiotic therapy in patients with severe infection, systemic illness, inadequate response to initial treatment, or concern for outbreak 1

3. Ensure adequate surgical drainage before or concurrent with antibiotic therapy—antibiotics alone are often insufficient for purulent collections 1, 3

4. Consider adding clindamycin if toxin-mediated symptoms are present (generalized rash, hypotension, diarrhea), as it has antitoxin properties 3

5. Avoid rifampin as monotherapy or adjunctive therapy for skin and soft tissue infections 1