What is the treatment approach for pediatric patients with Staphylococcus aureus (Staph) infections?

Treatment for Staphylococcus Aureus Infections in Pediatric Patients

Minor Skin Infections (Impetigo, Secondarily Infected Lesions)

For minor localized staphylococcal skin infections in children, apply mupirocin 2% topical ointment three times daily for 5-10 days. 1, 2

• Mupirocin is specifically recommended by the Infectious Diseases Society of America for minor infections such as impetigo and secondarily infected skin lesions (eczema, ulcers, lacerations) in pediatric patients 1, 2
• Retapamulin 1% ointment is an FDA-approved alternative, applied twice daily for 5 days to affected areas (up to 2% total body surface area in children ≥9 months) 3

Cutaneous Abscesses and Furuncles

Incision and drainage is the primary treatment for abscesses; antibiotics are adjunctive and indicated only for specific high-risk conditions. 1

When to Add Antibiotics After Incision and Drainage:

• Multiple abscesses or extensive disease involving multiple sites 1
• Rapid progression with associated cellulitis 1
• Signs of systemic illness (fever, tachycardia, hypotension) 1
• Immunosuppression or significant comorbidities (diabetes, HIV/AIDS) 1
• Extremes of age (infants, elderly) 1
• Difficult-to-drain locations (face, hand, genitalia) 1
• Lack of response to incision and drainage alone 1

Oral Antibiotic Options for Outpatient Treatment:

First-line oral antibiotics:

• Clindamycin 30-40 mg/kg/day divided into 3-4 doses (max 600 mg/dose) - provides coverage for both MSSA and MRSA, but ONLY use if local clindamycin resistance is <10% 1, 4
• TMP-SMX 8-12 mg/kg/day (based on TMP component) divided twice daily PLUS a beta-lactam (amoxicillin or cephalexin) - TMP-SMX covers MRSA but lacks streptococcal coverage, requiring combination therapy 1, 4
• Cephalexin 25-50 mg/kg/day divided 3-4 times daily - effective for MSSA but inadequate for MRSA 5

Important caveats:

• Avoid tetracyclines (doxycycline, minocycline) in children <8 years of age due to tooth discoloration risk 1, 6
• Treatment duration is typically 5-10 days for uncomplicated infections, with clinical response expected within 48-72 hours 4, 2
• If local clindamycin resistance rates are ≥10% or unknown, use TMP-SMX plus a beta-lactam instead of clindamycin monotherapy 4

Complicated Skin and Soft Tissue Infections (Hospitalized Patients)

For hospitalized children with complicated SSTIs, initiate IV vancomycin 15 mg/kg/dose every 6 hours. 1

Alternative IV Options for Stable Patients:

• Clindamycin 10-13 mg/kg/dose IV every 6-8 hours (40 mg/kg/day total) - acceptable if patient is stable without ongoing bacteremia or intravascular infection AND local clindamycin resistance is <10%, with transition to oral therapy if strain is susceptible 1, 6
• Linezolid - 10 mg/kg/dose IV/PO every 8 hours for children <12 years; 600 mg IV/PO twice daily for children ≥12 years 1, 6

Treatment Duration:

• 7-14 days depending on severity and clinical response 1

Bacteremia and Infective Endocarditis

Vancomycin 15 mg/kg/dose IV every 6 hours is the recommended treatment for pediatric MRSA bacteremia and endocarditis. 1

• Duration ranges from 2-6 weeks depending on source, presence of endovascular infection, and metastatic foci 1
• Daptomycin 6-10 mg/kg/dose IV once daily may be considered as an alternative, though pediatric data are limited 1, 7
• Do NOT use clindamycin or linezolid if endocarditis or endovascular source is suspected - reserve these only for bacteremia that rapidly clears and is not endovascular in origin 1
• Obtain echocardiogram in children with congenital heart disease, bacteremia lasting >2-3 days, or clinical findings suggestive of endocarditis 1
• Routine combination therapy with rifampin or gentamicin is not supported by sufficient data in children; individualize this decision 1

Pneumonia

For severe community-acquired pneumonia requiring ICU admission, necrotizing/cavitary infiltrates, or empyema, initiate empirical MRSA coverage with IV vancomycin. 1

• Alternative options include linezolid 600 mg IV/PO twice daily or clindamycin 10-13 mg/kg/dose IV every 6-8 hours if strain is susceptible 1
• Treatment duration is 7-21 days depending on extent of infection 1
• Empyema requires antimicrobial therapy combined with drainage procedures 1

Osteomyelitis

Surgical debridement and drainage of associated soft-tissue abscesses is the cornerstone of therapy and should be performed whenever feasible. 1

• Parenteral, oral, or sequential parenteral-to-oral therapy may be used depending on clinical response 1

Recurrent Infections and Decolonization

Hygiene and Wound Care (First-Line Prevention):

• Keep draining wounds covered with clean, dry bandages 1
• Regular handwashing with soap and water or alcohol-based hand gel, especially after touching infected skin 1, 2
• Avoid sharing personal items (razors, linens, towels) that contact infected skin 1, 2
• Clean high-touch surfaces (counters, doorknobs, bathtubs, toilet seats) with commercially available cleaners 1, 2

Decolonization Strategies (Consider if Recurrent Infections Persist):

Decolonization should be considered only after optimizing hygiene measures and in cases of recurrent SSTI or ongoing household transmission. 1

• Nasal decolonization: Mupirocin 2% ointment applied intranasally twice daily for 5-10 days 1
• Body decolonization: Chlorhexidine skin antiseptic for 5-14 days OR dilute bleach baths (1 teaspoon per gallon of water or ¼ cup per ¼ tub, 15 minutes twice weekly for 3 months) 1
• Evaluate and treat symptomatic household contacts; consider decolonization of asymptomatic contacts if transmission is ongoing 1
• Screening cultures prior to decolonization are not routinely needed if prior infection was documented as MRSA 1

Key Clinical Pitfalls

• Never use tetracyclines in children <8 years old 1, 6
• Clindamycin monotherapy is inappropriate if local resistance is ≥10% - this is a critical error that leads to treatment failure 4
• TMP-SMX lacks streptococcal coverage - always combine with a beta-lactam for empirical treatment of cellulitis where streptococci may be involved 1, 4
• Incision and drainage alone is often sufficient for simple abscesses - avoid unnecessary antibiotic exposure unless high-risk features are present 1
• Do not use clindamycin or linezolid for suspected endocarditis - vancomycin is mandatory for endovascular infections 1