Can tigecycline be used to treat a methicillin‑resistant Staphylococcus aureus (MRSA) skin or soft‑tissue abscess in a child?

Tigecycline for MRSA Skin Abscess in Children

Tigecycline should NOT be used for treating MRSA skin abscesses in children, as it is not approved for pediatric use (patients <18 years) and carries a black box warning for increased all-cause mortality. 1

FDA Approval and Age Restrictions

• Tigecycline is only indicated for patients 18 years of age and older for complicated skin and skin structure infections, including those caused by MRSA 1
• The FDA label explicitly restricts use to adults, making it inappropriate for pediatric patients with skin abscesses 1
• Taiwan FDA guidelines specifically state that tigecycline use is not recommended in patients <18 years of age unless no alternative antimicrobial agents are available 2

Black Box Warning Considerations

• Tigecycline carries a black box warning for increased all-cause mortality (0.6% mortality risk difference, 95% CI 0.1-1.2) observed in meta-analyses of clinical trials 1
• The drug should be reserved only for situations when alternative treatments are not suitable, which does not apply to pediatric MRSA abscesses where multiple effective alternatives exist 1

Appropriate Treatment Options for Pediatric MRSA Abscesses

Outpatient Management

• Incision and drainage is the primary treatment for cutaneous abscesses and may be adequate without antibiotics for simple abscesses <5 cm in immunocompetent children 2, 3
• When antibiotics are indicated, first-line oral options include:
  • Clindamycin 10-20 mg/kg/day divided into 3 doses (only if local resistance rates <10%) 2, 4
  • Trimethoprim-sulfamethoxazole (TMP-SMX) 8-12 mg/kg/day based on trimethoprim component in 2 divided doses 2, 4
  • Linezolid 10 mg/kg/dose every 8 hours for children <12 years 2

Hospitalized Children with Complicated Infections

• Vancomycin is the recommended first-line parenteral agent at 40 mg/kg/day in 4 divided doses (or 15 mg/kg/dose every 6 hours) 2, 5
• Clindamycin 10-13 mg/kg/dose IV every 6-8 hours can be used in stable patients without bacteremia if local clindamycin resistance is <10% 2
• Linezolid is an alternative: 600 mg twice daily for children >12 years or 10 mg/kg/dose every 8 hours for children <12 years 2

Critical Pediatric Considerations

• Tetracyclines (doxycycline, minocycline) should not be used in children <8 years of age due to tooth discoloration risk 2, 5
• Verify local clindamycin resistance patterns before use, as inducible resistance is common in MRSA 4, 5
• Culture abscesses when antibiotics are prescribed, in severe infections, or if there are signs of systemic illness 2

Treatment Duration

• 5-10 days for uncomplicated infections and 7-14 days for complicated infections, guided by clinical response 2, 4