In a 12-year-old child with two superficial cat‑scratch wounds on the dorsal hand now surrounded by mild cellulitis, who is otherwise systemically well, up‑to‑date on tetanus immunization and has no penicillin allergy, immunodeficiency, or chronic skin disease, is oral antibiotic therapy appropriate as first‑line treatment?

Oral Antibiotics Are Appropriate First-Line Treatment for This Case

For a 12-year-old with superficial cat-scratch wounds and surrounding cellulitis who is systemically well, oral antibiotic therapy is entirely appropriate as first-line treatment. 1

Recommended Oral Antibiotic Regimen

Prescribe amoxicillin-clavulanate 875/125 mg twice daily for 5 days as the optimal first-line agent for cat-related hand wounds with cellulitis. 1, 2 This combination provides:

• Single-agent coverage for Pasteurella multocida, the pathogen isolated in over 50% of cat bite/scratch wounds 3, 2
• Adequate coverage for streptococci and methicillin-sensitive Staphylococcus aureus, the typical cellulitis pathogens 1
• Polymicrobial coverage appropriate for animal-associated wounds 1, 2

Alternative regimens if amoxicillin-clavulanate is unavailable:

• Cephalexin 500 mg four times daily PLUS trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily for 5 days 1
• Clindamycin 300-450 mg every 6 hours for 5 days (if local MRSA clindamycin resistance <10%) 1

Treatment Duration

Treat for exactly 5 days if clinical improvement occurs (reduced warmth, tenderness, improving erythema); extend only if symptoms have not improved within this timeframe. 1, 4 High-quality randomized controlled trial evidence demonstrates that 5-day courses are as effective as 10-day courses for uncomplicated cellulitis. 1

Why Oral Therapy Is Sufficient

Beta-lactam therapy achieves 96% clinical success in typical cellulitis, and this patient lacks any criteria requiring hospitalization or intravenous therapy. 1 The child is:

• Systemically well (no fever, hypotension, altered mental status, or systemic inflammatory response syndrome) 1
• Without signs of deep infection (no severe pain out of proportion, skin anesthesia, rapid progression, or "wooden-hard" tissue) 1
• Appropriate for outpatient management with close follow-up 1

Critical Monitoring Requirements

Reassess within 24-48 hours to verify clinical response, as treatment failure rates of approximately 21% have been reported with some oral regimens. 1 Mandatory follow-up ensures early detection of:

• Progression despite appropriate therapy (suggesting resistant organisms or deeper infection) 1
• Development of abscess requiring drainage 1
• Signs of necrotizing infection requiring surgical consultation 1

When to Escalate to Intravenous Therapy

Hospitalize and initiate IV antibiotics only if any of the following develop:

• Systemic inflammatory response syndrome (fever >38°C, tachycardia, hypotension) 1, 4
• Signs of deep-space infection, flexor tenosynovitis, or necrotizing fasciitis 1
• Failure to improve after 48-72 hours of appropriate oral therapy 1
• Development of osteomyelitis (rare but reported with P. multocida) 3

Adjunctive Measures

Elevate the affected hand above heart level for at least 30 minutes three times daily to promote gravity drainage of edema and inflammatory substances. 1

Verify tetanus immunization status and update if needed, as this is routinely required for animal bite/scratch wounds. 2

Immobilize the hand if swelling or pain limits function, as hand infections can rapidly progress to deep-space involvement. 1

Cat-Scratch Disease Considerations

While Bartonella henselae (cat-scratch disease) typically presents with lymphadenopathy rather than acute cellulitis 5, 6, if lymph node enlargement develops or symptoms persist beyond 5 days despite appropriate antibiotics:

• Consider azithromycin 10 mg/kg on day 1 (maximum 500 mg), then 5 mg/kg daily on days 2-5 (maximum 250 mg) 5, 6
• Most cat-scratch disease cases are self-limited and do not require antibiotics 5, 6
• Serologic testing for B. henselae (IgG titers >1:256) can confirm diagnosis if clinical suspicion is high 6

Common Pitfalls to Avoid

Do not delay oral antibiotic initiation while awaiting culture results; P. multocida causes rapidly developing cellulitis within 12-24 hours of cat wounds and responds well to early treatment. 3

Do not use cephalexin alone for cat-related wounds, as first-generation cephalosporins lack reliable activity against P. multocida; amoxicillin-clavulanate is superior. 2

Do not automatically hospitalize all pediatric hand cellulitis cases; stable children with uncomplicated disease can be safely managed outpatient with close follow-up. 1

Do not continue ineffective antibiotics beyond 48 hours if the infection is progressing; reassess for resistant organisms, undrained abscess, or deeper infection. 1