How should I manage a pediatric skin infection such as cellulitis or impetigo in a child with tympanostomy tubes?

Management of Pediatric Skin Infection in a Child with Tympanostomy Tubes

When a child with tympanostomy tubes develops a skin infection such as cellulitis or impetigo, you must add systemic antibiotics to cover the skin pathogens—the presence of ear tubes requiring topical ear drops does NOT eliminate the need for oral antibiotics when cellulitis of the pinna or adjacent skin is present. 1

Critical Decision Point: Is There Cellulitis Involving the Pinna or Adjacent Skin?

The American Academy of Otolaryngology guidelines explicitly state that systemic antibiotic therapy is mandatory when cellulitis of the pinna or adjacent skin is present, even in children with tympanostomy tubes. 1 This represents one of the specific exceptions to the "topical-only" rule for ear tube otorrhea.

If Cellulitis is Present:

You must prescribe oral antibiotics immediately because cellulitis represents a deeper soft tissue infection that topical ear drops cannot adequately treat. 1

First-Line Oral Antibiotic Selection:

• For uncomplicated cellulitis without MRSA risk factors: Use amoxicillin-clavulanate 80-90 mg/kg/day (amoxicillin component) divided into 2-3 doses for 5-10 days 1, 2
• Alternative β-lactam options: Cephalexin or dicloxacillin if amoxicillin-clavulanate is not tolerated 1, 3

If MRSA Coverage is Needed:

Consider MRSA coverage if the child has:

• Failed initial β-lactam therapy after 48-72 hours 1
• Systemic toxicity (high fever, severe pain, toxic appearance) 1
• Known MRSA colonization or previous MRSA infection 1

MRSA-active oral options include:

• Clindamycin 10-13 mg/kg/dose every 6-8 hours (preferred if local resistance <10%) 1
• Trimethoprim-sulfamethoxazole (but must add amoxicillin for streptococcal coverage) 1
• Linezolid 10 mg/kg/dose every 8 hours for children <12 years 1

If Impetigo is Present (Without Cellulitis):

For limited impetigo (<100 cm² total area): Use topical mupirocin 2% ointment applied three times daily for 5-7 days 1, 4, 3

For extensive impetigo or multiple lesions: Oral antibiotics are indicated:

• Dicloxacillin or cephalexin for methicillin-susceptible organisms 4, 3
• Clindamycin, trimethoprim-sulfamethoxazole, or doxycycline (if child ≥8 years) for suspected MRSA 1, 4

Managing Concurrent Ear Tube Otorrhea

If the child also has active ear drainage from the tympanostomy tubes:

Prescribe topical quinolone ear drops (ofloxacin or ciprofloxacin-dexamethasone) for the ear drainage in addition to the systemic antibiotics for the skin infection. 1 The 2022 AAO-HNS guidelines confirm that topical drops remain superior to oral antibiotics for uncomplicated tube otorrhea, with cure rates of 77-96% versus 30-67% for systemic therapy alone. 1

Proper Ear Drop Administration:

• Clean the ear canal of debris by blotting or gentle suction before drop instillation 1
• Have caregivers "pump" the tragus several times after instilling drops to enhance middle ear penetration 1
• Limit topical therapy to a single 7-10 day course to avoid fungal superinfection 1

Common Pitfalls to Avoid

Do not rely on topical ear drops alone when cellulitis extends beyond the ear canal to involve the pinna or adjacent skin—this is explicitly listed as an exception requiring systemic antibiotics. 1

Do not use aminoglycoside-containing ear drops (such as neomycin-polymyxin) in children with tympanostomy tubes due to ototoxicity risk; only use quinolone drops (ofloxacin or ciprofloxacin-dexamethasone). 1

Do not use tetracyclines in children <8 years of age due to dental staining risk. 1

Do not add rifampin as adjunctive therapy for skin infections—it is not recommended. 1

Do not use trimethoprim-sulfamethoxazole as monotherapy unless streptococcal infection is ruled out, as it lacks adequate streptococcal coverage; combine with a β-lactam if streptococcal infection is possible. 1

Duration and Follow-Up

• Complete the full 5-10 day course of oral antibiotics for cellulitis, even if symptoms improve quickly 1, 4
• Reassess at 48-72 hours: If no improvement, consider MRSA coverage or alternative diagnosis 1, 5
• For impetigo: 5-7 days of topical or oral therapy is typically sufficient 1, 4, 3
• For ear tube otorrhea: 7-10 days of topical quinolone drops 1