Treatment of Secondary Bacterial Skin Infection in a 6-Year-Old with Severe Atopic Dermatitis
Yes, Augmentin (amoxicillin-clavulanate) is appropriate and recommended for this 6-year-old girl with severe atopic dermatitis and secondary bacterial skin infection. 1
Rationale for Systemic Antibiotic Use
Systemic antibiotics are indicated exclusively when clinical evidence of bacterial infection is present in children with atopic dermatitis on standard treatment. 1 The Taiwan Academy of Pediatric Allergy, Asthma and Immunology guidelines explicitly state that antibiotics should be considered in children with evidence of bacterial infection, particularly in moderate to severe AD cases 1.
Why Augmentin is the Preferred Choice
Primary Bacterial Targets
- Staphylococcus aureus and Streptococcus pyogenes are the main pathogens causing secondary infections in atopic dermatitis 2, 3
- S. aureus colonizes 87% of children with moderate to severe AD 4
- Mixed infections with both organisms are common in skin infections 5
Antimicrobial Coverage
Amoxicillin-clavulanate provides optimal coverage against beta-lactamase-producing S. aureus while maintaining activity against S. pyogenes. 6, 2, 7 The French Pediatric Infectious Disease Group specifically recommends amoxicillin-clavulanate as first-line therapy for severe skin infections in children, given the low incidence of methicillin-resistant S. aureus in most regions 2.
Resistance Patterns
- All S. aureus strains isolated from children with AD in susceptibility studies were susceptible to amoxicillin-clavulanate 4
- In contrast, erythromycin resistance reached 18-19% and amoxicillin alone showed 13% resistance 4
- Clindamycin resistance was only 1%, but carries risk of inducible resistance in erythromycin-resistant strains 6
Dosing for Pediatric Patients
For impetigo and skin/soft tissue infections, the recommended dose is 25 mg/kg/day of the amoxicillin component in 2 divided doses. 6 The standard formulation is 875/125 mg twice daily for adults, with pediatric dosing adjusted by weight 6.
For more severe infections, AUGMENTIN ES-600 provides 45 mg/kg every 12 hours and is FDA-approved for children 3 months to 12 years 8. This formulation should be administered with meals or snacks to reduce gastrointestinal upset 8.
Treatment Duration and Monitoring
- Continue treatment for 7-10 days for uncomplicated skin infections 2, 7
- Monitor for clinical improvement within the first week; 84-96% of children show clinical cure by day 7 9
- If toxinic symptoms develop (generalized rash, diarrhea, hypotension), add clindamycin for its antitoxin properties 2, 7
Important Caveats
When NOT to Use Augmentin
- Penicillin allergy with immediate hypersensitivity reactions: Use first-generation cephalosporins (cefadroxil, cephalexin) instead 6, 4
- Mononucleosis: Ampicillin-class antibiotics cause erythematous rash in high percentage of these patients 8
Adjunctive Measures
Topical anti-inflammatory therapy with corticosteroids or calcineurin inhibitors should continue, as these reduce S. aureus colonization by improving skin barrier function 1. Long-term topical antibiotics are NOT recommended due to resistance and sensitization risks 1.
Side Effects
- Common: nausea (9%), diarrhea (9%), rash (3%) 5
- Phenylketonurics warning: ES-600 suspension contains 7 mg phenylalanine per 5 mL 8
- If severe diarrhea develops lasting >2-3 days, contact physician immediately 8
Alternative Antibiotics (Second-Line)
If Augmentin cannot be used:
- First-generation cephalosporins (cefadroxil, cephalexin): Ideal for Gram-positive coverage, all strains susceptible 4
- Clindamycin: 10-20 mg/kg/day in 3 divided doses, but check for inducible resistance 6
- Dicloxacillin: 12 mg/kg/day in 4 divided doses for methicillin-susceptible strains 6
Avoid macrolides as empiric therapy given 18-19% primary resistance rates in AD patients 4, unless susceptibility is confirmed.