Wound Care Clinician’s Guide to Evaluation & Management of Pediatric SSTI in the Outpatient Clinic

Bacterial skin and soft tissue infections (SSTIs) occur frequently during childhood. Specific etiologies of these infections in children vary by patient age and exposures. Regardless of age, Staphylococcus species and Streptococcus species are the most common pathogens, with methicillin-resistant Staphylococcus aureus (MRSA) accounting for a growing number of infections.^1-6 In some parts of the United States, MRSA is estimated to account for more than 70% of staphylococcal infections, which may correlate with more severe cases or poor clinical outcomes.⁵ Because SSTIs encompass a variety of conditions ranging in severity from benign, superficial infections to life-threatening, dermatologic emergencies, it is important to distinguish an SSTI that can be managed in an outpatient setting from one that requires hospitalization for intravenous therapy or surgical management. In order to provide optimal care and minimize complications, wound care clinicians must understand the different variants of SSTIs, perform a careful history and physical exam to determine likely pathogens, and promptly re-evaluate therapy if a patient fails to respond.

Treatment modalities should be based upon the patient’s age, ability to tolerate oral medications, comorbid conditions, size and location of the lesion, and presence of systemic toxicity.^1,2,6 Children living with impaired immune function or with chronic diseases such as sickle cell anemia, diabetes mellitus, or cystic fibrosis are at risk for more severe infections, recurrent infections, or infection with atypical or opportunistic pathogens.  Similarly, patients with recent surgical history, exposure to human or animal bites, contact with fresh or saltwater, or a wound caused by injury involving a foreign body require special consideration when selecting treatment regimens. These patient-specific exposures, as well as local pathogen prevalence and immunization history, should be considered when selecting therapy.^1,3,7 This article will review the clinical features, risk factors, and treatment options for common pediatric SSTIs while placing emphasis on outpatient management.

Dosing Recommendations, Antimicrobial Spectra, Variants & Atypical Pathogens 

Table 1 contains dosing recommendations and antimicrobial spectra for selected oral agents that may be employed in the pediatric population. Tables 2-4 review common variants of SSTI including impetigo (Table 2) nonpurulent SSTIs (Table 3) and purulent SSTIs (Table 4) Table 5 offers guidance on atypical pathogens to consider in special clinical circumstances. 

Kathryn B. Brown is a neonatal intensive care unit pharmacist and Daniel B. Chastain is an infectious diseases pharmacy specialist at Phoebe Putney Memorial Hospital, Albany, GA.

References 

1. Lindquist B, Wang NE, Felter RA. Diagnosis and Treatment of Skin and Soft Tissue Infections. Pediatric Emergency Medicine Reports. 2015;20(7):69-79. 

2. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014;59(2):147-59.

3. Zitelli BJ, McIntire SC, Nowalk AJ. Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis: Expert Consult - Online and Print. 6th ed. Philadelphia, PA. Saunders/Elsevier Health Sciences; 2012. 

4. Hedrick J. Acute bacterial skin infections in pediatric medicine: current issues in presentation and treatment. Paediatr Drugs. 2003;5(Suppl 1):35-46. 

5. Williams DJ, Cooper WO, Kaltenbach LA, et al. Comparative effectiveness of antibiotic treatment strategies for pediatric skin and soft-tissue infections. Pediatrics. 2011;128(3):e479-e487. 

6. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of America for the treatment of Methicillin-Resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-e55. 

7. Le J, Lieberman JM. Management of community-associated methicillin-resistant Staphylococcus aureus infections in children. Pharmacotherapy. 2006;26(12):1758–70. 

8. Gilbert DN, Chambers HF, Eliopoulos GM, Saag MS. The Sanford Guide to Antimicrobial Therapy 2015. 45th ed. Sperryville, VA; Antimicrobial Therapy Inc.; 2015.

9. Cole C, Gazewood J. Diagnosis and treatment of impetigo. Am Fam Physician. 2007;75(6):859-64. 

10. Koning S, van der Sande R, Verhagen AP, et al. Interventions for impetigo. Cochrane Database Syst Rev. 2012;1:CD003261.

11. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-406. 

12. Headley AJ. Necrotizing soft tissue infections: a primary care review. Am Fam Physician. 2003;68(2):323-8.

13. Agrawal V, Wright A, Mehta B, et al. Risk factors associated with abscess formation in children 5 years of age and younger. Clin Pediatr (Phila). 2015;54(6):543-50. 

14. Brook I. Management of human and animal bite wound infection: an overview. Curr Infect Dis Rep. 2009;11(5):389-95.