Skin and Soft Tissue Infections (SSTI) in Children: Management

by Brian Alverson, MD

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    00:00 So, if we see a patient with a skin or impetigo infection, we generally want to start with a first generation cephalosporin such as cephalexin. That’s our first choice in children. An alternative would be nafcillin or oxacillin but these don’t typically come as a liquid that is delicious and so we tend to go with cephalexin first. If MRSA is suspected and we often suspect MRSA when there's an abscess because of the existence of that PVL gene, we may start with clindamycin. Keep in mind, clindamycin tastes very bad and it’s hard to get little children to eat it. Some areas in the United States have higher clindamycin resistance than others, typically in the south. As a result, sometimes we have difficulty finding an antibiotic that is likely to kill these resistant forms of bacteria such as MRSA. Alternatives exist such as doxycycline or trimethoprim/sulfamethoxazole.

    01:05 These aren’t perfect alternatives. The problem with doxycycline is: decreased sensitivity rates by staph and group A strep and also side effects like photosensitivity and esophagitis.

    01:18 Likewise, trimethoprim/sulfamethoxazole, while effective in the test tube against MRSA 99% of the time, doesn’t always work in the skin and is not totally clear why but we see a lot of resistance to Bactrim in bacterial infections and then we get the bacteria in the lab and it says it’s sensitive. We have a lot of treatment failure of MRSA with Bactrim in the skin. Ciprofloxacin is our drug of choice for treatment of Pseudomonas skin infections. It may be that a Staph aureus is listed as being sensitive to Cipro but this is a poor choice for Staph aureus infections as Staph can develop resistance during treatment with ciprofloxacin.

    02:03 It is worth mentioning that in cases with impetigo with limited number of lesions, mupirocin ointment can be applied, so there's no need for systemic administration of antibiotics.

    02:19 So, how do we manage abscesses? If we can drain an abscess effectively, antibiotics generally speaking, are not necessary. Just drainage is therapy enough. If there is a large underlying cellulitis though, we may need to treat that with antibiotics, but a simple abscess is not treated with antibiotics. All you do is drain it An appropriate technique is needed to do an incision and drainage. As you can see in this drawing, we're going to introduce generally an 11-blade scalpel, which is the long, sharp, pointy one directly down to the abscess and draw sideways, creating a small line that allows active drainage of that pus. We do not need to pack these lesions in general. Packing has been shown to be more painful and doesn't necessarily improve the likelihood of a child getting better. Do not drain abscesses with a needle, they simply re-form. You have to do an incision and drainage.

    03:22 Antibiotics are not needed for most abscesses but if there is a lot of cellulitis around, you should consider antibiotics and in particular because there’s an abscess, you should think about MRSA because MRSA is more likely to have the Panton-Valentine Leukocidin gene that's causing that abscess to form. Okay, there are some special considerations we should keep in mind. The first is cellulitis from a bite. Remember, the worst bite to have is actually a human bite though dog bites and other bites are associated with other bacteria. One test question commonly is "What bacteria is caused by a dog bite?" and the answer is Pasteurella. So, whatever the case may be, a cellulitis from a bite we need broader coverage and we will typically use amoxicillin-clavulanic acid that is effective against Staph but not MRSA. It’s effective against anaerobes which can be in bites, and it’s effective against gram negative organisms that can be in bites. What about if the cellulitis is of the hand? We take cellulitis of the hand very seriously. We admit these children for IV antibiotics and usually broad spectrum IV antibiotics.

    04:38 The reason for this is that the hand, we need to be able to use our hand effectively throughout our entire lives and with bad hand infections, scarring can cause a decreased mobility down the road. So, we are very aggressive about treating cellulitis of the hand. What about pilonidal or perirectal abscesses? For areas like this, we have to think about other underlying problems that might be going on, for example, inflammatory bowel disease. We also may consult a surgeon to evaluate for tract that’s going around the rectum and up from the inside. So, we need to thoroughly evaluate these patients more than just a simple abscess. Here’s an example of a perirectal abscess. You can notice this patient has 2 tracts. This patient has a fistula and required surgery. Last is MRSA colonization. This can be very challenging. What can happen even in entire families is MRSA can colonize their noses and cause recurrent abscesses. I'm sure you’ve seen this in a clinic near you, where families come in and everyone in the family has had a boil and these keep recurring and they can get very frustrating. There are some ways people have proposed to reduce the likelihood of MRSA colonization. This implies good hygiene and there are other techniques that are available such as mupirocin ointment to the nose or chlorhexidine wipes,or baths with bleach. These are all possible ways to reduce the likelihood of MRSA colonization but generally what we recommend is good hygiene and hopefully there'll be less likelihood of MRSA colonization in a family. That’s all I have to tell you today about Skin and Soft Tissue Infections in Kids. Thanks for your attention.

    About the Lecture

    The lecture Skin and Soft Tissue Infections (SSTI) in Children: Management by Brian Alverson, MD is from the course Pediatric Infectious Diseases.

    Included Quiz Questions

    1. If drained appropriately and not associated with cellulitis, antibiotics are usually not necessary.
    2. The abscess should be drained with a needle.
    3. Packing the wound will help healing.
    4. Drainage is not necessary.
    5. Cellulitis is not common complication.
    1. Cephalexin
    2. Nafcillin
    3. Oxacillin
    4. Ciprofloxacin
    5. Doxycycline
    1. Admission for IV antibiotics
    2. Admission for oral antibiotics
    3. Outpatient oral antibiotics
    4. Admission for surgical drainage of the hand
    5. Outpatient topical antibiotics

    Author of lecture Skin and Soft Tissue Infections (SSTI) in Children: Management

     Brian Alverson, MD

    Brian Alverson, MD

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    Excellent lecture
    By Jalil Z. on 04. August 2020 for Skin and Soft Tissue Infections (SSTI) in Children: Management

    I particularly liked the remarks regarding packing, and the management of pilonidal/perirectal abscess.