Acute bacterial skin infections in pediatric medicine: current issues in presentation and treatment

Bacterial skin and skin structure infections commonly encountered in children include impetigo, folliculitis, furunculosis, carbuncles, wound infections, abscesses, cellulitis, erysipelas, scarlet fever, acute paronychia, and staphylococcal scalded skin syndrome. If diagnosed early and treated appropriately, these infections are almost always curable, but some have the potential to cause serious complications such as septicemia, nephritis, carditis and arthritis if diagnosis is delayed and/or treatment is inadequate. During the initial evaluation, it is important to determine whether the infection is superficial or deep, and whether it is localized or spreading. Prompt treatment is essential if the infection appears to be spreading, as the sequelae can be life threatening. Once the proper diagnosis is made, the next important step is selecting the most appropriate therapy. In children presenting with mild or moderately severe bacterial skin and skin structure infections and not requiring inpatient management or urgent operative débridement, prompt provision of oral antimicrobial therapy avoids the risk of worsening infection or hospitalization. Empiric antimicrobial therapy should be directed at the most likely pathogens, (e.g. Staphylococcus aureus or Streptococcus pyogenes), although some infections (e.g. subcutaneous abscesses and cellulitis following animal or human bites) may have a polymicrobial origin. In choosing the appropriate antimicrobial therapy, one must take into account the resistance profile of the target pathogen, the agent's antibacterial profile and intrinsic activity against the target pathogen, and its pharmacokinetic properties (including absorption, elimination, and extent of tissue penetration). Other factors to consider include tolerability of the drug, convenience of the dosing regimen, and acceptability and palatability of the oral formulation administered. Any treatment plan for bacterial skin and skin structure infections should aim to minimize the emergence of resistant organisms so that the risk of their dissemination to others in the community is reduced. Oral antimicrobial agents currently available that may be considered include: beta-lactamase-stable penicillins (e.g. cloxacillin, dicloxacillin, and amoxicillin-clavulanate potassium), the macrolides (e.g. erythromycin, clarithromycin, and azithromycin), and the cephalosporins. Cephalosporins are now the most commonly used class, particularly because of increasing resistance among strains of S. pyogenes to erythromycin (and by implication, the other macrolides). The second- and third-generation cephalosporins have many advantages, with their extended spectra of antimicrobial activity, favorable pharmacokinetic and tolerability profiles, and convenient dosage schedules. The third-generation agent, cefdinir, has good activity against a broad range of likely pathogens, including staphylococci, a twice-daily administration schedule, a favorable efficacy and tolerability profile, is well accepted by young children when administered as an oral suspension, and may be an attractive alternative in the pediatric setting.