Cellulitis in Pediatric Patients: Recognition and Management in the Era of Evolving Resistance

Cellulitis, a bacterial skin infection most frequently caused by group A streptococci (Streptococcus pyogenes) and less so by Staphylococcus aureus, commonly occurs in pediatric patients. The non-specific clinical presentation of poorly demarcated, expanding erythema, and warmth is common to a multitude of similarly presenting conditions, contributing to challenges in accurate diagnosis. There is also no gold standard diagnostic test for cellulitis, as laboratory assessments, tissue and blood cultures, and imaging studies have not been helpful. These adjunctive studies may be useful, however, for ruling out mimickers or more serious or complicating conditions, such as osteomyelitis, necrotizing fasciitis, or abscess. Diagnosis remains largely clinical and evaluation by a dermatologist and/or infectious disease specialist continues to be the clinical gold standard. As a result, access to specialty care and further research into helpful adjunctive measures, such as thermal imaging, are imperative for accurate diagnosis and management to prevent inappropriate antibiosis. Multidrug resistance has continued to evolve since the initial emergence of community-associated methicillin-resistant Staphylococcus aureus, with more recent studies showing an overall decline of methicillin-resistant S. aureus in the community and highest rates remaining in the Southern region of the USA. Despite changing resistance patterns, inappropriate prescribing patterns have persisted and contribute to rising rates of resistance to antibiotics such as trimethoprim-sulfamethoxazole and clindamycin. Therefore, accurate diagnosis and subsequent management with the narrowest possible antimicrobial therapy is ideal both for individual patient outcomes and for public health.