Skin and
soft tissue infections in children are an important cause for hospitalization. A thorough history and physical examination can provide clues to the pathogens involved. Collection of purulent discharge from lesions should be completed prior to initiating antimicrobial
therapy, and results of bacteriologic studies (Gram
stain and culture) should guide therapeutic decisions. The main pathogens involved in these
infections are Staphylococcus aureus and group A beta-hemolytic streptococci, but enteric organisms also play a role especially in
nosocomial infections. Increasing antibacterial resistance is becoming a major problem in the treatment of these
infections worldwide. Specifically, the rise of methicillin-resistant S. aureus and
glycopeptide-resistant S. aureus pose challenges for the future.
Infections of the skin and soft tissues can be broadly classified based on the extent of tissue involvement. Superficial
infections such as
erysipelas,
cellulitis, bullous
impetigo,
bite infections, and
periorbital cellulitis may require hospitalization and parenteral antibacterials. Deeper
infections such as
orbital cellulitis,
necrotizing fasciitis, and
pyomyositis require surgical intervention as well as parenteral antibacterial
therapy. Surgery plays a key role in the treatment of
abscesses and for the
debridement of necrotic tissue in deep
infections.
Intravenous immunoglobulin, as an adjunctive
therapy, can be helpful in treating
necrotizing fasciitis. For most
infections an antistaphylococcal
beta-lactam antibacterial is first-line
therapy.
Third-generation cephalosporins and
beta-lactam/
beta-lactamase inhibitor antibacterials as well as
clindamycin or
metronidazole are often required to provide broad-spectrum coverage for
polymicrobial infections.Special populations, such as immunocompromised children, those with an
allergy to
penicillins, and those that acquire
infections in hospitals, require specific antibacterial strategies. These usually involve broader antimicrobial coverage with increased Gram-negative (including antipseudomonal) and anerobic coverage. In patients with a true
allergy to
penicillins,
clindamycin and
vancomycin play an important role in treating Gram-positive
infections. Newer
antibacterial agents, such as
linezolid and
quinupristin/dalfopristin, are increasingly being studied in children for the treatment of skin and
soft tissue infections. These agents hold promise for the future especially in the treatment of highly resistant, Gram-positive organisms such as methicillin-resistant S. aureus,
vancomycin-resistant S. aureus, and vancomycin-resistant enterococci.