Just in time for summer: How to manage bacterial skin and soft tissue infections in kids

In time for scraped knees, summer camp lice and waterborne pathogens, the Canadian Pediatric Society has released a position statement on management of skin and soft tissue infections in children, with a focus on infections acquired in the community.The position statement provides nine recommendations on management, including the following: Take a focused historyA medical history should focus on interactions between the host, pathogen and environment. Ask about skin traumas, water exposures, travel, contacts, healthcare interactions and other activities. A careful history should also include questions about underlying conditions, history of previous skin and soft tissue infections and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) infection. Recurrent skin and soft tissue infections are most often seen in children who are immunocompetent, but watch for red flags that suggest problems with immunity, such as failure to thrive or deep skin abscesses, among others.A clinical investigation should also assess severity. Although assessing severity is usually subjective, there are some useful scoring systems. One for cellulitis is the Melbourne ASSET score, the position statement notes. Severity can help inform if a physician should prescribe IV or oral antimicrobials. IV antimicrobials are rarely needed but some studies show pediatricians prescribe them in cases where there is rapidly expanding erythema or greater pain than expected based on clinical findings. The statement recommends using IV antimicrobials only for severe, deep-seated or necrotizing infections. Know what samples to send for testing Collect samples for microbiology testing of open wounds or lesions that have visible pus or fluid, the statement advises. Prioritize collecting pus by needle aspirate, surgery or manual drainage because it has a higher microbiological yield than samples collected by swab. The statement describes when it is appropriate to collect other samples, e.g., tissue samples if debridement is indicated; skin biopsies in instances of chronic infections or unusual exposures or viral swabs for herpes simplex virus, varicella zoster virus and enterovirus. Collecting blood samples is rarely indicated in mild to moderate cases of skin and soft tissue infections.Are antimicrobials are needed?Some minor infections may resolve with drainage and/or careful wound care alone. Physicians may need to prescribe a short-course (e.g., three to five days) topical antimicrobial medication. Over-the-counter topical antimicrobials don’t have clear evidence supporting their benefit. Initial empiric antimicrobials should target the most common or most likely pathogens. Locally sourced, pediatric-specific antibiograms can help. Consider oral cephalexin in the majority of cases. The position statement has a table of antimicrobials to use for skin and soft tissue infections and what dose is appropriate. It also has a treatment algorithm. Short courses of antimicrobials (e.g., five to seven days long) is often enough to treat the infections. There’s been a rise in methicillin-resistant Staphylococcus aureus (MRSA) cases in children in Canada, although the incidence is variable across provinces and territories. Certain groups have shown a greater rise in the number of cases, such as Indigenous communities, the practice statement notes. The antimicrobial of choice for outpatient MRSA cases is oral trimethoprim/sulfamethoxazole. Drainage and proper wound care is vitalSurgical or manual drainage of abscesses is important and, in some cases, antimicrobials may not be needed or may be discontinued after drainage if there’s no significant cellulitis surrounding the area. Physicians can consult Wounds Canada best practice recommendations for wound care. Managing skin conditions such as eczema is also important to prevent recurrence. In some cases, decolonization procedures may be needed to stop the spread of an infection. The position statement details these procedures.Consult when there are difficult or unusual cases Reach out to dermatology colleagues when treating children with difficult-to-control skin conditions that could lead to recurrence or serious infections. Consult infectious disease specialists for challenging cases that may or may not merit decolonization procedures (e.g., household outbreak). The Canadian Pediatric Society’s infectious diseases and immunization committee, led by Dr. Justin Penner and Dr. Sergio Fanella, prepared the position statement. It can be found on the CPS website.

Just in time for summer: How to manage bacterial skin and soft tissue infections in kids

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