Cellulitis/Abscess — Antibiotic Recommendations for Skin and Soft Tissue Infections — Clinical Pathway: Emergency Department and Inpatient

Cellulitis/Abscess Clinical Pathway — Emergency Department and Inpatient

Antibiotic Recommendations for Skin and Soft Tissue Infections

  • Empiric antibiotic choices below apply for both outpatients and inpatients.
    • Review prior MRSA history and the results of prior wound cultures when considering
      empiric antibiotics.
  • Drainage is the primary treatment for purulent cellulitis/abscess – all abscesses that are amenable to drainage should be drained and sent for gram stain and bacterial culture.
  • Tailor antibiotic therapy based on culture and susceptibility results when cultures are performed.
  • Durations below apply to most children – longer durations may be needed for severe disease, slow response to initial treatment, immunocompromised hosts, and/or inadequate source control. Consider ID consultation in these scenarios.
  • Review common organisms causing purulent skin and soft tissue infection and non-purulent cellulitis.

Impetigo (bullous and non-bullous)

Definition: Superficial papules or pustules that rupture to form honey-colored crusts or erythematous erosions surrounded by crust. Most often due to group A Streptococcus or Staphylococcus aureus

Indication First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration of Treatment/Comments
  • Topical Treatment
    • Preferred
  • Mupirocin, Topical
    • 2% topical ointment applied every 12 hours
 N/A 5 days
  • Oral Treatment
    • Indicated if numerous impetigo lesions present or in outbreak settings to reduce transmission
  • Cephalexin, PO
    • 50 mg/kg/day in 3 divided doses
    • Max: 500 mg/dose
  • Clindamycin, PO
    • 10 mg/kg/dose every 8 hours
    • Max: 600 mg/dose
  • or
  • Sulfamethoxazole/Trimethoprim, PO
    • 6 mg TMP/kg/dose every 12 hours
    • Max: 320 mg TMP/dose
 5 days

CHOP Formulary for complete drug information.

Non-purulent Cellulitis

Definition: Cellulitis without abscess or purulent drainage/exudate, ulceration; includes erysipelas.
Most often due to group A Streptococcus

Indication First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration of Treatment/Comments
Initial Treatment
  • Cephalexin, PO
    • 50 mg/kg/day in 3 divided doses
    • Max: 500 mg/dose
  • or
  • Cefazolin, IV
    • 20 mg/kg/dose every 8 hours
    • Max: 1,000 mg/dose
  • Clindamycin, PO
    • 10 mg/kg/dose every 8 hours
    • Max: 600 mg/dose
  • or
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
  • 5 days of effective therapy
  • Tailor antibiotics to prior culture susceptibilities, if available
  • Treatment Failure of First-line Therapy
    • Defined as progression of cellulitis or failure to improve following
      > 48h of antibiotics
  • Clindamycin, PO
    • 10 mg/kg/dose every 8 hours
    • Max: 600 mg/dose
  • or
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
 Discuss with ID
  • 5 days of effective therapy
  • If rapidly progressive cellulitis or ill, suggest ID consult
Infected Dog, Cat,
or Mammal Bite
  • Amoxicillin/Clavulanate, PO
    • 45 mg/kg/day of amoxicillin component divided twice daily
    • Max: 1,750 mg amoxicillin/day
    • Use only 7:1 formulation
      (i.e., amoxicillin/clavulanate
      400 mg/57 mg per 5 mL, amoxicillin/clavulanate
      875 mg/125 mg tablet)
  • or
  • Ampicillin-sulbactam, IV
    • 50 mg/kg/dose of ampicillin component every 6 hours
    • Max: 4000 mg ampicillin/day
  • Oral:
    Sulfamethoxazole/Trimethoprim, PO
    • 6 mg TMP/kg/dose every 12 hours
    • Max: 320 mg TMP/dose
  • and
  • Clindamycin, PO
    • 10 mg/kg/dose three times daily
    • Max: 600 mg/dose
  • Intravenous:
    Ceftriaxone, IV
    • 50 mg/kg/dose every 24 hours
    • Max: 2000 mg/dose
  • and
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
  • Suggest ID consultation, particularly for hospitalized children and immunocompromised children
  • Antibiotic choice may differ if child is on pre-emptive antibiotics at the time of presentation – suggest discussion with ID
  • Duration depends on source control and clinical course
Necrotizing Fasciitis
  • Piperacillin/Tazobactam, IV
    • 100 mg piperacillin/kg/dose every 6 hours
    • Max: 4000 mg/dose
  • and
  • Vancomycin, IV
    • 15 mg/kg/dose every 6 hours
    • Max: 750 mg/dose
  • and
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
 Discuss with ID Urgent surgical and infectious diseases consultation recommended
Wound Infection Following Water Exposure Discuss with ID

CHOP Formulary for complete drug information.

Purulent Skin and Soft Tissue Infection

Definition: Pus forming infection and inflammation of the deep dermis and subcutaneous tissues; includes furuncles, carbuncles, and abscesses. Most often due to Staphylococcus aureus (MSSA and MRSA). Review CHOP Outpatient Wound Antibiogram.

Indication First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration of Treatment/Comments
No Cellulitis and Single Drained Abscess < 2 cm Drainage alone is sufficient treatment for most small abscesses. Additional antibiotics may be considered per recommendations below based on shared decision-making, weighing risk of additional toxicity with slightly increased cure rates.  
  • Drained abscess ≥ 2 cm with or without cellulitis – WITHOUT MRSA risk factors, including:
    • No personal history of MRSA infection or carriage or
    • No known close/household contact with MRSA and/or with recurrent skin abscesses or
    • No use of IV drugs
  • Cephalexin, PO
    • 50 mg/kg/day in 3 divided doses
    • Max: 500 mg/dose
  • or
  • Cefazolin, IV
    • 20 mg/kg/dose every 8 hours
    • Max: 1,000 mg/dose
  • Clindamycin, PO
    • 10 mg/kg/dose every 8 hours
    • Max: 600 mg/dose
  • or
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
  • or
  • Sulfamethoxazole/Trimethoprim,
    PO or IV
    • 6 mg TMP/kg/dose every 12 hours
    • Max: 320 mg TMP/dose
  • Drained abscess ≥ 2 cm with or without cellulitis – WITH MRSA risk factors present, including:
    • Personal history of MRSA infection or carriage or
    • Known close/household contact with MRSA and/or with recurrent skin abscesses or
    • Use of IV drugs
  • See CHOP Outpatient Wound Antibiogram for Susceptibility Data
  • Clindamycin, PO
    • 10 mg/kg/dose every 8 hours
    • Max: 600 mg/dose
  • or
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
  • or
  • Sulfamethoxazole/Trimethoprim,
    PO or IV
    • 6 mg TMP/kg/dose every 12 hours
    • Max: 320 mg TMP/dose
  • Doxycycline, PO or IV
    • 2.2 mg/kg/dose every 12 hours
    • Max: 100 mg/dose
  • Cephalexin or Cefazolin Treatment Failure > 48h
    • Defined as progression of cellulitis or failure to improve following > 48h of antibiotics
  • Clindamycin, PO
    • 10 mg/kg/dose every 8 hours
    • Max: 600 mg/dose
  • or
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
    • Max: 900 mg/dose
  • or
  • Sulfamethoxazole/Trimethoprim,
    PO or IV
    • 6 mg TMP/kg/dose every 12 hours
    • Max: 320 mg TMP/dose
  • Doxycycline, PO or IV
    • 2.2 mg/kg/dose every 12 hours
    • Max: 100 mg/dose
  • Evaluate for recurrent or persistent abscess
  • If rapidly progressive cellulitis or ill-appearing, suggest ID consult and consideration of vancomycin
  • Tailor antibiotic choice to results of wound culture
  • Failed Clindamycin, Doxycycline, or Co-trimoxazole > 48h
    • Defined as progression of cellulitis or failure to improve following > 48h of antibiotics
  • Consider empiric antibiotic change to alternative anti-staphylococcal antibiotic depending on clinical scenario
  • See CHOP Outpatient Wound Antibiogram for Susceptibility Data
  • Evaluate for recurrent or persistent abscess
  • If rapidly progressive cellulitis or ill-appearing, suggest ID consult and consideration of vancomycin
  • Tailor antibiotic choice to results of wound culture

CHOP Formulary for complete drug information.