Cellulitis in children between 4 weeks and 16 years old ( including necrotising fasciitis )

Cellulitis in children between 4 weeks and 16 years old ( including necrotising fasciitis ) - Guideline for management of

Publication: 22/06/2011

Next review: 12/03/2024

Clinical Guideline

CURRENT

ID: 1610

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Cellulitis in children between 4 weeks and 16 years old (including necrotising fasciitis)

Please complete sepsis screening tool – if any concerns that the child is showing signs of severe illness please follow Sepsis Guideline and see below for high risk antibiotic choice.
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?id=6492

Diagnostics
Empirical Treatment
Review by 72
Appendix 1 - Risk factors associated with specific pathogens
Appendix 2 - Risk factors associated with treatment failure or adverse outcomes

DIAGNOSTICS

All patients	Consider the need for imaging: X-ray if concerns of a metallic foreign body; USS/MRI if concerns of an underlying infection, such as an abscess, osteomyelitis or joint infection.
Patients with open wounds or ulcers	Swab the wound/ulcer base for MC&S only if clinical signs of infection
Patients with identified abscess or purulent skin lesions	Send pus samples (not swabs) in sterile container
Patients undergoing debridement of necrotic lesions/tissue	Send tissue samples, and pus samples for bacterial MC&S and mycology (not swabs)
Selected patients (usually severe or IV’s required)	Blood culture prior to commencing antibiotics

EMPIRICAL TREATMENT

Non-antimicrobial management

Assess & treat for signs of shock/ dehydration (Resuscitation/Sepsis guideline) in severe cases
Refer to surgeons if necrotizing fasciitis suspected or for debridement or drainage of collections of pus
Analgesia may be required, but disproportionate pain should raise the possibility of deep soft tissue infection.
Elevation of the affected part, if practical is recommended.

Antimicrobial management

Low-risk cellulitis (no signs of systemic illness, scoring green on sepsis screening tool) Doses assume normal renal and hepatic function
Risk factor	First choice	Second choice (e.g. true allergy to first choice)
Duration: 5-7 days May need to be extended to 10-14 for severe infections.
No risk factors for unusual pathogens	PO Flucloxacillin age 1 month - 1 years 62.5mg - 125mg every 6 hours age 2 years - 9 years 125 - 250mg every 6 hours age 10 years - 17 years 250 - 500mg every 6 hours	PO Clindamycin age 1 month- 18 years 3-6mg/kg (min dose 37.5mg) every 6 hours Max. dose is 450mg
Previous infection or colonisation with Meticillin-resistant Staphylococcus aureus (MRSA).	PO Clindamycin age 1 month- 18 years 3-6mg/kg (min dose 37.5mg) every 6 hours Max. dose is 450mg OR Discuss with microbiology if isolate not sensitive	Refer to sensitivities or discuss with microbiology
Facial and orbital cellulitis (ENT/Dental/Ophthalmology review indicated)	PO Co-amoxiclav age 1 month- 1 year 0.25ml/kg of 125/31 suspension every 8 hours (may double in severe infections) age 1-5 years 5ml of 125/31 suspension (may double dose in severe infections) every 8 hours age 6-12 years 5ml of 250/62 suspension (may double dose in severe infections) every 8 hours age 12-18 years and >40kg one 250/125 strength tablet every 8 hours (increase in severe infections to one 500/125 strength tablet every 8 hours)	PO Cefalexin age 1–11 months 12.5 mg/kg 12 hourly, alternatively 125 mg twice daily age 1–4 years 12.5 mg/kg 12 hourly, alternatively 125 mg 3 times a day age 5–11 years 12.5 mg/kg 12 hourly, alternatively 250 mg 3 times a day age 12–17 years 500 mg 8-12 hourly PLUS PO Metronidazole age 1 month 7.5 mg/kg every 12 hours age 2 months–11 years 7.5 mg/kg every 8 hours (max. per dose 400 mg) age 12–17 years 400 mg every 8 hours
Pinna cellulitis following ear piercing	PO Flucloxacillin age 1 month - 1 years 62.5mg - 125mg every 6 hours age 2 years - 9 years 125 - 250mg every 6 hours age 10 years - 17 years 250 - 500mg every 6 hours	PO Clindamycin age 1 month- 18 years 3-6mg/kg (min dose 37.5mg) every 6 hours Max. dose is 450mg
Foot cellulitis secondary to puncture wound to sole	PO Flucloxacillin age 1 month - 1 years 62.5mg - 125mg every 6 hours age 2 years - 9 years 125 - 250mg every 6 hours age 10 years - 17 years 250 - 500mg every 6 hours	PO Clindamycin age 1 month- 18 years 3-6mg/kg (min dose 37.5mg) every 6 hours Max. dose is 450mg
Human, dog, cat bite	See “Guideline for the prevention of infection following animal or human bites in children”	See “Guideline for the prevention of infection following animal or human bites in children”
Sea or fresh water exposure of affected skin in previous week	Contact Microbiology	Contact Microbiology

High risk cellulitis (Signs of Systemic Involvement, Unwell child) Doses assume normal renal and hepatic function.
Risk factor	First choice	Second choice (e.g. true allergy to first choice)
For IV to Oral switches refer to options in low risk cellulitis.
Duration: 7 days May need to be extended to 10-14 for severe infections.
No risk factors for unusual pathogens	IV Flucloxacillin 25mg/kg (max. 1g) every 6 hours (dose doubled in severe infection)	IV Vancomycin 15mg/kg every 6 hours (max. daily dose 2g)
Necrotising fasciitis (amend when tissue culture results available)	IV Meropenem Child< 12 years old & body weight <50kg 10-20 mg/kg every 8 hours child >12 years old or weight >50kg 500mg - 1g every 8 hours	IV Vancomycin 15mg/kg every 6 hours (max daily dose 2g) PLUS IV Ciprofloxacin 10mg/kg (max 400mg) every 8 hours
Previous infection or colonisation with Meticillin-resistant Staphylococcus aureus (MRSA).	IV Vancomycin 15mg/kg every 6 hours (max daily dose 2g)	Refer to sensitivities or discuss with microbiology
Facial and orbital cellulitis (ENT/Dental/Opthalmology review indicated)	IV Ceftriaxone Child 1 month–11 years (body-weight up to 50 kg) 50–100 mg/kg once daily, doses at the higher end of the recommended range used in severe cases; max. 4 g per day. Child 9–11 years (body-weight 50 kg and above) 2 g once daily Child 12–17 years 2 g once daily	If confirmed severe penicillin allergy IV Clindamycin 10mg/kg (max. 1.2g) every 6hours PLUS IV Ciprofloxacin 10mg/kg (max 400mg) every 8 hours
Pinna cellulitis following ear piercing	IV Ceftazidime 25mg/kg every 8hours (dose doubled in severe infection) PLUS IV Flucloxacillin 25mg/kg (max. 1g) every 6 hours (dose doubled in severe infection)	IV Vancomycin 15mg/kg every 6 hours (max daily dose 2g) PLUS IV Ciprofloxacin 10mg/kg (max 400mg) every 8 hours
Foot cellulitis secondary to puncture wound to sole	IV Ceftazidime 25mg/kg every 8hours (dose doubled in severe infection) PLUS IV Flucloxacillin 25mg/kg (max. 1g) every 6 hours (dose doubled in severe infection)	IV Vancomycin 15mg/kg every 6 hours (max daily dose 2g) PLUS IV Ciprofloxacin 10mg/kg (max 400mg) every 8 hours
Human, dog, cat bite	See “Guideline for the prevention of infection following animal or human bites in children”	See “Guideline for the prevention of infection following animal or human bites in children”
Sea or fresh water exposure of affected skin in previous week	Contact Microbiology	Contact Microbiology

REVIEW BY 72

By 72 hours of antibacterial treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis.

If your patient in on IV treatment this should be reviewed daily.

The review, outcome and future plans (where appropriate) should be documented in the medical notes.

If the diagnosis is still correct your options are now:

IVOS	If your initial diagnosis is correct and the patient is prescribed IV antibiotics, review whether an oral switch is appropriate using the ACED criteria (see below). If they meet all 4 consider switching using the oral options listed in the table above. A - Afebrile for 24 hours C - Clinically improving E - Eating and drinking D - not Deep seated infection
Stop	If no signs of infection and diagnostics support this decision.
Change	If the patient is not clinically responding, check microbiology results to see if directed therapy is required or you may need to consider an alternative diagnosis.
Continue	If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch.

APPENDICES

Risk factors associated with specific pathogens

Risk factor	Unusual/problematic organism to consider
Previous infection or colonization with MRSA.	Meticillin-resistant Staphylococcus aureus
Suspected necrotising fasciitis	Type 2 Group A Streptococcus, type 1 mixed flora.
Human bite (see also children bites prophylaxis guideline).	Eikenella corrodens, anaerobes
Dog or cat bite. (see also children bites prophylaxis guideline).	Capnocytophaga canimorsus, Pasteurella multocida
Facial and orbital cellulitis.	Haemophilus influenzae, Streptococcus pneumoniae, MSSA, anaerobes, Eikenella corrodens.
Drug abuse (iv, subcutaneous).	Anaerobes (Clostridium sp.), MSSA, MRSA, Gram-negative bacilli
Pinna cellulitis secondary to ear piercing.	Staphylococcus aureus, Pseudomonas aeruginosa
Puncture wounds to sole of foot	Pseudomonas aeruginosa, Staphylococcus aureus
Sea water exposure of affected skin in previous week	Vibrio vulnificus
Fresh water exposure of affected skin in previous week	Aeromonas hydrophila
Immunocompromise/neutropaenia post chemotherapy or bone marrow transplant	See guidelines for the Management of Suspected Neutropenic Sepsis / Febrile Neutropenia

Risk factors associated with treatment failure or adverse outcomes
(Adapted from Eron, 2003)

Cellulitis affecting eye, face or perineum
Previous splenectomy
Chronic renal or liver disease
Immunocompromise
Treatment failure in the community
Diabetes mellitus
Chronic venous insufficiency
Morbid obesity
Lymphoedema

Provenance

Record:	1610
Objective:
Clinical condition:	Cellulitis (including necrotising fasciitis)
Target patient group:	children >4 week to <16 years old
Target professional group(s):	Secondary Care Doctors Secondary Care Nurses Pharmacists
Adapted from:

Evidence base

NICE guideline: Cellulitis and erysipelas: antimicrobial prescribing [NG141] 2019.
Malone JR, Durica SR, Thompson DM et al. Blood cultures in the evaluation of uncomplicated skin and soft tissue infections. Pediatrics . 2013
Sep; 132(3):454 9.
Eron LJ, Lipsky BA, Low DE, Nathwani D, Tice AD, Volturo GA. Managing skin and soft tissue infections: expert panel recommendations on key decision points. J Antimicrob Chemother 2003;52 Suppl 1:i3-17.
Ladhani S, Garbash M. Staphylococcal skin infections in children: rational drug therapy recommendations. Paediatr Drugs 2005;7(2):77-102.
Zimbelman J, Palmer A, Todd J. Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection. Pediatr Infect Dis J 1999;18(12):1096-100.
Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis 2011;52(3):285-92.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

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