OCTOBER 2017

DRUG
ANTIBIOTICS

CELLULITIS IN CHILDREN

CELLULITIS IN CHILDREN
This optimal usage guide is mainly intended for primary care health professionnals. It is provided for information purposes only and should not replace the clinician’s judgement.
The recommendations were developed using a systematic approach and are supported by the scientific literature and the knowledge and experience of Quebec clinicians and experts.
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GENERAL INFORMATION
IMPORTANT CONSIDERATIONS
„„Cellulitis can be observed on all skin surfaces, but most cases are found on the legs.
„„Cellulitis is typically caused by β-hemolytic streptococci or Staphylococcus aureus, although a pathogen is
isolated in less than 20 % of cases.
„„The following risk factors for developing cellulitis may be found in children :
•• Injury
•• Skin problem (e.g., eczema, chickenpox, ingrown nail, tinea pedis, etc.)
•• Immunosuppression
•• Uncorrected dental problem

DIAGNOSIS
Photos available to help with diagnosis
SIGNS AND SYMPTOMS
„„Cellulitis diagnosis is generally characterized by the acute appearance of a continuous erythematous area
(without an area of healthy skin inside) that’s edematous, warm and painful.
„„The patient may also have systemic symptoms (fever, nausea, vomiting, chills, malaise, lack of appetite).
„„Cellulitis generally does not cause any epidermal changes (scales, scabs, vesicles, etc.). If such changes are
present, suspect a different or related pathology (e.g., eczema, chickenpox, etc.).

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CLINICAL ASSESSMENT
„„Assess the general condition of the patient.
„„Palpate the affected area to assess skin sensitivity, the depth of infection, tissue firmness and the presence of
a fluctuant area.
„„Determine the source of the infection. A dental, sinusal or ophthalmic origin should always be suspected and
investigated during the initial diagnosis of cervicofacial cellulitis.
„„Look for the presence of special circumstances suggesting different pathogens.
„„Make a differential diagnosis before confirming the cellulitis diagnosis.
„„Mark the outline or photograph the infected area to follow its evolution.
 DIFFERENTIAL DIAGNOSIS Photos available to help with differential diagnosis

General

Contact dermatitis : An edema that is often itchy, non-painful and afebrile. Presence of scaling or microvesicles that can merge to
CELLULITIS IN CHILDREN

form bubbles. The shape of the affected area is very well defined and matches the point of contact.

Acute eczema : An erythema that is often edematous, frequently observed in cases of allergic contact dermatitis and interspersed
with very tight formations of micropapules and/or superficial microvesicles.

Insect bite : Edema and erythema with a central point. Itchy, afebrile, not very painful or painless and sometimes accompanied by a
vesicle or a minor subcutaneous ecchymosis.

Cutaneous herpes or shingles : Presence of vesicles a few millimetres in size grouped on an erythematous base. Shingles involves
dermatomal distribution.

Redness located in the upper and lower limbs

Septic arthritis : Localized erythema on a joint with pain occurring during mobilization.

Acute bursitis : Localized erythema around a joint.

Vaccine reaction : Often occurs within the first 24 hours after vaccination. The absence of fever and the patient’s good overall
condition point to a vaccine reaction. The pain is often minor compared to the extent of the erythematous zone.

Redness located in the face

Conjunctivitis : In some cases, manifests with a slight non-painful and afebrile palpebral or periorbital edema accompanied by
purulent secretions. Often bilateral.

Dacryocystitis : Localized edema and erythema in the internal angle (between the eye and nose) and often accompanied by
tearing.

Cold panniculitis : Circular induration with loss of sensation, usually localized on the cheeks and occurring after a few minutes of
exposure to icy and windy weather.

Other skin diseases

Erythema migrans, erythema nodosum, acute febrile neutrophilic dermatosis (Sweet syndrome), etc. : Erythema separated
by areas of healthy skin or ring-shaped erythema.

Main pathogens to suspect in addition to

SPECIAL CIRCUMSTANCES
β-hemolytic streptococci and S. aureus

• Pasteurella multocida, Capnocytophaga spp.

Animal bite
• Viridans streptococci
(cat or dog)
• Buccal anaerobes (Fusobacterium, peptostreptococci)
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Human bite • Eikenella corrodens

(including injuries caused by contact with another person’s • Viridans streptococci
teeth during a fight) • Buccal anaerobes (Fusobacterium, peptostreptococci)

• Viridans streptococci
Cellulitis of dental origin
• Buccal anaerobes (Fusobacterium, peptostreptococci)

• Streptococcus pneumoniae
Periorbital/orbital cellulitis of sinusal origin
• Haemophilus influenzae

• Aeromonas hydrophila (freshwater)

Injury while immersed in water
• Vibrio spp. (saltwater)

• Pseudomonas aeruginosa
Neutropenic patient
• Fungal pathogens

„„Cellulitis is rarely caused by methicillin-resistant S. aureus (MRSA). Moreover, in Québec, these resistant strains are isolated in only
10 % of cases of purulent skin infections caused by S. aureus (2015).

„„Community-associated MRSA should be suspected in the presence of an abscess and one of the following elements :

• Previous infection/colonization • Recurrent furunculosis or abscess

(in the patient or their family) • Patient belongs to an Aboriginal community

„„Microbiological tests on skin samples (culture and antibiotic sensitivity) are recommended only in cases of cellulitis with purulent
discharge.
 SEVERITY
„„The severity of the infection is assessed by clinical judgment and guides the choice of the antibiotic treatment’s
CELLULITIS IN CHILDREN route of administration. If necessary, consult a specialist.

WARNING SIGNS – IN-HOSPITAL CONSULTATION GENERALLY REQUIRED

General Suspected orbital involvement

• Fever
• Impairment of general condition (persistent fever) • Severe pain
• Hemodynamic impairment • Limited or painful extraocular movements
• Child < 3 months old • Difficulty or inability to open eye
• Pain disproportionate to clinical signs ! • Chemosis
• Rapid progression • Proptosis
• Vesicles with hemorrhagic content • Impaired vision
• Signs of dyspnea or dysphagia (cervicofacial cellulitis)
• Significant edema/erythema of the external auditory canal Special circumstances
and auricle
• Suspected joint involvement • Immunosuppressed patient
• Suspected osteomyelitis • Significant inflammation following the bite of an animal besides
• Failure of antibiotic treatment after 72 hours a cat or dog
• Injury while immersed in water
! Careful; when this symptom is present, suspect necrotizing fasciitis.

TREATMENT PRINCIPLES
„„Treating the primary source of infection, when it can be identified, is essential in managing cellulitis :
•• Treating the dental problem, wound or sinusitis, excising the foreign body, etc.
•• Treating the associated risk factors (e.g., eczema, ingrown nail, tinea pedis, etc.).
„„When there is an abscess, incision and drainage are essential aspects of initial treatment. In such cases, an
antibiotic treatment can sometimes be added depending on the clinical context.
„„Systemic antibiotic treatment is used to treat cellulitis. Topical antibiotic treatment is not indicated for this
type of infection and provides no additional benefit.
! In case of recurrent cellulitis, consider referring the patient to a specialized setting for a more in-depth
assessment (diagnosis, source of infection, treatment).

SUPPORTIVE TREATMENT
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„„Elevating the affected limb promotes the drainage of the edema by gravity.
„„To relieve pain, you may consider adding an analgesic/antipyretic (acetaminophen or ibuprofen*) to the
antibiotic treatment.
„„When a traumatic wound (including bites) is present, it is important to check the patient’s tetanus vaccination
schedule and consider rabies vaccination. For more information, refer to the protocole d’immunisation du
Québec (PIQ).
„„For more information on human bites in childcare settings, refer to the Canadian Pediatric Society’s position
statement.
* Ibuprofen is not recommended for children under 6 months of age.

HISTORY OF ALLERGIC REACTION TO A PENICILLIN ANTIBIOTIC

„„True penicillin allergy is uncommon. For 100 children with a history of penicillin allergy, fewer than 6 will be
CONFIRMED to have a true diagnosis of allergy and most of the reactions will be delayed non-severe rashes.
••It is therefore important to carefully assess the allergy status of a patient who reports a history of allergic
reaction to penicillins before considering using alternatives to beta-lactams. For help, consult the
decision-making tool in cases of allergy to penicillins.
 ANTIBIOTIC TREATMENT
„„In vitro resistance of methicillin-sensitive S. aureus to clindamycin is about 25 % in Québec (2015). Response
to this treatment should therefore be closely monitored.
„„If necessary, adjust the antibiotic treatment based on the results of culture and antibiotic sensitivity tests,
CELLULITIS IN CHILDREN

when available.
„„Persistence or slight progression of redness may be observed within the first 24 to 48 hours despite proper
treatment. In that case, decreased pain and a general improvement in the patient’s condition are usually
observed.
„„During intravenous treatment, oral relay should be considered when:
••The patient is afebrile after 48 hours of treatment.
••The infected area does not expand or decreases.
••The diagnosis is well established and the patient is able to tolerate oral treatment.

CELLULITIS WITH STRONG SUSPICION OF STREPTOCOCCI OR S. AUREUS

Total recommended duration of treatment : 7 to 10 days

Antibiotic Daily dosage Maximum dosage

Cephalexin 50-100 mg/kg/day PO ÷ TID 3 000 - 4 500 mg / day

Oral administration1 Cefadroxil2 30 mg/kg/day PO ÷ BID 2 000 mg / day

Cloxacillin3 50-100 mg/kg/day PO ÷ QID 6 000 mg / day

If history of allergic reaction Click here to view the cellulitis with strong suspicion of streptococci or S. aureus algorithm for
to a penicillin antibiotic help in choosing an oral antibiotic therapy

Cefazolin 50-100 mg/kg/day IV ÷ TID 6 000 mg / day

Intravenous administration 4

Cloxacillin 100-200 mg/kg/day IV ÷ QID 12 000 mg / day

If history of allergic reaction Click here to view the cellulitis with strong suspicion of streptococci or S. aureus algorithm for
to a penicillin antibiotic help in choosing an intravenous antibiotic therapy

„„Follow-up should be performed within 24 to 72 hours depending on the severity of the infection, the clinical evolution and the
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clinician’s judgment.
1. Amoxicillin/clavulanate (45–60 mg/kg/day PO ÷ TID; maximum 1 500 mg/day) may be a valid alternative when other treatment options cannot be used. In that case, the 7:1 formulation
(200 mg / 5 mL or 400 mg / 5 mL) is preferred due to its higher digestive tolerance.
2. The pediatric suspension of cefadroxil is not marketed in Canada.
3. Cloxacillin as an oral suspension is not widely used due to its unpleasant taste and interaction with food.
4. Ceftriaxone (50–75 mg/kg/day IV ÷ daily or BID; maximum 2 000 mg/day) may be a valid alternative when other treatment options cannot be used.
 CELLULITIS ASSOCIATED WITH A COMMON ANIMAL BITE (CAT OR DOG) OR A HUMAN BITE1
Total recommended duration of treatment : 7 to 10 days

Antibiotic Daily dosage Maximum dosage

CELLULITIS IN CHILDREN

Oral administration Amoxicillin/Clavulanate2 45-60 mg/kg/day PO ÷ TID 1 500 mg / day

If history of allergic reaction Click here to view the cellulitis associated with a common animal bite or a human bite algorithm
to a penicillin antibiotic for help in choosing an antibiotic therapy

„„It’s important to check for tendon, bone or joint involvement. If there is, and for any other complicated case, consult a specialist
or refer the patient to a hospital.
„„Usually, follow-up should be performed within 24 to 72 hours. However, follow-up within a maximum of 24 hours should be
performed in cases involving a bite to the hand or face.
„„In cases involving a human bite that broke the skin, patient management in infectiology should be considered, when available, to
assess the need for prophylaxis and follow-up for HIV, hepatitis B and hepatitis C.
„„Early antibiotic prophylaxis lasting 3 to 5 days is recommended for :
••All cases of cat bite
••Dog bites in an asplenic or immunosuppressed patient, in a patient with edema in the affected area or a moderate or
severe injury (especially to the hand, face or genitals) or one that may have breached the periosteum or joint capsule.

CELLULITIS OF DENTAL ORIGIN

Total recommended duration of treatment : 7 to 10 days

Antibiotic Daily dosage Maximum dosage

Oral administration Amoxicillin/Clavulanate2 45-60 mg/kg/day PO ÷ TID 1 500 mg / day

If history of allergic reaction Click here to view the cellulitis of dental origin algorithm for help in choosing an antibiotic
to a penicillin antibiotic therapy

„„When faced with an uncorrected dental problem, a consultation with a dentist or a maxillofacial specialist should be considered.
It is essential to treat the dental source of these infections.
„„In children, these infections can cause rapid deterioration of the patient’s general condition. Perform follow-up within 24 hours
and consider treating the patient under observation in a hospital setting. In the absence of response to treatment and in more
severe cases, consult a specialist or refer the patient to a hospital.

SIMPLE PERIORBITAL CELLULITIS OF SINUSAL ORIGIN3

(If the skin is broken, treat like cellulitis with strong suspicion of streptococci or S. aureus)
Minimum total recommended duration of treatment : 10 to 14 days

Antibiotic Daily dosage Maximum dosage

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Oral administration Amoxicillin/Clavulanate2,4 90 mg/kg/dayPO ÷ TID 3 000 mg / day

If history of allergic reaction Click here to view the simple periorbital cellulitis of sinusal origin algorithm for help in choosing
to a penicillin antibiotic an antibiotic therapy

!  nly simple cases of periorbital cellulitis should be treated in the primary care setting. These are characterized by mild edema
O
and erythema, the absence of severe pain, good eyelid opening, normal and non-painful extraocular movements, normal vision,
the absence of proptosis and chemosis, and the patient being in good overall condition.
! Follow-up on the evolution of these infections should be performed within 24 hours. In the absence of response to treatment, or
if orbital involvement is suspected, consult a specialist or refer the patient to a hospital.
1. Including injuries caused by contact with another person’s teeth during a fight.
2. The 7:1 formulation (200 mg / 5 mL or 400 mg / 5 mL) is preferred due to its higher digestive tolerance.
3. For the recommended supportive treatments to relieve sinus symptoms, see INESSS’s optimal usage guide on acute rhinosinusitis.
4. Some clinicians use a combination of amoxicillin (45 mg/kg/day) and amoxicillin/clavulanate (7:1 formulation) (45 mg/kg/day) to reduce adverse effects (total of 90 mg/kg/day, 14:1 equivalent).
The quantities of amoxicillin and amoxicillin/clavulanate (mL) may be different.
 CELLULITIS WITH SUSPICION OF CA-MRSA
Total recommended duration of treatment : 7 to 10 days

Antibiotic Daily dosage Maximum dosage

TMP component :
CELLULITIS IN CHILDREN

TMP/SMX1,2 320 mg of TMP / day

8-12 mg/kg/day PO ÷ BID
Oral administration 20 to 25 kg : 25-50 mg PO BID
Doxycycline1
25 to 40 kg : 50-75 mg PO BID 200 mg / day
(Child ≥ 8 years old)
> 40 kg : 100 mg BID

Intravenous administration Vancomycin3 60 mg/kg/day IV ÷ QID 4 000 mg / day

„„Follow-up should be performed within 24 to 72 hours depending on the severity of the infection, the clinical evolution and the
clinician’s judgment.
1. Note that doxycycline and TMP/SMX do not offer very good coverage against group A streptococcus.
2. TMP/SMX has not been approved by Health Canada for the treatment of cellulitis. However, it is frequently prescribed for this purpose, and experts agree that this antibiotic is an acceptable
treatment option when CA-MRSA is suspected.
3. If necessary, consult a specialist for alternative treatment options to vancomycin.

MAIN REFERENCES
Health Prince Edward Island. Provincial Antibiotic Advisory Team Skin & Soft Tissue Infection Empiric Treatment
Guidelines, Health PEI 2014.
Liu, C. 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. Clinical Infectious Diseases 2011;
52(3):e18–55.
Nassisi, D. and Oishi, M. L. Evidence-based guidelines for evaluation and antimicrobial therapy for common
emergency department infections. Emergency Medicine Practice 2012; 14(1):1–28.
Stevens, D. L. et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections:
2014 update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2014; 59(2):e10–52.
Wilson, L. and Caglar, D. Cellulitis and Abscess. Seattle Children’s Hospital 2013.

Please note that other references have been consulted.

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Any reproduction of this document in whole or in part

for non-commercial use is permitted on condition that
the source is mentioned.
 For dosages see next page

CELLULITIS WITH STRONG SUSPICION OF STREPTOCOCCI OR S. AUREUS

IN CHILDREN ORAL ADMINISTRATION

SEVERITY OF PREVIOUS ALLERGIC REACTION TO PENICILLIN ANTIBIOTICS

Vague history Non-severe reaction Severe reaction Very severe reaction

ASSESS THE SEVERITY OF THE INITIAL REACTION

or
Immediate reaction1 Immediate reaction
Immediate reaction
Unconvincing Isolated cutaneous Anaphylactic shock
history reported involvement Anaphylaxis4
(with or without intubation)
by patient (urticaria and/or angioedema)
or or
or family or
Delayed reaction2,3
Delayed reaction2,3
Delayed reaction 2,3
Severe skin reaction
Hemolytic anemia
Isolated cutaneous (desquamation, pustules, Kidney damage
involvement vesicles, purpura with fever Liver damage
(Rash and/or urticaria or joint pain, but no DRESS,
SJS/TEN or AGEP) DRESS, SJS/TEN, AGEP
and/or angioedema)
Serum sickness 3

or
Penicillin allergy CONFIRMED5
(severe or non-severe
reaction only)

THE FOLLOWING CAN BE PRESCRIBED SAFELY PRESCRIBE THE FOLLOWING WITH CAUTION AVOID PRESCRIBING

SIMILAR cephalosporins SIMILAR cephalosporins Beta-lactams6

Cephalexin OR Cefadroxil if history of Cephalexin OR Cefadroxil ONLY Choose another class of antibiotics.
allergy does not suggest an immediate if serum sickness-like reactions and
reaction… occurred in childhood3. PRESCRIBE THE FOLLOWING

The 1st dose should always be administered Clindamycin

DECISION-MAKING FOR CHOOSING A BETA-LACTAM

If in doubt about the possibility of an under medical supervision.

AND THE CONDITIONS OF ADMINISTRATION

immediate reaction… If history of :

1. Immediate reaction (type I or IgE-mediated) : generally occurs
A 1-hour observation period after the •• Immediate reactions, a drug provocation within 1 hour following the first dose of an antibiotic.
administration of the 1st dose of Cephalexin test should be performed; 2. Delayed reaction (type II, III and IV) : can occur at any time,
OR Cefadroxil under the supervision of a •• Delayed reactions, the patient or his/her starting 1 hour following the administration of an antibiotic.
health professional may be recommended family should be informed of the possible 3. The delayed skin reactions and serum sickness-like reactions
according to the clinician judgment. risk of recurrence in the days following that appear in children receiving antibiotic therapy are
or generally non-allergic and can be of viral origin.
initiation of the antibiotic.
PRESCRIBE THE FOLLOWING WITH CAUTION and 4. Anaphylaxis without shock or intubation : requires increased
AVOID PRESCRIBING vigilance.
5. With no recommendations concerning other beta-lactams.
Penicillins
6. Penicillins, cephalosporins and carbapenems.
Penicillins
Cloxacillin7 7. Amoxicillin/Clavulanate may be a valid alternative when other
Cloxacillin treatment options cannot be used.
The 1st dose should always be administered
under medical supervision. SIMILAR cephalosporins
For further information, see
If history of : Cephalexin OR Cefadroxil for all other the interactive tool and the decision-making tool.
•• Immediate reactions, a drug provocation clinical situations (with the exception
AGEP : acute generalized exanthematous pustulosis;
test should be performed; of children with a history of serum
DRESS : drug reaction with eosinophilia and systemic symptoms;
•• Delayed reactions, the patient or his/her sickness-like reactions3, as described SJS : Stevens–Johnson syndrome;
family should be informed of the possible above). TEN : toxic epidermal necrolysis.
risk of recurrence in the days following !
initiation of the antibiotic. IF A BETA-LACTAM6 CANNOT BE ADMINISTERED,
THE FOLLOWING CAN BE PRESCRIBED...

Clindamycin
CELLULITIS WITH STRONG SUSPICION OF STREPTOCOCCI OR S. AUREUS
IN CHILDREN ORAL ADMINISTRATION

FIRST-LINE ANTIBIOTIC THERAPY FOR CELLULITIS WITH STRONG SUSPICION OF STREPTOCOCCI OR S. AUREUS
IF HISTORY OF ALLERGIC REACTION TO A PENICILLIN ANTIBIOTIC

Recommended
Antibiotic Daily dosage Maximum dosage
duration

Cephalexin 50-100 mg/kg/day PO ÷ TID 3 000 - 4 500 mg / day

Beta-lactams
recommended,
according to the clinical Cefadroxil2 30 mg/kg/day PO ÷ BID 2 000 mg / day
judgment support
algorithm1 7 to 10 days

Cloxacillin3 50-100 mg/kg/day PO ÷ QID 6 000 mg / day

Alternative if a
beta-lactam cannot Clindamycin4,5,6 30-40 mg/kg/day PO ÷ TID 1 800 mg / day
be administered
1. Amoxicillin/clavulanate (45–60 mg/kg/day PO ÷ TID; maximum 1 500 mg/day) may be a valid alternative when other treatment options cannot be used. In that case, the 7:1 formulation
(200 mg / 5 mL or 400 mg / 5 mL) is preferred due to its higher digestive tolerance.
2. The pediatric suspension of cefadroxil is not marketed in Canada.
3. Cloxacillin as an oral suspension is not widely used due to its unpleasant taste and interaction with food.
4. Taking this antibiotic can cause diarrhea and intestinal symptoms that may worsen and require consultation. It is important to inform the patient of this.
5. Clindamycin in suspension tastes bad. Consult a pharmacist for ways to improve the taste of this drug.
6. If necessary, consult a specialist for alternatives to clindamycin.

Back to the optimal usage guide

 For dosages see next page

CELLULITIS WITH STRONG SUSPICION OF STREPTOCOCCI OR S. AUREUS

IN CHILDREN INTRAVENOUS ADMINISTRATION

SEVERITY OF PREVIOUS ALLERGIC REACTION TO PENICILLIN ANTIBIOTICS

Vague history Non-severe reaction Severe reaction Very severe reaction

ASSESS THE SEVERITY OF THE INITIAL REACTION

or
Immediate reaction1 Immediate reaction
Immediate reaction
Unconvincing Isolated cutaneous Anaphylactic shock
history reported involvement Anaphylaxis4
(with or without intubation)
by patient (urticaria and/or angioedema)
or or
or family or
Delayed reaction2,3
Delayed reaction2,3
Delayed reaction 2,3
Severe skin reaction
Hemolytic anemia
Isolated cutaneous (desquamation, pustules, Kidney damage
involvement vesicles, purpura with fever Liver damage
(Rash and/or urticaria or joint pain, but no DRESS,
SJS/TEN or AGEP) DRESS, SJS/TEN, AGEP
and/or angioedema)
Serum sickness 3

or
Penicillin allergy CONFIRMED5
(severe or non-severe
reaction only)

THE FOLLOWING CAN BE PRESCRIBED SAFELY PRESCRIBE THE FOLLOWING WITH CAUTION AVOID PRESCRIBING

DISSIMILAR cephalosporins DISSIMILAR cephalosporins Beta-lactams6

Cefazolin7 Cefazolin7 Choose another class of antibiotics.
or and
PRESCRIBE THE FOLLOWING WITH CAUTION The 1st dose should always be administered PRESCRIBE THE FOLLOWING
under medical supervision.
Penicillins If history of : Clindamycin
DECISION-MAKING FOR CHOOSING A BETA-LACTAM

Cloxacillin •• Immediate reactions, a drug provocation

AND THE CONDITIONS OF ADMINISTRATION

test should be performed; 1. Immediate reaction (type I or IgE-mediated) : generally occurs

The 1st dose should always be administered
•• Delayed reactions, the patient or his/her within 1 hour following the first dose of an antibiotic.
under medical supervision.
family should be informed of the possible 2. Delayed reaction (type II, III and IV) : can occur at any time,
If history of : risk of recurrence in the days following starting 1 hour following the administration of an antibiotic.
•• Immediate reactions, a drug provocation initiation of the antibiotic. 3. The delayed skin reactions and serum sickness-like reactions
test should be performed; and that appear in children receiving antibiotic therapy are
AVOID PRESCRIBING generally non-allergic and can be of viral origin.
•• Delayed reactions, the patient or his/her
4. Anaphylaxis without shock or intubation : requires increased
family should be informed of the possible vigilance.
Penicillins
risk of recurrence in the days following 5. With no recommendations concerning other beta-lactams.
initiation of the antibiotic. Cloxacillin 6. Penicillins, cephalosporins and carbapenems.
! 7. Ceftriaxone (50–75 mg/kg/day IV ÷ daily or BID; maximum
IF A BETA-LACTAM6 CANNOT BE ADMINISTERED, 2 000 mg/day) may be a valid alternative when other treat-
THE FOLLOWING CAN BE PRESCRIBED... ment options cannot be used.
For further information, see
Clindamycin the interactive tool and the decision-making tool.

AGEP : acute generalized exanthematous pustulosis;

DRESS : drug reaction with eosinophilia and systemic symptoms;
SJS : Stevens–Johnson syndrome;
TEN : toxic epidermal necrolysis.
CELLULITIS WITH STRONG SUSPICION OF STREPTOCOCCI OR S. AUREUS
IN CHILDREN INTRAVENOUS ADMINISTRATION

FIRST-LINE ANTIBIOTIC THERAPY FOR CELLULITIS WITH STRONG SUSPICION OF STREPTOCOCCI OR S. AUREUS
IF HISTORY OF ALLERGIC REACTION TO A PENICILLIN ANTIBIOTIC

Recommended
Antibiotic1 Daily dosage Maximum dosage
duration

Beta-lactams Cefazolin 50-100 mg/kg/day IV ÷ TID 6 000 mg / day

recommended,
according to the
clinical judgment
support algorithm2 Cloxacillin 100-200 mg/kg/day IV ÷ QID 12 000 mg / day 7 to 10 days

Alternative if a
beta-lactam cannot Clindamycin3,4 40 mg/kg/day IV ÷ TID 2 700 mg / day
be administered
1. Antibiotics are usually listed in alphabetical order using their generic name.
2. Ceftriaxone (50–75 mg/kg/day IV ÷ daily or BID; maximum 2 000 mg/day) may be a valid alternative when other treatment options cannot be used.
3. Taking this antibiotic can cause diarrhea and intestinal symptoms that may worsen and require consultation. It is important to inform the patient of this.
4. If necessary, consult a specialist for alternatives to clindamycin.

Back to the optimal usage guide

 For dosages see next page

CELLULITIS ASSOCIATED WITH A COMMON ANIMAL BITE (CAT OR DOG)

OR A HUMAN BITE* IN CHILDREN
* Including injuries caused by contact with another person’s teeth during a fight.

SEVERITY OF PREVIOUS ALLERGIC REACTION TO PENICILLIN ANTIBIOTICS

Vague history Non-severe reaction Severe reaction Very severe reaction

ASSESS THE SEVERITY OF THE INITIAL REACTION

or
Immediate reaction1 Immediate reaction
Immediate reaction
Unconvincing Isolated cutaneous Anaphylactic shock
history reported involvement Anaphylaxis4
(with or without intubation)
by patient (urticaria and/or angioedema)
or or
or family or
Delayed reaction2,3
Delayed reaction2,3
Delayed reaction 2,3
Severe skin reaction
Hemolytic anemia
Isolated cutaneous (desquamation, pustules, Kidney damage
involvement vesicles, purpura with fever Liver damage
(Rash and/or urticaria or joint pain, but no DRESS,
SJS/TEN or AGEP) DRESS, SJS/TEN, AGEP
and/or angioedema)
Serum sickness3
or
Penicillin allergy CONFIRMED5
(severe or non-severe
reaction only)

PRESCRIBE THE FOLLOWING WITH CAUTION AVOID PRESCRIBING

Penicillins Penicillins
Amoxicillin/Clavulanate
Amoxicillin/Clavulanate
DECISION-MAKING FOR CHOOSING A BETA-LACTAM

Choose another class of antibiotics.

The 1st dose should always be administered
AND THE CONDITIONS OF ADMINISTRATION

and
under medical supervision. PRESCRIBE THE FOLLOWING
If history of : Clindamycin + TMP/SMX OR
•• Immediate reactions, a drug provocation Doxycycline (child ≥ 8 years old)
test should be performed;
•• Delayed reactions, the patient or his/her 1. Immediate reaction (type I or IgE-mediated) : generally occurs
For further information, see
family should be informed of the possible within 1 hour following the first dose of an antibiotic.
the interactive tool and the decision-making tool.
risk of recurrence in the days following 2. Delayed reaction (type II, III and IV) : can occur at any time,
starting 1 hour following the administration of an antibiotic.
initiation of the antibiotic. AGEP : acute generalized exanthematous pustulosis;
3. The delayed skin reactions and serum sickness-like reactions
DRESS : drug reaction with eosinophilia and systemic symptoms;
that appear in children receiving antibiotic therapy are
SJS : Stevens–Johnson syndrome;
generally non-allergic and can be of viral origin.
TEN : toxic epidermal necrolysis.
4. Anaphylaxis without shock or intubation : requires increased
vigilance.
5. With no recommendations concerning other beta-lactams
(penicillins, cephalosporins and carbapenems).
CELLULITIS ASSOCIATED WITH A COMMON ANIMAL BITE (CAT OR DOG)
OR A HUMAN BITE* IN CHILDREN
* Including injuries caused by contact with another person’s teeth during a fight.

FIRST-LINE ANTIBIOTIC THERAPY FOR CELLULITIS ASSOCIATED WITH A COMMON ANIMAL BITE (CAT OR DOG)
OR A HUMAN BITE IF HISTORY OF ALLERGIC REACTION TO A PENICILLIN ANTIBIOTIC

Recommended
Antibiotic1 Daily dosage Maximum dosage
duration
Beta-lactams
recommended, Amoxicillin/
according to the 45-60 mg/kg/day PO ÷ TID 1 500 mg / day
clinical judgment Clavulanate2
support algorithm

Clindamycin3,4 30-40 mg/kg/day PO ÷ TID 1 800 mg / day

+ TMP component : 7 to 10 days
TMP/SMX5 8-12 mg/kg/day PO ÷ BID 320 mg de TMP / day
Alternative if a
beta-lactam cannot
be administered
20 to 25 kg : 25-50 mg PO BID
Doxycycline
25 to 40 kg : 50-75 mg PO BID 200 mg / day
(Child ≥ 8 years old)
> 40 kg : 100 mg BID

1. Antibiotics are usually listed in alphabetical order using their generic name.
2. The 7:1 formulation (200 mg / 5 mL or 400 mg / 5 mL) is preferred due to its higher digestive tolerance.
3. Taking this antibiotic can cause diarrhea and intestinal symptoms that may worsen and require consultation. It is important to inform the patient of this.
4. Clindamycin in suspension tastes bad. Consult a pharmacist for ways to improve the taste of this drug.
5. TMP/SMX has not been approved by Health Canada for the treatment of cellulitis. However, it is frequently prescribed for this purpose, and experts agree that this antibiotic is an acceptable treatment option in
combination with clindamycin in bite cases in young children.

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 For dosages see next page

CELLULITIS OF DENTAL ORIGIN IN CHILDREN

SEVERITY OF PREVIOUS ALLERGIC REACTION TO PENICILLIN ANTIBIOTICS

Vague history Non-severe reaction Severe reaction Very severe reaction

ASSESS THE SEVERITY OF THE INITIAL REACTION

or
Immediate reaction1 Immediate reaction
Immediate reaction
Unconvincing Isolated cutaneous Anaphylactic shock
history reported involvement Anaphylaxis4
(with or without intubation)
by patient (urticaria and/or angioedema)
or or
or family or
Delayed reaction2,3
Delayed reaction2,3
Delayed reaction 2,3
Severe skin reaction
Hemolytic anemia
Isolated cutaneous (desquamation, pustules, Kidney damage
involvement vesicles, purpura with fever Liver damage
(Rash and/or urticaria or joint pain, but no DRESS,
SJS/TEN or AGEP) DRESS, SJS/TEN, AGEP
and/or angioedema)
Serum sickness 3

or
Penicillin allergy CONFIRMED5
(severe or non-severe
reaction only)

PRESCRIBE THE FOLLOWING WITH CAUTION AVOID PRESCRIBING

Penicillins Penicillins
Amoxicillin/Clavulanate
Amoxicillin/Clavulanate
DECISION-MAKING FOR CHOOSING A BETA-LACTAM

Choose another class of antibiotics.

The 1st dose should always be administered
AND THE CONDITIONS OF ADMINISTRATION

and
under medical supervision. PRESCRIBE THE FOLLOWING
If history of :
Clindamycin
•• Immediate reactions, a drug provocation
test should be performed;
•• Delayed reactions, the patient or his/her 1. Immediate reaction (type I or IgE-mediated) : generally occurs
For further information, see
family should be informed of the possible within 1 hour following the first dose of an antibiotic.
the interactive tool and the decision-making tool.
risk of recurrence in the days following 2. Delayed reaction (type II, III and IV) : can occur at any time,
initiation of the antibiotic. starting 1 hour following the administration of an antibiotic.
AGEP : acute generalized exanthematous pustulosis;
3. The delayed skin reactions and serum sickness-like reactions
DRESS : drug reaction with eosinophilia and systemic symptoms;
that appear in children receiving antibiotic therapy are
SJS : Stevens–Johnson syndrome;
generally non-allergic and can be of viral origin.
TEN : toxic epidermal necrolysis.
4. Anaphylaxis without shock or intubation : requires increased
vigilance.
5. With no recommendations concerning other beta-lactams
(penicillins, cephalosporins and carbapenems).
CELLULITIS OF DENTAL ORIGIN IN CHILDREN

FIRST-LINE ANTIBIOTIC THERAPY FOR CELLULITIS OF DENTAL ORIGIN

IF HISTORY OF ALLERGIC REACTION TO A PENICILLIN ANTIBIOTIC

Recommended
Antibiotic Daily dosage Maximum dosage
duration
Beta-lactams
recommended, Amoxicillin/
according to the 45-60 mg/kg/day PO ÷ TID 1 500 mg / day
clinical judgment Clavulanate1
support algorithm
7 to 10 days
Alternative if a
beta-lactam cannot Clindamycin2,3,4 30-40 mg/kg/day PO ÷ TID 1 800 mg / day
be administered

1. The 7:1 formulation (200 mg / 5 mL or 400 mg / 5 mL) is preferred due to its higher digestive tolerance.
2. Taking this antibiotic can cause diarrhea and intestinal symptoms that may worsen and require consultation. It is important to inform the patient of this.
3. Clindamycin in suspension tastes bad. Consult a pharmacist for ways to improve the taste of this drug.
4. If necessary, consult a specialist for alternatives to clindamycin.

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 For dosages see next page

SIMPLE PERIORBITAL CELLULITIS OF SINUSAL ORIGIN IN CHILDREN

SEVERITY OF PREVIOUS ALLERGIC REACTION TO PENICILLIN ANTIBIOTICS

Vague history Non-severe reaction Severe reaction Very severe reaction

ASSESS THE SEVERITY OF THE INITIAL REACTION

or
Immediate reaction1 Immediate reaction
Immediate reaction
Unconvincing Isolated cutaneous Anaphylactic shock
history reported involvement Anaphylaxis4
(with or without intubation)
by patient (urticaria and/or angioedema)
or or
or family or
Delayed reaction2,3
Delayed reaction2,3
Delayed reaction 2,3
Severe skin reaction
Hemolytic anemia
Isolated cutaneous (desquamation, pustules, Kidney damage
involvement vesicles, purpura with fever Liver damage
(Rash and/or urticaria or joint pain, but no DRESS,
SJS/TEN or AGEP) DRESS, SJS/TEN, AGEP
and/or angioedema)
Serum sickness 3

or
Penicillin allergy CONFIRMED5
(severe or non-severe
reaction only)

PRESCRIBE THE FOLLOWING WITH CAUTION AVOID PRESCRIBING

Penicillins Penicillins
Amoxicillin/Clavulanate
Amoxicillin/Clavulanate
DECISION-MAKING FOR CHOOSING A BETA-LACTAM

Choose another class of antibiotics.

The 1st dose should always be administered
AND THE CONDITIONS OF ADMINISTRATION

and
under medical supervision. CONSULT
If history of :
Refer to specialized services to learn about alternative treatment options.
•• Immediate reactions, a drug provocation
test should be performed;
•• Delayed reactions, the patient or his/her 1. Immediate reaction (type I or IgE-mediated) : generally occurs
For further information, see
family should be informed of the possible within 1 hour following the first dose of an antibiotic.
the interactive tool and the decision-making tool.
risk of recurrence in the days following 2. Delayed reaction (type II, III and IV) : can occur at any time,
initiation of the antibiotic. starting 1 hour following the administration of an antibiotic.
AGEP : acute generalized exanthematous pustulosis;
3. The delayed skin reactions and serum sickness-like reactions
DRESS : drug reaction with eosinophilia and systemic symptoms;
that appear in children receiving antibiotic therapy are
SJS : Stevens–Johnson syndrome;
generally non-allergic and can be of viral origin.
TEN : toxic epidermal necrolysis.
4. Anaphylaxis without shock or intubation : requires increased
vigilance.
5. With no recommendations concerning other beta-lactams
(penicillins, cephalosporins and carbapenems).
SIMPLE PERIORBITAL CELLULITIS OF SINUSAL ORIGIN IN CHILDREN

FIRST-LINE ANTIBIOTIC THERAPY FOR SIMPLE PERIORBITAL CELLULITIS OF SINUSAL ORIGIN

IF HISTORY OF ALLERGIC REACTION TO A PENICILLIN ANTIBIOTIC

Recommended
Antibiotic Daily dosage Maximum dosage
duration
Beta-lactams
recommended, Amoxicillin/
according to the 90 mg/kg/day PO ÷ TID 3 000 mg / day 10 to 14 days
clinical judgment Clavulanate1
support algorithm

Alternative if a
beta-lactam cannot Seek a consultation with specialized services to learn about alternative treatment options.
be administered

1. The 7:1 formulation (200 mg / 5 mL or 400 mg / 5 mL) is preferred due to its higher digestive tolerance.

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