Primary pathogen (Group A Streptococcus (Streptococcus pyogenes) — >80% of erysipelas; occasionally Staphylococcus aureus with portal of entry)
Clinical context (Acute, well-demarcated, raised, tender superficial skin infection with lymphangitis — typically on face or extremities; non-purulent (IDSA, NICE, CHOP))
First-line therapy
Cephalexin • p.o. • 25–25 mg/kg/dose • 3×/day
Max 1000 mg/dose · Max 3000 mg/day · Duration: 5 days · IDSA/CHOP: 5 days of effective therapy when clinically improving — extend to 7 days if slow response; 25 mg/kg/dose TID (75 mg/kg/day) within IDSA 25–50 mg/kg/day range
Enter weight on Kids to calculate doses
Clindamycin • p.o. • 10–10 mg/kg/dose • 3×/day
Max 600 mg/dose · Max 1800 mg/day · Duration: 5 days · Beta-lactam allergy (non-anaphylactic) or treatment failure — covers GAS; MRSA coverage only if susceptible (IDSA, CHOP)
• Amoxicillin: preferred narrow streptococcal agent when culture confirms GAS or penicillin/amoxicillin preferred over cephalosporin — IDSA oral options for erysipelas/cellulitis include penicillin and amoxicillin (IDSA SSTI 2014, AAFP 2024).
• Clindamycin: non-anaphylactic beta-lactam allergy, or failure of cephalexin after 48 h — covers GAS and most CA-MRSA if susceptible; verify local resistance (D-test if inducible clindamycin resistance) (IDSA, CHOP).
• Penicillin V: historical first-line for streptococcal erysipelas — 25–50 mg/kg/day in 4 divided doses when amoxicillin/cephalexin unavailable (IDSA, AAP Red Book).
• Routine MRSA coverage NOT indicated for typical erysipelas — GAS-predominant; add MRSA-active agent only with purulent focus, MRSA risk factors, or treatment failure (IDSA strong, CHOP, CPS).
• Hospitalize and switch to IV cefazolin if systemic toxicity, unable to tolerate oral therapy, facial/periorbital involvement, or failed outpatient management (CHOP, NICE, CPS).
Enter weight on Kids to calculate doses
Clinical notes
• Typical streptococcal etiology: acute onset of sharply demarcated, raised, erythematous, tender plaque with possible lymphangitis and regional lymphadenopathy — >80% due to Group A Streptococcus (IDSA, NICE, AAP Red Book).
• Oral therapy indications: afebrile or mildly ill child, tolerating oral intake, reliable caregiver and follow-up, no signs of necrotizing infection or systemic toxicity — cephalexin or amoxicillin first-line (IDSA, CHOP, NICE).
• Hospitalization criteria: moderate–severe systemic illness, dehydration, age <3 months, periorbital/facial erysipelas, failed oral therapy at 48 h, immunocompromise, or concern for deeper infection — initiate IV cefazolin (CHOP, CPS, NICE).
• Surgical consultation: urgent evaluation if necrotizing infection suspected — pain out of proportion, bullae, skin necrosis, crepitus, rapid progression, hypotension, or LRINEC concern (IDSA, NICE NG141).
• Duration and follow-up: 5 days effective therapy when improving within 48–72 h; extend to 7 days if slow response — cultures of blood or skin not routinely needed for uncomplicated erysipelas (IDSA strong moderate, CHOP, VUMC 2026).
• IDSA — Practice guidelines for skin and soft tissue infections (erysipelas/cellulitis) (2014)
• CHOP — Cellulitis/abscess antibiotic pathway (includes erysipelas) (2024)
• AAP Red Book — Group A streptococcal infections (2024)
+ 4 more
• NICE NG141 — Cellulitis and erysipelitis (2022)
• CPS — Community-associated bacterial SSTI in children (2024)
• ESPID — Skin and soft tissue infection guidance (2024)
• AAFP — Common bacterial skin infections in children (2024)
