Pediatric emergency medicine trisk 1376 1376
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over an infection) with Staphylococcus aureus or Streptococcus pyogenes
may be present. S. pyogenes by itself may cause a secondary infection in an
atopic child that resembles eczema herpeticum, presenting with fever,
cellulitis, and clusters of pustular skin lesions.
The decision to admit to hospital should be determined by the degree of
toxicity. While patients may require in-hospital care for intravenous
hydration or intravenous antibiotic therapy to address widespread bacterial
infection or bacteremia, selected nontoxic patients with limited disease may
be successfully managed in the outpatient setting, as long as patients are
followed closely and reconsidered for admission if they do not respond
adequately or worsen clinically.
When a patient is suspected of having KVE, the initial history taking
should identify the existence of an underlying primary skin disease history,
its usual sites of anatomic involvement, and the suspected viral agent—
herpes simplex, enterovirus, vaccinia, or varicella zoster.
Recommended diagnostic studies include polymerase chain reaction
(PCR) assay, direct fluorescent antibody testing, or viral culture for herpes
simplex virus, varicella zoster virus, and if suspected, enteroviral PCR or
culture. Vaccinia virus may be considered in the appropriate exposure
context. Bacterial skin culture and blood culture for bacteria may be
obtained if a bacterial superinfection is suspected.
Recommended therapy involves empiric antiviral treatment with activity
against herpes simplex, such as acyclovir or valacyclovir. Empiric
antistaphylococcal and antistreptococcal coverage may be considered if
significant serous crusting is present, and especially if the child is febrile or
ill appearing. The optimal agent depends on local antibiotic resistance
patterns but will most likely include clindamycin, a first-generation
cephalosporin such as cephalexin or cefazolin, a penicillinase-resistant agent
such as oxacillin or nafcillin, or in more severe cases, vancomycin. If
trimethoprim-sulfamethoxazole is used, it may need to be combined with
another agent to provide adequate coverage for streptococci. Empiric
antiviral therapy for eczema herpeticum reduces the length of hospital stay
(LOS) when started promptly. As the antiviral medications are both
relatively safe and inexpensive, a low threshold for starting these agents is
recommended. In contrast, empiric systemic antibiotic therapy reduces LOS
only when there is bacteremia.
