From the Guidelines
For a pediatric patient with necrotizing fasciitis and a penicillin allergy, the recommended treatment is intravenous clindamycin, which is effective against Group A Streptococcus and Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA) 1. The dose of clindamycin is 40 mg/kg/day divided into 3-4 doses, with a maximum dose of 2,700 mg/day.
Alternative Treatment Options
- Vancomycin can be used, especially if there's a high suspicion of MRSA, at a dose of 40 mg/kg/day divided into 4 doses, with trough levels monitored to ensure therapeutic levels 1.
- Considering the potential for anaerobic bacteria, metronidazole can be added at a dose of 30 mg/kg/day divided into 3-4 doses.
Key Considerations
- It's crucial to start treatment as soon as possible and to monitor the patient closely for any signs of improvement or deterioration, adjusting the antibiotic regimen as needed based on culture and sensitivity results 1.
- Surgical debridement is also a critical component of treatment for necrotizing fasciitis and should be performed promptly 1.
Additional Recommendations
- Most patients with necrotizing fasciitis should return to the operating room 24–36 hours after the first debridement and daily thereafter until the surgical team finds no further need for debridement 1.
- Empiric treatment of polymicrobial necrotizing fasciitis should include agents effective against both aerobes, including MRSA, and anaerobes 1.
From the FDA Drug Label
Clindamycin Injection, USP is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. Clindamycin Injection, USP is also indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate. Skin and skin structure infections caused by Streptococcus pyogenes, Staphylococcus aureus, and anaerobes.
The treatment for necrotizing fasciitis in pediatric patients with a penicillin allergy may include clindamycin as it is indicated for the treatment of serious skin and skin structure infections caused by susceptible strains of streptococci, staphylococci, and anaerobes, and its use is reserved for penicillin-allergic patients 2.
- Clindamycin can be considered for the treatment of necrotizing fasciitis in pediatric patients with a penicillin allergy.
- Surgical procedures should be performed in conjunction with antibiotic therapy.
- It is essential to determine the causative organisms and their susceptibility to clindamycin through bacteriologic studies.
From the Research
Treatment for Necrotizing Fasciitis in Pediatric Patients with a Penicillin Allergy
- The treatment for necrotizing fasciitis in pediatric patients typically involves aggressive surgical debridement of necrotic tissues, fluid management, and appropriate parenteral antimicrobial therapy 3.
- For patients with a penicillin allergy, alternative antibiotics such as clindamycin and metronidazole may be used 4.
- In some cases, vancomycin may be considered for patients with a penicillin allergy, especially if methicillin-resistant Staphylococcus aureus (MRSA) is suspected 5.
- The use of intravenous immunoglobulin (IVIG) may also be considered as an adjunctive therapy 3.
- Negative Pressure Wound Therapy (NPWT) with Vacuum-Assisted Closure (VAC) and Oasis® extracellular matrix (ECM) graft placement may be used to manage the residual wound after surgical debridement 6.
Antibiotic Selection
- The choice of antibiotic should be based on the suspected or confirmed causative organism, as well as the patient's allergy history 4.
- Clindamycin is often used as an alternative to penicillin in patients with a penicillin allergy, as it has good coverage against Streptococci and Staphylococci 3, 4.
- Metronidazole may also be used in combination with other antibiotics to provide coverage against anaerobic organisms 4.