What are the treatment options for pediatric patients with necrotizing fasciitis who have a penicillin (Penicillin) allergy?

From the Guidelines

For pediatric patients with necrotizing fasciitis and a penicillin allergy, I strongly recommend treating with clindamycin as the first-line antibiotic, given its efficacy in suppressing streptococcal toxin and cytokine production, as supported by 1. The dosage for clindamycin is 10-13 mg/kg/dose every 6-8 hours, with a maximum dose of 900 mg per dose.

Key Considerations

• In severe cases or when the causative pathogen is unknown, consider adding vancomycin or linezolid combined with one of the following options:
  • Piperacillin-tazobactam
  • A carbapenem (imipenem-cilastatin, meropenem, and ertapenem)
  • Ceftriaxone plus metronidazole
  • A fluoroquinolone plus metronidazole, as recommended by 1 and 1.
• It's essential to monitor the patient's renal function and adjust the dosage accordingly.
• The treatment duration should be individualized based on the patient's response, but typically ranges from 7-14 days.
• Surgical debridement and supportive care, such as pain management and wound care, are crucial components of the treatment regimen, as emphasized by 1 and 1.
• Close monitoring of the patient's condition and adjustment of the antibiotic regimen as needed are essential to ensure effective treatment and minimize the risk of complications.

Additional Recommendations

• Intravenous immunoglobulin (IVIG) is not recommended due to lack of established efficacy in treating streptococcal toxic shock syndrome, as noted in 1.
• Macrolide resistance should be considered, especially in regions with high resistance rates, and alternative treatments should be chosen accordingly, as discussed in 1.

From the FDA Drug Label

Clindamycin is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. Clindamycin 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. Serious skin and soft tissue infections; septicemia; intra- abdominal infections such as peritonitis and intra-abdominal abscess Streptococci: Serious respiratory tract infections; serious skin and soft tissue infections. To reduce the development of drug-resistant bacteria and maintain the effectiveness of clindamycin hydrochloride and other antibacterial drugs, clindamycin hydrochloride should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria

For pediatric patients with necrotizing fasciitis who have a penicillin allergy, clindamycin may be considered as a treatment option, as it is effective against susceptible strains of streptococci and other bacteria that can cause skin and soft tissue infections 2.

• The decision to use clindamycin should be based on the severity of the infection and the results of susceptibility tests.
• It is essential to consider the risk of colitis and the suitability of less toxic alternatives before selecting clindamycin.
• Gentamicin may not be the best option for necrotizing fasciitis, as it is primarily used to treat gram-negative infections, and its effectiveness against streptococci is not well-established 3.

From the Research

Treatment Options for Pediatric Patients with Necrotizing Fasciitis and Penicillin Allergy

• Surgical debridement of the affected area is a crucial treatment option for pediatric patients with necrotizing fasciitis, regardless of penicillin allergy 4, 5, 6, 7, 8
• Intravenous antibiotic treatment is essential, but alternative antibiotics should be used in patients with penicillin allergy, such as clindamycin 4, 7
• Other treatment options include:
  • Supportive therapy, such as fluid management and management of multisystem organ failure 7
  • Use of intravenous immunoglobulin (IVIG) 7
  • Negative Pressure Wound Therapy (NPWT) with Vacuum-Assisted Closure (VAC) and Oasis® extracellular matrix (ECM) graft placement for wound closure and epithelization 6
• Early aggressive surgical treatment is the treatment of choice for pediatric patients with necrotizing fasciitis 5, 8
• The management of the residual wound after surgical debridement requires a patient-specific approach and constant reevaluation of the management plan 6

Antibiotic Treatment Alternatives for Penicillin Allergy

• Clindamycin is a suitable alternative for patients with penicillin allergy 4, 7
• Other antibiotics, such as vancomycin or linezolid, may also be considered, but the choice of antibiotic should be guided by the results of microbiological cultures and susceptibility testing 8
• It is essential to note that the use of alternative antibiotics may vary depending on the specific microorganism causing the infection and the patient's individual circumstances 5, 8