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, as it is effective against group A streptococci and has been shown to suppress toxin and cytokine production 1. The dosage for clindamycin is 40 mg/kg/day divided into 3-4 doses, with a maximum dose of 2,700 mg/day.

Treatment Considerations

• The treatment should be continued for at least 7-10 days, but the duration may be extended based on the patient's response to therapy and the severity of the infection.
• It's essential to monitor the patient closely for signs of improvement or potential side effects, such as diarrhea or pseudomembranous colitis.
• Surgical debridement should be performed promptly to remove the infected tissue and promote healing, as it is the primary therapeutic modality in cases of necrotizing fasciitis 1.
• In severe cases or when clindamycin is not appropriate, vancomycin may be considered as an alternative, with a dosage of 40 mg/kg/day divided into 3-4 doses, but its use should be reserved for severe cases or when clindamycin is not effective.

Key Points

• Empiric antibiotic treatment should be broad, covering both aerobes and anaerobes, as the etiology can be polymicrobial or monomicrobial 1.
• The treatment regimen should be tailored to the individual patient's needs, and the patient should be closely monitored for signs of improvement or potential complications.
• Clindamycin is a suitable alternative to penicillin in patients with a penicillin allergy, and its use is supported by the Infectious Diseases Society of America guidelines 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. Vancomycin Hydrochloride for Injection, USP is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (β-lactam-resistant) staphylococci It is indicated for penicillin-allergic patients, for patients who cannot receive or who have failed to respond to other drugs, including the penicillins or cephalosporins, and for infections caused by vancomycin-susceptible organisms that are resistant to other antimicrobial drugs

For pediatric patients with necrotizing fasciitis who have a penicillin allergy, treatment options may include:

• Clindamycin 2, as it is indicated for the treatment of serious infections caused by susceptible anaerobic bacteria, streptococci, pneumococci, and staphylococci.
• Vancomycin 3, as it is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci and is suitable for penicillin-allergic patients.

From the Research

Treatment Options for Pediatric Patients with Necrotizing Fasciitis and Penicillin Allergy

• The treatment of necrotizing fasciitis in pediatric patients typically involves aggressive surgical debridement, antimicrobial therapy, and supportive care 4, 5, 6, 7.
• For patients with a penicillin allergy, alternative antimicrobial agents such as clindamycin may be used 4, 5.
• In some cases, a combination of antibiotics including an aminoglycoside and metronidazole may be used 6.
• The management of the residual wound after surgical debridement may involve the use of Negative Pressure Wound Therapy (NPWT) and Oasis® extracellular matrix (ECM) graft placement 8.
• Early surgical debridement and intensive supportive care are crucial in reducing mortality and morbidity associated with necrotizing fasciitis in children 6, 7.

Antimicrobial Therapy

• Clindamycin is a suitable alternative to penicillin for the treatment of necrotizing fasciitis in patients with a penicillin allergy 4, 5.
• The choice of antimicrobial agent should be based on culture data and susceptibility testing 6.
• A combination of antibiotics may be necessary to cover a range of potential pathogens, including streptococci, staphylococci, and anaerobes 6, 7.

Surgical Management

• Aggressive surgical debridement is essential in the treatment of necrotizing fasciitis to remove necrotic tissue and prevent further spread of the infection 4, 5, 6, 7.
• Multiple operations may be necessary to achieve complete debridement and wound closure 6.
• The use of NPWT and ECM graft placement may be useful in managing the residual wound after surgical debridement 8.