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

From the Guidelines

For a pediatric patient with necrotizing fasciitis and a penicillin allergy, the recommended initial treatment is clindamycin, which can be administered at a dose of 10-13 mg/kg every 6-8 hours, not to exceed 2.7 grams per day for severe infections, as suggested by the Infectious Diseases Society of America guidelines 1.

Key Considerations

• In cases where anaerobic coverage is also desired, metronidazole can be added at a dose of 7.5-10 mg/kg every 8 hours.
• It's essential to monitor the patient closely for signs of improvement or deterioration and adjust the antibiotic regimen as necessary based on culture and sensitivity results.
• Surgical debridement is also a critical component of treatment for necrotizing fasciitis and should be performed promptly.
• Second-line interventions may include the use of other broad-spectrum antibiotics such as vancomycin or linezolid, especially if there's concern for MRSA or other resistant organisms, as recommended by the guidelines 1.
• However, these should be used judiciously and with careful consideration of the patient's clinical status and potential side effects.

Antibiotic Regimens

• The choice of antibiotic regimen should be based on the suspected or confirmed etiology of the infection, as well as the patient's allergy status.
• For polymicrobial infections, a broad-spectrum antibiotic regimen such as vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem may be necessary, as suggested by the guidelines 1.
• For monomicrobial infections, such as those caused by group A streptococci, penicillin plus clindamycin may be recommended, but in the case of a penicillin allergy, clindamycin alone or in combination with another antibiotic may be used 1.

From the FDA Drug Label

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 A safety and efficacy study provided experience on the use of ZYVOX in pediatric patients for the treatment of nosocomial pneumonia, complicated skin and skin structure infections, catheter-related bacteremia, bacteremia of unidentified source, and other infections due to Gram-positive bacterial pathogens, including methicillin-resistant and -susceptible Staphylococcus aureus and vancomycin-resistant Enterococcus faecium.

Treatment options for pediatric patients with necrotizing fasciitis who have a penicillin allergy:

• Clindamycin 2 may be considered for the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci in penicillin-allergic patients.
• Vancomycin 3 may be considered for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci in penicillin-allergic patients.
• Linezolid 4 may be considered for the treatment of complicated skin and skin structure infections, including those caused by Gram-positive bacterial pathogens, in pediatric patients.

From the Research

Treatment Options for Pediatric Patients with Necrotizing Fasciitis and Penicillin Allergy

• Surgical debridement is a crucial treatment option for necrotizing fasciitis, and it should be performed as early as possible to prevent delay in treatment 5, 6.
• Antibiotic therapy is also essential in the treatment of necrotizing fasciitis. However, for patients with a penicillin allergy, alternative antibiotics such as clindamycin, an aminoglycoside, and metronidazole can be used 6.
• In some cases, linezolid can be added to the treatment regimen for patients who do not improve with standard therapy 7.
• Negative pressure wound therapy (NPWT) and vacuum-assisted closure (VAC) can be used to manage the residual wound after surgical debridement 8, 9.
• The management of necrotizing fasciitis requires a patient-specific approach and constant reevaluation of the management plan 8.

Alternative Antibiotics for Penicillin Allergy

• Clindamycin can be used as an alternative to penicillin in the treatment of necrotizing fasciitis 6, 9.
• Linezolid can be added to the treatment regimen for patients who do not improve with standard therapy 7.
• An aminoglycoside and metronidazole can also be used in combination with other antibiotics to treat necrotizing fasciitis 6.

Wound Management

• Negative pressure wound therapy (NPWT) and vacuum-assisted closure (VAC) can be used to manage the residual wound after surgical debridement 8, 9.
• Oasis® extracellular matrix (ECM) graft placement can be used to promote wound healing and closure 8.
• Skin sparing surgeries and limited surgical debridement can be used to preserve as much skin tissue as possible 9.