From the Guidelines
For pediatric patients with necrotizing fasciitis and a penicillin allergy, the recommended first-line treatment is a combination of intravenous antibiotics: vancomycin plus either clindamycin or linezolid, as this regimen is effective against both aerobes, including MRSA, and anaerobes, and is supported by the Infectious Diseases Society of America guidelines 1.
Treatment Regimen
- Vancomycin: 15-20 mg/kg/dose every 6-8 hours
- Clindamycin: 10-13 mg/kg/dose every 6-8 hours, or
- Linezolid: 10 mg/kg/dose every 8 hours for children <12 years; 600 mg every 12 hours for ≥12 years
This antibiotic therapy should be initiated immediately upon diagnosis and continued for at least 14 days, or longer depending on clinical response, as the goal is to cover the infection until further debridement is no longer necessary, the patient has improved clinically, and fever has been absent for 48–72 hours 1.
Additional Interventions
In addition to antibiotics, aggressive surgical debridement of infected tissue is crucial and should be performed as soon as possible, with multiple debridements may be necessary, as surgical intervention is the primary therapeutic modality in cases of necrotizing fasciitis 1. Some second-line interventions may include:
- Hyperbaric oxygen therapy, if available, to enhance tissue oxygenation and aid healing
- Intravenous immunoglobulin (IVIG) in cases of streptococcal toxic shock syndrome
- Consideration of alternative antibiotics such as daptomycin or tigecycline if the patient doesn't respond to initial therapy Close monitoring in an intensive care unit is essential, with attention to fluid resuscitation, pain management, and nutritional support, and early involvement of infectious disease specialists and pediatric surgeons is recommended for optimal management.
From the FDA Drug Label
The safety of daptomycin for injection was evaluated in one clinical trial (in cSSSI), which included 256 pediatric patients (1 to 17 years of age) treated with intravenous daptomycin for injection and 133 patients treated with comparator agents *Comparators included intravenous therapy with either vancomycin, clindamycin, or an anti-staphylococcal semi-synthetic penicillin (nafcillin, oxacillin or cloxacillin)
For pediatric patients with necrotizing fasciitis who have a penicillin allergy, daptomycin may be considered as a treatment option.
- The drug label mentions that daptomycin was evaluated in pediatric patients with complicated skin and skin structure infections (cSSSI), which includes necrotizing fasciitis.
- The label also mentions that comparators included vancomycin and clindamycin, which are alternative antibiotics that may be used in patients with penicillin allergy.
- However, it is essential to note that the label does not explicitly state that daptomycin is approved for the treatment of necrotizing fasciitis in pediatric patients with penicillin allergy. 2
From the Research
Treatment Options for Pediatric Patients with Necrotizing Fasciitis and Penicillin Allergy
- Surgical debridement is a crucial step in the management of necrotizing fasciitis, and it should be performed promptly 3, 4, 5.
- For patients with a penicillin allergy, alternative antibiotics such as clindamycin, metronidazole, and linezolid can be used 6, 5.
- The use of negative pressure wound therapy (NPWT) and vacuum-assisted closure (VAC) can aid in wound healing and closure 7, 4.
- In some cases, the use of extracellular matrix (ECM) graft placement can also contribute to wound closure and epithelization 7.
- The management of necrotizing fasciitis requires a patient-specific approach and constant reevaluation of the management plan 7, 3, 5.
Antibiotic Treatment Options
- Clindamycin and metronidazole can be used as initial antibiotic treatment for patients with a penicillin allergy 3, 5.
- Linezolid can be added to the treatment regimen if the patient does not improve with standard therapy 6.
- Aminopenicillin ± sulbactam in combination with clindamycin and/or metronidazole can also be used as initial calculated antibiotic treatment 5.