What is the treatment for necrotizing fasciitis in pediatric patients with a penicillin (antibiotic) allergy?

From the Guidelines

For pediatric patients with necrotizing fasciitis and a penicillin allergy, the recommended treatment involves immediate surgical debridement combined with broad-spectrum antibiotic therapy, such as vancomycin plus clindamycin and either meropenem or ciprofloxacin, as suggested by the Infectious Diseases Society of America guidelines 1.

Key Considerations

• Surgical debridement should be performed as soon as possible and repeated as necessary, with most patients requiring return to the operating room 24-36 hours after the first debridement and daily thereafter until no further need for debridement is found 1.
• Antibiotic therapy should be broad-spectrum, covering both gram-positive and gram-negative bacteria, including anaerobes, and should continue for 2-3 weeks, adjusted based on clinical response and culture results 1.
• Close monitoring in an intensive care setting is crucial, with ongoing assessment of wound healing and potential need for further surgical interventions 1.

Antibiotic Regimens

• Vancomycin (15 mg/kg IV every 6 hours) plus clindamycin (10-13 mg/kg IV every 8 hours) and either meropenem (20 mg/kg IV every 8 hours) or ciprofloxacin (10 mg/kg IV every 12 hours) for children over 1 year old is a suitable antibiotic regimen 1.
• Other options may include linezolid or daptomycin, pending results of culture and susceptibility tests 1.

Important Notes

• The treatment of necrotizing fasciitis and/or streptococcal toxic shock syndrome caused by group A streptococci should include clindamycin and penicillin, but in patients with a penicillin allergy, alternative agents such as vancomycin or linezolid may be used 1.
• The use of intravenous immunoglobulin (IVIG) for the treatment of streptococcal toxic shock syndrome is not recommended with certainty, due to limited evidence 1.

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 a penicillin allergy and necrotizing fasciitis, daptomycin can be considered as a treatment option, as it has been evaluated in clinical trials for complicated skin and skin structure infections (cSSSI) in pediatric patients.

• The dosing for pediatric patients is age-dependent, ranging from 10mg/kg for 1 to < 2 years to 5 mg/kg for 12 to 17 years of age.
• Vancomycin and clindamycin were used as comparators in the clinical trial, and may also be considered as alternative treatment options for pediatric patients with a penicillin allergy and necrotizing fasciitis 2.

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 and antibiotic therapy 3, 4, 5, 6, 7.
• For patients with a penicillin allergy, alternative antibiotics such as clindamycin and metronidazole may be used 6.
• The choice of antibiotic therapy should be based on the results of microbiological tests and the patient's allergy history.
• Surgical debridement should be performed as early as possible to prevent the spread of the infection and promote wound healing 3, 4, 5, 6, 7.
• Additional treatments such as negative pressure wound therapy (NPWT) and vacuum-assisted closure (VAC) may be used to enhance wound healing and closure 4, 7.
• The management of necrotizing fasciitis in pediatric patients requires a multidisciplinary approach and close monitoring of the patient's condition to ensure the best possible outcome 3, 4, 5, 6, 7.

Antibiotic Therapy for Pediatric Patients with a Penicillin Allergy

• Clindamycin is a commonly used antibiotic for the treatment of necrotizing fasciitis in patients with a penicillin allergy 6.
• Metronidazole may also be used in combination with other antibiotics to treat necrotizing fasciitis in patients with a penicillin allergy 6.
• The choice of antibiotic therapy should be based on the results of microbiological tests and the patient's allergy history 6.

Surgical Debridement and Wound Management

• Surgical debridement should be performed as early as possible to prevent the spread of the infection and promote wound healing 3, 4, 5, 6, 7.
• The extensiveness of surgical debridement may vary depending on the location and severity of the infection 7.
• Negative pressure wound therapy (NPWT) and vacuum-assisted closure (VAC) may be used to enhance wound healing and closure 4, 7.