From the Guidelines
For pediatric patients with necrotizing fasciitis and a penicillin allergy, the recommended treatment involves a combination of surgical intervention and alternative broad-spectrum antibiotics, with a combination of vancomycin and clindamycin being a suitable option, as suggested by the Infectious Diseases Society of America guidelines 1.
Treatment Approach
The treatment approach for pediatric patients with necrotizing fasciitis and a penicillin allergy should prioritize immediate surgical debridement of infected tissue, as well as broad-spectrum antibiotic coverage.
- Surgical intervention is the primary therapeutic modality in cases of necrotizing fasciitis and is indicated when this infection is confirmed or suspected 1.
- Features suggestive of necrotizing fasciitis include clinical findings, failure of cellulitis to respond to antibiotics, profound toxicity, skin necrosis, and presence of gas in the soft tissues 1.
Antibiotic Therapy
For antibiotic therapy, a combination of vancomycin (15 mg/kg IV every 6 hours) and clindamycin (10-13 mg/kg IV every 8 hours) should be initiated, as these antibiotics provide coverage against both gram-positive and gram-negative organisms, including group A streptococcus and staphylococcus species, which are common causes of necrotizing fasciitis 1.
- Additionally, either meropenem (20 mg/kg IV every 8 hours) or ceftazidime (50 mg/kg IV every 8 hours) should be added to the regimen to provide further coverage against gram-negative organisms.
Supportive Care
Supportive care, including fluid resuscitation, pain management, and nutritional support, is also essential in the treatment of pediatric patients with necrotizing fasciitis and a penicillin allergy.
- Close monitoring in an intensive care unit is necessary due to the severity of the condition. This approach ensures comprehensive treatment while avoiding penicillin-based antibiotics, addressing the specific needs of pediatric patients with this life-threatening infection.
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.