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, the recommended treatment is a combination of clindamycin and vancomycin, along with aggressive surgical debridement. Medication regimen:

• Clindamycin: 10-13 mg/kg IV every 8 hours
• Vancomycin: 10-15 mg/kg IV every 6 hours This antibiotic combination provides broad-spectrum coverage against the most common causative organisms, including group A Streptococcus and Staphylococcus aureus, while avoiding beta-lactam antibiotics, as recommended by the Infectious Diseases Society of America 1. Surgical intervention is crucial and should be performed as soon as possible. Extensive debridement of all necrotic tissue is necessary, often requiring multiple procedures. Additional important measures:

• Fluid resuscitation and hemodynamic support
• Pain management
• Nutritional support
• Close monitoring in an intensive care unit The combination of clindamycin and vancomycin is effective because:

• Clindamycin inhibits bacterial protein synthesis and suppresses toxin production
• Vancomycin provides coverage against gram-positive organisms, including MRSA Treatment duration typically lasts 2-4 weeks, depending on clinical response and the extent of tissue involvement. Transition to oral antibiotics can be considered once the patient shows significant clinical improvement and wound healing. It's crucial to note that while this regimen is generally effective, treatment should be tailored to the individual patient based on culture results and clinical response. Close monitoring and adjustment of therapy may be necessary. Key points to consider:

• The patient's penicillin allergy necessitates the use of alternative antibiotics, such as clindamycin and vancomycin
• Surgical debridement is essential for the treatment of necrotizing fasciitis
• The treatment regimen should be individualized based on the patient's clinical response and culture results, as recommended by the Infectious Diseases Society of America 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 soon as possible 5, 6, 7, 8.
• Antibiotic treatment is also essential, but the choice of antibiotics may need to be adjusted in patients with a penicillin allergy 5, 6, 9.
• In patients with a penicillin allergy, alternative antibiotics such as clindamycin, an aminoglycoside, and metronidazole may be used 6.
• Linezolid may also be considered as an additional treatment option in cases where the patient is not improving with standard therapy 9.
• Supportive therapy, including intravenously administered fluids, blood transfusions, and calcium, is also important in the management of necrotizing fasciitis 8.
• Wound closure techniques, such as Negative Pressure Wound Therapy (NPWT) and Oasis® extracellular matrix (ECM) graft placement, may be used to manage the residual skin and soft tissue deficit after surgical debridement 7.

Antibiotic Treatment Considerations

• The choice of antibiotics should be based on culture data, as gram stain results may not be reliable 6.
• The use of broad-spectrum antibiotics, such as penicillin, an aminoglycoside, and metronidazole, may be necessary to cover the range of potential pathogens involved in necrotizing fasciitis 6.
• In patients with a penicillin allergy, alternative antibiotics should be chosen based on the suspected or confirmed causative microorganism 9.