What is the recommended treatment regimen for pediatric patients with necrotizing fascitis and a penicillin allergy?

From the Guidelines

For pediatric patients with necrotizing fasciitis who have penicillin allergies, treatment should include prompt surgical debridement combined with alternative antibiotic therapy, such as clindamycin plus vancomycin or linezolid, as recommended by the Infectious Diseases Society of America 1. The recommended antibiotic regimen is clindamycin (40 mg/kg/day divided every 8 hours, maximum 2.7 g/day) plus either vancomycin (15 mg/kg/dose every 6 hours) or linezolid (10 mg/kg every 8 hours for children under 12; 600 mg every 12 hours for older children) 1.

Key Considerations

• Aggressive surgical debridement is essential and should be performed immediately, with repeat debridements as needed until all necrotic tissue is removed 1.
• Supportive care including fluid resuscitation, pain management, and nutritional support is crucial 1.
• Hyperbaric oxygen therapy may be considered as an adjunctive treatment in facilities where available.
• The alternative antibiotic choices work by different mechanisms than penicillins - clindamycin inhibits protein synthesis and suppresses toxin production, while vancomycin or linezolid target cell wall synthesis or protein synthesis in gram-positive bacteria, effectively covering the common causative organisms without triggering penicillin allergy reactions 1.

Treatment Duration

• Treatment duration typically ranges from 2-4 weeks depending on clinical response 1.

Broader Coverage

• For broader coverage, add ciprofloxacin (20-30 mg/kg/day divided every 12 hours) or aztreonam (90-120 mg/kg/day divided every 6-8 hours) 1. The most recent and highest quality study, published in 2014 by the Infectious Diseases Society of America, provides guidance on the diagnosis and management of skin and soft tissue infections, including necrotizing fasciitis 1.

Surgical Intervention

• 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 apparently uncomplicated cellulitis to respond to antibiotics, profound toxicity, skin necrosis, and presence of gas in the soft tissues 1. Most patients with necrotizing fasciitis should return to the operating room 24–36 hours after the first debridement and daily thereafter until the surgical team finds no further need for debridement 1. Although discrete pus is usually absent, these wounds can discharge copious amounts of tissue fluid, and aggressive fluid administration is a necessary adjunct 1. In the absence of definitive clinical trials, antimicrobial therapy should be administered until further debridement is no longer necessary, the patient has improved clinically, and fever has been absent for 48–72 hours 1. Empiric treatment of polymicrobial necrotizing fasciitis should include agents effective against both aerobes, including MRSA, and anaerobes 1. Among the many choices is vancomycin, linezolid, or daptomycin combined with one of the following options: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 1. Once the microbial etiology has been determined, the antibiotic coverage should be appropriately modified 1. Necrotizing fasciitis and/or streptococcal toxic shock syndrome caused by group A streptococci should be treated with both clindamycin and penicillin, but in cases of penicillin allergy, alternative antibiotics such as vancomycin or linezolid should be used 1. Clindamycin suppresses streptococcal toxin and cytokine production, and was found to be superior to penicillin in animal models, and 2 observational studies show greater efficacy for clindamycin than β-lactam antibiotics 1. Penicillin should be added because of potential resistance of group A streptococci to clindamycin, but in cases of penicillin allergy, this should be avoided 1. The efficacy of intravenous immunoglobulin (IVIG) in treating streptococcal toxic shock syndrome has not been established 1.

From the FDA Drug Label

The recommended dosage regimens based on age for pediatric patients with cSSSI are shown in Table 1. Administer daptomycin for injection intravenously in 0. 9% sodium chloride injection once every 24 hours for up to 14 days Table 1: Recommended Dosage of Daptomycin for Injection in Pediatric Patients (1 to 17 Years of Age) with cSSSI, Based on Age Age Range Dosage Regimen* Duration of therapy 12 to 17 years 5 mg/kg once every 24 hours infused over 30 minutes Up to 14 days 7 to 11 years 7 mg/kg once every 24 hours infused over 30 minutes 2 to 6 years 9 mg/kg once every 24 hours infused over 60 minutes 1 to less than 2 years 10 mg/kg once every 24 hours infused over 60 minutes

Treatment of Necrotizing Fascitis in Pediatrics with Penicillin Allergy

• Daptomycin can be used as an alternative treatment for necrotizing fascitis in pediatric patients with a penicillin allergy.
• The dosage regimen for pediatric patients with complicated skin and skin structure infections (cSSSI), including necrotizing fascitis, is based on age and weight.
• For pediatric patients between 1 to 17 years of age, the recommended dosage regimens are:
  • 12 to 17 years: 5 mg/kg once every 24 hours infused over 30 minutes
  • 7 to 11 years: 7 mg/kg once every 24 hours infused over 30 minutes
  • 2 to 6 years: 9 mg/kg once every 24 hours infused over 60 minutes
  • 1 to less than 2 years: 10 mg/kg once every 24 hours infused over 60 minutes
• Treatment should be administered for up to 14 days, depending on the severity of the infection and clinical response.
• It is essential to monitor patients for potential adverse reactions, including elevated CPK levels, and adjust the dosage regimen as needed 2.

From the Research

Treatment Options for Necrotizing Fasciitis in Pediatrics with Penicillin Allergy

• The treatment of necrotizing fasciitis in pediatrics involves early aggressive surgical treatment, as stated in the study 3.
• For patients with a penicillin allergy, alternative antibiotics such as clindamycin can be considered, as it is effective in the treatment of deep infections caused by Group A Streptococcus 4.
• In cases where methicillin-resistant Staphylococcus aureus (MRSA) is suspected, MRSA-directed antibiotic therapy such as linezolid can be used 5, 6.
• The use of empiric linezolid has been shown to reduce the duration of MRSA-active therapy and lower the incidence of new-onset acute kidney injury 6.

Antibiotic Therapy

• Clindamycin can be added to the beta-lactam antibiotic regimen when necrotizing fasciitis is present, as it is effective in the treatment of deep infections caused by Group A Streptococcus 4.
• Linezolid provides both MRSA coverage and toxin inhibition, making it a suitable alternative for empiric treatment of necrotizing soft tissue infections 6.
• Vancomycin and clindamycin can also be used for empiric treatment, but may be associated with a higher incidence of new-onset acute kidney injury 6.

Surgical Treatment

• Early aggressive surgical treatment is the treatment of choice for necrotizing fasciitis, as it is crucial for reducing morbidity and mortality 3, 7.
• Surgical debridement is the criterion standard for diagnosis and the mainstay of therapy for necrotizing fasciitis 7.