From the Guidelines
For pediatric patients with necrotizing fasciitis who have a penicillin allergy, treatment should include prompt surgical debridement combined with alternative antibiotic therapy, such as clindamycin plus vancomycin and either ciprofloxacin or aztreonam, as recommended by the Infectious Diseases Society of America 1.
Key Considerations
- Surgical intervention must be aggressive and may require multiple debridements to ensure removal of all necrotic tissue.
- The recommended antibiotic regimen provides broad-spectrum coverage against the polymicrobial infections typically seen in necrotizing fasciitis, including group A streptococci, staphylococci, and gram-negative organisms.
- Intravenous immunoglobulin (IVIG) can be considered as adjunctive therapy, particularly for streptococcal toxic shock syndrome, although its efficacy has not been established 1.
Antibiotic Regimen
- Clindamycin (40 mg/kg/day divided every 8 hours, maximum 2.7 g/day) plus vancomycin (15 mg/kg/dose every 6 hours) and either ciprofloxacin (for children >1 year: 20-30 mg/kg/day divided every 12 hours, maximum 1.5 g/day) or aztreonam (30 mg/kg/dose every 6-8 hours, maximum 8 g/day).
Additional Therapies
- Hyperbaric oxygen therapy may also be beneficial if available.
- Close monitoring in a pediatric intensive care unit is essential, with attention to fluid resuscitation, pain management, and nutritional support.
Duration of Therapy
- Antibiotic therapy should continue for at least 2-3 weeks, with transition to oral antibiotics only after clinical improvement, resolution of fever, and normalization of inflammatory markers. The most recent and highest quality study 1 supports the use of this antibiotic regimen, and it is consistent with the recommendations of the Infectious Diseases Society of America 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment of Necrotizing Fasciitis in Pediatrics with Penicillin Allergy
- The treatment of necrotizing fasciitis (NF) in pediatric patients with a penicillin allergy requires a comprehensive approach, including surgical debridement, antibiotic therapy, and wound management 2, 3, 4.
- For patients with a penicillin allergy, alternative antibiotics such as clindamycin may be considered, as it has been shown to be effective in treating deep infections caused by Group A Streptococcus 5.
- The use of intravenous immunoglobulin (IVIG) as an adjunctive therapy may also be beneficial in the management of NF, particularly in cases caused by Group A Streptococcus 5, 4.
- Surgical debridement is a crucial component of NF treatment, and repeated debridements may be necessary to remove necrotic tissue 2, 3, 4.
- Wound management techniques such as Negative Pressure Wound Therapy (NPWT) and Oasis® extracellular matrix (ECM) graft placement may be used to promote wound closure and epithelialization 2.
Diagnostic Considerations
- Early diagnosis of NF is critical to reduce morbidity and mortality, and clinicians should be aware of the distinguishing features of pediatric NF, including fever, erythema, localized swelling, and tenderness or pain 3.
- Laboratory markers and imaging studies may aid in diagnosis, but intraoperative tissue culture remains the gold standard for diagnosis 4.