From the Guidelines
The recommended treatment for necrotizing fasciitis in pediatric patients involves immediate surgical debridement combined with broad-spectrum antibiotics. Surgical intervention should be aggressive and prompt, removing all infected and necrotic tissue until healthy, bleeding tissue is reached, often requiring multiple debridements 1. Initial empiric antibiotic therapy should include coverage for Group A Streptococcus, Staphylococcus aureus (including MRSA), and gram-negative organisms. A typical regimen includes vancomycin (15 mg/kg IV every 6 hours) or clindamycin (10-13 mg/kg IV every 6-8 hours) plus piperacillin-tazobactam (100 mg/kg IV every 6-8 hours) or a carbapenem like meropenem (20 mg/kg IV every 8 hours) 1.
Key Considerations
- Clindamycin is particularly important as it inhibits toxin production in streptococcal and staphylococcal infections 1.
- Antibiotics should be adjusted based on culture results and continued for at least 2-3 weeks.
- Supportive care is crucial, including:
- Fluid resuscitation
- Pain management
- Nutritional support
- Possibly IVIG (1-2 g/kg) in cases of streptococcal toxic shock syndrome 1.
Additional Therapies
- Hyperbaric oxygen therapy may be considered as an adjunctive treatment in facilities where it's available.
- Early infectious disease and surgical consultation is essential, as mortality rates can be significant without prompt and appropriate intervention 1.
From the Research
Management of Necrotizing Fasciitis in Pediatrics
The management of necrotizing fasciitis in pediatric patients involves prompt recognition, aggressive therapy, and a multidisciplinary approach.
- Early diagnosis is crucial to reduce morbidity and mortality, but initial symptoms are often nonspecific 2.
- Surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process 3.
- Aggressive surgical treatment, including debridement and fascial excision, is essential for the management of necrotizing fasciitis in pediatric patients 4.
- The use of Negative Pressure Wound Therapy (NPWT) with Vacuum-Assisted Closure (VAC) and Oasis® extracellular matrix (ECM) graft placement can be effective in managing the residual wound after surgical debridement 5.
Treatment Approaches
- Immediate surgical debridement and coverage with broad-spectrum antibiotics, such as penicillin, an aminoglycoside, and metronidazole, are essential for the treatment of necrotizing fasciitis in pediatric patients 4.
- The management of the residual wound after surgical debridement requires a patient-specific approach and constant reevaluation of the management plan 5.
- Frozen section tissue biopsy can be a useful adjunct in establishing an early, accurate diagnosis of necrotizing fasciitis 6.
Key Considerations
- Pediatric necrotizing fasciitis has distinguishing features that differ from adult necrotizing fasciitis, including triggers, symptoms, and laboratory and microbiological findings 2.
- Monomicrobial necrotizing (type 2) fasciitis is more common than polymicrobial (type 1) fasciitis in pediatric patients 2.
- Knowledge of the distinguishing features of pediatric necrotizing fasciitis can increase early diagnosis and improve treatment 2.