From the Guidelines
For pediatric patients with necrotizing fasciitis who have penicillin allergies, the recommended treatment is a combination of clindamycin plus either piperacillin-tazobactam or ceftriaxone and metronidazole, with or without vancomycin, as suggested by the most recent guidelines 1.
Key Considerations
- The treatment should be administered intravenously and continued for at least 2-3 weeks, depending on clinical response.
- Urgent surgical debridement is essential and should be performed as soon as possible, with repeat debridements as needed until all necrotic tissue is removed.
- Supportive care including fluid resuscitation, pain management, and possibly IVIG (intravenous immunoglobulin) may be beneficial, especially in cases of streptococcal toxic shock syndrome.
Antibiotic Choices
- Clindamycin is particularly important as it inhibits protein synthesis and toxin production even when bacteria aren't actively dividing.
- Vancomycin may be added if methicillin-resistant Staphylococcus aureus (MRSA) is suspected or confirmed.
- The choice of antibiotic should be guided by culture results and clinical response, with adjustments made as necessary.
Dosage
- Clindamycin: 30-40 mg/kg/day divided every 6-8 hours, maximum 2.7 g/day.
- Vancomycin: 15 mg/kg/dose every 6 hours.
- Piperacillin-tazobactam: 60-75 mg/kg/dose of the piperacillin component every 6 hours IV.
- Ceftriaxone: 50 mg/kg/dose every 6 hours IV.
- Metronidazole: 7.5 mg/kg/dose every 6 hours IV.
Monitoring
- Close monitoring of renal function is necessary when using vancomycin.
- Antibiotic therapy should be adjusted based on culture results and clinical response. The Infectious Diseases Society of America guidelines support the use of clindamycin plus piperacillin-tazobactam or ceftriaxone and metronidazole, with or without vancomycin, for the treatment of necrotizing fasciitis 1. Additionally, the WHO Model List of Essential Medicines recommends clindamycin plus piperacillin-tazobactam or ceftriaxone and metronidazole, with or without vancomycin, as first-line treatment for necrotizing fasciitis 1.
From the FDA Drug Label
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
The recommended treatment for pediatric patients with necrotizing fasciitis who are allergic to penicillin is not explicitly stated in the provided drug label.
- Key points:
- The label indicates vancomycin is used for penicillin-allergic patients.
- It does not provide specific guidance for pediatric patients with necrotizing fasciitis. 2
From the Research
Treatment of Pediatric Patients with Necrotizing Fasciitis
The treatment of pediatric patients with necrotizing fasciitis who are allergic to penicillin requires a multifaceted approach, consisting of surgical source control with immediate surgical debridement along with life support, clinical monitoring, and antimicrobial therapy 3.
Antimicrobial Therapy
- Acceptable monotherapy regimens include piperacillin-tazobactam or a carbapenem 3.
- However, for patients allergic to penicillin, alternative antibiotics such as clindamycin can be used 4.
- Other alternatives include ceftolozane-tazobactam, ceftazidime-avibactam in association with an antianaerobic agent (metronidazole or clindamycin) 3.
- New cephalosporins active against methicillin-resistant Staphylococcus aureus (MRSA), such as ceftaroline, and ceftobiprole, can also be considered as an alternative to nonbetalactam anti-MRSA agents for necrotizing fasciitis management 3.
Key Considerations in Pediatric Patients
- Pediatric necrotizing fasciitis has distinguishing features that differ from adult necrotizing fasciitis, including a higher incidence of monomicrobial infections and a lower case-fatality rate 5, 6.
- Early aggressive surgical treatment is the treatment of choice for pediatric patients with necrotizing fasciitis 5, 4.
- Clinical suspicion remains the key to diagnosing necrotizing fasciitis in pediatric patients, and a combination of swelling, pain, erythema, and a systemic inflammatory response syndrome might indicate necrotizing fasciitis 6.