What is the treatment for necrotizing fasciitis in pediatric patients with a penicillin (antibiotic) 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, specifically clindamycin plus either vancomycin or linezolid, as recommended by the most recent guidelines 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. Some key points to consider in the treatment of necrotizing fasciitis in pediatric patients with penicillin allergies include:

• Prompt 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.
• The alternative antibiotic choices target the common causative organisms including group A Streptococcus, Staphylococcus aureus (including MRSA), and gram-negative bacteria while avoiding beta-lactams.
• Clindamycin specifically inhibits toxin production, which is important in managing the systemic effects of necrotizing fasciitis.
• Close monitoring of the patient's clinical status, laboratory values, and wound healing is necessary to adjust therapy as needed. It's worth noting that the guidelines from the Infectious Diseases Society of America 1 and the World Health Organization 1 provide evidence-based recommendations for the selection of antimicrobial therapy for patients with necrotizing fasciitis. The most recent study from 2024 1 provides the most up-to-date recommendations for the treatment of necrotizing fasciitis in pediatric patients with penicillin allergies.

From the FDA Drug Label

Clindamycin is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. 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

For pediatric patients with a penicillin allergy and necrotizing fasciitis, the treatment options are:

• Clindamycin 2 for serious skin and soft tissue infections, which may include necrotizing fasciitis
• Vancomycin 3 for serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci, which may be a cause of necrotizing fasciitis in some cases

Key considerations:

• The choice of antibiotic should be based on the suspected or confirmed causative organism and its susceptibility to the antibiotic.
• Bacteriologic studies should be performed to determine the causative organisms and their susceptibility to the chosen antibiotic.
• The treatment should be adjusted according to the results of the bacteriologic studies and the clinical response of the patient.

From the Research

Treatment for Necrotizing Fasciitis in Pediatric Patients with Penicillin Allergy

• The treatment of necrotizing fasciitis in pediatric patients with a penicillin allergy requires a multifaceted approach, including surgical source control, life support, clinical monitoring, and antimicrobial therapy 4.
• Broad-spectrum coverage is advisable, and acceptable monotherapy regimens include piperacillin-tazobactam or a carbapenem 4.
• In case of penicillin allergy, alternative antibiotics such as clindamycin, a first-generation cephalosporin, or a macrolide (if the susceptibility of the strain was checked) can be used 5.
• Clindamycin is particularly useful in treating necrotizing fasciitis caused by Group A Streptococcus, as it reduces extracellular DNase Sda1 and streptolysin O (SLO) activity in vivo 6.
• The use of new cephalosporins active against methicillin-resistant Staphylococcus aureus (MRSA), such as ceftaroline and ceftobiprole, may also be considered as an alternative to non-betalactam anti-MRSA agents for necrotizing fasciitis management 4.
• Conservative management of necrotizing fasciitis, including aggressive fluid resuscitation, analgesia, broad-spectrum antibiotics, and dressing with povidone iodine ointment, can be effective in pediatric patients 7.

Antibiotic Options

• Clindamycin: effective against Group A Streptococcus and can reduce virulence factors 6.
• First-generation cephalosporin: alternative to penicillin in case of allergy 5.
• Macrolide: alternative to penicillin in case of allergy, if the susceptibility of the strain was checked 5.
• Piperacillin-tazobactam or carbapenem: broad-spectrum coverage for polymicrobial infections 4.
• New cephalosporins (ceftaroline, ceftobiprole): alternative to non-betalactam anti-MRSA agents 4.