What is the treatment for necrotizing fasciitis (NF) with impaired renal function in pediatric patients?

From the Guidelines

The treatment for necrotizing fasciitis (NF) in pediatric patients with impaired renal function requires immediate aggressive intervention with three key components: surgical debridement, antibiotic therapy, and supportive care. Urgent surgical debridement is essential and should be performed as soon as possible to remove all infected and necrotic tissue, often requiring multiple operations, as emphasized by the guidelines for the diagnosis and management of skin and soft-tissue infections 1. Antibiotic therapy should begin immediately with broad-spectrum coverage, taking into consideration the patient's renal impairment. Given the potential for vancomycin resistance and its limitations in renal impairment, alternative antibiotics such as daptomycin or linezolid for anti-MRSA coverage, and meropenem or other appropriate agents for anti-Gram-negative coverage, should be considered based on local resistance patterns and the patient's specific needs, as recommended by the 2018 WSES/SIS-E consensus conference 1. For example, meropenem (20 mg/kg IV every 8 hours, adjusted for renal impairment) and clindamycin (10 mg/kg IV every 6-8 hours) could be part of the initial empiric regimen, with adjustments based on culture results and clinical response. Antibiotic doses must be carefully adjusted based on the degree of renal impairment, with regular monitoring of drug levels when applicable. Supportive care includes:

• Fluid resuscitation (carefully managed to avoid fluid overload in renal impairment)
• Pain management
• Nutritional support
• Possibly renal replacement therapy if needed Hyperbaric oxygen therapy may be considered as an adjunctive treatment in certain facilities. The multidisciplinary approach should involve pediatric infectious disease specialists, nephrologists, surgeons, and critical care physicians to manage both the infection and renal complications. Early recognition and aggressive treatment are crucial as NF progresses rapidly and can be life-threatening, with mortality rates significantly higher when treatment is delayed. De-escalation of antibiotic therapy should be based on clinical improvement, cultured pathogens, and results of rapid diagnostic tests where available 1.

From the FDA Drug Label

DOSAGE TABLE FOR VANCOMYCIN IN PATIENTS WITH IMPAIRED RENAL FUNCTION (Adapted from Moellering et al. 1) Creatinine ClearancemL/minVancomycin Dosemg/24 h 1001,545 901,390 801,235 701,080 60925 50770 40620 30465 20310 10155 The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.

The treatment for necrotizing fasciitis (NF) with impaired renal function in pediatric patients involves administering vancomycin with dosage adjustments based on renal function.

• The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.
• The maintenance dose can be calculated using the provided dosage table, which takes into account the patient's creatinine clearance.
• In patients with marked renal impairment, it may be more convenient to give maintenance doses of 250 to 1,000 mg once every several days rather than administering the drug on a daily basis.
• Close monitoring of serum concentrations of vancomycin is recommended in these patients, especially in seriously ill patients with changing renal function 2.

From the Research

Treatment Overview

The treatment for necrotizing fasciitis (NF) in pediatric patients with impaired renal function involves a combination of surgical debridement, antibiotic therapy, and supportive care.

• Surgical debridement is essential to remove the necrotic tissue and prevent further spread of the infection 3, 4, 5, 6.
• Antibiotic therapy should be broad-spectrum and adjusted based on culture data, as gram stain results may not be reliable 5.
• Supportive care, including fluid resuscitation, ventilation, and vasoactive drugs, is crucial to manage the systemic effects of the infection 4.

Renal Considerations

While there is limited information on the specific treatment of NF in pediatric patients with renal failure, the general principles of treatment remain the same.

• It is essential to consider the renal function when selecting antibiotics and adjusting dosages to avoid nephrotoxicity 7.
• Close monitoring of renal function and electrolyte balance is necessary to prevent further complications.

Surgical Approach

The surgical approach for NF in pediatric patients with renal failure may involve conservative surgery, which has been shown to have better outcomes in terms of hospital stay, complications, and cost of treatment 6.

• Aggressive surgical debridement may be necessary in some cases, and the decision should be made on a case-by-case basis 3, 5.

Antibiotic Selection

The selection of antibiotics for NF in pediatric patients with renal failure should be based on culture data and susceptibility patterns.

• Broad-spectrum antibiotics, such as penicillin, an aminoglycoside, and metronidazole, may be used initially, with adjustments made based on culture results 5.
• The potential involvement of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) should be considered, especially in cases where the infection is suspected to be community-acquired 7.