What is the treatment for pediatric patients with necrotizing fasciitis (NF) and a penicillin allergy?

From the Guidelines

For pediatric patients with necrotizing fasciitis (NF) and a penicillin allergy, the treatment should consist of immediate surgical debridement combined with non-beta-lactam antibiotic therapy, such as vancomycin (15 mg/kg IV every 6 hours) plus clindamycin (10-13 mg/kg IV every 8 hours) as recommended by the Infectious Diseases Society of America 1.

When managing NF in pediatric patients with a penicillin allergy, it is crucial to consider the polymicrobial nature of the infection, which often includes a mix of gram-positive, gram-negative, and anaerobic organisms. The choice of antibiotics should reflect this complexity.

• Vancomycin is effective against gram-positive organisms, including methicillin-resistant Staphylococcus aureus (MRSA) 1.
• Clindamycin provides coverage against gram-positive cocci, including Streptococcus and Staphylococcus species, as well as anaerobes 1.
• The addition of other antibiotics may be necessary based on the suspected or confirmed causative pathogens and local resistance patterns.

Surgical intervention is a critical component of NF treatment, aiming to remove all necrotic tissue promptly.

• Aggressive and early surgical debridement within 24 hours of diagnosis is recommended, with repeat debridements as needed until all necrotic tissue is removed.
• Supportive care, including wound management, pain control, and monitoring for complications, is also essential.

The duration of antibiotic therapy should be tailored to the individual patient's response, typically continuing for at least 14 days or until there is clear clinical improvement and normalization of inflammatory markers.

• Adjunctive treatments, such as hyperbaric oxygen therapy and intravenous immunoglobulin (IVIG), may be considered in specific cases, like streptococcal toxic shock syndrome, although their use should be guided by clinical judgment and evidence-based recommendations 1.

In summary, the treatment of pediatric patients with NF and a penicillin allergy requires a multifaceted approach that includes prompt surgical intervention, appropriate antibiotic coverage with vancomycin and clindamycin, and supportive care, with adjunctive therapies considered as necessary.

From the FDA Drug Label

Vancomycin Injection is indicated in adults and pediatric patients for whom appropriate dosing with this formulation can be achieved [see Dosage and Administration (2) and Use in Specific Populations (8. 4)] for the treatment of skin and skin structure infections due to: • Susceptible isolates of MRSA and coagulase negative staphylococci. • Methicillin-susceptible staphylocci in penicillin-allergic patients, or those patients who cannot receive or who have failed to respond to other drugs, including penicillins or cephalosporins.

The treatment for pediatric patients with necrotizing fasciitis (NF) and a penicillin allergy may include Vancomycin Injection as it is indicated for the treatment of skin and skin structure infections due to susceptible isolates of MRSA and coagulase negative staphylococci, as well as methicillin-susceptible staphylococci in penicillin-allergic patients.

• Key considerations:
  • The patient's specific condition and medical history should be taken into account.
  • The dosage and administration of Vancomycin Injection should be according to the instructions in the drug label 2. However, it is essential to note that the provided drug label does not explicitly mention necrotizing fasciitis, and therefore, the treatment should be guided by a conservative clinical decision and in consultation with a qualified healthcare professional.

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 multifaceted approach, consisting of surgical source control with immediate surgical debridement, life support, clinical monitoring, and antimicrobial therapy 3, 4.
• Broad-spectrum coverage is advisable, and acceptable monotherapy regimens include piperacillin-tazobactam or a carbapenem, however, in patients with penicillin allergy, alternative antibiotics such as clindamycin, metronidazole, or linezolid may be used 4, 5.
• Surgical considerations in pediatric NF include aggressive surgical debridement, and in some cases, early amputations of the affected tissues and maximum intensive care treatment, in case of sepsis 3, 6, 7.
• Conservative surgery has been shown to have better outcomes in terms of hospital stay, complications, and cost of treatment 6.
• The initial antibiotic treatment should be based on the severity of the infection and the suspected causative organisms, and subsequent changes in antibiotics should be based on culture data 3, 7.

Antibiotic Options for Penicillin Allergy

• Clindamycin and metronidazole are commonly used in the treatment of NF, and can be used as an alternative to penicillin in patients with a penicillin allergy 3, 7.
• Linezolid has been shown to be effective in the treatment of NF and streptococcal toxic shock syndrome, and may be considered as an alternative to traditional antibiotics 5.
• Other antibiotic options, such as ceftolozane-tazobactam, ceftazidime-avibactam, and the new long-acting lypoglycopeptides, oritavancin and dalbavancin, may also be considered in the treatment of NF 4.