What are the treatment options for pediatric patients with necrotizing fasciitis and a penicillin (Penicillin) allergy?

From the Guidelines

For pediatric patients with necrotizing fasciitis who have a penicillin allergy, the recommended treatment includes a combination of surgical debridement and antibiotic therapy, with clindamycin plus vancomycin as the preferred antibiotic regimen. The primary treatment should be immediate surgical debridement of all necrotic tissue, which is essential regardless of antibiotic choice, as emphasized by the Infectious Diseases Society of America guidelines 1.

Key Considerations

• Surgical debridement is the primary therapeutic modality in cases of necrotizing fasciitis and is indicated when this infection is confirmed or suspected.
• For antibiotic coverage in penicillin-allergic children, clindamycin (30-40 mg/kg/day divided every 6-8 hours, maximum 2.7 g/day) plus vancomycin (15 mg/kg/dose every 6 hours) is recommended, as it provides coverage against the common causative organisms including Group A Streptococcus, Staphylococcus aureus (including MRSA) 1.
• For broader coverage, add ciprofloxacin (20-30 mg/kg/day divided every 12 hours) or aztreonam (90-120 mg/kg/day divided every 6-8 hours) if Gram-negative organisms are suspected.
• Treatment duration typically ranges from 2-4 weeks depending on clinical response, with transition to oral antibiotics when the patient shows improvement.
• Close monitoring of renal function is necessary when using vancomycin, as recommended by the guidelines 1.

Rationale

The rationale for this regimen is to provide coverage against the common causative organisms while avoiding beta-lactam antibiotics, which is crucial in patients with a penicillin allergy. Hyperbaric oxygen therapy may be considered as an adjunctive treatment in facilities where it's available. The guidelines emphasize the importance of prompt surgical consultation and broad empiric antibiotic treatment, including vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem, or plus ceftriaxone and metronidazole 1.

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 necrotizing fasciitis and a penicillin allergy, treatment options may include:

• Clindamycin 2, as it is indicated for serious skin and soft tissue infections, including those caused by susceptible strains of streptococci and staphylococci.
• Vancomycin 3, as it is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci and is an option for penicillin-allergic patients.

From the Research

Treatment Options for Pediatric Patients with Necrotizing Fasciitis and Penicillin Allergy

• For pediatric patients with necrotizing fasciitis and a penicillin allergy, treatment options are limited but can be guided by the severity of the infection and the causative pathogens 4.
• In cases of necrotizing fasciitis, clindamycin should be added to a beta-lactam due to its action on protein synthesis, which helps reduce toxin production 4.
• For patients with a penicillin allergy, alternative antibiotics such as first-generation cephalosporins, macrolides (if the susceptibility of the strain is checked), or pristinamycine (after 6 years of age) can be considered 4.
• Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging cause of necrotizing fasciitis, and empirical treatment should include antibiotics active against this pathogen, such as clindamycin, trimethoprim-sulfamethoxazole, and rifampin 5, 6, 7.
• Early aggressive surgical treatment is also crucial in the management of necrotizing fasciitis, regardless of the causative pathogen 8.

Antibiotic Selection

• The choice of antibiotic should be based on the suspected or confirmed causative pathogen, as well as the patient's allergy history 4.
• Clindamycin is a suitable option for the treatment of necrotizing fasciitis caused by CA-MRSA, as it is effective against this pathogen and has a good safety profile 5, 6, 7.
• Other antibiotics, such as trimethoprim-sulfamethoxazole and rifampin, may also be effective against CA-MRSA, but their use should be guided by susceptibility testing and clinical experience 5.

Surgical Intervention

• Early surgical debridement is essential in the treatment of necrotizing fasciitis, as it helps to remove infected tissue and reduce the risk of further complications 8, 7.
• Surgical intervention should be performed promptly, ideally within hours of diagnosis, to minimize the risk of mortality and morbidity 8.