What are the treatment options for necrotizing fasciitis (nec fac) in pediatric patients with a penicillin allergy?

From the Guidelines

For pediatric patients with necrotizing fasciitis (NEC FAC) who have penicillin allergies, the recommended treatment includes clindamycin (30-40 mg/kg/day divided every 6-8 hours, maximum 2.7 g/day) combined with either ciprofloxacin (20-30 mg/kg/day divided every 12 hours, maximum 1.5 g/day) or a third-generation cephalosporin like ceftriaxone (50-75 mg/kg/day divided every 12-24 hours, maximum 4 g/day) if cross-reactivity is not a concern.

Key Considerations

• The treatment should target the polymicrobial nature of necrotizing fasciitis, including group A streptococci, staphylococci, and anaerobes, while avoiding beta-lactam antibiotics that could trigger allergic reactions 1.
• Immediate surgical debridement is essential regardless of antibiotic choice, with most patients requiring return to the operating room 24-36 hours after the first debridement and daily thereafter until no further need for debridement is found 1.
• Treatment duration typically ranges from 2-4 weeks depending on clinical response, with transition to oral antibiotics once the patient shows significant improvement 1.
• Hyperbaric oxygen therapy may be considered as adjunctive treatment, although its efficacy is not well established 1.
• Close monitoring of renal function, complete blood counts, and inflammatory markers is necessary throughout treatment 1.

Antibiotic Choices

• For severe penicillin allergies with anaphylaxis history, vancomycin (40-60 mg/kg/day divided every 6-8 hours, maximum 4 g/day) plus aztreonam (90-120 mg/kg/day divided every 6-8 hours, maximum 8 g/day) is appropriate 1.
• Clindamycin is useful for coverage of anaerobes and aerobic gram-positive cocci, including most S. aureus serogroups, while metronidazole has the greatest anaerobic spectrum against the enteric gram-negative anaerobes 1.
• The choice of antibiotics should be guided by the suspected or confirmed microbial etiology, with modification of antibiotic coverage once the microbial etiology has been determined 1.

From the Research

Treatment Options for Necrotizing Fasciitis in Pediatric Patients with a Penicillin Allergy

• Surgical debridement is a crucial treatment option for necrotizing fasciitis, as it involves the removal of infected tissue to prevent the spread of the infection 2, 3, 4, 5.
• Antibiotic therapy is also essential in the treatment of necrotizing fasciitis, but in cases of penicillin allergy, alternative antibiotics such as clindamycin can be used 3, 4, 5.
• Negative Pressure Wound Therapy (NPWT) with Vacuum-Assisted Closure (VAC) can be an effective option for managing the residual wound after surgical debridement 2, 4.
• Oasis® extracellular matrix (ECM) graft placement can also be used to promote wound healing and epithelialization 2.
• Hyperbaric oxygen therapy may be used as an adjunctive therapy in some cases, although its effectiveness is not universally agreed upon 3.
• The choice of treatment should be individualized based on the patient's specific needs and circumstances, and may involve a combination of these options 2, 4, 5.

Considerations for Pediatric Patients

• Pediatric patients with necrotizing fasciitis may require more aggressive treatment due to their smaller size and potentially weaker immune systems 3, 4.
• The use of ultrasonography as an imaging technique can be helpful in diagnosing necrotizing fasciitis in pediatric patients 4.
• Skin-sparing surgical techniques may be used to preserve as much skin tissue as possible, particularly in areas such as the neck 4.

Antibiotic Treatment in Penicillin Allergy

• In cases of penicillin allergy, alternative antibiotics such as clindamycin, ampicillin, or metronidazole may be used 3, 4, 5.
• The choice of antibiotic should be based on the suspected or confirmed causative organism, as well as the patient's allergy status 5.