From the Guidelines
Treatment for necrotizing fasciitis in pediatric patients typically involves prompt surgical debridement and broad-spectrum antibiotics, as supported by studies 1. This approach is necessary due to the rapid progression of the disease, which can lead to significant morbidity and mortality if left untreated. Surgical debridement helps to remove the infected tissue, reducing the bacterial load and preventing further spread of the infection. The decision to undertake aggressive surgery should be based on several considerations, including failure to respond to antibiotics, profound toxicity, fever, hypotension, or advancement of the skin and soft-tissue infection during antibiotic therapy, as well as skin necrosis with easy dissection along the fascia by a blunt instrument 1.
Most patients with necrotizing fasciitis should return to the operating room 24–36 hours after the first debridement and daily thereafter until the surgical team finds no further need for debridement 1. Broad-spectrum antibiotics should be administered to cover a wide range of potential pathogens, including Streptococcus and Staphylococcus species, until culture results can guide more targeted therapy 1. For example, vancomycin, linezolid, or daptomycin combined with one of the following options: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole, may be used for empiric treatment of polymicrobial necrotizing fasciitis 1.
Necrotizing fasciitis and/or streptococcal toxic shock syndrome caused by group A streptococci should be treated with both clindamycin and penicillin, as clindamycin suppresses streptococcal toxin and cytokine production 1. The efficacy of intravenous immunoglobulin (IVIG) in treating streptococcal toxic shock syndrome has not been established 1. Supportive care, such as fluid resuscitation and pain management, is also crucial in managing the condition and promoting recovery 1. A delayed first surgical intervention (more than 12 hours) is associated with higher mortality, and antibiotics should be given as any septic shock patient in the first 6 hours, with a duration of antibiotic treatment between 7–14 days 1.
In addition to surgical debridement and antibiotic therapy, source control measures, including topical actions, incision and drainage, debridement, and amputation, may be necessary to manage necrotizing soft tissue infections 1. The choice of antibiotic therapy should be guided by the results of culture and sensitivity testing, and should be modified as necessary to ensure adequate coverage of the causative pathogens 1. Overall, prompt and aggressive treatment is essential to improve outcomes in pediatric patients with necrotizing fasciitis.
From the Research
Treatment Overview
The treatment for necrotizing fasciitis in pediatric patients typically involves a combination of surgical debridement, antibiotic therapy, and wound management.
- Surgical debridement is a crucial step in the treatment of necrotizing fasciitis, as it helps to remove the affected tissue and prevent the spread of the infection 2.
- Antibiotic therapy is also essential, with broad-spectrum antibiotics such as penicillin, an aminoglycoside, and metronidazole often used as initial treatment 2.
- Wound management may involve the use of Negative Pressure Wound Therapy (NPWT) with Vacuum-Assisted Closure (VAC) and Oasis® extracellular matrix (ECM) graft placement to promote wound closure and epithelialization 3.
Surgical Debridement
Surgical debridement should be performed promptly, ideally within 3 hours of admission, to improve survival rates 2.
- The extent of debridement may vary, with some cases requiring fascial excision of up to 35% of total body surface area 2.
- Multiple operations may be required, with a mean of 3.8 operations reported in one study 2.
Wound Management
Wound management is a critical aspect of treatment, with the goal of promoting wound closure and epithelialization.
- NPWT with VAC and ECM graft placement have been shown to be effective in managing residual skin and soft tissue deficits after surgical debridement 3.
- A patient-specific approach is necessary, with constant reevaluation of the management plan to ensure optimal outcomes 3.
Antibiotic Therapy
Antibiotic therapy should be initiated promptly, with broad-spectrum antibiotics used as initial treatment.