From the Guidelines
Treatment for Necrotizing Fasciitis in Pediatric Patients
The treatment for Necrotizing Fasciitis in pediatric patients typically involves prompt surgical debridement, antibiotics, and supportive care 1. This approach is necessary because Necrotizing Fasciitis is a rapidly progressing infection that can cause significant tissue damage and mortality if left untreated.
Surgical Debridement
Surgical debridement is crucial to remove the infected tissue and prevent further spread of the infection. 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.
Antibiotics
Antimicrobial therapy must be directed at the pathogens and used in appropriate doses until repeated operative procedures are no longer needed, the patient has demonstrated obvious clinical improvement, and fever has been absent for 48–72 hours 1. Empiric treatment of polymicrobial necrotizing fasciitis should include agents effective against both aerobes, including MRSA, and anaerobes. Recommended antibiotic regimens include:
- Vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem
- Vancomycin or linezolid plus ceftriaxone and metronidazole 1
- Clindamycin plus penicillin for documented group A streptococcal necrotizing fasciitis 1
Supportive Care
Supportive care, including fluid resuscitation, pain management, and monitoring for organ dysfunction, is also essential to manage the systemic effects of the infection and promote recovery 1.
Specific Recommendations
The Infectious Diseases Society of America guidelines recommend the following for necrotizing fasciitis:
- Prompt surgical consultation for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene (strong, low) 1
- Empiric antibiotic treatment should be broad, as the etiology can be polymicrobial or monomicrobial (strong, low) 1
- Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis (strong, low) 1
First- and Second-Choice Antibiotics
The WHO Model List of Essential Medicines recommends the following for necrotizing fasciitis:
- First choice: clindamycin + piperacillin-tazobactam (with or without vancomycin), ceftriaxone + metronidazole (with or without vancomycin) 1
- Second choice: antibiotics proposed by the Working Group but not selected by the Committee, such as fluoroquinolones and meropenem 1
From the Research
Treatment Overview
The treatment for Necrotizing Fasciitis in pediatric patients typically involves a combination of medical and surgical interventions.
- Antibiotic treatment is administered to combat the underlying infection 2, 3, 4, 5.
- Surgical debridement of the affected tissues is often necessary to remove dead tissue and prevent further spread of the infection 2, 3, 4.
- Additional treatments such as hyperbaric oxygen and immunoglobulin therapy may also be used in some cases 3.
Wound Management
After surgical debridement, wound management is critical to promote healing and prevent further complications.
- Negative Pressure Wound Therapy (NPWT) with Vacuum-Assisted Closure (VAC) can be effective in managing the residual wound 2.
- Application of Oasis® extracellular matrix (ECM) graft placement can also be used to promote wound closure and epithelialization 2.
- Conservative management with aggressive fluid resuscitation, analgesia, broad-spectrum antibiotics, and dressing with povidone iodine ointment can also be effective in some cases 4.
Timing and Approach
The timing and approach to treatment can vary depending on the individual case, and delays in diagnosis and management can occur 5.
- Prompt antibiotic administration, infectious disease consults, surgical consults, and debridement surgeries are critical to improving outcomes 5.
- A standardized approach to the pediatric patient with suspected Necrotizing Fasciitis is necessary to minimize delays in management and optimize treatment outcomes 5.