From the Guidelines
Treatment options for pediatric patients with necrotizing fasciitis who have a penicillin allergy are limited, but vancomycin, linezolid, or daptomycin combined with other agents can be effective.
Key Considerations
- Surgical intervention is the primary therapeutic modality in cases of necrotizing fasciitis, and antimicrobial therapy should be administered until further debridement is no longer necessary, the patient has improved clinically, 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, such as vancomycin, linezolid, or daptomycin combined with piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 1.
- For patients with a penicillin allergy, vancomycin, linezolid, or daptomycin can be used as alternative agents, and the choice of antibiotic should be guided by the suspected or confirmed pathogen and local resistance patterns 1.
- The use of procalcitonin monitoring may be useful to guide antimicrobial discontinuation, and the expert panel recommends that antimicrobial therapy should be administered until further debridement is no longer necessary, the patient has improved clinically, and fever has been resolved for 48–72 h 1.
Treatment Options
- Vancomycin plus piperacillin-tazobactam or a carbapenem
- Linezolid plus piperacillin-tazobactam or a carbapenem
- Daptomycin plus piperacillin-tazobactam or a carbapenem
- Clindamycin plus piperacillin-tazobactam or a carbapenem (although clindamycin is bacteriostatic and may not be as effective as other options)
Dosage
- Vancomycin: 15 mg/kg/dose every 6 hours IV
- Linezolid: 10-13 mg/kg/dose every 8 hours IV
- Daptomycin: not recommended for pediatric patients due to lack of data
- Clindamycin: 10-13 mg/kg/dose every 8 hours IV
- Piperacillin-tazobactam: 60-75 mg/kg/dose of the piperacillin component every 6 hours IV
- Carbapenem (e.g. meropenem): 20 mg/kg/dose every 8 hours IV
From the Research
Treatment Options for Pediatric Patients with Necrotizing Fasciitis and Penicillin Allergy
- The primary treatment for necrotizing fasciitis involves early aggressive surgical debridement and broad-spectrum antibiotics 2, 3.
- For patients with a penicillin allergy, alternative antibiotics such as clindamycin and amoxy-clavulanate can be used, as most isolates are sensitive to these medications 4.
- The choice of antibiotic therapy should be guided by the results of pus and blood cultures, as well as the patient's allergy history.
- Repeated debridements may be necessary to ensure that disease progression has been halted 3.
- In addition to surgical and antibiotic treatment, supportive care and close monitoring of the patient's condition are crucial to improve outcomes.
Antibiotic Options for Patients with Penicillin Allergy
- Clindamycin is a suitable alternative for patients with penicillin allergy, as it is effective against many of the bacteria that cause necrotizing fasciitis, including methicillin-resistant Staphylococcus aureus (MRSA) 4.
- Amoxy-clavulanate is another option for patients with penicillin allergy, although its use may be limited in patients with severe allergies 4.
- Other antibiotics, such as vancomycin and linezolid, may also be considered in patients with penicillin allergy, although their use should be guided by the results of culture and sensitivity testing 5.
Importance of Early Recognition and Treatment
- Early recognition and treatment of necrotizing fasciitis are critical to improve outcomes and reduce morbidity and mortality 2, 6.
- A high level of suspicion is needed to properly identify and treat necrotizing fasciitis in a timely manner, especially in pediatric patients with nonspecific initial symptoms 3, 6.
- Prompt surgical consultation and intervention are essential to manage potential necrotizing fasciitis, especially when the initial symptoms may be misleading 6.