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

From the Guidelines

For pediatric patients with necrotizing fasciitis and a penicillin allergy, treatment with clindamycin is recommended at a dose of 40 mg/kg/day divided into 3-4 doses, with a maximum dose of 2.7 grams per day 1. Alternatively, vancomycin may be used at a dose of 40-60 mg/kg/day divided into 4 doses, with trough levels maintained between 15-20 mcg/mL 1.

Key Considerations

• Duration of treatment is typically 7-14 days, although this may be extended based on clinical response and surgical debridement requirements 1.
• Surgical consultation is essential for prompt debridement and management of the affected tissue 1.
• Empiric antibiotic treatment should be broad, including agents effective against both aerobes and anaerobes, such as vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem, or ceftriaxone and metronidazole 1.
• Once the microbial etiology has been determined, the antibiotic coverage should be appropriately modified 1.

Additional Treatment Options

• Linezolid may be considered as an alternative to vancomycin, with a dose of 30-40 mg/kg/day divided into 3 doses, with a maximum dose of 600 mg per day 1.
• Daptomycin may also be considered, with a dose of 4-6 mg/kg/day divided into 1 dose, with a maximum dose of 500 mg per day 1.
• Ceftriaxone and metronidazole may be used in combination with vancomycin or linezolid as an alternative to piperacillin-tazobactam or a carbapenem 1. It is essential to note that the treatment of necrotizing fasciitis should be individualized based on the patient's specific needs and the results of microbiological tests 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

The treatment options for necrotizing fasciitis in pediatric patients with a penicillin allergy are:

• Clindamycin: may be used to treat serious skin and soft tissue infections, including those caused by susceptible strains of streptococci, pneumococci, and staphylococci 2
• Vancomycin: may be used to treat serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci, including skin and skin structure infections 3 Pediatric dosing:

• Clindamycin: 8 to 16 mg/kg/day (4 to 8 mg/lb/day) divided into three or four equal doses for serious infections, and 16 to 20 mg/kg/day (8 to 10 mg/lb/day) divided into three or four equal doses for more severe infections 2 Note: The dosage and administration of vancomycin in pediatric patients is not specified in the provided drug labels.

From the Research

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

• The primary treatment for necrotizing fasciitis involves prompt surgical debridement of affected tissue and broad-spectrum antibiotics 4, 5, 6, 7, 8.
• For pediatric patients with a penicillin allergy, alternative antibiotics such as clindamycin and/or metronidazole can be used as initial calculated antibiotic treatment 5.
• The choice of antibiotic therapy should be guided by the results of microbiological cultures and sensitivity testing 5.
• Surgical debridement is the mainstay of treatment, and multiple sessions may be necessary to ensure complete removal of necrotic tissue 4, 5, 7, 8.
• In addition to surgical and antibiotic treatment, supportive care such as wound management and pain control are also important aspects of treatment 4, 7, 8.

Considerations for Pediatric Patients

• Pediatric patients with necrotizing fasciitis may present with nonspecific symptoms such as fever, erythema, and localized swelling, making early diagnosis challenging 7, 8.
• A high index of suspicion and prompt surgical consultation are crucial for early diagnosis and treatment of necrotizing fasciitis in pediatric patients 4, 7, 8.
• The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score can be used to support the diagnosis of necrotizing fasciitis, but a low score does not rule out the condition 4.

Antibiotic Therapy Options

• Clindamycin and/or metronidazole can be used as alternative antibiotics for patients with a penicillin allergy 5.
• Broad-spectrum antibiotics should be started empirically and adjusted based on microbiological culture results 4, 5, 6.
• The choice of antibiotic therapy should be guided by local antimicrobial resistance patterns and the results of microbiological cultures and sensitivity testing 5.