From the Guidelines
In 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, linezolid may be used at a dose of 30 mg/kg/day divided into 2-3 doses, with a maximum dose of 600 mg per day 1.
Key Considerations
- Surgical intervention is the primary therapeutic modality in cases of necrotizing fasciitis, and should be performed promptly in patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene 1.
- Empiric antibiotic treatment should be broad, covering both aerobes and anaerobes, and should include agents such as vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem, or ceftriaxone and metronidazole 1.
- Treatment duration is typically 7-14 days, depending on the severity of the infection and clinical response, and should be guided by surgical debridement and clinical assessment 1.
Additional Options
- Vancomycin may be used as an alternative to clindamycin or linezolid, particularly in cases where MRSA is suspected or confirmed 1.
- Daptomycin may also be considered as an alternative, although its use is limited by the potential for myopathy 1.
Important Notes
- Penicillin allergy should be carefully evaluated, and alternative antibiotics should be chosen based on the severity of the allergy and the suspected or confirmed pathogens involved 1.
- Surgical debridement is a critical component of treatment, and should be performed promptly and repeatedly as needed to ensure adequate removal of necrotic tissue and control of the infection 1.
From the FDA Drug Label
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.
Anaerobes: Serious respiratory tract infections such as empyema, anaerobic pneumonitis, and lung abscess; serious skin and soft tissue infections; septicemia; intra- abdominal infections such as peritonitis and intra-abdominal abscess
Streptococci: Serious respiratory tract infections; serious skin and soft tissue infections.
Staphylococci: Serious respiratory tract infections; serious skin and soft tissue infections.
For pediatric patients with necrotizing fasciitis who have a penicillin allergy, clindamycin may be considered as a treatment option, as it is effective against susceptible strains of streptococci, staphylococci, and anaerobes, which can cause necrotizing fasciitis 2.
- Key considerations:
- Bacteriologic studies should be performed to determine the causative organisms and their susceptibility to clindamycin.
- Clindamycin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.
- Local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
- Alternative options:
- Linezolid may also be considered for the treatment of infections due to Gram-positive pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) 3.
- However, its effectiveness in treating necrotizing fasciitis specifically is not directly addressed in the provided drug label.
From the Research
Treatment Options for Pediatric Patients with Necrotizing Fasciitis and Penicillin Allergy
- The treatment of necrotizing fasciitis in pediatric patients with a penicillin allergy requires careful consideration of alternative antibiotics 4, 5, 6.
- Aminopenicillin ± sulbactam in combination with clindamycin and/or metronidazole is recommended as initial calculated antibiotic treatment for necrotizing fasciitis 4.
- However, in patients with a penicillin allergy, alternative antibiotics such as clindamycin, vancomycin, or linezolid may be used 5, 6.
- Early aggressive surgical treatment is also crucial in the management of necrotizing fasciitis, regardless of the patient's allergy status 5, 6, 7, 8.
- The choice of antibiotic therapy should be guided by the results of microbiological cultures and susceptibility testing, as well as the patient's clinical response to treatment 4, 5, 6.
Antibiotic Options for Pediatric Patients with Penicillin Allergy
- Clindamycin is a suitable alternative to penicillin for the treatment of necrotizing fasciitis in pediatric patients with a penicillin allergy 4, 5.
- Vancomycin or linezolid may also be used as alternative antibiotics in patients with a penicillin allergy, although their use should be guided by the results of microbiological cultures and susceptibility testing 5, 6.
- The use of broad-spectrum antibiotics, such as carbapenems or fluoroquinolones, may also be considered in pediatric patients with necrotizing fasciitis and a penicillin allergy, although their use should be guided by the results of microbiological cultures and susceptibility testing 6, 7.
Surgical Management
- Early aggressive surgical treatment is crucial in the management of necrotizing fasciitis, regardless of the patient's allergy status 5, 6, 7, 8.
- Surgical debridement and wound care are essential components of the treatment of necrotizing fasciitis, and should be performed in conjunction with antibiotic therapy 4, 5, 6, 7, 8.