Streptococcus pyogenes necrotising fasciitis

In adults and children with ​Streptococcus pyogenes ​necrotising fasciitis, as a 3-drug regimen in combination with surgical debridement, use​​Kadri, 2017​Linner, 2014​​National Blood Authority Australia (NBA), 2018​:

benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment. See advice on modification and duration of therapy benzylpenicillin benzylpenicillin benzylpenicillin

PLUS

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly1. Switch to oral clindamycin as tolerated. See advice on modification and duration of therapy; see below for dosage and duration of therapy clindamycin clindamycin clindamycin

PLUS

intravenous immunoglobulin (IVIg) (adult and child) 2 g/kg intravenously, as a single dose as soon as possible but not later than 72 hours after symptom onset. It is reasonable to give the dose in divided doses if it is not possible to give a single dose. intravenous immunoglobulin (IVIg) intravenous immunoglobulin (IVIg)

When oral clindamycin is tolerated, replace intravenous clindamycin with:

clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 6-hourly until intravenous therapy is stopped. clindamycin clindamycin clindamycin

For patients who have had a nonsevere (immediate or delayed) or a severe immediate2 hypersensitivity reaction to a penicillin, replace benzylpenicillin in the above regimen with:

cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. See advice on modification and duration of therapy. cefazolin cefazolin cefazolin

For patients who have had a severe delayed3 hypersensitivity reaction to a penicillin, seek expert advice.

Note: Consider prophylaxis for close contacts of patients with S. pyogenes necrotising fasciitis.

Consider prophylaxis for close contacts of patients with S. pyogenes necrotising fasciitis (see Prevention of invasive group A streptococcal infection for regimens).

The majority of observational studies strongly support the use of intravenous immunoglobulin (IVIg) to treat S. pyogenes necrotising fasciitisBruun, 2021Carapetis, 2014Linner, 2014; however, not all studies have demonstrated benefitKadri, 2017. It is the consensus view of the Antibiotic Expert Group that IVIg should be used when available.

Clindamycin is recommended for S. pyogenes necrotising fasciitis because of a theoretical reduction in bacterial toxin production; however, clinical evidence is limited.

1 There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return
2 Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return
3 Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return