Necrotizing Fasciitis

Patient Population: Pediatric
Condition Major Pathogens  First Choice Therapy Alternative Therapy Comments

Necrotizing fasciitis or other necrotizing soft tissue infection 

Diagnosis is supported by signs of systemic toxicity with toxic-shock-like symptoms, severe pain or pain out of proportion to physical findings, altered mental status, rapidly advancing infection, crepitus, hemorrhage, sloughing.

Intraoperative findings include  presence of grayish fascia, lack of resistance of normally adherent muscular fascia to blunt dissection, lack of bleeding of the fascia during dissection and presence of foul-smelling "dishwater" pus

Group A streptococcus 

Can be polymicrobial including anaerobes, Clostridium spp, with skin flora 

(follow link for dosing & monitoring) 


100 mg piperacillin/kg/dose (max 4000 mg piperacillin/dose) IV q6h  


10 mg/kg/dose (max 900 mg/dose) IV q8h  

Penicillin or cephalosporin allergy with higher risk for allergic reaction

Consult ID/ASP for guidance on alternative therapy 


Urgent Surgery consult recommended 

ID consult recommended 

Therapy should be modified as indicated based on isolated pathogen(s), including narrowing the initial regimen to target identified pathogen(s) and stopping clindamycin after initial clinical improvement.  

Duration: 7-14 days, guided by response to therapy. Continue until further debridement is not necessary, patient has clinically improved, and is afebrile for 48-72 hours 


American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.  

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.