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Necrotizing Fasciitis Empiric Therapy 

Necrotizing Fasciitis Empiric Therapy 

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General recommendations and empiric therapeutic regimens for necrotizing fasciitis are outlined below, including treatment based on Gram stain results and treatment for patients allergic to penicillin. [1, 2] Although necrotizing fasciitis is most often associated with bacterial infections, zygomycosis is an uncommon cause. Of 18 such patients with zygomycotic necrotizing fasciitis recently described, 15 were immunocompetent. [3] One must take fungal and bacterial cultures early, even in immunocompetent patients so antifungal therapy can be instituted. [4] However, instituting empiric therapy for fungi is not recommended. In the case of a cobra and other snake bite, identification of the snake and use of a specific antivenin may be pivotal. [5]

One should recall that severe pain is an important clinical symptom separating necrotizing infections from more superficial ones. [6] Tachycardia and elevated levels of creatine kinase, C-reactive protein, and creatinine may also suggest necrotizing fasciitis.

Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus (MRSA), an emerging phenomenon, must be considered, especially in endemic areas and high-risk situations such as jails and dormitories. Accordingly, specific empiric antibiotic therapy against MRSA is necessary. [7, 8]  

Hyperbaric oxygen therapy may also be used, especially if the infection is due to anaerobic organisms, although evidence to support or refute its value is lacking. [9] One can consider combining appropriate intravenous antibiotic therapy with conservative surgery and hyperbaric oxygen and negative-pressure wound therapy in an effort to preserve vital tissues and control the advancing infection. [10] Negative-pressure wound therapy with vacuum-assisted closure should be considered after wound debridement to enhance clinical benefit. [11]

Additional FDA-approved antibiotics for the treatment of acute bacterial skin and skin structure infections include oritavancin (Orbactiv), dalbavancin (Dalvance), and tedizolid (Sivextro). These agents are active against Staphylococcus aureus (including methicillin-susceptible and methicillin-resistant S aureus [MSSA, MRSA] isolates), Streptococcus pyogenes, Streptococcus agalactiae, and Streptococcus anginosus group (includes Streptococcus anginosus, Streptococcus intermedius, and Streptococcus constellatus), among others. For complete drug information, including dosing, see the following monographs:

Oritavancin

Dalbavancin

Tedizolid

Surgical intervention is the major therapeutic modality in cases of necrotizing fasciitis:

Most patients with necrotizing fasciitis should return to the operating room 24-36h after the first debridement and then daily thereafter until the surgical team finds no further need for debridement

Antimicrobial therapy should continue for 48-72h after fever resolves, clinical improvement is evident, and no further surgical debridement is necessary

A Gram stain and, if suggested a fungal stain, of the exudate demonstrates the presence of pathogens and can provide an early clue to the preferred treatment recommendations [1]

If history reflects exposure to sewage-contaminated water, gram-negative coverage should be instituted for organisms such Pseudomonas and Aeromonas. [12]

MRSA is a significant threat in soft-tissue infections, becoming identified more frequently in necrotizing fasciitis. [13]

With urogenital necrotizing fasciitis (Fournier gangrene), prior to surgical resection of necrotic tissues, patients should receive intensive intravenous fluid replacement and parenteral broad-spectrum triple antimicrobial therapy, using a third-generation cephalosporin combined with metronidazole and/ or an aminoglycoside. [14]

Sometimes, classic triple therapy may be replaced with newer groups of antibiotics, such as piperacillin-tazobactam. [14] Clindamycin suppresses toxin production and also may be used.

Treatment should be guided by local antibiograms. Studies have documented that group A Streptococcus responds better to tedizolid, a second-generation oxazolidinone antibiotic, than to linezolid. A combination of doxycycline plus either ceftriaxone or cefotaxime has been recommended for necrotizing fasciitis due to Vibrio vulnificus. [15]

Gram-positive cocci in chains:

Penicillin 1-4 million U IV q4h or ampicillin-sulbactam 1.5-3 g IV q6-8h plus

Clindamycin 600-900 mg IV q8h

Gram-positive rods:

Clindamycin 600 mg IV q8h or

Ampicillin-sulbactam 1.5-3 g IV q6h

Gram-negative rods or gram-positive cocci in clusters or mixed: [16]

Ampicillin-sulbactam 1.5-3 g IV q6-8h plus  clindamycin 600-900 mg IV q8h plus ciprofloxacin 400 mg IV q12h or

Piperacillin-tazobactam 3.375 g IV q6-8h plus  clindamycin 600-900 mg IV q8h plus  ciprofloxacin 400 mg IV q12h or

Imipenem-cilastatin 1 g IV q6-8h or

Meropenem 1 g IV q8h or

Ertapenem 1 g IV q24h or

Cefotaxime 2 g IV q6h plus  (metronidazole 500 mg IV q6h or clindamycin 600-900 mg IV q8h)

Since none of the above covers MRSA, in appropriate clinical situations consider vancomycin 1 g IV q12h, daptomycin 6-10 mg/kg IV q24h, [17] or linezolid 600 mg IV q12h

See the list below:

Clindamycin 600 mg IV q8h plus  (vancomycin 15 mg/kg IV q12h or linezolid 600 mg PO or IV q12h) plus  (aztreonam 1-2 g IV q6-8h or gentamicin 3-5 mg/kg/day IV in 3 divided doses or ciprofloxacin 400 mg IV q12h)

The Infectious Diseases Society of America recently updated their guidelines for the diagnosis and management of skin and soft tissue infections. For the full guidelines, see Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. [18, 19]

Stevens DL, Bisno AL, Chambers HF, et al, and the Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005. 41:1373-406.

Schwartz RA, Kapila R. Dermatologic manifestations of necrotizing fasciitis. Medscape Reference. Updated March 9, 2011. Available at http://emedicine.medscape.com/article/1054438-overview. Accessed: May 16, 2011.

Rath S, Kar S, Sahu SK, Sharma S. Fungal periorbital necrotizing fasciitis in an immunocompetent adult. Ophthal Plast Reconstr Surg. 2009 Jul-Aug. 25(4):334-5. [Medline].

Jain D, Kumar Y, Vasishta RK, Rajesh L, Pattari SK, Chakrabarti A. Zygomycotic necrotizing fasciitis in immunocompetent patients: a series of 18 cases. Mod Pathol. 2006 Sep. 19(9):1221-6. [Medline].

Hsieh YH, Hsueh JH, Liu WC, Yang KC, Hsu KC, Lin CT, et al. Contributing Factors for Complications and Outcomes in Patients With Snakebite: Experience in a Medical Center in Southern Taiwan. Ann Plast Surg. 2017 Feb 14. [Medline].

Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2018 Mar 8. 378 (10):971. [Medline].

Govindan S, Chakrakodi B, Prabhakara S, Arakere G, Kumar S, Bairy I. Necrotizing fasciitis caused by a variant of epidemic methicillin resistant Staphylococcus aureus -15. Indian J Med Microbiol. 2012 Oct-Dec. 30(4):476-9. [Medline].

Miller LG, Perdreau-Remington F, Rieg G, Mehdi S, Perlroth J, Bayer AS, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med. 2005 Apr 7. 352(14):1445-53. [Medline].

Levett D, Bennett MH, Millar I. Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Database Syst Rev. 2015 Jan 15. 1:CD007937. [Medline].

Marongiu F, Buggi F, Mingozzi M, Curcio A, Folli S. A rare case of primary necrotising fasciitis of the breast: combined use of hyperbaric oxygen and negative pressure wound therapy to conserve the breast. Review of literature. Int Wound J. 2016 May 5. [Medline].

El-Sabbagh AH. Negative pressure wound therapy: An update. Chin J Traumatol. 2017 Jan 25. [Medline].

Kumar S, Mukhopadhyay P, Chatterjee M, Bandyopadhyay MK, Bandyopadhyay M, Ghosh T, et al. Necrotizing fasciitis caused by Aeromonas caviae. Avicenna J Med. 2012 Oct. 2(4):94-6. [Medline]. [Full Text].

Lee TC, Carrick MM, Scott BG, Hodges JC, Pham HQ. Incidence and clinical characteristics of methicillin-resistant Staphylococcus aureus necrotizing fasciitis in a large urban hospital. Am J Surg. 2007 Dec. 194(6):809-12; discussion 812-3. [Medline].

Kuzaka B, Wróblewska MM, Borkowski T, Kawecki D, Kuzaka P, Młynarczyk G, et al. Fournier’s Gangrene: Clinical Presentation of 13 Cases. Med Sci Monit. 2018 Jan 28. 24:548-555. [Medline].

Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7. 377 (23):2253-2265. [Medline].

Turunç V, Eroğlu A, Cihandide E, Tabandeh B, Oruğ T, Güven B. Escherichia Coli-Related Necrotizing Fasciitis After Renal Transplantation: A Case Report. Transplant Proc. 2015 Jun. 47 (5):1518-21. [Medline].

Seaton RA. Daptomycin: rationale and role in the management of skin and soft tissue infections. J Antimicrob Chemother. 2008 Nov. 62 Suppl 3:iii15-23. [Medline].

Barclay L. IDSA: skin and soft tissue infections guidelines updated. Medscape Medical News. Available at http://www.medscape.com/viewarticle/827399. Accessed: June 26, 2014.

[Guideline] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. 2014 Jul 15. 59(2):e10-52. [Medline]. [Full Text].

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Rajendra Kapila, MD, MBBS Professor, Department of Medicine, Rutgers New Jersey Medical School

Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, Infectious Diseases Society of New Jersey

Disclosure: Nothing to disclose.

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Kelley Struble, DO Fellow, Department of Infectious Diseases, University of Oklahoma College of Medicine

Kelley Struble, DO is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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