Necrotizing Fasciitis Organism-Specific Therapy 

Necrotizing Fasciitis Organism-Specific Therapy 

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General recommendations and organism-specific therapeutic regimens for necrotizing fasciitis are provided below, including those for Streptococcus pyogenes, methicillin-susceptible Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), and Clostridium species. [1, 2]

One should recall that severe pain is an important clinical symptom separating necrotizing infections from more superficial ones. [3] Tachycardia and elevated levels of creatine kinase, C-reactive protein, and creatinine may also suggest necrotizing fasciitis.

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

Aggressive surgical intervention is the major therapeutic modality for patients with necrotizing fasciitis and should be performed as early as possible [4] . Rarely, cobra and other snake bites may be linked with necrotizing fasciitis. In that case, the bite location, patient’s clinical features, and use of a specific antivenin as well as suitable antibiotics are pivotal for a favorable outcome. [5]

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

A Gram stain of the exudate demonstrates the presence of pathogens and can provide an early clue to the preferred treatment recommendations [1, 6]

Hyperbaric oxygen therapy may also be used, especially if the infection is due to anaerobic organisms [7, 8] ; however, its use should not delay pivotal surgical debridement; in addition, the value of hyperbaric oxygen therapy for treating those with necrotizing fasciitis has been questioned, [8]  with evidence of to support or refute its value 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 tissues and control the advancing infection. [10] Vacuum-assisted closure can be used immediately after debridement. [11]

Patients with necrotizing fasciitis should be in an intensive care unit.

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. [12]

Sometimes, classic triple therapy may be replaced with newer groups of antibiotics, such as piperacillin-tazobactam. [12] 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. [13]

See the list below:

Penicillin G 2-4 million U IV q4-6h plus clindamycin 600 mg IV q8h

See the list below:

Nafcillin 1-2 g IV q4h or

Oxacillin 1-2 g IV q4h or

Cefazolin 1 g IV q8h

See the list below:

Vancomycin 15 mg/kg IV q12h or

Linezolid 600 mg IV q12h or

Daptomycin 6-8 mg/kg IV q24h or

Quinupristin/dalfopristin 7.5 mg/kg IV q12h

See the list below:

Clindamycin 600-900 mg/kg IV q8h or

Penicillin G 2-4 million U IV q4-6h

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. [14, 15]

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.

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

Bucca K, Spencer R, Orford N, Cattigan C, Athan E, McDonald A. Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study. ANZ J Surg. 2013 May. 83(5):365-70. [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].

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].

Sroczynski M, Sebastian M, Rudnicki J, Sebastian A, Agrawal AK. A Complex Approach to the Treatment of Fournier’s Gangrene. Adv Clin Exp Med. 2013 Jan-Feb. 22(1):131-5. [Medline].

Willy C, Rieger H, Vogt D. [Hyperbaric oxygen therapy for necrotizing soft tissue infections: contra]. Chirurg. 2012 Nov. 83(11):960-72. [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].

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].

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.

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.

Necrotizing Fasciitis Organism-Specific Therapy 

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