Necrotizing fasciitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

Overview

Necrotizing fasciitis is a medical and surgical emergency. The mainstay of therapy for necrotizing fasciitis includes surgical exploration and debridement along with antimicrobial therapy. Initial pharmacologic therapy often includes a combination of intravenous antibiotics including penicillin, vancomycin, and/or clindamycin.

Treatment

The diagnosis is confirmed by either blood cultures or aspiration of pus from tissue, but early medical treatment is crucial and often presumptive; thus, antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including penicillin, vancomycin and clindamycin. If necrotizing fasciitis is suspected, surgical exploration is always necessary, often resulting in aggressive debridement (removal of infected tissue). As in other maladies characterized by massive wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy, but is not widely available. Amputation of the affected organ(s) may be necessary. Repeat explorations usually need to be performed to remove additional necrotic tissue. Typically, this leaves a large open wound which often requires skin grafting. The associated systemic inflammatory response is usually profound, and most patients will require monitoring in an intensive care unit.

Antimicrobial regimen

• Necrotizing fasciitis

• 1. Mixed infections

• 1.1 Adults

• Preferred regimen (1): Piperacillin-tazobactam 3.37 g IV q6–8h AND Vancomycin 30 mg/kg/day IV q12h
• Note: In case of severe pencillin allergy, use clindamycin or metronidazole with an aminoglycoside or fluoroquinolone
• Preferred regimen (2): Imipenem-cilastatin 1 g IV q6–8h
• Preferred regimen (3): Meropenem 1 g IV q8h
• Preferred regimen (4): Ertapenem 1 g IV q24h
• Preferred regimen (5): Cefotaxime 2 g IV q6h AND Metronidazole 500 mg IV q6h
• Preferred regimen (6): Cefotaxime 2 g IV q6h AND Clindamycin 600–900 mg IV q8h

• 1.2 Pediatrics

• Preferred regimen (1): Piperacillin-tazobactam 60–75 mg/kg/dose of the Piperacillin component IV q6h AND Vancomycin 10–13 mg/kg/dose IV q8h
• Note: Severe pencillin allergy, use clindamycin or metronidazole with an aminoglycoside or fluoroquinolone)
• Preferred regimen (2): Meropenem 20 mg/kg/dose IV q8h
• Preferred regimen (3): Ertapenem 15 mg/kg/dose IV q12h for children 3 months-12 years
• Preferred regimen (4): Cefotaxime 50 mg/kg/dose IV q6h AND Metronidazole 7.5 mg/kg/dose IV q6h
• Preferred regimen (5): Cefotaxime 50 mg/kg/dose IV q6h AND Clindamycin 10–13 mg/kg/dose IV q8h

• 2. Streptococcus infection

• 2.1 Adults

• Preferred regimen: Penicillin 2–4 MU IV q4–6h AND Clindamycin 600–900 mg IV q8h
• Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin

• 2.2 Pediatric

• Preferred regimen: Penicillin 0.06–0.1 MU/kg/dose IV q6h AND Clindamycin 10–13 mg/kg/dose IV q8h
• Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin

• 3. Staphylococcus aureus

• 3.1 Adults

• Preferred regimen (1): Nafcillin 1–2 g IV q4h
• Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
• Preferred regimen (2): Oxacillin 1–2 g IV q4h
• Preferred regimen (3): Cefazolin 1 g IV q8h
• Preferred regimen (4): Vancomycin 30 mg/kg/day IV q12h
• Preferred regimen (5): Clindamycin 600–900 mg IV q8h

• Pediatrics

• Preferred regimen (1): Nafcillin 50 mg/kg/dose IV q6h
• Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
• Preferred regimen (2): Oxacillin 50 mg/kg/dose IV q6h
• Preferred regimen (3): Cefazolin 33 mg/kg/dose IV q8h
• Preferred regimen (4): Vancomycin 15 mg/kg/dose IV q6h
• Preferred regimen (5): Clindamycin 10–13 mg/kg/dose IV q8h (bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)

• 4. Clostridium species

• 4.1 Adults

• Preferred regimen: Clindamycin 600–900 mg IV q8h AND Penicillin 2–4 MU IV q4–6h

• 4.2 Pediatrics

• Preferred regimen: Clindamycin 10–13 mg/kg/dose IV q8h AND Penicillin 0.06-0.1 MU/kg/dose IV q6h

• 5. Aeromonas hydrophila

• 5.1 Adults

• Preferred regimen (1): Doxycycline 100 mg IV q12h AND Ciprofloxacin 500 mg IV q12h

• Preferred regimen (2): Doxycycline 100 mg IV q12h AND Ceftriaxone 1 to 2 g IV q24h

• 5.2 Pediatrics

• Not recommended for children but may need to use in life-threatening situations

• 6. Vibrio vulnificus

• 6.1 Adults

• Preferred regimen (1): Doxycycline 100 mg IV q12h AND Ceftriaxone 1 g IV qid
• Preferred regimen (2): Doxycycline 100 mg IV q12h AND Cefotaxime 2 g IV tid

• 6.2 Pediatrics

• Not recommended for children but may need to use in life-threatening situation

Nutritional Support

• The metabolic demands of necrotizing fasciitis patients are similar to those of other major trauma or burns.
• Nutritional support to replace lost proteins and fluids from large wounds and/or the result of shock is required from the first day of patients hospital admission.

Hyperbaric oxygen

• Delivery of 100% hyperbaric oxygen at two or three times the atmospheric pressure for 30 to 90 minutes with three to four treatments daily.
• Hyperbaric oxygen inhibits infection and exotoxin release.
• It enhances efficacy of antibiotics by increasing local oxygen tension in tissue and augment oxidative burst and killing ability of leukocytes.
• These effects results in reduced need for surgical debridement and improved morbidity and mortality in patients with necrotizing fasciitis.

Contraindications to hyperbaric oxygen are:

• Pneumothorax
• Cisplatin (which decreases the production of superoxide dismutase which is protective against damaging effects of high partial O2 pressure)
• Doxorubicin therapy

Side effects of hyperbaric oxygen are:

• Barotrauma of the middle ear
• Seizures
• Loss of respiratory drive in hypercapnic patients (therefore, frequent periods of breathing in room air are interposed when patients are on HBOT)
• Vasoconstriction

IV γ-globulin

• Use of intravenous immune globulin is not FDA approved
• If used, this treatment is restricted to critically ill patients with either staphylococcal or streptococcal infections