eMedicine Specialties > Dermatology > Bacterial Infections
Necrotizing Fasciitis: Treatment & Medication
Updated: May 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Once the diagnosis of necrotizing fasciitis is confirmed, initiate treatment without delay. Because of the complexity of this disease, a team approach is best (see Consultations). Ideally, the patient should be moved to the surgical intensive care unit, and his or her hemodynamic parameters should be closely monitored.
The medical care of a patient with necrotizing fasciitis may involve the administration of antibiotics, hyperbaric oxygen (HBO), and/or intravenous immunoglobulin.
- Antibiotics: Gram staining of the exudate may provide a clue as to whether type I or type II infection is present; the type influences antibiotic therapy. Empirically, broad-spectrum antibiotics should be administered immediately. A foul smell in the lesion strongly suggests the presence of anaerobic organisms.
- Combination therapy: This approach involves the use of 2 or 3 antibiotics. To cover aerobes (usually gram-negative organisms), ampicillin and gentamicin are useful. For anaerobes, clindamycin or metronidazole has been used. In group A streptococcal infections, clindamycin has been used, specifically in combination with beta-lactam antibiotics.
- Single antibiotic coverage: Broad-spectrum beta-lactam drugs such as imipenem cover aerobes, including Pseudomonas species. Ampicillin sulbactam also has broad-spectrum coverage, but it does not cover Pseudomonas species. The maximum doses of the antibiotics should be used, with consideration of the patient's weight and liver and renal status. Once culture and sensitivity results are available, the antibiotic coverage should be reevaluated.
- Vancomycin: The use of vancomycin to treat methicillin-resistant S aureus is often discussed and may depend on the clinical situation. For example, use may depend on whether a nasocranial infection is present, or it may need to be avoided in patients, who are likely to be carriers of methicillin-resistant S aureus (eg, those with diabetes, those who use illicit drugs, those undergoing hemodialysis).
- HBO therapy24,25 : Once other modalities, including surgical debridement and antibiotic administration, have been used, HBO therapy may be considered. Some believe that treatment reduces the mortality rate related to necrotizing soft tissue infections. A small retrospective analysis of HBO therapy associated its use with a marked reduction in mortality as part of an aggressive treatment regimen for necrotizing fasciitis.26
- Intravenous immunoglobulin: In severe streptococcal infections associated with necrotizing fasciitis, the use of intravenous immunoglobulin (IVIG) may be a useful adjunct treatment. To the author's knowledge, no randomized trials have been reported in the literature, but results from anecdotal cases strongly support its use.
- Related guidelines
- Society of Critical Care Medicine -Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008
- Infectious Diseases Society of America -Practice guidelines for the diagnosis and management of skin and soft-tissue infections
Surgical Care
In all patients, examination by an experienced surgeon is critical.
- Once the diagnosis is made, immediate surgical debridement is necessary. This regimen outlined below is continued until further tissue necrosis stops and the growth of fresh viable tissue is observed. If a limb or organ is involved, amputation may be necessary because of irreversible necrosis and gangrene or because of overwhelming toxicity, which occasionally occurs. Prompt surgery ensures a higher likelihood of survival.
- The surgical incisions should be deep and extend beyond the areas of necrosis until viable tissue is reached.
- The entire necrotic area should be excised.
- The wound should be well irrigated.
- Hemostasis should be maintained, and the wound should be kept open.
- Surgical debridement and evaluations should be repeated almost on a daily basis.
- The wound should be inspected in the operating room.
Consultations
- A team approach is the best method of treating this complicated disorder. Team members should include the following: a surgeon, an infectious disease specialist, a pathologist, and a microbiologist.
- Depending on the area involved, the team may also include a urologist; a specialist in plastic surgery; or an ear, nose, and throat surgeon in cases of infections of the cervical area.
- The specialists and subspecialists involved should discuss the patient's condition and determine a comprehensive plan of treatment.
Medication
The goals of pharmacotherapy are to eradicate the infection, prevent complications, and reduce morbidity.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.
Ampicillin (Principen, Omnipen)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to administer medication orally or in serious infections.
Adult
250-500 mg IV/IM q6h; if no IV access, use IM
Pediatric
<40 kg: 25-50 mg/kg/d IV/IM divided q6h
>40 kg: Administer as in adults
Refer to PDR for further information about alternative dosing
Probenecid and disulfiram increase levels; allopurinol decreases effects and has additive effects on ampicillin-induced rash; may decrease effects of oral contraceptives; concomitant penicillin and aminoglycoside therapy reported to result in inactivation of aminoglycoside both in vivo and in vitro (amikacin appears to possess the greatest stability in presence of penicillins; half-life of amikacin is minimally affected by presence of carbenicillin; appears that in treatment of severely ill patients requiring both penicillin and aminoglycoside therapy, amikacin is aminoglycoside of choice); antibiotics that possess bacterial activity against Salmonella typhi organisms may interfere with immunological response to live typhoid vaccine (allow 24 h or more to elapse between administration of last dose of antibiotic and live typhoid vaccine)
Documented hypersensitivity to this and other beta-lactam antibiotics
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; GI disturbance; LFT and CBC count abnormalities noted; evaluate rash and differentiate from hypersensitivity reaction; patients with mononucleosis (EBV or CMV infections) are at increased risk for rash; administer drug on empty stomach when given orally, at least 0.5 h ac or 2 h pc; may cause false-positive reaction for urine glucose using Benedict's solution, Fehling's solution, or Clinitest tab. Enzyme-based urine glucose tests (eg, Clinistix, Tes-Tape) should be used in patients receiving ampicillin therapy because they are not affected by this interaction
Gentamicin (Garamycin, Jenamicin)
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Not the DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust dose with CrCl and changes in volume of distribution. Monitor drug levels and renal function at regular intervals, and adjust dose or discontinue accordingly.
Adult
3 mg/kg/d IV/IM divided tid q8h
Pediatric
<28 wk gestational age: 2.5 mg/kg IV q24-36 h
28-32 wk gestational age: 2.5 mg/kg IV q18 h
33-42 wk gestational age: 2.5 mg/kg IV q12 h
Term neonates >1 wk and infants and children <5 y: 2.5 mg/kg IV q8h
>5 years: 2-2.5 mg/kg IV q8h
Neurotoxic, ototoxic, and nephrotoxic medications; general anesthetics and neuromuscular blocking agents; coadministration with other aminoglycosides, cephalosporins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents (prolonged respiratory depression may occur); coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; irreversible hearing loss of varying degrees possible (monitor regularly); concomitant penicillin and aminoglycoside therapy reported to result in inactivation of aminoglycoside both in vivo and in vitro (amikacin appears to possess the greatest stability in presence of penicillins; half-life of amikacin is minimally affected by presence of carbenicillin; appears that in treatment of severely ill patients requiring both penicillin and aminoglycoside therapy, amikacin is aminoglycoside of choice); concomitant magnesium and aminoglycosides can produce neuromuscular weakness and possibly paralysis; high incidence of renal failure (serum creatinine increase >50%) observed in patients treated with polygeline 3.5% and gentamicin for elective coronary artery bypass graft
If antibiotic therapy necessary during BCG treatment, consider antibiotic with low activity against bacillus Calmette Gu é rin (eg, amoxicillin, TMP-SMZ, cephalosporin)
Documented hypersensitivity to this class of antibiotics and to sulfites; do not use in non – dialysis-dependent renal insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); preexisting inner ear or renal impairment, especially if patient recently received ototoxic or nephrotoxic medications; caution in local irrigation; caution in renal failure (patient not on dialysis); caution in myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; may cause fetal deafness; age (very young/very old), and dehydration; risk factor for toxicity
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes and arresting RNA-dependent protein synthesis.
Adult
600-1200 mg/d IV/IM divided bid/tid/qid; not to exceed 600 mg per single IM injection or 1200 mg/h IV
More severe infection: 1200-2700 mg/d IV/IM divided bid/tid/qid
Serious infection: 2700-4800 mg/d IV/IM divided bid/tid/qid
Pediatric
<1 month: 15-20 mg/kg/d IV/IM divided tid/qid
>1 month: 20-40 mg/kg/d IV/IM divided tid/qid
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in premature infants (may contain benzyl alcohol as a preservative); regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis; adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile; dysgeusia; monitor periodic blood counts and renal and hepatic function if use prolonged; rare cardiopulmonary adverse reactions possible with rapid IV administration
Metronidazole (Flagyl)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis).
Adult
Loading dose: 15 mg/kg IV infused over 1 h (approximately 1 g for 70-kg adult)
Maintenance dose: 7.5 mg/kg infused over 1 h q6h (approximately 500 mg for 70-kg adult) for 7-10 d or longer if necessary; not to exceed 4 g/d
Pediatric
Initial loading dose: 15 mg/kg IV infused over 60 min
Term infants: 7.5 mg/kg IV q24h, starting 48 h after initial dose
Term infants (1-4 wk), maintenance: 7.5 mg/kg IV q12h starting 24 h after initial dose
Infants and children, maintenance: 30 mg/kg/d IV divided q6h, not to exceed 4 g/d
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; phenytoin or phenobarbital may reduce levels; disulfiram reaction may occur with ethanol ingestion; metronidazole may increase toxicity of amprenavir oral solution (avoid concurrent administration); cholestyramine decreases effects; increases adverse effects of fluorouracil
Documented hypersensitivity to drug or components; first trimester of pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; caution in history of CNS disease or fluid retention; fluid retention with corticosteroids; GI discomfort; dysgeusia; GU discomfort; leukopenia or thrombocytopenia
Imipenem and cilastatin (Primaxin)
For treatment of infections due to multiple organisms in which other agents do not have wide-spectrum coverage or are contraindicated because of potential for toxicity.
Adult
500-1000 mg IV/IM q6-8h depending on the severity of disease and the infecting organisms
Pediatric
<1 week: 25 mg/kg IV q12h
1-4 weeks: 25 mg/kg IV q8h
1-3 months: 25 mg/kg IV q6h
>3 months: 15-25 mg/kg IV q6h
Not to exceed 4 g/d
Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures; avoid use with probenecid
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency; avoid use in children <12 y; CNS adverse effects (eg, seizures) possible; pseudomembranous colitis; monitor renal, hepatic, and hematopoietic systems with prolonged use; not recommended if patient <30 kg with renal impairment (data lacking); not recommended in children with CNS infections (increased seizure risk); not recommended if CrCl <5 mL/min/1.73 m2 unless hemodialysis performed within 48 h
Ampicillin and sulbactam (Unasyn)
Combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for treatment of nosocomial pathogens.
Adult
1.5-3 g IV/IM q6h; not to exceed 4 g/d sulbactam
Pediatric
<12 years: 100-200 mg/kg/d (ampicillin component) IV/IM divided q6h; not to exceed 4 g sulbactam/d
>12 years: Administer as in adults
Probenecid and disulfiram increase ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity to this and other beta-lactam antibiotics
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash; adjust for renal insufficiency; differentiate from hypersensitivity reaction; may cause diarrhea, pseudomembranous colitis, and false-positive results with urine glucose test or other laboratory tests (eg, liver, hematologic, albumin, total protein, renal); administer on empty stomach when given orally at least 0.5 h ac or 2 h pc
Vancomycin (Lyphocin, Vancoled, Vancocin)
Antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in treatment of septicemia and skin-structure infections. Indicated for patients who cannot take or whose conditions fail to respond to penicillins and cephalosporins or those with infections with resistant staphylococci. To prevent toxicity, current recommendation is to assay vancomycin trough levels after third dose, with samples obtained 0.5 h prior to next dose. Use CrCl to adjust dose in renal impairment.
Adult
2 g IV divided 500 mg q6h or 1 g q12h; administered at a rate of <10 mg/min or over 60 min
Pediatric
<1 year: 15 mg/kg initial dose IV, followed by 10 mg/kg IV q12h ( <1 wk old) or q8h (1-4 wk old); administer over at least 60 min
>1 year: 10 mg/kg per dose IV q6h; administer over at least 60 min
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; concurrent administration of other potentially ototoxic, nephrotoxic, or neurotoxic agents (eg, aminoglycosides, paralytic agents) may increase risk of the same adverse event; coadministration with trospium may result in increased serum concentrations of either drug
Documented hypersensitivity; corn allergy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; adjust dose in renal insufficiency; caution in history of hearing loss or recent ototoxic agent; may cause ototoxicity, neutropenia, local necrosis, or phlebitis about infusion or injection site, chemical peritonitis possible if administered via peritoneal dialysis; red man syndrome caused by too-rapid IV infusion (dose administered over only few min) but rare with 2-h or PO or IP administration (red man syndrome is not an allergic reaction); pseudomembranous colitis; avoid IM administration
More on Necrotizing Fasciitis |
| Overview: Necrotizing Fasciitis |
| Differential Diagnoses & Workup: Necrotizing Fasciitis |
 Treatment & Medication: Necrotizing Fasciitis |
| Follow-up: Necrotizing Fasciitis |
| Multimedia: Necrotizing Fasciitis |
| References |
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References
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Further Reading
Keywords
necrotizing fasciitis, hospital gangrene, acute infective gangrene, necrotizing erysipelas, hemolytic streptococcus gangrene, suppurative fasciitis, flesh-eating bacterial infection, killer bug disease, Fournier's gangrene, Fournier gangrene, polymicrobial necrotizing fasciitis, group A streptococcal necrotizing fasciitis, gas gangrene, clostridial myonecrosis, fascial necrosis, group A beta-hemolytic streptococci, septicemia
streptococcal pyrogenic exotoxins, streptococcal superantigen, frostbite, chronic venous leg ulcers, open bone fractures, insect bites, surgical wounds, skin abscesses, diabetes mellitus, violaceous discoloration, black necrotic eschar, metastatic cutaneous plaques, nonclostridial anaerobic infections, blistering necrosis, cyanosis, Haemophilus aphrophilus, Staphylococcus, phycomycetesVibrio species, varicella infection, Clostridium perfringens, Clostridium septicum, colon cancer, leukemia
