Necrotizing Fasciitis Organism-Specific Therapy 

Updated: Mar 03, 2017
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Thomas E Herchline, MD  more...
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Specific Organisms and Therapeutic Regimens

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]

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:

General recommendations

Aggressive surgical intervention is the major therapeutic modality for patients with necrotizing fasciitis and should be performed as early as possible [3] . 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. [4]

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, 5]

Hyperbaric oxygen therapy may also be used, especially if the infection is due to anaerobic organisms [6, 7] ; 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, [7]  with evidence of to support or refute its value lacking [8] 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. [9] Vacuum-assisted closure can be used immediately after debridement. [10]

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

Streptococcus pyogenes

See the list below:

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

MSSA

See the list below:

MRSA or penicillin allergy

See the list below:

Clostridium spp

See the list below:

  • Clindamycin 600-900 mg/kg IV q8h or
  • Penicillin G 2-4 million U IV q4-6h

Guidelines

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. [11, 12]