eMedicine Specialties > Emergency Medicine > Infectious Diseases
Necrotizing Fasciitis: Treatment & Medication
Updated: Mar 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
- Aggressively treat the patient with suspected necrotizing fasciitis to reduce morbidity and mortality.
- Perform endotracheal intubation in patients who are unable to maintain their airway.
- Provide supplemental oxygen.
- Obtain IV access. Be careful to not use an infected extremity.
- Place patient on continuous cardiac monitoring.
- Begin fluid resuscitation with normal saline or lactated Ringer solution.
- In patients with suspected hypovolemia, Foley catheterization may be needed to monitor urine output. This procedure should probably be avoided in patients with Fournier gangrene.
- Begin antibiotics as soon as possible.
Consultations
- Obtain early surgical consultation for aggressive debridement; however, surgical consultation should not wait for results of laboratory, microbiology, or radiological studies.
- Consider surgical subspecialty consultation for necrotizing fasciitis involving specific anatomic areas, as needed.
- Obtain urological consultation in cases of Fournier gangrene.
- Consult with a hyperbaric specialist.
- A consultation with an infectious disease specialist may be useful to guide initial empiric antibiotic therapy.
Medication
It is common to see misdirected treatment that is aimed at coexisting flora instead of the causative organism. If streptococci are the identified major pathogens, the DOC is penicillin G, with clindamycin as the alternative. To ensure adequate treatment, there must be coverage for aerobic and anaerobic bacteria. The anaerobic coverage can be provided by metronidazole or third-generation cephalosporins. Gentamicin, combined with clindamycin or chloramphenicol, has been proposed as a standard coverage. Ampicillin may be added to the basic regimen to treat enterococci if suspected by Gram stain.
Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting.
Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
8-10 million U/d IV divided q4-6h
Pediatric
500,000-800,000 U/kg/d IV divided q4-6h
Probenecid can increase effects; coadministration of tetracyclines decreases effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function and elevated potassium levels
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 causing RNA-dependent protein synthesis to arrest. To be used as an alternative to penicillin G.
Adult
600 mg IV q6h
Pediatric
5 mg/kg IV q6h
Use with erythromycin or chloramphenicol may decrease effects of clindamycin; increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, and antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
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). Appears to be absorbed into cells of microorganisms containing nitroreductase. Unstable intermediate compounds that bind DNA and inhibit synthesis are formed, causing cell death.
Adult
Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h
Maintenance dose: 6 h following loading dose; infuse 7.5 mg/kg or 500 mg IV for 70-kg adult over 1 h q6-8h; not to exceed 4 g/d
Pediatric
15-30 mg/kg/d IV divided bid/tid; not to exceed 2 g/d
Cimetidine may increase toxicity; may increase effects of anticoagulants (monitor PT); may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol; phenobarbital, phenytoin, and other hepatic enzyme-inducing drugs decrease metronidazole levels
Documented hypersensitivity
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
Ceftriaxone (Rocephin)
DOC in initial treatment. Third-generation cephalosporin with broad-spectrum, gram-negative activity. Lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
1-2 g IV qd or divided bid
Pediatric
75 mg/kg/d IV divided bid
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin
Gentamicin (Garamycin)
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.
Adjust dose based on CrCl and changes in volume of distribution. Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing). Peak level may be drawn 0.5 h after 30-min infusion.
Adult
3 mg/kg/d IV divided q8h
Pediatric
2 mg/kg/d IV divided q8h
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
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
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Chloramphenicol (Chloromycetin)
Binds to 50 S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
50-100 mg/kg/d IV divided q6h; not to exceed 4 g/d
Pediatric
Administer as in adults
Concomitant use with clindamycin may cause a decrease in the effects of clindamycin; Concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants (monitor PT); may increase serum hydantoin levels, possibly resulting in toxicity
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
Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Ampicillin (Omnipen)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally. May be added to initial regimen if Gram stain suggests enterococci.
Adult
8-14 g/d IV divided q6h
Pediatric
100-200 mg/kg/d IV divided q6h
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
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 and differentiate from hypersensitivity reaction
More on Necrotizing Fasciitis |
| Overview: Necrotizing Fasciitis |
| Differential Diagnoses & Workup: Necrotizing Fasciitis |
 Treatment & Medication: Necrotizing Fasciitis |
| Follow-up: Necrotizing Fasciitis |
| Multimedia: Necrotizing Fasciitis |
| References |
| « Previous Page | Next Page » |
References
Cheng NC, Su YM, Kuo YS, Tai HC, Tang YB. Factors affecting the mortality of necrotizing fasciitis involving the upper extremities. Surg Today. 2008;38(12):1108-13. [Medline].
Mao JC, Carron MA, Fountain KR, Stachler RJ, Yoo GH, Mathog RH, et al. Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome. Am J Otolaryngol. Jan-Feb 2009;30(1):17-23. [Medline].
Baker DJ. Selected aerobic and anaerobic soft tissue infections - diagnosis and the use of hyperbaric oxygen. Hyperbaric Medicine Practice. 1994;395-418.
Baracco GJ, Bisno AL. Therapeutic Approaches to Streptococcal Toxic Shock Syndrome. Curr Infect Dis Rep. Aug 1999;1(3):230-237. [Medline].
Brothers TE, Tagge DU, Stutley JE, et al. Magnetic resonance imaging differentiates between necrotizing and non-necrotizing fasciitis of the lower extremity. J Am Coll Surg. Oct 1998;187(4):416-21. [Medline].
Cullen TS. A progressively enlarging ulcer of abdominal wall involving the skin and fat, following drainage of an abdominal abscess apparently of appendiceal origin. Surg Gynecol Obstet.
Demello FJ, Haglin JJ, Hitchcock CR. Comparative study of experimental Clostridium perfringens infection in dogs treated with antibiotics, surgery, and hyperbaric oxygen. Surgery. Jun 1973;73(6):936-41. [Medline].
Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. Jun 2000;87(6):718-28. [Medline].
File TM, Tan JS. Group A streptococcus necrotizing fasciitis. Compr Ther. 2000;26(2):73-81. [Medline].
Fink S, Chaudhuri TK, Davis HH. Necrotizing fasciitis and malpractice claims. South Med J. Aug 1999;92(8):770-4. [Medline].
Fournier JA. Jean-Alfred Fournier 1832-1914. Gangrene foudroyante de la verge (overwhelming gangrene). Sem Med 1883. Dis Colon Rectum. Dec 1988;31(12):984-8. [Medline].
Fujisawa N, Yamada H, Kohda H, et al. Necrotizing fasciitis caused by Vibrio vulnificus differs from that caused by streptococcal infection. J Infect. May 1998;36(3):313-6. [Medline].
Hart GB, Lamb RC, Strauss MB. Gas gangrene. J Trauma. Nov 1983;23(11):991-1000. [Medline].
Hirn M, Niinikoski J, Lehtonen OP. Effect of hyperbaric oxygen and surgery on experimental gas gangrene. Eur Surg Res. 1992;24(6):356-62. [Medline].
Holmstrom B, Grimsley EW. Necrotizing fasciitis and toxic shock-like syndrome caused by group B streptococcus. South Med J. Nov 2000;93(11):1096-8. [Medline].
Hsiao GH, Chang CH, Hsiao CW, et al. Necrotizing soft tissue infections. Surgical or conservative treatment?. Dermatol Surg. Feb 1998;24(2):243-7; discussion 247-8. [Medline].
Jones RB, Hirschmann JV, Brown GS, Tremann JA. Fournier's syndrome: necrotizing subcutaneous infection of the male genitalia. J Urol. Sep 1979;122(3):279-82. [Medline].
Kaul R, McGeer A, Low DE, et al. Population-based surveillance for group A streptococcal necrotizing fasciitis: Clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med. Jul 1997;103(1):18-24. [Medline].
Korhonen K, Kuttila K, Niinikoski J. Tissue gas tensions in patients with necrotising fasciitis and healthy controls during treatment with hyperbaric oxygen: a clinical study. Eur J Surg. Jul 2000;166(7):530-4. [Medline].
Lamerton AJ. Fournier's gangrene: non-clostridial gas gangrene of the perineum and diabetes mellitus. J R Soc Med. Apr 1986;79(4):212-5. [Medline].
Larsson A, Elmqvist, Stenberg A. Cervical necrotizing fasciitis - 11 cases treated according to a multidisciplinary protocol. Undersea Hyperb Med. 2002;29(2):105.
Mader JT. Mixed anaerobic and aerobic soft tissue infection. In: Problem Wounds: The Role of Oxygen. 1988:173-186.
McGeehan DF, Asmal AB, Angorn IB. Fournier's gangrene. S Afr Med J. Nov 10 1984;66(19):734-7. [Medline].
Meleney FL. Hemolytic streptococcus gangrene. Arch Surg. 1924;9:317-364. [Medline].
Mohammedi I, Ceruse P, Duperret S, Vedrinne J, Boulétreau P. Cervical necrotizing fasciitis: 10 years' experience at a single institution. Intensive Care Med. Aug 1999;25(8):829-34. [Medline].
Mulla ZD. Hyperbaric oxygen in necrotizing fasciitis. Plast Reconstr Surg. Dec 2008;122(6):1984-5. [Medline].
Niinikoski J, Aho A. Combination of hyperbaric oxygen, surgery and antibiotics in the treatment of clostridial gas gangrene. Infect Surg. 1983;2:23-27.
Nomikos IN. Necrotizing perineal infections (Fournier's disease): old remedies for an old disease. Int J Colorectal Dis. 1998;13(1):48-51. [Medline].
Reyzelman AM, Armstrong DG, Vayser DJ, et al. Emergence of non-group A streptococcal necrotizing diabetic foot infections. J Am Podiatr Med Assoc. Jun 1998;88(6):305-7. [Medline].
Riseman JA, Zamboni WA, Curtis A, et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery. Nov 1990;108(5):847-50. [Medline].
Somers WJ, Lowe FC. Localized gangrene of the scrotum and penis: a complication of heroin injection into the femoral vessels. J Urol. Jul 1986;136(1):111-3. [Medline].
Sriskandan S, Kemball-Cook G, Moyes D, et al. Contact activation in shock caused by invasive group A Streptococcus pyogenes. Crit Care Med. Nov 2000;28(11):3684-91. [Medline].
Stephenson H, Dotters DJ, Katz V, Droegemueller W. Necrotizing fasciitis of the vulva. Am J Obstet Gynecol. May 1992;166(5):1324-7. [Medline].
Stevens DL, Bryant AE, Adams K, Mader JT. Evaluation of therapy with hyperbaric oxygen for experimental infection with Clostridium perfringens. Clin Infect Dis. Aug 1993;17(2):231-7. [Medline].
Wilkinson D, Doolette D. Hyperbaric oxygen treatment and survival from necrotizing soft tissue infection. Arch Surg. Dec 2004;139(12):1339-45. [Medline].
Wysoki MG, Santora TA, Shah RM, Friedman AC. Necrotizing fasciitis: CT characteristics. Radiology. Jun 1997;203(3):859-63. [Medline].
Zamboni WA, Mazolewski PJ, Erdmann D, et al. Evaluation of penicillin and hyperbaric oxygen in the treatment of streptococcal myositis. Ann Plast Surg. Aug 1997;39(2):131-6. [Medline].
Zerr DM, Alexander ER, Duchin JS, et al. A case-control study of necrotizing fasciitis during primary varicella. Pediatrics. Apr 1999;103(4 Pt 1):783-90. [Medline].
Zerr DM, Rubens CE. NSAIDS and necrotizing fasciitis. Pediatr Infect Dis J. Aug 1999;18(8):724-5. [Medline].
Zurawski CA, Bardsley M, Beall B, et al. Invasive group A streptococcal disease in metropolitan Atlanta: a population-based assessment. Clin Infect Dis. Jul 1998;27(1):150-7. [Medline].
Further Reading
Keywords
Fournier's gangrene, Fournier gangrene, Meleney's ulcer, Meleney ulcer, postoperative progressive bacterial synergistic gangrene, flesh-eating bacteria, Cullen's ulcer, Cullen ulcer, hemolytic streptococcal gangrene, acute dermal gangrene, hospital gangrene, suppurative fascitis, synergistic necrotizing cellulitis, group A hemolytic streptococci, Staphylococcus aureus, Bacteroides fragilis, Escherichia coli, nonclostridial myonecrosis, Vibrio vulnificus, diabetes mellitus, fascial necrosis
