Medication Summary

Treatment of ecthyma gangrenosum (EG) requires the use of antipseudomonal penicillins, aminoglycosides, fluoroquinolones, third-generation cephalosporins, or aztreonam. Initially, antipseudomonal penicillin (piperacillin) is used in conjunction with an aminoglycoside (gentamicin). Further adjustment of antibiotics may be required after sensitivity results are known.

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic selection should be guided by blood culture sensitivity whenever feasible.

Piperacillin (Pipracil)

View full drug information

Piperacillin is a broad-spectrum penicillin. It inhibits the biosynthesis of cell wall mucopeptides and the stage of active multiplication. It has antipseudomonal activity.

Gentamicin (Gentacidin, Garamycin)

View full drug information

Gentamicin is an aminoglycoside antibiotic for gram-negative coverage. It is used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Gentamicin is not the drug of choice. Consider it 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 the dose based on CrCl and changes in the volume of distribution. Gentamicin may be given IV/IM.

Ciprofloxacin (Cipro)

View full drug information

Ciprofloxacin inhibits bacterial DNA synthesis and, consequently, growth. It is a fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. Continue treatment for at least 2 days (7-14 d typical) after signs and symptoms have disappeared.

Ceftazidime (Fortaz, Ceptaz)

View full drug information

Ceftazidime is a third-generation cephalosporin with broad-spectrum, gram-negative activity; it has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Ceftazidime arrests bacterial growth by binding to one or more penicillin-binding proteins.

Questions

Korte AKM, Vos JM. Ecthyma Gangrenosum. N Engl J Med. 2017 Dec 7. 377 (23):e32. [QxMD MEDLINE Link].
Mouna K, Akkari H, Faten H, Yosra K, Hichem B, Maha M, et al. Ecthyma Gangrenosum Caused by Escherichia coli in a Previously Healthy Girl. Pediatr Dermatol. 2015 Jul-Aug. 32 (4):e179-80. [QxMD MEDLINE Link].
Miyake S, Nobeyama Y, Baba-Honda H, Nakagawa H. Case of ecthyma gangrenosum in which only methicillin-resistant Staphylococcus epidermidis was detected. J Dermatol. 2016 Apr. 43 (4):460-2. [QxMD MEDLINE Link].
Firoz M, Jamal A, Ur Rehman SI. Non-pseudomonal Ecthyma Gangrenosum and Idiopathic Myelofibrosis in a Two-Year-Old Girl. Cureus. 2018 Apr 6. 10 (4):e2441. [QxMD MEDLINE Link].
Ferguson L, Chong H, Singh M. Ecthyma gangrenosum without bacteraemia: evidence in favour of a broader definition. Clin Exp Dermatol. 2017 Apr. 42 (3):324-327. [QxMD MEDLINE Link].
Marques SA, Abbade LPF. Severe bacterial skin infections. An Bras Dermatol. 2020 Jul - Aug. 95 (4):407-417. [QxMD MEDLINE Link].
Hamed A, Niehaus AG, Bosshardt Hughes O, Jakharia N. Ecthyma gangrenosum without bacteremia in a 54-year-old woman with heart transplant. Transpl Infect Dis. 2020 Aug. 22 (4):e13319. [QxMD MEDLINE Link].
Shah M, Crane JS. Ecthyma Gangrenosum. StatPearls [Internet]. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Ungaro R, Mikulska M. The skin and soft tissue infections in hematological patients. Curr Opin Infect Dis. 2020 Apr. 33 (2):101-109. [QxMD MEDLINE Link].
Yan W, Li W, Mu C, Wang L. Ecthyma gangrenosum and multiple nodules: cutaneous manifestations of Pseudomonas aeruginosa sepsis in a previously healthy infant. Pediatr Dermatol. 2011 Mar-Apr. 28(2):204-5. [QxMD MEDLINE Link].
Reich HL, Williams Fadeyi D, Naik NS, Honig PJ, Yan AC. Nonpseudomonal ecthyma gangrenosum. J Am Acad Dermatol. 2004 May. 50(5 Suppl):S114-7. [QxMD MEDLINE Link].
Aygencel G, Dizbay M, Sahin G. Burkholderia cepacia as a Cause of Ecthyma Gangrenosum-like Lesion. Infection. 2008 Jun. 36(3):271-3. [QxMD MEDLINE Link].
Brown KL, Stein A, Morrell DS. Ecthyma gangrenosum and septic shock syndrome secondary to Chromobacterium violaceum. J Am Acad Dermatol. 2006 May. 54(5 Suppl):S224-8. [QxMD MEDLINE Link].
Del Pozo J, García-Silva J, Almagro M, Martínez W, Nicolas R, Fonseca E. Ecthyma gangrenosum-like eruption associated with Morganella morganii infection. Br J Dermatol. 1998 Sep. 139(3):520-1. [QxMD MEDLINE Link].
Leslie KS, McCann BG, Levell NJ. Candidal ecthyma gangrenosum in a patient with malnutrition. Br J Dermatol. 2005 Oct. 153(4):847-8. [QxMD MEDLINE Link].
Bonduel M, Santos P, Turienzo CF, Chantada G, Paganini H. Atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii in two patients after allogeneic bone marrow transplantation. Bone Marrow Transplant. 2001 Jun. 27(12):1311-3. [QxMD MEDLINE Link].
Fergie JE, Huang DB, Purcell K, Milligan T. Successful treatment of Fusarium solani ecthyma gangrenosum in a child with acute lymphoblastic leukemia in relapse. Pediatr Infect Dis J. 2000 Jun. 19(6):579-81. [QxMD MEDLINE Link].
Kimyai-Asadi A, Tausk FA, Nousari HC. Ecthyma secondary to herpes simplex virus infection. Clin Infect Dis. 1999 Aug. 29(2):454-5. [QxMD MEDLINE Link].
Prindaville B, Nopper AJ, Lawrence H, Horii KA. Chronic granulomatous disease presenting with ecthyma gangrenosum in a neonate. J Am Acad Dermatol. 2014 Aug. 71(2):e44-5. [QxMD MEDLINE Link].
Koo SH, Lee JH, Shin H, Lee JI. Ecthyma gangrenosum in a previously healthy infant. Arch Plast Surg. 2012 Nov. 39(6):673-5. [QxMD MEDLINE Link]. [Full Text].
Downey DM, O'Bryan MC, Burdette SD, Michael JR, Saxe JM. Ecthyma gangrenosum in a patient with toxic epidermal necrolysis. J Burn Care Res. 2007 Jan-Feb. 28(1):198-202. [QxMD MEDLINE Link].
Gresik CM, Brewster LP, Abood G, Supple KG, Silver GM, Gamelli RL, et al. Ecthyma gangrenosum following toxic epidermal necrolysis syndrome in a 3-year-old boy-a survivable series of events. J Burn Care Res. 2008 May-Jun. 29(3):555-8. [QxMD MEDLINE Link].
Ghosheh FR, Kathuria SS. Bilateral periorbital ecthyma gangrenosum. Ophthal Plast Reconstr Surg. 2006 Nov-Dec. 22(6):492-3. [QxMD MEDLINE Link].
Inamadar AC, Palit A, Athanikar SB, Sampagavi VV, Deshmukh NS. Periocular ecthyma gangrenosum in a diabetic patient. Br J Dermatol. 2003 Apr. 148(4):821. [QxMD MEDLINE Link].
Kim JS, Ricafort R, Garfein ES, Levin TL. Imaging findings of ecthyma gangrenosum, an unusual complication of pseudomonas sepsis. HSS J. 2011 Oct. 7(3):279-81. [QxMD MEDLINE Link]. [Full Text].
Halpern AV and WR Heymann. Bacterial Diseases. Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. Spain: Elsevier Limited; 2008. Vol 1: Ch 73.
Craigie RJ, Ahmed S, Mullassery D, Panarese A, Caswell M, Kenny SE. A spot that can kill. Lancet. 2007 May 5. 369(9572):1540. [QxMD MEDLINE Link].
Khalil BA, Baillie CT, Kenny SE, Lamont GL, Turnock RR, Pizer BL, et al. Surgical strategies in the management of ecthyma gangrenosum in paediatric oncology patients. Pediatr Surg Int. 2008 Jul. 24(7):793-797. [QxMD MEDLINE Link].
Gregorini M, Castello M, Rampino T, Bosio F, Bedino G, Esposito P, et al. GM-CSF contributes to prompt healing of ecthyma gangrenosum lesions in kidney transplant recipient. J Nephrol. 2012 Jan-Feb. 25(1):137-9. [QxMD MEDLINE Link].

Media Gallery

Violaceous plaques and necrotic ulcers on the abdomen of a renal transplant patient. Tissue cultures were positive for Pseudomonas aeruginosa.

of 1

Author

Mina Yassaee Kingsbery, MD Co-Chief Resident, Department of Dermatology, New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons

Mina Yassaee Kingsbery, MD is a member of the following medical societies: American Academy of Dermatology, Society for Pediatric Dermatology, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Acknowledgements

Sarina Berger Elmariah, MD, PhD Resident Physician, Robert O Perelman Department of Dermatology, New York University School of Medicine

Sarina Berger Elmariah, MD, PhD is a member of the following medical societies: Phi Beta Kappa

Disclosure: Nothing to disclose.

Frederick Fish, MD Director, Department of Dermatology and Cutaneous Surgery, St Paul Ramsey Medical Center; Associate Clinical Professor, Department of Dermatology, University of Minnesota

Frederick Fish, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physicians, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Dermatopathology, Pacific Dermatologic Association, and Sigma Xi

Disclosure: Nothing to disclose.

Nobuyoshi Kageyama, MD Resident Physician, Assistant Clinical Professor of Dermatology, Department of Dermatology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Disclosure: Nothing to disclose.

Ravi Ubriani, MD Assistant Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center

Disclosure: Nothing to disclose.