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Medication

Medication Summary

Antibiotic therapy is a key consideration. Possible regimens include a combination of penicillin G and an aminoglycoside (if renal function permits), as well as clindamycin (to cover streptococci, staphylococci, gram-negative bacilli, and anaerobes).

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

Penicillin G (Pfizerpen)

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Penicillin G interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Clindamycin (Cleocin)

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Clindamycin is a lincosamide for treatment of serious skin and soft tissue staphylococcal infections. It is also effective against aerobic and anaerobic streptococci (except enterococci). This agent inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer RNA (t-RNA) from ribosomes causing RNA-dependent protein synthesis to arrest. It is used as an alternative to penicillin G.

Metronidazole (Flagyl)

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Metronidazole is an imidazole ring–based antibiotic active against various anaerobic bacteria and protozoa. It is used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

Metronidazole appears to be absorbed into cells of microorganisms containing nitroreductase. Unstable intermediate compounds that bind DNA and inhibit synthesis are formed, causing cell death.

Ceftriaxone (Rocephin)

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Ceftriaxone is the drug of choice in initial treatment. It 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. It arrests bacterial growth by binding to one or more penicillin-binding proteins.

Gentamicin

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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. It is not the drug of choice, but should be considered 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 the dose based on creatinine clearance (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 a 30-min infusion.

Chloramphenicol

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Chloramphenicol binds to 50 S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. It is effective against gram-negative and gram-positive bacteria.

Ampicillin

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Ampicillin has bactericidal activity against susceptible organisms. It is an alternative to amoxicillin when the patient is unable to take medication orally. It may be added to the initial regimen if the Gram stain suggests that enterococci are present.

Imipenem and cilastatin (Primaxin)

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This combination is used 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.

Ampicillin and sulbactam (Unasyn)

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This combination of ampicillin and a beta-lactamase inhibitor covers skin, enteric flora, and anaerobes. It is not ideal for treatment of nosocomial pathogens.

Vancomycin (Vancocin)

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Vancomycin is an antibiotic directed against gram-positive organisms and active against Enterococcus species. It is useful in the treatment of septicemia and skin-structure infections. Vancomycin is 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, the current recommendation is to assay vancomycin trough levels after the third dose, with samples obtained 0.5 h prior to the next dose. Use the CrCl to adjust the dose in patients with renal impairment.

Questions

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Media Gallery

Left upper extremity shows necrotizing fasciitis in an individual who used illicit drugs. Cultures grew Streptococcus milleri and anaerobes (Prevotella species). Patient would grease, or lick, the needle before injection.
Necrotizing fasciitis at a possible site of insulin injection in the left upper part of the thigh in a 50-year-old obese woman with diabetes.
Photomicrograph of Fournier gangrene (necrotizing fasciitis), oil immersion at 1000X magnification. Note the acute inflammatory cells in the necrotic tissue. Bacteria are located in the haziness of their cytoplasm. Courtesy of Billie Fife, MD, and Thomas A. Santora, MD.
Left lower extremity in a 56-year-old patient with alcoholism who was found comatose after binge drinking. Surgical drainage was performed to treat the pyomyositis-related, large, non–foul-smelling (sweetish) bullae. Gram staining showed the presence of gram-positive rods. Cultures revealed Clostridium perfringens. The diagnosis was clostridial myonecrosis.
Sixty-year-old woman who had undergone postvaginal hysterectomy and repair of a rectal prolapse has a massive perineal ulceration with foul-smelling discharge. Cultures revealed Escherichia coli and Bacteroides fragilis. The diagnosis was perineal gangrene.
Necrotizing fascitis of entire thoracolumbar posterior area in 20-year-old patient with chronic myelogenous leukemia and neutropenia (WBC count, 680/uL). Cultures revealed gram-negative Pseudomonas species and Bacteroides fragilis.

of 6

Author

Steven A Schulz, MD Clinical Instructor/Faculty in Plastic and Reconstructive Surgery, Fellow in Reconstructive Microsurgery, Department of Plastic Surgery, Ohio State University Wexner Medical Center, Ohio State University College of Medicine

Steven A Schulz, MD is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Richard F Edlich, MD, PhD, FACS, FACEP, FASPS † Former Distinguished Professor Emeritus of Plastic Surgery, Biomedical Engineering and Emergency Medicine, University of Virginia Health Care System

Richard F Edlich, MD, PhD, FACS, FACEP, FASPS is a member of the following medical societies: Alpha Omega Alpha, American Burn Association, American College of Emergency Physicians, American College of Surgeons, American Society of Plastic Surgeons, American Spinal Injury Association, American Surgical Association, American Trauma Society, Plastic Surgery Research Council, Society of University Surgeons, Surgical Infection Society

Disclosure: Nothing to disclose.

William B Long, III, MD, FACS President, Trauma Specialists, LLP; President, Pacific Surgical, PC; Trauma Medical Director, Legacy Emanuel Trauma Center, Legacy Emanuel Hospital

William B Long, III, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Thoracic Society, American Trauma Society, Society of Thoracic Surgeons, Pacific Coast Surgical Association, Western Trauma Association, North Pacific Surgical Association

Disclosure: Nothing to disclose.

K Dean Gubler, DO, MPH Assistant Clinical Professor, Department of Surgery, Oregon Health Sciences University; Consulting Surgeon, Department of Surgery, Pacific Surgical, PC, Mount Hood Medical Center, Good Samaritan Hospital, Legacy Emanuel Hospital Trauma Program

K Dean Gubler, DO, MPH is a member of the following medical societies: American College of Surgeons, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Joseph U Becker, MD Fellow, Global Health and International Emergency Medicine, Stanford University School of Medicine

Joseph U Becker, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Shahin Javaheri, MD Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery

Shahin Javaheri, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Wayne Karl Stadelmann, MD Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Acknowledgments

The authors wish to thank Research Assistants Julie Garrison and Jennifer Nearants for their assistance with this Medscape Reference article.

Necrotizing Fasciitis Medication

Medication Summary

Antibiotics

Class Summary

Penicillin G (Pfizerpen)

Penicillin G (Pfizerpen)

Clindamycin (Cleocin)

Clindamycin (Cleocin)

Metronidazole (Flagyl)

Metronidazole (Flagyl)

Ceftriaxone (Rocephin)

Ceftriaxone (Rocephin)

Gentamicin

Gentamicin

Chloramphenicol

Chloramphenicol

Ampicillin

Ampicillin

Imipenem and cilastatin (Primaxin)

Imipenem and cilastatin (Primaxin)

Ampicillin and sulbactam (Unasyn)

Ampicillin and sulbactam (Unasyn)

Vancomycin (Vancocin)

Vancomycin (Vancocin)

Necrotizing Fasciitis Medication

Medication Summary

Antibiotics

Class Summary

Penicillin G (Pfizerpen)

Clindamycin (Cleocin)

Metronidazole (Flagyl)

Ceftriaxone (Rocephin)

Gentamicin

Chloramphenicol

Ampicillin

Imipenem and cilastatin (Primaxin)

Ampicillin and sulbactam (Unasyn)

Vancomycin (Vancocin)

References

Tables

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