Necrotizing fasciitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

Overview

Necrotizing fasciitis is a medical and surgical emergency. The mainstay of therapy for necrotizing fasciitis includes surgical exploration and debridement along with antimicrobial therapy. Initial pharmacologic therapy often includes a combination of intravenous antibiotics including penicillin, vancomycin, and/or clindamycin.

Treatment

The diagnosis is confirmed by either blood cultures or aspiration of pus from tissue, but early medical treatment is crucial and often presumptive; thus, antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including penicillin, vancomycin and clindamycin. If necrotizing fasciitis is suspected, surgical exploration is always necessary, often resulting in aggressive debridement (removal of infected tissue). As in other maladies characterized by massive wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy, but is not widely available. Amputation of the affected organ(s) may be necessary. Repeat explorations usually need to be performed to remove additional necrotic tissue. Typically, this leaves a large open wound which often requires skin grafting. The associated systemic inflammatory response is usually profound, and most patients will require monitoring in an intensive care unit.

Antimicrobial regimen

  • Necrotizing fasciitis[1]
  • 1. Mixed infections
  • 1.1 Adults
  • 1.2 Pediatrics
  • Preferred regimen (1): Piperacillin-tazobactam 60–75 mg/kg/dose of the Piperacillin component IV q6h AND Vancomycin 10–13 mg/kg/dose IV q8h
  • Note: Severe pencillin allergy, use clindamycin or metronidazole with an aminoglycoside or fluoroquinolone)
  • Preferred regimen (2): Meropenem 20 mg/kg/dose IV q8h
  • Preferred regimen (3): Ertapenem 15 mg/kg/dose IV q12h for children 3 months-12 years
  • Preferred regimen (4): Cefotaxime 50 mg/kg/dose IV q6h AND Metronidazole 7.5 mg/kg/dose IV q6h
  • Preferred regimen (5): Cefotaxime 50 mg/kg/dose IV q6h AND Clindamycin 10–13 mg/kg/dose IV q8h
  • 2. Streptococcus infection
  • 2.1 Adults
  • Preferred regimen: Penicillin 2–4 MU IV q4–6h AND Clindamycin 600–900 mg IV q8h
  • Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
  • 2.2 Pediatric
  • Preferred regimen: Penicillin 0.06–0.1 MU/kg/dose IV q6h AND Clindamycin 10–13 mg/kg/dose IV q8h
  • Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
  • 3. Staphylococcus aureus
  • 3.1 Adults
  • Preferred regimen (1): Nafcillin 1–2 g IV q4h
  • Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
  • Preferred regimen (2): Oxacillin 1–2 g IV q4h
  • Preferred regimen (3): Cefazolin 1 g IV q8h
  • Preferred regimen (4): Vancomycin 30 mg/kg/day IV q12h
  • Preferred regimen (5): Clindamycin 600–900 mg IV q8h
  • Pediatrics
  • Preferred regimen (1): Nafcillin 50 mg/kg/dose IV q6h
  • Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
  • Preferred regimen (2): Oxacillin 50 mg/kg/dose IV q6h
  • Preferred regimen (3): Cefazolin 33 mg/kg/dose IV q8h
  • Preferred regimen (4): Vancomycin 15 mg/kg/dose IV q6h
  • Preferred regimen (5): Clindamycin 10–13 mg/kg/dose IV q8h (bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)
  • 4. Clostridium species
  • 4.1 Adults
  • 4.2 Pediatrics
  • 5. Aeromonas hydrophila
  • 5.1 Adults
  • 5.2 Pediatrics
  • Not recommended for children but may need to use in life-threatening situations
  • 6. Vibrio vulnificus
  • 6.1 Adults
  • 6.2 Pediatrics
  • Not recommended for children but may need to use in life-threatening situation

Nutritional Support

  • The metabolic demands of necrotizing fasciitis patients are similar to those of other major trauma or burns.[2]
  • Nutritional support to replace lost proteins and fluids from large wounds and/or the result of shock is required from the first day of patients hospital admission.

Hyperbaric oxygen

Contraindications to hyperbaric oxygen are:[6][7]

  • Pneumothorax
  • Cisplatin (which decreases the production of superoxide dismutase which is protective against damaging effects of high partial O2 pressure)
  • Doxorubicin therapy

Side effects of hyperbaric oxygen are:

IV γ-globulin

References

  1. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
  2. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A (2014). "Current concepts in the management of necrotizing fasciitis". Front Surg. 1: 36. doi:10.3389/fsurg.2014.00036. PMC 4286984. PMID 25593960.
  3. Escobar SJ, Slade JB, Hunt TK, Cianci P (2005). "Adjuvant hyperbaric oxygen therapy (HBO2)for treatment of necrotizing fasciitis reduces mortality and amputation rate". Undersea Hyperb Med. 32 (6): 437–43. PMID 16509286.
  4. Korhonen K (2000). "Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions". Ann Chir Gynaecol Suppl (214): 7–36. PMID 11199291.
  5. Hyperbaric oxygen therapy. http://onlinelibrary.wiley.com/doi/10.1080/110241500750008583/abstract (2016) Accessed on September 12, 2016
  6. Kindwall EP, Gottlieb LJ, Larson DL (1991). "Hyperbaric oxygen therapy in plastic surgery: a review article". Plast Reconstr Surg. 88 (5): 898–908. PMID 1924583.
  7. Capelli-Schellpfeffer M, Gerber GS (1999). "The use of hyperbaric oxygen in urology". J Urol. 162 (3 Pt 1): 647–54. PMID 10458334.
  8. Darabi K, Abdel-Wahab O, Dzik WH (2006). "Current usage of intravenous immune globulin and the rationale behind it: the Massachusetts General Hospital data and a review of the literature". Transfusion. 46 (5): 741–53. doi:10.1111/j.1537-2995.2006.00792.x. PMID 16686841.

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