From the Guidelines
The first line treatment for necrotizing fasciitis is immediate surgical debridement combined with broad-spectrum intravenous antibiotics, as recommended by the Infectious Diseases Society of America 1.
Key Considerations
- Surgical intervention is the primary therapeutic modality in cases of necrotizing fasciitis, and should be performed as soon as possible, with aggressive removal of all infected and necrotic tissue, often requiring multiple debridements 1.
- Antibiotic therapy should include coverage for gram-positive, gram-negative, and anaerobic organisms, typically with a combination of piperacillin-tazobactam or meropenem, plus vancomycin or linezolid, and clindamycin 1.
- Clindamycin is particularly important as it inhibits toxin production, and is recommended for treatment of documented group A streptococcal necrotizing fasciitis, in combination with penicillin 1.
Treatment Approach
- Most patients with necrotizing fasciitis should return to the operating room 24–36 hours after the first debridement and daily thereafter until the surgical team finds no further need for debridement 1.
- Aggressive administration of fluid is a necessary adjunct, as these wounds can discharge copious amounts of tissue fluid 1.
- Antimicrobial therapy must be directed at the pathogens and used in appropriate doses until repeated operative procedures are no longer needed, the patient has demonstrated obvious clinical improvement, and fever has been absent for 48–72 hours 1.
Important Considerations
- Early surgical consultation is critical, as delayed debridement significantly increases mortality 1.
- Hemodynamic support with IV fluids and vasopressors is often necessary, as these patients frequently develop septic shock 1.
- Hyperbaric oxygen therapy may be considered as an adjunctive treatment in certain facilities, but its effectiveness is not well established 1.
From the Research
First Line Treatment for Necrotizing Fasciitis
The first line treatment for necrotizing fasciitis involves a multifaceted approach, including:
- Surgical source control with immediate surgical debridement
- Life support and clinical monitoring
- Antimicrobial therapy with broad-spectrum coverage 2 Some acceptable monotherapy regimens include:
- Piperacillin-tazobactam
- A carbapenem Alternative options may include:
- Ceftolozane-tazobactam
- Ceftazidime-avibactam in association with an antianaerobic agent (metronidazole or clindamycin) 2
- New long-acting lypoglycopeptides, such as oritavancin and dalbavancin, which are effective against Gram-positive cocci, including MRSA and streptococci 2
Key Components of Treatment
The treatment of necrotizing fasciitis requires:
- Immediate surgical debridement to remove necrotic tissue 3, 4
- Broad-spectrum antibiotics to cover polymicrobial infections 3, 5
- Supportive measures, such as wound packing and nutritional support 3, 5
- Prompt and aggressive surgical debridements to prevent further tissue damage 5
Importance of Early Diagnosis and Treatment
Early recognition and treatment of necrotizing fasciitis are crucial for survival, as the infection can spread rapidly 6, 4 Frozen section tissue biopsy can be a useful adjunct in establishing an early and accurate diagnosis of necrotizing fasciitis 4