What is the treatment for necrotizing fasciitis?

From the Guidelines

Necrotizing fasciitis requires immediate aggressive treatment with surgical debridement, broad-spectrum intravenous antibiotics, and supportive care. The primary therapeutic modality in cases of necrotizing fasciitis is surgical intervention, which is indicated when this infection is confirmed or suspected 1. Features suggestive of necrotizing fasciitis include clinical findings such as profound toxicity, fever, hypotension, or advancement of the skin and soft tissue infection (SSTI) during antibiotic therapy, skin necrosis with easy dissection along the fascia by a blunt instrument, or presence of gas in the soft tissues.

Key Components of Treatment

• Surgical debridement: 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.
• Broad-spectrum intravenous antibiotics: Empiric treatment of polymicrobial necrotizing fasciitis should include agents effective against both aerobes, including MRSA, and anaerobes, such as a combination of vancomycin, piperacillin-tazobactam, and clindamycin 1.
• Supportive care: Aggressive fluid administration is a necessary adjunct, and supportive measures include fluid resuscitation, pain management, nutritional support, and sometimes hyperbaric oxygen therapy.

Antibiotic Therapy

• Initial empiric antibiotic therapy should cover gram-positive, gram-negative, and anaerobic organisms.
• Specific antibiotic regimens may include:
  • Vancomycin (15-20 mg/kg IV every 8-12 hours) plus piperacillin-tazobactam (4.5g IV every 6-8 hours) 1.
  • Clindamycin (600-900 mg IV every 8 hours) is particularly important as it inhibits toxin production by group A streptococci 1.
• Antibiotics should be adjusted based on culture results and continued for at least 2-3 weeks.

Special Considerations

• For streptococcal toxic shock syndrome, penicillin plus clindamycin is recommended 1.
• Intravenous immunoglobulin may be considered for streptococcal toxic shock syndrome, although its efficacy has not been established 1.

From the Research

Treatment Overview

The treatment of necrotizing fasciitis is a multifaceted approach that requires immediate attention. The key components of treatment include:

• Surgical source control with immediate surgical debridement
• Life support and clinical monitoring
• Antimicrobial therapy, which may involve broad-spectrum antibiotics 2, 3
• Hyperbaric oxygen therapy as an adjuvant treatment in some cases 4, 5

Antimicrobial Therapy

Antimicrobial therapy is crucial in the treatment of necrotizing fasciitis. Acceptable monotherapy regimens include:

• Piperacillin-tazobactam
• Carbapenem Alternative therapies 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

Surgical Debridement

Surgical debridement is a critical component of treatment, and may be performed in combination with:

• Maggot debridement therapy (MDT) to reduce the number of surgical debridements 6
• Hyperbaric oxygen therapy to support wound healing and reduce infection 4, 5

Adjuvant Therapies

Adjuvant therapies, such as hyperbaric oxygen therapy, may be used to support treatment and promote wound healing. However, these therapies should not replace the combination of early aggressive debridements and wide-spectrum antibiotic therapy 5