Treatment for Infection with Blackening in the Affected Area
Urgent surgical debridement is the primary treatment for infections with blackening, which likely represents necrotizing soft tissue infection (NSTI) or Fournier's gangrene, combined with broad-spectrum antibiotics and supportive care. 1
Immediate Management
- Prompt surgical consultation is essential for patients with aggressive infections showing signs of systemic toxicity or suspected necrotizing fasciitis/gas gangrene 1
- Surgical debridement must be early, aggressive, and radical to halt progression of infection, continuing into healthy-looking tissue 1
- Multiple debridements (24-36 hours after initial surgery and daily thereafter) are typically required until no further necrotic tissue is found 1
- Cultures of infected fluid and tissues should be obtained during initial surgical debridement to guide antibiotic therapy 1
Antibiotic Therapy
- Empiric broad-spectrum antibiotic treatment should be initiated immediately, as the etiology can be polymicrobial or monomicrobial 1
- Recommended empiric regimen includes:
- Vancomycin or linezolid (for MRSA coverage)
- PLUS one of the following:
- Piperacillin-tazobactam
- A carbapenem (imipenem-cilastatin, meropenem, or ertapenem)
- Ceftriaxone plus metronidazole 1
- For documented group A streptococcal necrotizing fasciitis, penicillin plus clindamycin is recommended 1
- Antibiotics should be administered until further debridement is no longer necessary, the patient has improved clinically, and fever has been resolved for 48-72 hours 1
Supportive Care
- Aggressive fluid resuscitation is necessary as these wounds can discharge copious amounts of tissue fluid 1
- Hemodynamic support is critical, especially for patients with Fournier's gangrene 1
- For Fournier's gangrene with fecal contamination, consider fecal diversion through colostomy or fecal tube system 1
Wound Management
- Negative pressure wound therapy (NPWT) should be considered after complete removal of necrosis 1
- NPWT can be used in combination with fecal diversion tubes for effective isolation of the wound from fecal contamination 1
- Procalcitonin monitoring may be useful to guide antimicrobial discontinuation, with a ratio of day 1 to day 2 PCT levels higher than 1.14 indicating successful surgical intervention 1
Special Considerations
- For Fournier's gangrene, the Fournier's Gangrene Severity Index (FGSI) can help predict outcomes, with scores above 9 being sensitive and specific as mortality predictors 1
- Imaging studies (CT, MRI) may help identify the extent of soft-tissue involvement but should not delay definitive surgical treatment 1
- Hyperbaric oxygen therapy is not recommended for gas gangrene as it has not been proven beneficial and may delay resuscitation and surgical debridement 1
Pitfalls to Avoid
- Delaying surgical intervention while waiting for imaging studies can increase mortality 1
- Underestimating the extent of infection - the relatively benign appearance of the skin can be misleading as infection can spread unrecognized along fascial planes 2
- Inadequate debridement - surgical debridement must be aggressive and extend into healthy-looking tissue 1
- Stopping antibiotics too early - continue until clinical improvement and resolution of fever for 48-72 hours 1