From the Guidelines
Strep A skin lesions with necrotizing fasciitis require immediate surgical debridement combined with high-dose intravenous antibiotics, with the recommended regimen including penicillin G plus clindamycin for 10-14 days, as stated in the 2014 practice guidelines by the Infectious Diseases Society of America 1. The treatment approach should prioritize prompt surgical consultation and empiric antibiotic treatment, considering the potential for polymicrobial or monomicrobial etiology.
- Key considerations include:
- Prompt surgical debridement to prevent further tissue destruction
- High-dose intravenous antibiotics, such as penicillin G (4 million units IV every 4 hours) plus clindamycin (600-900 mg IV every 8 hours) for 10-14 days
- Alternative antibiotics, such as vancomycin (15-20 mg/kg IV every 12 hours), for penicillin-allergic patients
- ICU admission for close monitoring and supportive care
- Laboratory monitoring, including complete blood count, C-reactive protein, and creatine kinase levels Although some studies suggest considering intravenous immunoglobulin (IVIG) therapy for source control in necrotizing infections caused by Group A Streptococcus (GAS) 1, the current evidence does not support its routine use, and the primary focus should remain on prompt surgical and antibiotic intervention.
- The use of IVIG therapy may be considered in specific cases, but its efficacy and safety are still being evaluated, and the current evidence is not sufficient to recommend its routine use in clinical practice 1.
From the FDA Drug Label
Clindamycin Injection, USP is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. Clindamycin Injection, USP is also indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci Skin and skin structure infections caused by Streptococcus pyogenes, Staphylococcus aureus, and anaerobes.
Treatment options for Streptococcus A (Strep A) skin lesions with necrotizing fasciitis:
- Clindamycin (IV) may be used to treat serious skin and skin structure infections caused by Streptococcus pyogenes, which is a type of Strep A bacteria.
- The recommended dosage for clindamycin (IV) is 600 mg to 1,200 mg per day in 2,3 or 4 equal doses for adults with serious infections.
- Penicillin G (IV) may also be used to treat infections caused by susceptible strains of streptococci, including Strep A.
- The recommended dosage for penicillin G (IV) is 150,000 - 300,000 units/kg/day divided in equal doses every 4 to 6 hours for pediatric patients, and 10 million units/day in 4 equally divided doses for adults with disseminated gonococcal infections.
- Surgical intervention, such as debridement, may be necessary in conjunction with antibiotic therapy to treat necrotizing fasciitis.
- Antibiotic therapy should be maintained for at least 10 days to reduce the risk of rheumatic fever in patients with Group A β-hemolytic streptococcal infections 2, 2, 3.
From the Research
Treatment Options for Streptococcus A (Strep A) Skin Lesions with Necrotizing Fasciitis
- The primary treatment for necrotizing fasciitis involves surgical debridement of infected tissue, supportive care, antibiotics, and hemodynamic monitoring 4, 5, 6.
- Intravenous immunoglobulin (IVIG) may be a useful adjunct in the treatment of streptococcal toxic shock syndrome (STSS) associated with necrotizing fasciitis 4, 5.
- Hyperbaric oxygen therapy (HBOT) might also have a role as an adjuvant therapy 5.
- Soft tissue reconstruction may be necessary following surgery 5.
- Intensive anti-infection therapy, including antibiotics such as penicillin, clindamycin, or other inhibitors of protein synthesis, is essential for the treatment of streptococcal infections 7.
- In cases of polymicrobial infections, initial therapy should include treatment for staphylococci and anaerobes, and broad-spectrum antibiotics may be needed 7.