Necrotizing fasciitis

Back

1st line –

surgical debridement

When debridement is performed, surgical incisions should extend beyond the areas of visible necrosis and the entire necrotic area excised.[3]

Back

Plus –

intravenous antibiotics

Treatment recommended for ALL patients in selected patient group

In addition to urgent surgical debridement, antibiotics should be administered that cover the most common etiologies of type I necrotizing fasciitis (a mixed infection with anaerobes such as Bacteroides or Peptostreptococcus with a facultative anaerobe such as Escherichia coli, Enterobacter, Klebsiella, Proteus, MRSA, or non-group A streptococcus).

Recommendations for type I mixed infections include vancomycin, linezolid, tedizolid, or daptomycin combined with either: piperacillin/tazobactam or a carbapenem (e.g., meropenem, imipenem/cilastatin, ertapenem).[2][5]

When further information is available and the etiologic agent has been determined, antibiotic therapy should be tailored to target the specific agent.

Primary options

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

linezolid: 600 mg intravenously every 12 hours

tedizolid phosphate: 200 mg intravenously every 24 hours

daptomycin: 4 mg/kg intravenously every 24 hours

-- AND --

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

imipenem/cilastatin: 1 g intravenously every 6-8 hours

meropenem: 1 g intravenously every 8 hours

ertapenem: 1 g intravenously every 24 hours

type II necrotizing fasciitis due to group A streptococcus

Back

1st line –

surgical debridement

When debridement is performed, surgical incisions should extend beyond the areas of visible necrosis and the entire necrotic area excised.[3]

Consider – intravenous immune globulin (IVIG)

streptococcal toxic shock

Back

Consider –

intravenous immune globulin (IVIG)

Treatment recommended for SOME patients in selected patient group

The addition of IVIG may be considered for treatment of streptococcal toxic shock syndrome, although data on efficacy are conflicting.[2][3][5]

Primary options

immune globulin (human): 1 g/kg intravenously on day 1, followed by 0.5 g/kg on days 2 and 3; or 2 g/kg intravenously as a single dose

type II necrotizing fasciitis due to Staphylococcus aureus

Back

1st line –

surgical debridement

When debridement is performed, surgical incisions should extend beyond the areas of visible necrosis and the entire necrotic area excised.[3]

After complete removal of necrotic tissue and final debridement, negative pressure wound therapy may be considered to help with granulation and healing of the wound.[15]

Back

Plus –

intravenous antibiotics

Treatment recommended for ALL patients in selected patient group

In addition to urgent surgical debridement, antistaphylococcal antibiotics should be administered.

Antibiotics active against MRSA should be used until cultures confirm susceptibilities. Options include vancomycin, linezolid, tedizolid, or daptomycin; ceftaroline, telavancin, or dalbavancin are also reasonable choices, although clinical data are sparse.[2][5]

Nafcillin, oxacillin, or cefazolin may be used if methicillin susceptibility is confirmed.

Primary options

MRSA

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

MRSA

linezolid: 600 mg intravenously every 12 hours

MRSA

tedizolid phosphate: 200 mg intravenously every 24 hours

MRSA

daptomycin: 4 mg/kg intravenously every 24 hours

Secondary options

MRSA

ceftaroline fosamil: 600 mg intravenously every 12 hours

MRSA

dalbavancin: 1500 mg intravenously as a single dose; or 1000 mg intravenously as a single dose followed by 500 mg one week later

MRSA

telavancin: 10 mg/kg intravenously every 24 hours

Tertiary options

MSSA

nafcillin: 1-2 g intravenously every 4 hours

MSSA

oxacillin: 1-2 g intravenously every 4 hours

MSSA

cefazolin: 1 g intravenously every 6-8 hours

type II necrotizing fasciitis due to Vibrio vulnificus

Back

1st line –

surgical debridement

When debridement is performed, surgical incisions should extend beyond the areas of visible necrosis and the entire necrotic area excised.[3]

type II necrotizing fasciitis due to Aeromonas hydrophila

Back

1st line –

surgical debridement

When debridement is performed, surgical incisions should extend beyond the areas of visible necrosis and the entire necrotic area excised.[3]

Back

Plus –

intravenous antibiotics

Treatment recommended for ALL patients in selected patient group

Aeromonas hydrophila infection may cause necrotizing fasciitis in patients with suppressed immune systems, burns, and trauma in an aquatic setting.[10]

Doxycycline is used in the management of type II necrotizing fasciitis attributable to Aeromonas hydrophila alongside a cephalosporin (e.g., ceftriaxone) or a fluoroquinolone (e.g., ciprofloxacin).[5]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[56] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Primary options

doxycycline: 100 mg intravenously every 12 hours

-- AND --

ceftriaxone: 2 g intravenously every 12-24 hours

ciprofloxacin: 400 mg intravenously every 8-12 hours

type II necrotizing fasciitis due to mucorales

Back

1st line –

surgical debridement

When debridement is performed, surgical incisions should extend beyond the areas of visible necrosis and the entire necrotic area excised.[3]

After complete removal of necrotic tissue and final debridement, negative pressure wound therapy may be considered to help with granulation and healing of the wound.[15]