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Antibiotic Management of Necrotizing Fasciitis

Reporter: Aviva Lev-Ari, PhD, RN

Personal Nursing Notes:

• In Nursing School at Northeastern University, 9/2005 – 12/2007, wrote a paper on Causes of Necrotiszing Tissue
• In Medical-Surgical Rotation at BWH, Boston, 2006, shadowed post-surgical case of Necrotizing Fasciitis and treatment with vacuum-assisted wound closing device (VAC). Postoperative management of the surgical wound benefited from exudate removal and exact monitoring of exudate accumulation in VAC canister recorded by the Nursing staff.
• In Vulnerable Populations rotation at Barbara McGinnis House in Jamaica Plain, 2006, delivered wound care to a patient with type 3 fasciitis on a lower extremity
• In LTACH, Kindred Waltham Hospital, as Hospital Supervisor, 2009, supervised administration of triple IV antibiotic treatment for a patient with Type 3 Fasciitis of the lower extremity
• In personal communication with Dr. T.H., OCB, Boston, 2003, he reported the cardinal importance of triple IV antibiotic treatment in curing Fasciitis in lower extremity following Hip replacement surgery.

Report Based on

Current Concepts in the Management of Necrotizing Fasciitis

Since ischemia and hypoxia compromise the adequate delivery of antibiotics to the infection site, conservative treatment with antibiotics alone has little value in the management of NF (58). However, they play a significant role in surgical management of the infection. Patients should be immediately treated with broad-spectrum antibiotics, when NF is suspected. The empirical usage of antibiotics is based on the microbiological classification of NF. Antibiotic treatment of a polymicrobial infection should be based on history, Gram stain, and culture. Initial treatment includes ampicillin or ampicillin–sulbactam combined with metronidazole or clindamycin (59). Anaerobic coverage is quite important for type 1 infection; metronidazole, clindamycin, or carbapenems (imipenem) are effective antimicrobials. Broad gram-negative coverage is necessary as an initial empirical therapy for patients who have recently been treated with antibiotics, or been hospitalized. In such cases, antibiotics such as ampicillin–sulbactam, piperacillin–tazobactam, ticarcillin–clavulanate acid, third or fourth generation cephalosporins, or carbapenems are used, and at a higher dosage.

Type 2 disease is treated with antibiotics against S. pyogenes and S. aureus, which usually coexist with the former. Hence, first or second generation of cephalosporins are used for the coverage of methicillin-sensitive Staphylococcus aureus (MSSA). MRSA tends to be covered by vancomycin, or daptomycin and linezolid in cases where S. aureus is resistant to vancomycin. Some studies suggest that clindamycin is superior to penicillin in managing streptococcal infections (60), but this has yet to be satisfactorily proven. Another study has proposed that clinicians should consider adding clindamycin to the beta-lactam antibiotic regimen when NF or myositis is present (61).

Type 3 NF should be managed with clindamycin and penicillin, which cover the Clostridium species. If Vibrio infection is suspected, the early use of tetracyclines (including doxycycline and minocycline) and third-generation cephalosporins is crucial for the survival of the patient, since these antibiotics have been shown to reduce the mortality rate drastically (59).

Finally, type 4 NF can be treated with amphotericin B or fluoroconazoles, but the results of this treatment are generally disappointing.

As in every empirical antibiotic therapy, the dosage should be tapered, based on the results of the initial blood, wound, and tissue cultures, but continued until the infection is under control and for at least 48 h after clinical and hemodynamic stabilization of the patient has been achieved. Antibiotics should be administered for up to 5 days after local signs and symptoms have resolved (62). The mean duration of antibiotic therapy for NF is 4–6 weeks.

Intravenous immunoglobulin (IVIG) has recently been described as a reasonable and desirable option for neutralizing streptococcal toxins (63). There is evidence that a high dose of IVIG may prove beneficial in severe streptococcal infections (64), but this has yet to be demonstrated with randomized studies.

Nursing comments:

Nutrition

Nutritional support is required from the first day of the patient’s admission to hospital (preferably the ICU), to replace lost proteins and fluid from large wounds and/or the resultant toxic shock. Metabolic demands are similar to those of other major trauma or burns, which means that the patient needs twice the basic caloric requirements.

Wound dressing and debridement

Postoperative management of abdominal wall wounds involves serial dressing changes over the following days, until the wound is free of recurrent or ongoing infection. The use of a vacuum-assisted wound closing device (VAC) can also be helpful. After surgical debridement, the use of the VAC system helps wound healing by absorbing excess exudates; reducing localized edema, and finally drawing wound edges together

Conclusion

Necrotizing fasciitis is a rare but life-threatening condition, with a high mortality rate (median mortality 32.2%) that approaches 100% without treatment. Numerous conditions are associated with this pathology, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis, which can be conductive to the rapid spread of necrosis, and increase in the mortality rate. The diagnosis of NF is difficult and the differential diagnosis between NF and other necrotizing soft tissue infections more so. However, the clinician should do their utmost to secure the diagnosis of NF, as a delay in diagnosis can be fatal, and septic shock is inevitable if the disease remains untreated. The characteristic of NF is the clinical status change over time. The early clinical picture includes erythema, swelling, tenderness to palpation, and local warmth; once the infection develops, the infection site presents skin ischemia with blisters and bullae. The diagnosis of NF can be secured faster with the use of laboratory-based scoring systems, such as the LRINEC score or the FGSI score, especially in cases of Fournier’s gangrene. However, the diagnosis is definitely established by performing explorative surgery at the infected site.

Management of the infection begins with antibiotic treatment. In the majority of cases with NF (70–90%) the reasonable pathogens are two or more, suggesting the use of broad-spectrum antibiotics. The value of antibiotic treatment in NF is relatively low, and early and aggressive drainage and debridement is required. In NF of the extremities, the clinician should consider amputating the infected limb, although this will not reduce the risk of mortality. Finally, postoperative management of the surgical wound is important, along with proper nutrition of the patient. The use of VAC therapy in wound management has greatly improved the results of postoperative management.

SOURCE includes the References mentioned, above

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286984/