Abstract
Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.
Highlights
Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues
group A streptococcus (GAS) infections remain highly susceptible to beta-lactams, penicillin, association with clindamycin is strongly recommended in the case of NSTI [11]
It was reported to be satisfactory for aminoglycosides [86]. Though it could be lower for beta-lactams [81,87], in the case of high-protein binding [88], small scale pharmacokinetic studies on healthy subjects or monte-carlo simulations have found prolonged time periods above the minimum inhibitory concentrations 90 (MIC90) of S. aureus and S. pyogenes in blisters for meropenem, imipenem and piperacillin-tazobactam [89,90], and high probabilities of target attainment for cefazolin in the interstitial fluid [91]
Summary
Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should ideally achieve the following goals: (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases; (2) decrease toxin production, mainly in proven or suspected group A streptococcus (GAS) infections; and (3) achieve the best possible tissular diffusion in the face of impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations among these frequently critically-ill patients. The aim of this article is to review the currently available knowledge regarding antibiotic use in NSTIs and provide clinicians with a practical tool to use at bedside
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