Empirical therapy for necrotising skin and soft tissue infection not associated with water exposure
For necrotising skin and soft tissue infections, empirical antibiotic therapy should be used in combination with surgical debridement. In adults and children with necrotising skin and soft tissue infection not associated with water exposure, as a 3-drug regimen, useAbdul-Aziz 2024Dulhunty 2024:
meropenem intravenously. For dosage adjustment in adults with kidney impairment, see meropenem dosage adjustment. See advice on modification and duration of therapy meropenem meropenem meropenem
patients without septic shock and not requiring intensive care support: 1 g (child: 20 mg/kg up to 1 g) 8-hourly1
patients with septic shock or requiring intensive care support: 1 g (child: 20 mg/kg up to 1 g) administered as a loading dose over 30 minutes. After 4 hours, administer 1 g (child: 20 mg/kg up to 1 g) 8-hourly, as consecutive 8-hour infusions123
PLUS
vancomycin intravenously; see advice on modification and duration of therapy vancomycin vancomycinvancomycin
adult: 25 mg/kg (actual body weight) rounded up to nearest 125 mg, up to 3 g intravenously, as a loading dose. See Calculated vancomycin loading dosage in critically ill adults for calculated weight-based loading doses. Subsequent doses are dependent on weight and kidney function; see Intermittent vancomycin dosing in critically ill adults
child: for initial dosing, see Intermittent vancomycin dosing in young infants and children
PLUS
clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly4. See advice on modification and duration of therapy.clindamycin clindamycin clindamycin
If meropenem is not immediately available or if there is a low suspicion of multidrug-resistant gram-negative infection, piperacillin+tazobactam may be a suitable alternative to meropenem. Replace meropenem in the above regimen withAbdul-Aziz 2024Dulhunty 2024:
piperacillin+tazobactam intravenously. For dosage adjustment in adults with kidney impairment, see piperacillin+tazobactam dosage adjustment. See advice on modification and duration of therapy piperacillin + tazobactam piperacillin+tazobactam piperacillin+tazobactam
patients without septic shock and not requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) 6-hourly
patients with septic shock or requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) administered as a loading dose over 30 minutes. After 3 hours, start a continuous infusion of 16+2 g (child: 400+50 mg/kg up to 16+2 g) administered over 24 hours56.
For patients who report hypersensitivity to penicillins (for advice on assessing and managing hypersensitivity, see Approach to assessment and management of patients reporting hypersensitivity to penicillins in whom a beta-lactam antibiotic is the preferred drug), the meropenem-containing regimen7 may be suitable.
The Antibiotic Expert Group recommend that intravenous immunoglobulin be used if Streptococcus pyogenes necrotising fasciitis is suspected (typically infection involving a limb and associated with nonpenetrating trauma or an injury that breaks the skin). Add to either of the above regimensKadri 2017Linner 2014:
intravenous immunoglobulin (IVIg) (adult and child) 2 g/kg intravenously, as a single dose as soon as possible but not later than 72 hours after symptom onset. It is reasonable to give the dose in divided doses if it is not possible to give a single dose. intravenous immunoglobulin (IVIg) intravenous immunoglobulin (IVIg)
Clindamycin is recommended for empirical therapy of necrotising skin and soft tissue infection because of a theoretical reduction in bacterial toxin production; however, clinical evidence is limited.