Review Question - QID 221214

This patient with fever, rapidly progressive rash, and severe pain in the setting of poorly treated diabetes, most likely has necrotizing fasciitis. The most appropriate next step in management is empiric broad antibiotic coverage with vancomycin, piperacillin-tazobactam, and clindamycin, as well as surgical debridement.

Necrotizing fasciitis is a rapidly progressive bacterial infection of the deep soft tissues. Organisms involved include Streptococcus pyogenes, Staphylococcus aureus, mixed anaerobes, and gram-negative rods. Bacteria are generally introduced into the soft tissues during surgery, minor trauma, or any open wound. The infection is more common in immunosuppressed patients such as diabetics, transplant patients, or patients with HIV. The infection can progress over minutes to days and results in profound tissue damage and death. A physical exam may reveal crepitus; however, this is not a necessary finding to make the diagnosis since many organisms do not produce gas. The appropriate treatment involves coverage for MRSA (vancomycin), a carbapenem or beta-lactam + beta-lactamase inhibitor, and clindamycin for toxin suppression. Patients must also undergo surgical debridement, as there is nearly a 100% mortality rate without a surgical intervention.

Leiblein et al. review strategies for diagnosing and managing necrotizing fasciitis. They discuss how diabetes mellitus is a risk factor for amputation in these patients. They recommend emergent surgical debridement.

Figure A/Illustration A is a clinical photograph demonstrating large expansile necrotizing patches and plaques (red circle). These findings are consistent with a diagnosis of necrotizing fasciitis.

Incorrect Answers:
Answer 1: Ceftriaxone is an appropriate IV antibiotic that can be given for cellulitis that is refractory to oral antibiotics. If this patient had a slowly spreading red and warm leg without systemic symptoms, then oral cephalexin could be given first, followed by ceftriaxone if not responsive to this oral antibiotic.

Answer 2: Vancomycin and ceftriaxone is a broad-spectrum regimen that covers MRSA and skin flora. Vancomycin would be added to treatment if the patient presented with cellulitis refractory to treatment and an abscess, purulence, or MRSA risk factors.

Answer 3: Vancomycin, cefepime, clindamycin, and surgical debridement are a broad-spectrum regimen; however, a carbapenem or beta-lactam + beta-lactamase inhibitor must be given for necrotizing fasciitis. Cefepime could be given if there is an allergy to piperacillin-tazobactam.

Answer 4: Vancomycin, cefepime, piperacillin-tazobactam, and surgical debridement are a broad-spectrum regimen; however, it misses out on the toxin suppression of clindamycin.

Bullet Summary:
The treatment of necrotizing fasciitis are broad-spectrum antibiotics in addition to surgical debridement.