Necrotizing Faciitis, Typical of Group A Strep

Most likely pathogen

Streptococcus pyogenes (Group A Strep)

Consult

Infectious Diseases

Duration of therapy

Depending upon clinical response, may continue 14 days after last positive culture (surgical debridement)

Suggested regimen

Penicillin G 0.25 million units/kg/24h IV divided q4-6h
Maximum: 24 million units/24h

AND

Clindamycin 8-13 mg/kg/dose IV q8h
Maximum: 900 mg/dose

Consideration may be given to discontinuing clindamycin after 48 h to 72 h of treatment if the patient is hemodynamically stable, blood is sterile and there is no further progression of necrosis. Clindamycin is not recommended for monotherapy of

because GAS resistance rates to clindamycin have increased, whereas, to date, there is no GAS resistance to penicillin.

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AND IF TOXIC SHOCK SYNDROME:
Intravenous immune globulin (IVIG) should be considered on the day of clinical presentation in the treatment of streptococcal TSS or other severe invasive (toxin-mediated) disease, especially when the patient is severely ill or the condition is refractory to initial aggressive therapy with fluids. The proposed mechanism of action of IVIG in is multifactorial and includes toxin neutralization, opsonization and improved phagocytic killing, and suppression of the massive inflammatory response through Fc-receptor interactions.

IV Immunoglobulin (IVIG) 1-2 grams/kg/dose IV as a single dose or
150-500 mg/kg/dose IV daily for 5 to 6 days

Penicillin allergy

Ceftriaxone 50-75 mg/kg/dose IV q24h
Maximum: 2000 mg/dose

AND

Clindamycin 8-13 mg/kg/dose IV q8h
Maximum: 900 mg/dose

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AND IF TOXIC SHOCK SYNDROME:
IV Immunoglobulin (IVIG) 1 gram/kg/dose IV on day 1,
then 500 mg/kg/dose IV on day 2 & 3