Optimizing Antibiotic Choice, Administration, and Duration in NSTI Treatment

TL;DR

This paper discusses how to best choose and use antibiotics for treating severe soft tissue infections based on infection type and patient factors.

Contribution

The paper provides a structured approach to optimizing antibiotic selection and duration for different types of necrotizing soft tissue infections.

Findings

NSTIs are categorized into four types based on causative pathogens.

Broad-spectrum antibiotics are commonly used initially, but should be adjusted based on microbiological data.

Adjunct therapies like IVIG and clindamycin may improve outcomes by targeting toxins.

Abstract

Necrotizing soft tissue infections (NSTIs) are serious and aggressive infections which can result in significant morbidity and mortality. Both prompt surgical intervention and early antibiotics can decrease patient mortality. Based on microbiology, NSTIs can be categorized into four different types. Type I is polymicrobial, caused by a mix of both anaerobic and aerobic bacteria. Type II is monomicrobial, usually caused by either Streptococcus or Staphylococcus. Type III infections are caused by Gram-negative bacteria, often marine-related organisms, such as Vibrio. Lastly, Type IV infections are caused by fungi, and they are often associated with trauma. Despite the possibility of all these different pathogens in NSTI, early therapy often consists of a broad Gram-positive antimicrobial such as linezolid or vancomycin, and a broad Gram-negative agent such as piperacillin/tazobactam. Multiple factors including patient comorbidities, environmental exposures, and clinical presentation must also be considered when choosing antimicrobial agents and dosing. Adjunct medical therapies such as intravenous immunoglobulin (IVIG) and the antibiotics clindamycin and linezolid that are aimed at toxin suppression may be utilized to improve outcomes. Microbiological data are critical for optimizing the antimicrobial regimen.