# Top unanswered questions in antimicrobial management of necrotizing soft tissue infections

## TL;DR

This paper reviews key questions about antibiotic treatment for severe soft tissue infections, aiming to improve care and reduce resistance.

## Contribution

The paper highlights novel strategies for optimizing antibiotic duration and de-escalation in necrotizing soft tissue infections.

## Key findings

- Shorter antibiotic courses may be effective after surgical debridement in necrotizing soft tissue infections.
- Linezolid could be a safe alternative to clindamycin for anti-toxin therapy due to rising resistance.
- Antibiotic management should be individualized based on surgical source control rather than fixed durations.

## Abstract

Necrotizing soft tissue infections (NSTIs) are life-threatening conditions that require prompt surgical and antimicrobial intervention. An upward global trend in invasive group A streptococcal infections, concerning for a synchronous rise in NSTIs, warrants a standardized approach to antibiotic management of NSTIs to optimize care. Emerging data support a shorter antibiotic course following definitive surgical debridement, even in cases with concurrent streptococcal bacteremia. Individualized antibiotic management guided by surgical source control, as opposed to fixed durations, may help minimize unnecessary antibiotic exposure and the resultant adverse events and antimicrobial resistance. The use of clindamycin as an adjunctive anti-toxin antibiotic remains a common practice, though rising resistance and comparative studies suggest linezolid may be a safe alternative. This review aims to offer strategies to optimize antibiotic care in NSTIs by reviewing the growing body of evidence on antibiotic duration, de-escalation strategies, and adjunctive anti-toxin therapy.