Infectious Diseases I
Antibiotic therapy is empiric or definitive.
Empiric antibiotic therapy should be initiated as early as possible.
ii.
Polymicrobial infection should be suspected, with empiric therapy that is active against aerobic
and anaerobic gram-positive and gram-negative pathogens
| (a) | Vancomycin or linezolid, plus: |
|---|---|
| (b) | Piperacillin/tazobactam, broad-spectrum carbapenem, or cefepime plus metronidazole |
| (c) | If linezolid is not initially chosen, adding clindamycin to the treatment regimen can be |
considered.
| (1) | Both demonstrate potential decrease in pathogenic toxin and cytokine production if |
|---|
Streptococcus pyogenes is suspected.
| (2) | Both seem to be clinically effective, with limited data supporting the benefit of one |
|---|
over the other (Open Forum Infect Dis. 2023;10(6):ofad258).
iii.
Empiric antibiotic therapy should be de-escalated according to final culture results.
iv.
Definitive antibiotic therapy should be based on final culture results and antibiotic susceptibility.
Infection caused by S. pyogenes should be treated with an active Ξ²-lactam or vancomycin (in
severe penicillin allergy) plus clindamycin for up to 72 hours or while the patient requires
surgical debridement. Use of intravenous immunoglobulin (IVIG) is controversial. Limited
evidence suggests a shorter time to no further need for debridement but no effect on mortality.
Antibiotic therapy should be continued until surgical debridement is no longer necessary and
until resolution of infection-related signs and symptoms.
Organ or space infection: See individual chapters, sections, or guidelines for managing organ/space-
specific infection (e.g., pancreatitis, intra-abdominal infection; genitourinary tract).
Patient Case
Questions 17 and 18 pertain to the following case.
R.J. is a 57-year-old man admitted to the SICU after a bowel resection following an acute bowel obstruction.
On postoperative day 3, R.J. has worsening tachycardia and decreased urinary output together with a maximum
temperature of 102.9Β°F (39.4Β°C) and a WBC of 18.2 x 103 cells/mm3. R.J. reports worsening pain around his
large abdominal surgical wound despite minimal erythema. On opening a few sutures of the wound, pus is
expressed on examination, and crepitus is noted in the area surrounding the wound. R.J. is emergently taken
to the operating room for exploration and is noted to require significant debridement of necrotic subcutaneous
tissue, including the involved fascia. R.J.βs wound is left open with a temporary gauze dressing.
chains and moderate nonβlactose-fermenting gram-negative bacilli. R.J. is to undergo serial intraoperative
debridements of necrotic tissue. Given the concern for S. pyogenes from the Gram stain, which pharmaco-
therapeutic intervention would be most appropriate for treatment of R.J.βs necrotizing fasciitis?