Antibiotics in Necrotizing Soft Tissue Infections

Abstract

Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.

A Comparison of Pre-Emptive Co-Amoxiclav, Postoperative Amoxicillin, and Metronidazole for Prevention of Postoperative Complications in Dentoalveolar Surgery: A Randomized Controlled Trial

“…Another possibility of dry socket and infection after surgical extraction is not using proper irrigation with normal saline [ 4 , 5 , 17 ]. This means that bony and dental debris remain inside the socket of extracted tooth, which prevent the formation of a healthy blood clot [ 7 , 9 , 11 ]. Clinically, there is a socket filled with a blood clot containing a collection of dirty tissue that forms a fertile focus for the multiplication of aerobic and anaerobic bacteria.…”

“…Bacteria attack on the site of extraction increases dehydration and accelerates the formation of microscopic clots in the bony surfaces of the extracted tooth socket [ 4 , 8 ]. These microscopic clots impede blood flow at the site of extraction, causing a decreased ability to eliminate bacterial virulence [ 5 , 7 , 21 ]. Thus, the site of extraction becomes fragile and susceptible to various degrees of infection, the least severe of which is alveolar osteitis (dry socket) and the most severe of which is osteomyelitis.…”

“…Since surgical extraction requires raising the flap and removing bone on the buccal side using a low- and high-speed drill, this implies trauma to adjacent tissues [ 1 , 2 , 3 , 4 , 5 , 6 ]. Failure to raise the mucoperiosteal flap well leads to its rupture [ 7 ]. It is known that the bone is nourished by blood supply from both bone marrow and periosteum [ 5 , 6 , 7 , 8 ].…”

“…Failure to raise the mucoperiosteal flap well leads to its rupture [ 7 ]. It is known that the bone is nourished by blood supply from both bone marrow and periosteum [ 5 , 6 , 7 , 8 ]. Therefore, the rupture of the periosteum or its burning during the removal of the bone with the rotating surgical burs results in the formation of foci of periosteal necrosis [ 6 , 8 ].…”

“…Hence the importance of giving antibiotics to patients undergoing surgical extraction under local anesthetic in order to reduce the chance of their exposure to dry socket and infection [ 1 , 4 , 7 ]. As long as there are odontogenic infections, elevation of the flaps and removal of the bone, there is a possibility of dry socket and involvement of facial spaces.…”