Question

Diabetic patient with active intravenous drug use presents with hypotension, fever, and tenderness of right arm. What's the diagnosis and what antibiotic(s) would you start?

Answer

Right arm with necrotizing fasciitis

• Necrotizing fasciitis (NF) may occur secondary to either mono-microbial (e.g., Strep, Staph, Clostridial species, etc.) or poly-microbial (above in addition to anaerobes and/or gram negative) bacteria; etiology may be unclear from history alone.
• Urgent surgical debridement is the key to management but because the infection can spread rapidly, antibiotics are essential while awaiting surgery.
• Empiric antibiotics should provide broad-spectrum coverage as well as cover MRSA if the patient is at increased risk (e.g., recent hospital admission).
• Clindamycin is often been added for its theoretical anti-toxin effects from certain streptococcal species. Although there is little in vivo data to support this practice, it is still a reasonable approach considering the high-morbidity and mortality from NF
• Other adjunctive therapies to consider are IVIG and hyperbaric oxygen

References

http://lifeinthefastlane.com/education/ccc/necrotising-fasciitis/

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