A 71-year-old man with diabetes, obesity, hypertension, and benign prostatic hypertrophy is admitted to the intensive care unit with abrupt-onset groin pain, fever, and a rapidly spreading erythematous groin and lower abdominal rash with ill-defined margins. The rash is exquisitely tender and firm to palpation. He develops hypotension with mean arterial pressure measured at 52 mm Hg, refractory to intravenous fluid resuscitation.
What is the MOST appropriate sequence of events to manage his disease?A. Insert a central venous catheter, start vasopressors, obtain two sets of blood cultures, and start antibiotic therapy with vancomycin, meropenem, and clindamycin
Correct Answer: C
This scenario describes the clinical presentation of necrotizing fasciitis, specifically Fournier gangrene, a necrotizing soft tissue infection of the perineum. The microbiology of this disease comprises facultative organisms (Escherichia coli, Enterococcus spp.) and anaerobes (anaerobic or microaerophilic streptococci, Bacteroides, Clostridium, Fusobacterium). Thus, antimicrobial therapy should target this spectrum of bacterial pathogens and should also include clindamycin, for its antitoxin properties against toxin-producing streptococci and staphylococci. Meropenem or piperacillin-tazobactam is an appropriate component of first-line regimens, which should also include clindamycin. Patients with risk factors for methicillin-resistant S. aureus should also be given vancomycin or daptomycin. Hemodynamic instability is common with necrotizing soft tissue infections and requires aggressive supportive care with intravenous fluids and vasopressors. Vasopressor therapy should not be delayed until a central line can be placed, and hypotensive shock should be addressed before or simultaneously as blood cultures are drawn and antibiotics are started, and not delayed. Surgical consult should not be delayed by obtaining CT, MRI, or other imaging looking for soft tissue gas collections to support a diagnosis of necrotizing soft tissue infection. Surgical exploration is the only way to truly establish the diagnosis and obtain source control. Early surgical debridement has also been shown to improve outcomes.