Empirical treatment requires use of a combination of antimicrobials that can provide all 4 of the pillars below:

• Pillar 1: Cover for gram positive organisms (mainly beta-haemolytic streptococci and S. aureus)
• Pillar 2: Cover for gram negative organisms
• Pillar 3: Cover for anaerobic organisms
• Pillar 4: an agent that reduces toxin-production by Group A streptococci

Use the table below to identify the most appropriate agents for these elements of antimicrobial cover for the patient.

• FigureNecrotising fasciitis - treatment overview

Check previous bacterial culture results carefully for isolates of MRSA and gram negative organisms that are extended-spectrum beta-lactamase (ESBL) producers.

Necrotising fasciitis cannot be excluded based on imaging, as not all organisms involved will produce the appearance of gas in the fascial plane. S. pyogenes / Group A Streptococcus does not produce gas and can cause necrotising fasciitis in the absence of other organisms.

Samples of tissue and/or pus in universal container must be sent for culture to allow tailoring of antimicrobial therapy.