Emerging treatments
Hyperbaric oxygen (HBO)
HBO has been advocated by some physicians based upon its beneficial effects on cutaneous wound healing, but there is a lack of prospective controlled studies to demonstrate its efficacy.[1][55] HBO may be considered if readily available; however, its use must not delay surgical debridement or appropriate antibiotic treatment.
Newer antibiotics
Guidance by an infectious disease expert should be sought if any of these agents are being considered. Antibiotics with activity against gram-positive organisms (including MRSA) - such as the lipoglycopeptide oritavancin, the aminomethylcycline omadacycline (spectrum includes gram-positive, gram-negative aerobes, anaerobes, and atypical bacteria), and the fluoroquinolone delafloxacin - may be considered for inclusion in an antimicrobial regimen for necrotizing fasciitis.[56][57][58] However, clinical data supporting their use is limited. Although not specifically approved by the Food and Drug Administration for acute bacterial skin and skin-structure infections, ceftazidime/avibactam and meropenem/vaborbactam offer a spectrum of activity against resistant gram-negative organisms, including those with extended-spectrum beta-lactamases and some carbapenamases. The efficacy of these agents has not been rigorously demonstrated in necrotizing fasciitis. With the exception of use in uncommon and specific antibiotic resistance patterns in an isolated causative organism, there is thus far no compelling evidence to recommend their use in necrotizing fasciitis.
Reltecimod
Reltecimod is a T-lymphocyte CD28 receptor antagonist that acts early in the host immune response by inhibiting T-cell activation, thereby modulating acute inflammation that leads to systemic organ failure. It has been evaluated for suspected organ dysfunction or failure in patients ages ≥12 years with necrotizing soft tissue infection, in conjunction with surgical debridement, antibiotic therapy, and supportive care. In a phase 3 randomized controlled trial, reltecimod did not demonstrate significant improvement in a composite endpoint for patients with necrotizing soft-tissue infections; however, it was associated with improved resolution of organ dysfunction and hospital discharge status.[59] Other immunomodulating agents may have a role in the treatment of necrotizing fasciitis in the future.
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