Although some necrotizing infections may still be susceptible to penicillin, clindamycin is the treatment of choice for necrotizing infections

If staphylococci or gram-negative rods are involved, vancomycin and other antibiotics to treat gram-negative organisms other than aminoglycosides may be required

For example, use may depend on whether a nasocranial infection is present, or it may need to be avoided in patients who are likely to be carriers of MRSA (eg, those with diabetes, those who use illicit drugs, those undergoing hemodialysis).

A more specifically targeted antibiotic regimen may be begun after the results of initial gram-stained smear, culture, and sensitivities are available.

Empiric antibiotics should be started immediately. Initial antimicrobial therapy should be broad-based, to cover aerobic gram-positive and gram-negative organisms and anaerobes. A foul smell in the lesion strongly suggests the presence of anaerobic organisms. The maximum doses of the antibiotics should be used,

The activities of cefotaxime, moxalactam, MK 0787 (N-formimidoyl thienamycin), ampicillin, oxacillin, vancomycin, and clindamycin were compared against gram-positive cocci.

Data from retrospective studies[138,139] and one observational prospective study[140] of patients with severe pneumococcal bacteremia have suggested that combination therapy may be associated with reduced mortality, as compared with β-lactam monotherapy, irrespective of the level of resistance to penicillins.

Other alternative drugs include the carbapenems, newer quinolones, clindamycin, telithromycin, linezolid, and vancomycin

In critically ill patients, cefotaxime or ceftriaxone is most often the primary alternative if there is no indication of a type 1 allergy to penicillin

Penicillin remains the drug of choice for fully sensitive strains with minimum inhibitory concentration (MIC) < 0.1 µg/L. Also strains with moderately decreased susceptibility (MIC 0.1-1.0 µg/L) can be effectively treated with penicillin G, provided that the dose and dosing intervals are adequate

Group A Streptococci

1. Vancomycin, Clindamycin, and Piperacillin/ tazobactam 2. Linezolid and Piperacillin/tazobactam

The recommended course of treatment is the use of vancomycin, linezolid, or daptomycin to treat MRSA and gram-positive bacteria, an agent to treat anaerobic bacteria (e.g., clindamycin), and an agent to treat gram-negative bacteria. Alternatively, anaerobic and gram-negative bacteria can be treated with one drug that covers both

These casereports suggest the following risk factors for the development ofpneumococcal NF – a history of diabetes, systemic lupuserythematosus, immunosuppression, alcohol use, coronaryartery disease and administration of intramuscular nonsteroidalanti-inflammatory drugs (NSAIDs)