›Empiric broad spectrum regimen
›Core coverage goals
›Streptococci and MSSA
›MRSA
›Gram negative organisms
›Anaerobes
›Standard severe NSTI regimen
›Piperacillin tazobactam IV 4.5 g every 6 hours
›Renal adjustment for reduced eGFR
›Extended infusion per local protocol if available
›Vancomycin IV 15 to 20 mg/kg loading
›Target AUC based dosing per local protocol
›Trough based approach only if AUC unavailable
›Clindamycin IV 900 mg every 8 hours
›Toxin suppression for streptococci and staphylococci
›Continue even if cultures show streptococci
›Alternative beta lactam strategy
›Meropenem IV 1 g every 8 hours
›Use for ESBL risk or severe polymicrobial infection
›Renal adjustment required
›Cefepime IV 2 g every 8 hours
›Add metronidazole IV 500 mg every 8 hours for anaerobes
›Avoid monotherapy for anaerobes
›Specific exposure guided additions
›Seawater exposure with severe SSTI
›Doxycycline IV 100 mg every 12 hours
›Add to broad regimen for Vibrio coverage
›Avoid in pregnancy if alternatives available
›Freshwater exposure with severe SSTI
›Ciprofloxacin IV 400 mg every 12 hours
›Consider for Aeromonas coverage
›QT prolongation risk review
›Evidence level framing
›Class I recommendation for early broad spectrum antibiotics in sepsis with suspected source
›ACEP Level B recommendation for early antibiotics in septic shock pathways
Surgery and source control
›Operative management
›Surgical exploration
›Early exploration for high suspicion despite equivocal imaging
›Bedside incision and fascial inspection only if immediate OR unavailable
›Debridement principles
›Wide excision of necrotic fascia and nonviable tissue
›Tissue viability reassessment at each surgery
›Repeat debridement within 12 to 24 hours typical
›Intraoperative cues
›Gray necrotic fascia
›Lack of bleeding
›Thin dishwater fluid
›Easy finger dissection along fascial planes
›Evidence level framing
›Class I recommendation for urgent surgical debridement as definitive therapy
Hemodynamic resuscitation and organ support
›Sepsis management bundle
›Fluids
›Balanced crystalloid 30 ml/kg for hypotension or lactate elevation
›Smaller boluses with frequent reassessment if heart failure risk
›Vasopressors
›Norepinephrine infusion initiation if persistent hypotension after fluids
›Titrate every 2 to 5 minutes to MAP target
›Peripheral initiation via large bore IV acceptable with close monitoring
›Vasopressin infusion addition if high norepinephrine requirement
›Fixed dose per local protocol
›Norepinephrine sparing strategy
›Epinephrine infusion consideration if refractory shock
›Add on agent in septic shock
›Lactate interpretation caution
›Steroids
›Hydrocortisone IV 50 mg every 6 hours for refractory septic shock
›Consider if vasopressor dependent despite adequate fluids
›Class IIa recommendation in refractory shock contexts
›Ventilation
›Lung protective ventilation if intubated
›Target oxygenation avoiding hyperoxia
›Monitoring
›Repeat lactate within 2 to 4 hours if elevated
›Strict intake and output
›Glucose control with insulin protocol as needed
›Toxin mediated syndrome management
›Clindamycin continuation
›Continue with confirmed group A streptococcus
›Continue with suspected streptococcal toxic shock syndrome
›IVIG considerations
›Consider in streptococcal toxic shock syndrome with shock despite source control and antibiotics
›Dose strategy per local protocol and specialist guidance
›Evidence uncertainty acknowledged
›Hyperbaric oxygen
›Use limitations
›Not a substitute for surgery
›Consider only after debridement and stabilization
›Transfer decisions should not delay initial surgery
›Anticoagulation and DVT prophylaxis
›Pharmacologic prophylaxis when bleeding risk acceptable
›Mechanical prophylaxis if high bleeding risk