Short versus Long Antibiotic Duration for Necrotizing Soft Tissue Infection: A Systematic Review and Meta-Analysis

Author(s):
Nicole Lyons; Brianna Cohen; Christopher O’Neil; Walter Ramsey; Kenneth G Proctor; Nicholas Namias; Jonathan Meizoso

Background:

Necrotizing soft tissue infections (NSTI) are rapidly spreading and life-threatening infections that require emergent and aggressive surgical intervention with immediate antibiotic initiation. However, there are wide variations in clinical practice and no expert consensus on duration of antibiotic therapy after source control.

Hypothesis:

We hypothesized that a short course of antibiotics would be as effective as a longer course.

Methods:

A systematic review of the literature was performed using PubMed, Embase, and Cochrane Library from inception to November 2022 following the PRISMA guidelines. Observational studies comparing short (<7 days) versus long (≥7 days) antibiotic duration for NSTI were included. Primary outcome was mortality and secondary outcomes included limb amputation and Clostridium difficile infection (CDI). Cumulative analysis was performed with Fisher’s exact test. Meta-analysis was performed using a fixed effects model and heterogeneity was assessed using Higgins I-square.

Results:

A total of 622 titles were screened and four observational studies evaluating 532 patients met inclusion criteria (Table). Kenneally et al defined long course as >2 days, so these patients were excluded. The average age of patients was 52 years, 67% were male, 61% had Fournier’s gangrene, and 40% had diabetes mellitus. There was no difference in mortality when comparing short to long duration antibiotics on both cumulative analysis (5.6% vs 4.0%, p=0.51) and meta-analysis (relative risk= 0.9, 95% confidence interval= 0.8 to 1.0, I-square=0, p=0.19)(Figure). There was no significant difference in rates of limb amputation (11% vs 8.5%, p=0.50) or CDI (20.8% vs 13.3%, p=0.14). Meta-analysis for secondary outcomes could not be performed as these were only reported in two studies.

Conclusions:

Short duration antibiotics may be as effective as longer duration antibiotics for NSTI after source control. Further high-quality data such as randomzied clinical trials are required to create evidence-based guidelines.