Top unanswered questions in antimicrobial management of necrotizing soft tissue infections

Necrotizing soft tissue infections (NSTIs) are life-threatening conditions that require prompt surgical and antimicrobial intervention. An upward global trend in invasive group A streptococcal infections, concerning for a synchronous rise in NSTIs, warrants a standardized approach to antibiotic management of NSTIs to optimize care. Emerging data support a shorter antibiotic course following definitive surgical debridement, even in cases with concurrent streptococcal bacteremia. Individualized antibiotic management guided by surgical source control, as opposed to fixed durations, may help minimize unnecessary antibiotic exposure and the resultant adverse events and antimicrobial resistance. The use of clindamycin as an adjunctive anti-toxin antibiotic remains a common practice, though rising resistance and comparative studies suggest linezolid may be a safe alternative. This review aims to offer strategies to optimize antibiotic care in NSTIs by reviewing the growing body of evidence on antibiotic duration, de-escalation strategies, and adjunctive anti-toxin therapy.