From the Guidelines
Necrotizing fasciitis has a mortality rate ranging from 7.5% to 88% depending on the study, with the most recent and highest quality study suggesting a mortality rate of 7.5%. Early diagnosis and aggressive treatment are critical for survival, with delays in surgical debridement significantly increasing mortality risk 1. Factors that worsen prognosis include advanced age, immunocompromised status, diabetes, obesity, and involvement of the trunk or perineum rather than extremities. Treatment requires immediate surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and intensive supportive care including fluid resuscitation and vasopressors if needed. The use of scoring systems such as the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score and the Fournier’s Gangrene Severity Index (FGSI) can aid in diagnosis and prognosis, but their accuracy is still a matter of debate 1.
Some key points to consider in the management of necrotizing fasciitis include:
- Prompt recognition and treatment are crucial to reduce mortality and morbidity
- Surgical debridement is the primary therapeutic modality, with most patients requiring multiple debridements
- Broad-spectrum antibiotics should be used empirically, with coverage for both aerobes and anaerobes
- Intensive supportive care, including fluid resuscitation and vasopressors, is often necessary
- Scoring systems such as LRINEC and FGSI can aid in diagnosis and prognosis, but their accuracy is still debated
The most recent and highest quality study suggests that the FGSI score is a reliable tool for predicting patient mortality, with a reported sensitivity of 65-88% and specificity of 70-100% 1. However, the debate on which scoring system performs best is still ongoing, and more research is needed to determine the optimal scoring system for necrotizing fasciitis.
In terms of antibiotic therapy, the use of broad-spectrum antibiotics such as piperacillin-tazobactam, meropenem, and vancomycin is recommended, with the addition of clindamycin for its anti-toxin effects in cases of streptococcal toxic shock syndrome 1. The use of intravenous immunoglobulin (IVIG) has not been established as a recommended treatment for streptococcal toxic shock syndrome.
Overall, the management of necrotizing fasciitis requires a multidisciplinary approach, with prompt recognition and treatment being critical to reducing mortality and morbidity.
From the Research
Mortality Rate of Necrotizing Fasciitis
- The overall mortality rate of necrotizing fasciitis (NF) was reported to be 17.7% in a study conducted in 2017 2.
- A study published in 2020 found that the overall mortality risk of NF was 12.6% with no substantial change in the annual trend 3.
- Another study conducted in 2023 reported a mortality rate of 26.6% for NF 4.
- Factors associated with a higher mortality risk included older age, chronic liver diseases, disseminated intravascular coagulopathy, septic shock, pulmonary complications, acute renal failure, and not undergoing surgical intervention 3.
Factors Influencing Mortality
- Advanced age (over 65 years) and female sex were found to be significantly correlated with mortality in a study published in 2017 2.
- Diabetes mellitus was found to be a common coexisting disease in patients with NF, but mortality in patients with diabetes was substantially lower (8.5% vs. 16.5%) 3.
- Septic shock was found to be strongly correlated with mortality in a study published in 2017 2.
- The speed of management was not found to vary in mortality rate in a study published in 2023 5.
Treatment and Management
- Early diagnosis and aggressive surgical management are of high significance for the management of NF 2.
- Surgical debridement was performed in all patients in a study published in 2017, with a mean number of repeated debridement of 4.8 2.
- Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) may have a role in the treatment of NF 6.
- Soft tissue reconstruction may be necessary following surgery 6.