From the Guidelines
The recommended treatment for necrotizing fasciitis involves immediate surgical debridement combined with broad-spectrum antibiotics, with the goal of reducing morbidity, mortality, and improving quality of life. Surgery should be performed urgently to remove all infected and necrotic tissue, often requiring multiple debridements, as suggested by the 2014 update by the Infectious Diseases Society of America 1. Initial antibiotic therapy should include agents that cover gram-positive, gram-negative, and anaerobic organisms, such as a combination of piperacillin-tazobactam or meropenem, plus vancomycin or linezolid.
- The choice of antibiotics should be based on the most recent and highest quality study, which recommends empiric treatment with broad-spectrum antibiotics, including coverage for MRSA and invasive GAS virulence proteins 1.
- For group A streptococcal infections, adding clindamycin is recommended to inhibit toxin production, as it has been shown to be superior to penicillin in animal models and observational studies 1.
- Antibiotics should be adjusted based on culture results and continued for at least 48-72 hours after the patient is clinically stable with no fever or leukocytosis, as recommended by the 2018 WSES/SIS-E consensus conference 1.
- Supportive care is essential, including fluid resuscitation, pain management, and nutritional support, to reduce morbidity and mortality.
- Hyperbaric oxygen therapy may be considered as an adjunctive treatment in certain cases, although its effectiveness is still being studied.
- Early diagnosis is critical, as mortality increases with delayed surgical intervention, with the infection rapidly spreading along fascial planes and causing tissue destruction through bacterial toxins and enzymes that impair blood supply and cause tissue necrosis.
- The use of procalcitonin monitoring may be useful to guide antimicrobial discontinuation, as it has been shown to be a useful biomarker in patients with bacterial infections 1.
From the Research
Treatment Overview
The recommended treatment for necrotizing fasciitis involves a combination of aggressive surgical management, broad-spectrum antibiotic therapy, and supportive care.
- Surgical debridement is the mainstay of treatment, with the goal of removing all necrotic tissue to prevent further spread of the infection 2, 3, 4, 5, 6.
- Broad-spectrum antibiotics should be initiated promptly to cover a range of potential pathogens, including group A streptococcus, Staphylococcus aureus, and Gram-negative bacteria 3, 5.
- Supportive care, such as fluid resuscitation, nutritional support, and wound care, is also crucial in managing patients with necrotizing fasciitis 4, 5.
Surgical Management
Surgical debridement should be performed urgently, with the goal of removing all necrotic tissue to prevent further spread of the infection.
- Repeated surgical debridement may be necessary to ensure complete removal of necrotic tissue 2, 5.
- Amputation of the affected limb may be necessary in some cases to prevent further spread of the infection 2.
Diagnostic Methods
Diagnosis of necrotizing fasciitis relies on a combination of clinical symptoms, laboratory markers, and imaging studies.
- The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score can be used to aid in diagnosis, with a positive predictive value of 92% 6.
- Intraoperative tissue culture is considered the gold standard for diagnosis 5.
- Frozen section tissue biopsy can be a useful adjunct in establishing an early, accurate diagnosis of necrotizing fasciitis 4.
Adjuvant Therapies
Adjuvant therapies, such as intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT), may have a role in the management of necrotizing fasciitis.