What is the treatment for necrotizing fasciitis?

Treatment of Necrotizing Fasciitis

Immediate surgical debridement is the primary treatment for necrotizing fasciitis, accompanied by broad-spectrum antibiotics and aggressive supportive care. 1

Diagnosis

Early recognition is crucial for survival. Key diagnostic features include:

• Severe pain disproportionate to physical findings
• Failure to respond to initial antibiotic therapy
• Hard, wooden feel of subcutaneous tissue extending beyond visible skin involvement
• Systemic toxicity with altered mental status
• Edema/tenderness beyond cutaneous erythema
• Crepitus (gas in tissues)
• Bullous lesions or skin necrosis/ecchymoses 1

The LRINEC score (Laboratory Risk Indicator for Necrotizing Fasciitis) can aid diagnosis, but has limited sensitivity (68.2% at ≥6 points) and should not be used to rule out necrotizing fasciitis. 1

Treatment Algorithm

1. Surgical Management (Primary Treatment)

• Immediate aggressive surgical debridement of all necrotic tissue until reaching healthy-looking tissue 1, 2
• Return to operating room every 24-36 hours for repeat debridement until no further necrotic tissue is present 1
• Consider negative pressure wound therapy after complete removal of necrosis 2
• In cases of extensive perineal involvement, consider diverting colostomy 2

2. Antimicrobial Therapy

Empiric broad-spectrum antibiotics should be started immediately when diagnosis is suspected:

For polymicrobial necrotizing fasciitis (most common):

• Vancomycin, linezolid, or daptomycin (for MRSA coverage) PLUS one of:
  • Piperacillin-tazobactam
  • A carbapenem (imipenem-cilastatin, meropenem, or ertapenem)
  • Ceftriaxone plus metronidazole
  • A fluoroquinolone plus metronidazole 1

For Group A streptococcal necrotizing fasciitis:

• Clindamycin PLUS penicillin 1

Continue antibiotics until:

• No further debridement is necessary
• Patient has improved clinically
• Patient has been afebrile for 48-72 hours 1

3. Supportive Care

• Aggressive fluid resuscitation (wounds discharge copious amounts of fluid) 1
• Intensive care monitoring for patients with signs of sepsis or organ dysfunction 1, 2
• Consider using qSOFA score (systolic BP ≤100 mmHg, respiratory rate ≥22/min, altered mentation) to identify patients needing critical care 1

Prognostic Factors and Mortality Risk

Mortality risk factors include:

• Female gender (RR=1.37)
• Age >60 (RR=1.39)
• Chronic heart disease (RR=1.64)
• Cirrhosis (RR=2.36)
• Skin necrosis (RR=1.22)
• Pulse rate >130/min (RR=2.26)
• Systolic BP <90 mmHg (RR=2.05)
• Serum creatinine ≥1.6 mg/dL (RR=3.06) 3

Delay in treatment >12 hours significantly increases mortality risk 4. The overall mortality rate ranges from 7.5-88% depending on severity and promptness of treatment 2.

Multidisciplinary Approach

A team approach involving surgeons, infectious disease specialists, intensivists, and wound care specialists is essential for optimal outcomes 1, 2. This coordinated care should continue through the acute phase and into rehabilitation.

Common Pitfalls

1. Delayed diagnosis - Often initially misdiagnosed as cellulitis 5
2. Inadequate initial debridement - Must be aggressive and complete
3. Inappropriate antibiotic selection - Must cover both aerobic and anaerobic organisms
4. Failure to recognize and manage sepsis - Requires aggressive fluid resuscitation and intensive care
5. Inadequate follow-up debridements - Multiple operations are typically required

Early recognition, immediate surgical intervention, appropriate antibiotics, and intensive supportive care are the cornerstones of successful treatment for this life-threatening condition.