What is the preferred evaluation and treatment of Necrotizing Fasciitis (NF)?

From the Guidelines

Necrotizing fasciitis requires immediate surgical debridement combined with broad-spectrum antibiotics for optimal outcomes. Evaluation should include a thorough physical examination looking for pain disproportionate to findings, skin changes (erythema, edema, crepitus), and systemic toxicity. Laboratory tests should include complete blood count, comprehensive metabolic panel, C-reactive protein, and creatine kinase. Imaging with CT or MRI can help define the extent of infection, but should not delay surgical intervention.

Key Considerations

• The cornerstone of treatment is urgent and aggressive surgical debridement of all necrotic tissue, which may require multiple operations.
• Empiric antibiotic therapy should begin immediately with a combination regimen that covers gram-positive, gram-negative, and anaerobic organisms, typically including piperacillin-tazobactam 4.5g IV every 6 hours plus vancomycin 15-20 mg/kg IV every 8-12 hours plus clindamycin 600-900 mg IV every 8 hours, as recommended by 1.
• Clindamycin is particularly important as it inhibits toxin production.
• For patients with penicillin allergies, alternatives include meropenem 1g IV every 8 hours or ceftriaxone 2g IV daily plus metronidazole 500 mg IV every 8 hours.
• Antibiotics should be adjusted based on culture results and continued for at least 48-72 hours after the patient is clinically improving and no further debridement is needed, as suggested by 1.
• Supportive care with fluid resuscitation, vasopressors if needed, and nutritional support is essential.
• Hyperbaric oxygen therapy may be considered as an adjunct but should not delay surgical management.

Treatment Approach

• Surgical intervention is the primary therapeutic modality in cases of necrotizing fasciitis and is indicated when this infection is confirmed or suspected, as stated in 1.
• Features suggestive of necrotizing fasciitis include clinical findings, failure of apparently uncomplicated cellulitis to respond to antibiotics, profound toxicity, and presence of gas in the soft tissues.
• Most patients with necrotizing fasciitis should return to the operating room 24–36 hours after the first debridement and daily thereafter until the surgical team finds no further need for debridement, as recommended by 1 and 1.

From the Research

Evaluation of Necrotizing Fasciitis (NF)

• The evaluation of NF is crucial for early diagnosis and treatment, as mortality rates can be high, ranging from 33-73% 2.
• A multidisciplinary approach is recommended, including surgical debridement, polyantibiotic therapy, and hyperbaric oxygen therapy 2, 3.
• Frozen section tissue biopsy can be a useful adjunct in establishing an early, accurate diagnosis of NF 4.

Treatment of Necrotizing Fasciitis (NF)

• The treatment of NF typically involves a combination of:
  • Surgical debridement of necrotic areas 2, 3, 4, 5
  • Broad-spectrum antibiotics 2, 3, 4, 5
  • Hyperbaric oxygen therapy 2, 6, 5
  • Negative pressure wound therapy 5
• The addition of hyperbaric oxygen therapy to surgical and antimicrobial treatment has been shown to reduce mortality and the need for debridements 6.
• Early recognition and treatment are critical to achieving a favorable patient outcome, with delayed diagnosis and advanced age being associated with higher mortality rates 2, 5.