Who surgically manages necrotizing fasciitis of the foot?

From the Guidelines

Necrotizing fasciitis of the foot is typically managed surgically by a multidisciplinary team led by orthopedic surgeons, podiatric surgeons, or general surgeons with expertise in foot and ankle surgery. The primary treatment involves immediate and aggressive surgical debridement to remove all infected and necrotic tissue, as recommended by the Infectious Diseases Society of America 1. This procedure is often performed in the operating room under general anesthesia, where the surgeon will make incisions to expose the affected areas, remove dead tissue, and drain any purulent material. Multiple debridements may be necessary, sometimes daily, until all infected tissue is removed.

Key Considerations

• The aggressive nature of this infection requires prompt surgical intervention because necrotizing fasciitis spreads rapidly along fascial planes, causing tissue destruction and potentially leading to sepsis, organ failure, and death if not treated quickly 1.
• Alongside surgery, patients receive broad-spectrum intravenous antibiotics, typically including combinations such as piperacillin-tazobactam, vancomycin, and clindamycin to cover gram-positive, gram-negative, and anaerobic organisms, as suggested by the 2018 WSES/SIS-E consensus conference 1.
• These antibiotics are adjusted based on culture results and continued for at least 2-3 weeks.
• Hyperbaric oxygen therapy may be used as an adjunctive treatment in some cases.
• After the infection is controlled, reconstructive surgery may be necessary to address the resulting tissue defects.

Classification and Diagnosis

• Necrotizing infections can be classified into different types, including type I (polymicrobial), type II (mono-microbial), and type III (gas gangrene) 1.
• The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score can be used to identify patients at high risk of poor outcome 1.
• Early warning system scores, such as the quick SOFA (qSOFA) score, can be used to identify patients with suspected infection who are likely to have poor outcomes 1.

From the Research

Surgical Management of Necrotizing Fasciitis in the Foot

• Orthopaedic surgeons are often the first physicians to evaluate patients with necrotizing fasciitis and therefore play a crucial role in its management 2.
• Surgical debridement is a critical component of treatment, and orthopaedic surgeons may perform this procedure to remove compromised tissues 2, 3.
• In some cases, surgical debridement may need to be repeated, with an average of 4.8 repeated debridements per patient 3.
• Amputation of the infected limb may be necessary in severe cases, with 25.8% of patients in one study requiring amputation 3.
• Other healthcare professionals, such as general surgeons or plastic surgeons, may also be involved in the surgical management of necrotizing fasciitis, particularly in cases where the infection is located in other areas of the body or requires specialized care.

Importance of Prompt Surgical Intervention

• Prompt diagnosis and immediate surgical intervention are critical to reducing morbidity and mortality in patients with necrotizing fasciitis 2, 3, 4.
• Delayed surgical treatment can lead to increased risk of complications, including septic shock, multiple-organ failure, and death 3.
• Early diagnosis and aggressive surgical management can improve outcomes and reduce the need for repeated debridements or amputations 3, 4.