From the Guidelines
Necrotizing fasciitis requires immediate medical attention with aggressive surgical debridement and broad-spectrum intravenous antibiotics, such as a combination of piperacillin-tazobactam, vancomycin, and clindamycin, to reduce morbidity, mortality, and improve quality of life. The treatment of necrotizing fasciitis involves a combination of surgical intervention and antimicrobial therapy. According to the guidelines by the Infectious Diseases Society of America 1, surgical intervention is the primary therapeutic modality in cases of necrotizing fasciitis and is indicated when this infection is confirmed or suspected. Features suggestive of necrotizing fasciitis include clinical findings such as severe pain, fever, hypotension, or advancement of the skin and soft tissue infection during antibiotic therapy.
Key Considerations
- Prompt surgical consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene 1.
- Empiric antibiotic treatment should be broad, covering a wide range of potential pathogens including group A Streptococcus, Staphylococcus aureus, and anaerobes 1.
- Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis 1.
- Supportive care with IV fluids, pain management, and possibly intensive care monitoring is necessary to manage the infection and its complications.
Antibiotic Regimens
- A typical antibiotic regimen includes a combination of piperacillin-tazobactam (4.5g IV every 6 hours), vancomycin (15-20 mg/kg IV every 8-12 hours), and clindamycin (600-900 mg IV every 8 hours) 1.
- Alternative regimens may include imipenem-cilastatin, meropenem, or ertapenem, with or without vancomycin or linezolid, depending on the suspected or confirmed pathogens 1.
Importance of Early Recognition
- Early recognition of necrotizing fasciitis is crucial, with warning signs including severe pain disproportionate to visible skin changes, rapid spread of redness or swelling, skin discoloration, and systemic symptoms like fever and confusion.
- Mortality rates remain high (20-30%) even with appropriate treatment, emphasizing the need for immediate intervention 1.
From the Research
Definition and Diagnosis of Necrotizing Fasciitis
- Necrotizing fasciitis is a rare soft tissue infection that requires immediate medical attention to prevent its fulminant development, which can lead to amputation or death of the patient 2.
- The diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging, with the gold standard for diagnosis being intraoperative tissue culture 3.
- Imaging is very useful to confirm the diagnosis, assess the extent of the disorder, and detect underlying etiologies, with the main finding being thickening of the deep fasciae due to fluid accumulation and reactive hyperemia 4.
Treatment of Necrotizing Fasciitis
- Aggressive debridement is a cornerstone intervention in necrotizing fasciitis, with the aim of removing all infected tissue in a single operation to halt the progression of the fasciitis and minimize unnecessary returns to the operating room 5.
- Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics, with adjuvant therapies such as intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) potentially playing a role 3.
- Soft tissue reconstruction may be necessary following surgery, and early multidisciplinary treatment with aggressive and repeated debridement is necessary to prevent the development of metachronous lesions 2.
Epidemiology and Microbiological Profiles
- Necrotizing soft tissue infections (NSTIs) have diverse microbiological profiles, categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus, and some Gram-negative pathogens 3.
- The incidence of NSTIs is influenced by factors such as climate and seasonal variations, with rates ranging from 0.86 to 32.64 per 100,000 person-years 3.
Case Reports and Outcomes
- A case report of a 58-year-old man who developed necrotizing fasciitis of both lower limbs with a four-day delay between each lesion, treated with intravenous antibiotics and urgent fasciotomy, resulted in a full recovery without amputation or intervention by Plastic Surgery 2.
- Another case report of a 33-year-old male patient treated with intravenous immunoglobulin (IVIG) for necrotizing fasciitis, which rapidly improved his clinical condition, suggests that IVIG therapy might be an additional option in the treatment of NF, particularly in hemodynamically unstable, critically ill patients 6.