Guideline sources The following summarized guidelines for the evaluation and management of necrotizing fasciitis are prepared by our editorial team based on guidelines from the Surgical Infection Society Europe (SIS- E/WSES 2018), the Eastern Association for the Surgery of Trauma (EAST 2018), and the Infectious Diseases Society of America (IDSA 2014). 1 2 3 4 5 5 5 6 6 Definition Necrotizing fasciitis is a rapidly progressive and life-threatening infectious disease involving the skin fascia and subcutaneous tissue. 4 Epidemiology Typical microbiological etiologies include Group A Streptococcus (48%), S. aureus (22%), gram- negative bacteria (21%), Clostridium species (5%), and anerobic organisms (3%). A port of entry for https://web.pathway.md/diseases/recso4gB5VaMADqUX 1/6 6/30/23, 1:15 AM Necrotizing fasciitis Pathway infection may result from a traumatic injury, surgical intervention, or minor skin or mucosal breach (including skin tears, abrasions, lacerations, and insect bites). 5 Pathophysiology The estimated incidence of necrotizing fasciitis is 4 cases per 100,000 person-years in the United States. Immunosuppression, diabetes mellitus, liver cirrhosis, and malignancy increase the risk of necrotizing fasciitis. 5 6 Disease course Exotoxins released by pathogens cause local tissue damage resulting in erythema and swelling, which further progresses to eccyhmoses and bullae. Platelet-leucocyte aggregation causes microvascular occlusion, with involvement of deeper tissues and larger venules and arterioles, leading to necrosis, sepsis, shock, multiorgan failure, and death. 6 Prognosis and risk of recurrence In the United States, the overall mortality rate for necrotizing fasciitis-related death is 0.48 per 100,000 person-years. 5 Calculator Laboratory Risk Indicator for Ne Guidelines 1. Screening and diagnosis Clinical presentation: suspect necrotizing soft tissue infection in patients with pain out of proportion to clinical findings, edema extending beyond zones of skin erythema, rapid progression of disease, and fever. B 2. Classification and risk stratification Severity assessment: classify patients with necrotizing soft tissue infections according to risk of poor outcome. Scores used for severity assessment of patients with necrotizing infections may be useful in the emergency room or outside the ICU and may identify patients who require early surgical treatment and perioperative intensive care management. B 3. Diagnostic investigations https://web.pathway.md/diseases/recso4gB5VaMADqUX 2/6 6/30/23, 1:15 AM Necrotizing fasciitis Pathway Diagnostic imaging: consider obtaining diagnostic imaging to provide useful information when the diagnosis of necrotizing fasciitis is uncertain B while not delaying surgical consultation and intervention. B Show 2 more 4. Medical management General principles: Ensure a multidisciplinary team approach in the management of patients with necrotizing soft tissue infection. B Initiate treatment of necrotizing infection early because of the rapid progression of the inflammatory process. B Initiate early and aggressive supportive treatment to halt the progression of the inflammatory process. A Empiric antibiotic therapy: As per WSES 2018 guidelines, initiate rapid antibiotic treatment in patients with necrotizing soft tissue infection. B Show 4 more As per IDSA 2014 guidelines, initiate broad-spectrum empiric antibiotic treatment (such as vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem, or plus ceftriaxone and metronidazole) in patients with suspected or documented necrotizing fasciitis, including coverage for aerobes, anaerobes, group A streptococci, and MRSA. B Show 2 more Antitoxin therapy: include either clindamycin or linezolid in the empirical antibiotic regimen for the treatment of necrotizing soft tissue infection. B Duration of antibiotics: continue antibiotic therapy until further debridement is no longer necessary, the patient has improved clinically, and fever has resolved for 48-72 h. B Show 2 more Intravenous immunoglobulin: consider IVIG therapy in patients with necrotizing infections caused by group A Streptococcus. C Immunomodulatory agents: insufficient evidence to make a recommendation for AB103 (reltecimod), a new agent for modulation of inflammation after necrotizing infections. Further study is warranted to establish efficacy. I 5. Therapeutic procedures Negative pressure wound therapy: consider offering negative pressure wound therapy for wound care after complete removal of necrosis in patients with necrotizing soft tissue infection. B 6. Surgical interventions https://web.pathway.md/diseases/recso4gB5VaMADqUX 3/6 6/30/23, 1:15 AM Necrotizing fasciitis Pathway Surgical source control: As per EAST 2018 guidelines, perform early initial debridement within 12 hours of diagnosis in patients with necrotizing soft tissue infection. B As per WSES 2018 guidelines, perform surgical source control in patients with suspected necrotizing soft tissue infection as soon as possible, but at least within the first 12 hours after admission. Provide early source control, antimicrobial therapy, and supportive care for the treatment of patients with sepsis or septic shock caused by necrotizing soft tissue infection. B As per IDSA 2014 guidelines, obtain prompt surgical consultation for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene. B Surgical re-exploration: consider performing the first surgical re-exploration within 12-24 hours and repeat re-explorations until the patient is free of necrosis. B 7. Specific circumstances Patients with Fournier's gangrene: Initiate appropriate antibiotic therapy, provide hemodynamic support, and perform early debridement in patients with Fournier's gangrene. B Consider fecal diversion, either by colostomy or fecal tube system, with or without negative pressure therapy, in patients with Fournier's gangrene in whom fecal contamination is present. C Clinical findings Symptoms Past medical history Diarrhea Cancer Dizziness Diabetes mellitus Fatigue Immunocompromising condition Fever Inflammation Nausea Kidney failure Pain Liver cirrhosis PAD Past events Social history Skin puncture or injury Exposure to salt water Vital signs Neurological exam Signs of shock body temperature Altered level of consciousness Hypersensitive skin Integument exam https://web.pathway.md/diseases/recso4gB5VaMADqUX 4/6 6/30/23, 1:15 AM Necrotizing fasciitis Pathway Lab findings Hemorrhagic bullae Purplish skin discoloration blood glucose Skin blisters serum CK Skin crepitus serum CRP Skin erythema serum sodium Skin induration Skin tenderness Microbiological findings Skin ulceration Mrsa colonization Skin warmth Hematological findings WBC count Imaging findings Finding of necrotizing fasciitis Likelihood Ratios Pertinent positives The following findings increase the probability of necrotizing fasciitis in adults. 6 7 9 Finding LR+ Value Presence of finding of necrotizing fasciitis 7.1 Presence of finding of necrotizing fasciitis 5.3 Increased LRINEC score ( 6) 2.4 Pertinent negatives The following findings decrease the probability of necrotizing fasciitis in adults. 6 7 9 Finding LR- Value Absence of finding of necrotizing fasciitis 0.01 Absence of finding of necrotizing fasciitis 0.01 LRINEC score not increased (< 6) 0.3 Studies 2017 INSTINCT In ICU patients with necrotizing soft tissue infection, intravenous polyspecific IgG was not superior to placebo with respect to physical component summary score at 6 m. Martin B Madsen et al. Intensive Care Med. 2017 Nov. https://web.pathway.md/diseases/recso4gB5VaMADqUX 5/6 6/30/23, 1:15 AM Necrotizing fasciitis Pathway References 1. Stevens DL, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59 2):e10 52. Open 2. Sartelli M, Guirao X, Hardcastle TC et al. 2018 WSES/SIS E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg. 2018 Dec 14;13 58. Open 3. Rondi B Gelbard, Paula Ferrada, D Dante Yeh et al. Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018 Jul;85 1 208 214. Open 4. Wang JM, Lim HK. Necrotizing fasciitis: eight-year experience and literature review. Braz J Infect Dis. 2014 Mar-Apr;18 2 137 43. Open 5. Arif N, Yousfi S, Vinnard C. Deaths from necrotizing fasciitis in the United States, 2003 2013. Epidemiol Infect. 2016 Apr;144 6 1338 44. Open 6. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377 23 2253 2265. Open 7. Holland MJ. Application of the Laboratory Risk Indicator in Necrotising Fasciitis LRINEC score to patients in a tropical tertiary referral centre. Anaesth Intensive Care. 2009 Jul;37 4 588 92. Open 8. Zacharias N, Velmahos GC, Salama A et al. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch Surg. 2010 May;145 5 452 5. Open 9. Wall DB, Klein SR, Black S et al. A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. J Am Coll Surg. 2000 Sep;191 3 227 31. Open 10. Schmid MR, Kossmann T, Duewell S. Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol. 1998 Mar;170 3 615 20. Open 11. Martin B Madsen, Peter B Hjortrup, Marco B Hansen et al. Immunoglobulin G for patients with necrotising soft tissue infection INSTINCT a randomised, blinded, placebo-controlled trial. Intensive Care Med. 2017 Nov;43 11 1585 1593. Open https://web.pathway.md/diseases/recso4gB5VaMADqUX 6/6