Emergent Management of Necrotizing Fasciitis 

Necrotizing fasciitis is a progressive, rapidly spreading, inflammatory infection located in the deep fascia, with secondary necrosis of the subcutaneous tissues (see the images below). Because of the presence of gas-forming organisms, subcutaneous air is classically described in necrotizing fasciitis. This may be seen only on radiographs or not at all. The speed of spread is directly proportional to the thickness of the subcutaneous layer. Necrotizing fasciitis moves along the deep fascial plane.

This condition has also been referred to as hemolytic streptococcal gangrene, Meleney ulcer, acute dermal gangrene, hospital gangrene, suppurative fascitis, and synergistic necrotizing cellulitis. Fournier gangrene is a form of necrotizing fasciitis that is localized to the scrotum and perineal area.

These infections can be difficult to recognize in their early stages, but they rapidly progress and require prompt recognition and aggressive treatment to combat the associated high morbidity and mortality.^[1] The causative bacteria may be aerobic, anaerobic, or mixed flora, and the expected clinical course varies from patient to patient.

See also the following:

• Necrotizing Fasciitis
• Dermatologic Manifestations of Necrotizing Fasciitis
• Fournier Gangrene

Early in the course of the disease, necrotizing fasciitis may appear quite benign. Be wary of the patient with pain out of proportion to physical findings.

Patients with suspected necrotizing fasciitis must be promptly and aggressively treated to reduce morbidity and mortality.

Obtain intravenous (IV) access; be careful to not use an infected extremity. Administer IV broad-spectrum antibiotics as soon as possible, and begin fluid resuscitation with normal saline or lactated Ringer solution.

Debridement

Aggressive surgical debridement of all necrotic tissue and administration of antibiotics are necessary. Debridement is best accomplished by early and extensive incision of skin and subcutaneous tissue wide into healthy tissue, followed by excision of all necrotic fascia and nonviable skin and subcutaneous tissue. Meticulous hemostasis is critical.

Antibiotic selection

Treatment should be aimed at the causative organism instead of coexisting flora. If streptococci are the identified major pathogens, the drug of choice (DOC) is penicillin G, with clindamycin as the alternative. To ensure adequate treatment, there must be coverage for aerobic and anaerobic bacteria. The anaerobic coverage can be provided by metronidazole or third-generation cephalosporins. Gentamicin, combined with clindamycin or chloramphenicol, has been proposed as a standard coverage. Ampicillin may be added to the basic regimen to treat enterococci if suspected by Gram stain.

Cardiorespiratory management

Provide supplemental oxygen; perform endotracheal intubation in patients who are unable to maintain their airway. Place the patient on continuous cardiac monitoring.

In patients with suspected hypovolemia, Foley catheterization may be needed to monitor urine output. However, this procedure should probably be avoided in patients with Fournier gangrene.

Hyperbaric oxygen therapy (HBO) involves the use of oxygen at increased pressure in a monoplace or a multiplace chamber.^{[2, 3, 4, 5]} This treatment increases the normal oxygen saturation in the infected wounds by 1000-fold, leading to a bacteriocidal effect, improved polymorphonuclear lymphocyte (PMN) function, and enhanced wound healing. Some authors have noted higher oxygen saturation (PO₂) in infected necrotic tissue secondary to HBO-induced vasodilation.

Although no large, controlled randomized studies have been published to support the complete effectiveness of HBO in necrotizing fasciitis, it has been shown that HBO improves the tissue defense against infection and prevents the necrosis from spreading.

HBO cannot replace surgery. The best outcome is obtained using a combined approach of antibiotics, surgery, and HBO, when readily available.

A typical treatment protocol involves HBO, given aggressively after the first surgical debridement. Three treatment sessions, in a multiplace chamber at 3 atmosphere absolute (ATA), 100% oxygen for 90 minutes each, can be given in the first 24 hours. Appropriate air breaks are given, as necessary.

In a monoplace chamber, 2.5-2.8 ATA, 100% oxygen for 90 minutes per session, can be given. On the second day, twice daily treatments can ensue until granulation is obtained to a total of 10-15 treatments.

Obtain early surgical consultation for aggressive debridement; however, surgical consultation should not wait for results of laboratory, microbiology, or radiology studies. Consider surgical subspecialty consultation for necrotizing fasciitis involving specific anatomic areas, as needed.

Consult a urologist in cases of Fournier gangrene; consult a hyperbaric specialist; and consult an infectious disease specialist, who may help guide initial empiric antibiotic therapy.

If the current facility is not capable of handling the aggressive care, monitoring, and serial surgical debridement that these patients require, then arrangements for transfer should be made. Transfer to a hyperbaric center may be necessary after initial debridement; however, patients should not be considered for transfer until they remain hemodynamically stable.