Guidelines Summary

In 2014, the Infectious Diseases Society of America (IDSA) issued an update of the Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections^[47]and had the following recommendations for the evaluation and management of necrotizing fasciitis, including Fournier gangrene:

Prompt/urgent surgical consultation is necessary for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene.
Empiric antibiotic treatment should be broad-spectrum (eg, vancomycin or linezolid plus [1] piperacillin-tazobactam or a carbapenem or [2] ceftriaxone and metronidazole).
Penicillin plus clindamycin is recommended for treatment of documented clostridial gas gangrene or group A streptococcal necrotizing fasciitis.
Hyperbaric oxygen (HBO) therapy is not recommended because it has not been proven as a benefit to the patient and may delay resuscitation and surgical debridement.

Medication

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Media Gallery

A patient developed gas gangrene after injecting cocaine. Clostridium septicum was isolated in both blood and wound cultures.
Gas feathering in the arm soft tissue of a patient with gas gangrene.
Extension of gas gangrene to the chest wall despite initial debridement.

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Table 1. Laboratory Risk Indicators for Necrotizing Fasciitis

Variable	Score
C-reactive protein level
< 150 mg/L	0
≥150 mg/L	4
Total WBC count
< 15 cells/µL	0
15-25 cells/µL	1
>25 cells/µL	2
Sodium level
≥135 mmol/L	0
< 135 mmol/L	2
Hemoglobin level
>13.5 g/dL	0
11-13.5 g/dL	1
< 11 g/dL	2
Creatinine level
≤ 141 mmol/L	0
>141 mmol/L	2
Glucose level
≤10 mmol/L	0
>10 mmol/L	1

Table 2. Clinical Score Predictive of Death for Patients with Necrotizing Soft Tissue Infections

*Variable on Admission*			*Points*
Heart rate >110 bpm			1
Temperature < 36°C			1
Serum creatinine level >1.5 mg/dL			1
Age >50 years			3
WBC count >40,000/µL			3
Hematocrit >50%			3
Group category	Number of points	Mortality risk (%)
1	0-2	6
2	3-5	24
3	≥6	88

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Author

Hoi Ho, MD Former Associate Dean for Faculty Affairs and Development, Professor, Department of Internal Medicine, Director, Center for Advanced Teaching and Assessment in Clinical Simulation (ATACS), Paul L Foster School of Medicine, Texas Tech University Health Sciences Center; Consulting Physician, University Medical Center

Hoi Ho, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Forensic Examiners Institute, American College of Physicians, American Society for Microbiology, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Uyen Vinh Pham Huynh, MD Lecturer, Department of Obstetrics and Gynecology, University of Medicine and Pharmacy, Nhan Dan Gia Dinh Hospital, Vietnam

Disclosure: Nothing to disclose.

Phuc Minh Nguyen, MD, MS (GenSurg) Lecturer, General Surgery Department, University of Medicine and Pharmacy of Ho Chi Minh City; Surgeon, Gastrointestinal Surgery Ward, Binh Dan Hospital; Endoscopist, Endoscopy Department, University Medical Center of UMP, Vietnam

Phuc Minh Nguyen, MD, MS (GenSurg) is a member of the following medical societies: Vietnam Association of Endolaparoscopic Surgeons, Vietnam Association of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Charles V Sanders, MD Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine in New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for Physician Leadership, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physicians, American Federation for Medical Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, The Scientific Research Honor Society, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, Southwestern Association of Clinical Microbiology, The Foundation for AIDS Research

Disclosure: Receives royalties from Baxter International for: Takeda-receives royalties; UpToDate-receives royalties.

Chief Editor

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Enes Kanlic, MD Professor, Department of Orthopedic Surgery, Texas Tech University Health Science Center

Disclosure: Nothing to disclose.

Lorenzo B Aragon, MD Associate Professor, Department of Family Medicine, Paul L Foster Texas Tech University Health Sciences Center; Medical Director, Ambrosio Guillen Texas State Veterans Home

Lorenzo B Aragon, MD is a member of the following medical societies: American Academy of Family Physicians, AMDA - The Society for Post-Acute and Long-Term Care Medicine, Society of Teachers of Family Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

Juan B Figueroa-Casas, MD Associate Professor, Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Disclosure: Nothing to disclose.

David G Maxfield Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

David G Maxfield is a member of the following medical societies: American College of Physicians, Texas Medical Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthors Jeffrey P Nelson, MD; Miguel Angel Pena-Ruiz, MD; and Karl C Bentley, MS, to the development and writing of this article.