INDEX

    Necrotizing Fasciitis – Treatment

    Infections

    Last Updated Nov 14, 2017
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    Context

    • Necrotizing fasciitis is a rare but life/limb threatening disease and is a true surgical emergency. There are about 100 cases annually in Canada (1/350,000).
    • Necrotizing fasciitis carries a high mortality rate (>30%), and early diagnose is crucial.
    • The hallmark of necrotizing fasciitis is pain out of proportion to findings.
    • The management of necrotizing fasciitis is surgical, so early referral is key.
    • The most common pitfall is failure to recognize necrotizing fasciitis and failure to refer to surgery/plastic surgery early.

    Recommended Treatment

    • The definitive treatment of necrotizing fasciitis is surgery.
    • Antibiotics should be administered early. Piperacillin-tazobactam 3.375 grams IV OR Penicillin 4 million units IV with vancomycin (weight based dosing) is recommended.
    • In penicillin allergic patients, ertapenem 1 gram IV is a reasonable alternative, again with vancomycin.
    • There is some evidence (animal studies) that adding clindamycin (900 mg IV) to the above regimens, helps with synergy and decreasing inflammation.
    • There is no role for corticosteroids.
    • There is no evidence that hyperbaric oxygen adds benefit.
    • Patients with necrotizing fasciitis frequently are in septic shock, and it is crucial to manage this as well.

    Criteria For Hospital Admission

    • All patients with suspected necrotizing fasciitis require hospital admission.

    Criteria For Transfer To Another Facility

    • Necrotizing fasciitis treatment requires highly specialized care, including surgery or plastic surgery services as well as intensive care. Transfer to another facility must be weighed against the observation that patients with necrotizing fasciitis are frequently unstable.

    Criteria For Close Observation And/or Consult

    • Suspicion of necrotizing fasciitis necessitates early referral to surgery/plastic surgery.
    • It is better to refer early, and have the diagnosis be a severe case of cellulitis as opposed to waiting too long for a diagnosis of necrotizing fasciitis.

    Quality Of Evidence?

    Justification

    Necrotizing fasciitis is so uncommon that all published literature is based on case series or individual cases.

    Low

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