Necrotizing Fasciitis – Treatment
Infections
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?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Necrotizing fasciitis is so uncommon that all published literature is based on case series or individual cases.
Related Information
OTHER RELEVANT INFORMATION
Skin and Soft Tissue Infections – The Infectious Diseases Society of America
Necrotizing Fasciitis (St Paul’s EM Update 2018)
Presenter: Simon Jones, Clinical Instructor, UBC Department of Emergency Medicine
Reference List
Relevant Resources
RELEVANT RESEARCH IN BC
Sepsis and Soft Tissue InfectionsRESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Nov 14, 2017
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