Management (general and specific)

(i) General Principles of Management

• • Necrotising fasciitis is a life and limb threatening surgical emergency and, if suspected, merits immediate senior surgical input.
  • Broad spectrum IV antibiotics should also be administered immediately – in accordance with local consultant microbiologist advice.
  • Initial resuscitation should be aggressive – with IV crystalloid, blood products and inotropes, as required, to achieve haemodynamic, haemostatic and electrolyte stability.
  • The mainstay of treatment for necrotising fasciitis, however, remains early and aggressive surgical debridement of necrotic tissue until healthy, viable (bleeding) tissue is reached^5,6,9.

(ii) Initial Resuscitation Phase

• • Aim: to establish adequate tissue perfusion and oxygen delivery to prevent or arrest the development of multi-organ dysfunction
  • Involves large volumes of IV crystalloid due to septic vasoplegia and significant 3^rd space losses, usually with invasive blood pressure monitoring and central venous access to allow inotropic support if indicated.
  • Early critical care review should be sought in addition to surgical consultation due to the anticipated clinical course for these patients, who are at high risk of multiorgan failure and significant associated mortality.^3,4

(iii) Antibiotic Therapy

• • Antibiotics are a vital adjunct to source control and may attenuate the progression of septic shock when given early (within 1 hour), as well as reducing mortality.¹³
  • Antibiotics should be high dose, broad spectrum and given IV – and should be chosen to cover all likely causative organisms (Streptococci, Staphylococci, gram negative rods and anaerobes)¹⁴.
  • Example regimes are detailed below – though please follow local guidelines and discuss urgently with a local consultant microbiologist for patient specific advice.
  • In particular for suspected Type 2 NF, consider early administration of Clindamycin. Its bacteriostatic mechanisms inhibit the production of Streptococcal superantigen, felt to play a major role in the septic shock seen in these patients¹¹.
  • Antibiotic therapy should be rationalised and tailored as culture results become available.

(iv) Surgical Management

• • Early and extensive debridement is the mainstay of management – timing and adequacy of debridement have been shown repeatedly to be the main determinant of patient’s outcomes⁶.
  • The goal of surgical intervention is to remove all necrotic and non-viable tissue until healthy tissue is reached^7,8. This may involve amputation of limbs to gain control of infection.
  • Tissue samples should be sent urgently from theatre to a waiting lab for gram staining and culture, to help guide further antibiotic treatment.
  • Wounds should be covered, and the patient returned to the operating theatre 24 hours after initial debridement for a reassessment. Serial episodes of debridement may be required over a period of days^6-8.

(v) Post-Operative Phase

• • Patients should be cared for in intensive care, using a multispecialty and multidisciplinary approach. Multidisciplinary team involvement is especially important during the rehabilitation phase.
  • Extensive debridement may result in significant wounds requiring vacuum assisted wound devices, skin grafting and specialist reconstructive surgery. This should be considered only when the patient has been stabilised and the infection fully eradicated⁴.