Necrotizing fasciitis: Difference between revisions
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==Background==
==Background==
*A rapidly progressive infection primarily involving the fascia and subcutaneous tissue
*'''Rapidly progressive, life-threatening infection''' involving fascia and subcutaneous tissue
*Formerly a rare diagnosis, frequency has risen due to an increase in immunocompromised patients with significant risk factors<ref>Hakkarainen TW et al. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014 Aug. 51 (8):344-72.</ref>
*Mortality: 20-40% even with treatment; increases with delayed diagnosis<ref>Hakkarainen TW et al. Necrotizing soft tissue infections: review and current concepts. ''Curr Probl Surg''. 2014;51(8):344-72. PMID 25069713</ref>
*Gas-formation is NOT a requirement for diagnosis, and radiographical lack of the classically taught gas formation should NEVER rule out necrotizing infection<ref>Misiakos EP et al. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014. 1:36.</ref>
*Early surgical exploration and debridement are the most important prognostic factors
*Most severe form of soft tissue infection and potentially limb and life threatening
*Gas formation is NOT required for diagnosis; absence of gas on imaging does NOT rule out NF<ref>Misiakos EP et al. Current concepts in the management of necrotizing fasciitis. ''Front Surg''. 2014;1:36. PMID 25593960</ref>
*Early recognition and aggressive debridement are major prognostic determinants and delay increases mortality<ref>Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004). "The LRINEC Laboratory Rother soft tissue infections". Critical Care Medicine 32 (7): 1535–1541. doi:10.1097/01.CCM.0000129486.35458.7D. PMID 15241098</ref>


===Categories===
===Types===
*Type I, polymicrobial
*Type I (Polymicrobial): mixed aerobic/anaerobic organisms; most common overall
*Type II, [[group A streptococcal]]
**Typically in diabetics, immunocompromised, post-surgical patients
*Type III, gas gangrene or [[clostridial]] myonecrosis
**Abdominal wall, perineum ([[Fournier gangrene]])
*Type II (Monomicrobial): Group A Streptococcus (most common) or ''Staphylococcus aureus''
**Can occur in young, healthy patients
**Extremities most common site
*Type III (Gas gangrene): ''Clostridium perfringens'' (myonecrosis)
**Extremely rapid progression; crepitus common
*Type IV: Fungal (immunocompromised, trauma)


===Risk Factors===
===Risk Factors===
*[[DM]]
*[[Diabetes]] (most common comorbidity), IV drug use, obesity
*Drug use
*Immunosuppression ([[HIV]], malignancy, chronic steroids)
*Obesity
*Recent surgery or traumatic wounds
*Immunosuppression
*Peripheral vascular disease, chronic [[renal failure]], [[cirrhosis]]
*Recent surgery
*NSAIDs (may mask early symptoms and promote GAS virulence)
*Traumatic wounds


==Clinical Features==
==Clinical Features==
[[File:NectrotizingFasciitis.jpeg|thumb|Nectrotizing fasciitis]]
*Pain out of proportion to exam (most important early clinical clue)
*Skin exam
**However: some patients present with "la belle indifference" (painless) — ischemic insensate tissue<ref>TheHealthScience. Emergent Management of Necrotizing Soft Tissue Skin Infections. 2013.</ref>
**Erythema (without sharp margins)
*Erythema without sharp margins (unlike [[erysipelas]])
**Exquisitely tender (pain out of proportion to exam)
*Rapidly progressive swelling and induration
***Caveat - some patients present with "la belle indifference"
*Hemorrhagic bullae (violaceous/dusky bullae)
***May be a result of ischemic, insensate tissue<ref>TheHealthScience. Emergent Management of Necrotizing Soft Tissue Skin Infections. Nov 22, 2013. https://thehealthscience.com/topics/emergent-management-necrotizing-soft-tissue-skin-infections.</ref>
*Skin anesthesia (destruction of superficial cutaneous nerves — late but specific)
**Skip lesions
*Crepitus (type I infections; absent in many cases)
**Hemorrhagic bullae (violaceous bullae)
*Skip lesions (areas of normal-appearing skin between involved areas)
***May be preceded by skin anesthesia (destruction of superficial nerves)
*Lymphangitis and lymphadenopathy are ABSENT (fascia lacks lymphatic drainage)<ref>Seal DV. Necrotizing fasciitis. ''Curr Opin Infect Dis''. 2001;14(2):127-32. PMID 11979122</ref>
**Crepitus (in type I infections)
*Systemic toxicity: fever, tachycardia, [[shock]], [[DIC]]
**Lymphangitis and lymphadenopathy are absent in necrotizing fasciitis alone<ref>Seal DV. Necrotizing fasciitis. Curr Opin Infect Dis. 2001;14(2):127–32.</ref><ref>Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR. Mortality in patients with necrotizing fasciitis. Plast Reconstr Surg. 2007;119(6):1803–7.</ref>
***Lymphangitis is seen in [[cellulitis]]
***Fascia has no lymph drainage
*Swelling/edema may produce compartment syndrome
*Constitutional or toxic shock-like syndrome<ref>Puvanendran R et al. Necrotizing fasciitis. Can Fam Physician. 2009 Oct; 55(10): 981–987.</ref>
**Fever
**Tachycardia
**Systemic toxicity, [[sepsis]]
**[[Conjunctivitis]]


==Differential Diagnosis==
==Differential Diagnosis==
{{SSTI DDX}}
*[[Cellulitis]] (most common misdiagnosis — cellulitis improves with antibiotics; NF does not)
{{Necrotizing Rashes DDX}}
*[[DVT]]
*[[Compartment syndrome]]
*Pyomyositis
*Gas gangrene without fasciitis
*[[Erysipelas]]
 
{{Skin and soft tissue infection DDX}}


==Evaluation==
==Evaluation==
[[File:CTNecrotizingFasciitis.png|thumb|CT of necrotizing fasciitis]]
===Labs===
===Work-Up===
*CBC: leukocytosis (or leukopenia in severe sepsis)
*CBC
*BMP: creatinine (AKI), sodium <135 (associated with NF)
*Chem
*CRP: >150 mg/L
*PT/PTT/INR
*Lactate: elevated (tissue ischemia)
*CK
*CK: may be elevated (myonecrosis)
*Lactate
*Blood cultures, wound cultures
*Coagulation studies (DIC screening)
 
===LRINEC Score<ref>Wong CH, et al. The LRINEC score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. ''Crit Care Med''. 2004;32(7):1535-1541. PMID 15241098</ref>===
*Has NOT been prospectively validated
*Score ≥6: PPV 92% for NF
*10% of patients with score <6 still had NF — low score does NOT rule out NF
*CRP ≥150 (+4), WBC 15-25 (+1) / >25 (+2), Hgb 11-13.5 (+1) / <11 (+2), Na <135 (+2), Cr >1.6 (+2), Glucose >180 (+1)
 
===HUCLA Criteria<ref>Wall DB et al. A simple model to help distinguish NF from non-NF soft tissue infection. ''J Am Coll Surg''. 2000;191(3):227-31. PMID 10989895</ref>===
*WBC >15.4 OR Na <135: associated with NF
*PPV 26%, NPV 99% — useful to rule out NF, not confirm it


===Evaluation===
===Imaging===
*Surgical exploration is the ONLY way to definitively establish the diagnosis of necrotizing infection
*Should NOT delay surgical exploration if clinical suspicion is high
*Imaging
*CT (study of choice if imaging obtained): soft tissue gas, fascial thickening, fluid collections, fat stranding
**Should not delay surgical exploration
*MRI: T2 fascial/subcutaneous edema (very sensitive but time-consuming)
**CT is study of choice - soft tissue gas, edema and fluid collections, fascial thickening with fat stranding
*Bedside US: thickened fascia, subcutaneous fluid, subcutaneous emphysema; limited by gas artifact<ref>Core Ultrasound: Soft Tissue. https://www.coreultrasound.com/sti/</ref>
**US may show thickened fascial planes, fluid between fascial planes, irregularity of the fascia, subcutaneous emphysema. The study may be limited by soft tissue gas. Video lecture<ref>Soft Tissue Ultrasound with Jacob Avila on Core Ultrasound. https://www.coreultrasound.com/sti/</ref>.
*Absence of gas on imaging does NOT exclude NF
**MRI - T2 subcutaneous, intramuscular, and fascial edema
*Absence of gas on imaging '''does not''' exclude diagnosis, as gas may be occult and/or certain organisms do not classically produce gas (i.e. [[Streptococcus|Group A Strep]])
{{LRINEC SCORE}}


===HUCLA NF vs Non-NF Criteria:<ref>Wall DB et al. A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. J Am Coll Surg. 2000 Sep;191(3):227-31.</ref>===
===Definitive Diagnosis===
*Retrospective study discovered:
*Surgical exploration is the ONLY way to definitively diagnose NF
**'''WBC count''' '''>15.4'''(x10<sup>3</sup>/mm<sup>3</sup>) OR '''Na''' '''<135'''(mmol/L)
*Findings: grayish necrotic fascia, lack of tissue resistance to blunt dissection, "dishwater" pus, thrombosed vessels
**Associated with NF and combo of both increased likelihood of NF
**PPV 26%/NPV 99%
*Useful tool to rule out NF, not a good tool for confirming presence of NF
**Helps distinguish NF from non-NF infection, when classic 'hard' signs of NF are absent however clinical judgment should still be used in patient with high suspicion of the disease


==Management==
==Management==
*Surgical exploration and debridement is both the definitive diagnostic modality and the definitive treatment
===Surgical===
**Indicated in setting of severe pain, toxicity, fever, elevated CK (with or without radiographic evidence)
*Emergent surgical exploration and debridement — the single most important intervention
*[[Antibiotics]]
*Indicated if: severe pain, systemic toxicity, elevated CK, clinical suspicion with or without imaging findings
**Must cover [[gram positives]], [[gram negatives]], and [[anaerobes]] (especially [[GAS]] and [[clostridium]])
*Repeat debridement (planned "second look") typically at 24-48 hours
**[[Piperacillin-Tazobactam]] 3.375-4.5g q6hr AND [[clindamycin]] 600-900mg q8hr AND [[vancomycin]] 1gm IV q12hr (consider weight base dosing of 20 mg/kg)
*Average: 3-4 debridements before wound management
**[[Piperacillin-Tazobactam]] 3.375-4.5g q6hr and [[linezolid]] 600mg q12hr is an alternative regimen<ref>Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444</ref>
*Delay in surgery increases mortality by approximately 9x
*In diabetics, maintain strict glycemic control (with [[IVFs]] and IV [[insulin]] if necessary)
 
===Antibiotics===
*Must cover '''gram-positives (including MRSA), gram-negatives, AND anaerobes'''
*Empiric regimen:
**Piperacillin-tazobactam 4.5g IV q6h (or meropenem 1g IV q8h)
**+ Vancomycin 25-30 mg/kg IV loading dose (or linezolid 600 mg IV q12h) — MRSA coverage
**+ Clindamycin 900 mg IV q8h — suppresses toxin production (especially GAS exotoxins)<ref>Stevens DL, et al. Practice guidelines for the diagnosis and management of SSTI: 2014 update by IDSA. ''Clin Infect Dis''. 2014;59(2):e10-e52. PMID 24973422</ref>
*Clindamycin should be included in all regimens regardless of other antibiotics
 
===Supportive Care===
*Aggressive IV fluid resuscitation
*Vasopressors for [[septic shock]]
*Serial lactate monitoring
*Blood products for DIC
*ICU admission
 
===IVIG===
*Consider for streptococcal toxic shock syndrome associated with NF (controversial)


==Disposition==
==Disposition==
*Admit to ICU
*ICU admission for all patients
*Surgery consult in ED for any suspected case
*Serial debridements as needed
*Wound management: VAC therapy, skin grafting after infection controlled
 
==Calculators==
{{LRINEC Calculator}}
{{LRINEC Score Calculator}}


==See Also==
==See Also==
*[[Necrotizing soft tissue infections]]
*[[Necrotizing soft tissue infections]]
*[[LRINEC_score|Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score]]
*[[Fournier gangrene]]
*[[EBQ:LRINEC Score]]
*[[Cellulitis]]
*[[Gas gangrene]]
*[[Sepsis]]


==References==
==References==
<references/>
<references/>
*Golger A, et al. Mortality in patients with necrotizing fasciitis. ''Plast Reconstr Surg''. 2007;119(6):1803-7. PMID 17440360
*Puvanendran R et al. Necrotizing fasciitis. ''Can Fam Physician''. 2009;55(10):981-987. PMID 19826154
*Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. ''Clin Infect Dis''. 2007;44(5):705-710. PMID 17278065


[[Category:ID]]
[[Category:Infectious Disease]]
[[Category:Surgery]]

Latest revision as of 09:55, 22 March 2026

Background

  • Rapidly progressive, life-threatening infection involving fascia and subcutaneous tissue
  • Mortality: 20-40% even with treatment; increases with delayed diagnosis[1]
  • Early surgical exploration and debridement are the most important prognostic factors
  • Gas formation is NOT required for diagnosis; absence of gas on imaging does NOT rule out NF[2]

Types

  • Type I (Polymicrobial): mixed aerobic/anaerobic organisms; most common overall
    • Typically in diabetics, immunocompromised, post-surgical patients
    • Abdominal wall, perineum (Fournier gangrene)
  • Type II (Monomicrobial): Group A Streptococcus (most common) or Staphylococcus aureus
    • Can occur in young, healthy patients
    • Extremities most common site
  • Type III (Gas gangrene): Clostridium perfringens (myonecrosis)
    • Extremely rapid progression; crepitus common
  • Type IV: Fungal (immunocompromised, trauma)

Risk Factors

  • Diabetes (most common comorbidity), IV drug use, obesity
  • Immunosuppression (HIV, malignancy, chronic steroids)
  • Recent surgery or traumatic wounds
  • Peripheral vascular disease, chronic renal failure, cirrhosis
  • NSAIDs (may mask early symptoms and promote GAS virulence)

Clinical Features

  • Pain out of proportion to exam (most important early clinical clue)
    • However: some patients present with "la belle indifference" (painless) — ischemic insensate tissue[3]
  • Erythema without sharp margins (unlike erysipelas)
  • Rapidly progressive swelling and induration
  • Hemorrhagic bullae (violaceous/dusky bullae)
  • Skin anesthesia (destruction of superficial cutaneous nerves — late but specific)
  • Crepitus (type I infections; absent in many cases)
  • Skip lesions (areas of normal-appearing skin between involved areas)
  • Lymphangitis and lymphadenopathy are ABSENT (fascia lacks lymphatic drainage)[4]
  • Systemic toxicity: fever, tachycardia, shock, DIC

Differential Diagnosis

Template:Skin and soft tissue infection DDX

Evaluation

Labs

  • CBC: leukocytosis (or leukopenia in severe sepsis)
  • BMP: creatinine (AKI), sodium <135 (associated with NF)
  • CRP: >150 mg/L
  • Lactate: elevated (tissue ischemia)
  • CK: may be elevated (myonecrosis)
  • Blood cultures, wound cultures
  • Coagulation studies (DIC screening)

LRINEC Score[5]

  • Has NOT been prospectively validated
  • Score ≥6: PPV 92% for NF
  • 10% of patients with score <6 still had NF — low score does NOT rule out NF
  • CRP ≥150 (+4), WBC 15-25 (+1) / >25 (+2), Hgb 11-13.5 (+1) / <11 (+2), Na <135 (+2), Cr >1.6 (+2), Glucose >180 (+1)

HUCLA Criteria[6]

  • WBC >15.4 OR Na <135: associated with NF
  • PPV 26%, NPV 99% — useful to rule out NF, not confirm it

Imaging

  • Should NOT delay surgical exploration if clinical suspicion is high
  • CT (study of choice if imaging obtained): soft tissue gas, fascial thickening, fluid collections, fat stranding
  • MRI: T2 fascial/subcutaneous edema (very sensitive but time-consuming)
  • Bedside US: thickened fascia, subcutaneous fluid, subcutaneous emphysema; limited by gas artifact[7]
  • Absence of gas on imaging does NOT exclude NF

Definitive Diagnosis

  • Surgical exploration is the ONLY way to definitively diagnose NF
  • Findings: grayish necrotic fascia, lack of tissue resistance to blunt dissection, "dishwater" pus, thrombosed vessels

Management

Surgical

  • Emergent surgical exploration and debridement — the single most important intervention
  • Indicated if: severe pain, systemic toxicity, elevated CK, clinical suspicion with or without imaging findings
  • Repeat debridement (planned "second look") typically at 24-48 hours
  • Average: 3-4 debridements before wound management
  • Delay in surgery increases mortality by approximately 9x

Antibiotics

  • Must cover gram-positives (including MRSA), gram-negatives, AND anaerobes
  • Empiric regimen:
    • Piperacillin-tazobactam 4.5g IV q6h (or meropenem 1g IV q8h)
    • + Vancomycin 25-30 mg/kg IV loading dose (or linezolid 600 mg IV q12h) — MRSA coverage
    • + Clindamycin 900 mg IV q8h — suppresses toxin production (especially GAS exotoxins)[8]
  • Clindamycin should be included in all regimens regardless of other antibiotics

Supportive Care

  • Aggressive IV fluid resuscitation
  • Vasopressors for septic shock
  • Serial lactate monitoring
  • Blood products for DIC
  • ICU admission

IVIG

  • Consider for streptococcal toxic shock syndrome associated with NF (controversial)

Disposition

  • ICU admission for all patients
  • Surgery consult in ED for any suspected case
  • Serial debridements as needed
  • Wound management: VAC therapy, skin grafting after infection controlled

Calculators

LRINEC Score

LRINEC Score — Necrotizing Soft Tissue Infection
Lab Value Select
CRP (mg/L) 1 <150 (0)   ≥150 (+4)
WBC (×10³/μL) 1 <15 (0)   15–25 (+1)   >25 (+2)
Hemoglobin (g/dL) 1 >13.5 (0)   11–13.5 (+1)   <11 (+2)
Sodium (mEq/L) 1 ≥135 (0)   <135 (+2)
Creatinine (mg/dL) 1 ≤1.6 (0)   >1.6 (+2)
Glucose (mg/dL) 1 ≤180 (0)   >180 (+1)
LRINEC Score / 13
Interpretation
<6 Low risk — <50% probability of necrotizing fasciitis. Consider other diagnoses but maintain clinical suspicion.
6–7 Moderate risk — 50–75% probability. Consider surgical consultation and advanced imaging.
≥8 High risk — >75% probability of necrotizing fasciitis. Urgent surgical consultation for exploration.
References
  • Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541. PMID 15241098.
  • Caution: LRINEC has limited sensitivity (~80%). A low score does NOT rule out necrotizing fasciitis. Clinical suspicion should always guide management.

Template:LRINEC Score Calculator

See Also

References

  1. ↑ Hakkarainen TW et al. Necrotizing soft tissue infections: review and current concepts. Curr Probl Surg. 2014;51(8):344-72. PMID 25069713
  2. ↑ Misiakos EP et al. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014;1:36. PMID 25593960
  3. ↑ TheHealthScience. Emergent Management of Necrotizing Soft Tissue Skin Infections. 2013.
  4. ↑ Seal DV. Necrotizing fasciitis. Curr Opin Infect Dis. 2001;14(2):127-32. PMID 11979122
  5. ↑ Wong CH, et al. The LRINEC score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541. PMID 15241098
  6. ↑ Wall DB et al. A simple model to help distinguish NF from non-NF soft tissue infection. J Am Coll Surg. 2000;191(3):227-31. PMID 10989895
  7. ↑ Core Ultrasound: Soft Tissue. https://www.coreultrasound.com/sti/
  8. ↑ Stevens DL, et al. Practice guidelines for the diagnosis and management of SSTI: 2014 update by IDSA. Clin Infect Dis. 2014;59(2):e10-e52. PMID 24973422
  • Golger A, et al. Mortality in patients with necrotizing fasciitis. Plast Reconstr Surg. 2007;119(6):1803-7. PMID 17440360
  • Puvanendran R et al. Necrotizing fasciitis. Can Fam Physician. 2009;55(10):981-987. PMID 19826154
  • Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis. 2007;44(5):705-710. PMID 17278065
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