Necrotizing Fasciitis

  • CC: Severe soft tissue pain / swelling

  • PP: Rapid onset, constant progressively worsening pain, pain out of proportion to exam, erythema, swelling, fever, chills, no improvement with prior antibiotics

  • PN: No improvement despite antibiotics, monitor for absence/presence of crepitus, bullae, systemic toxicity

  • pertinent SHx: tobacco, EtOH, drug use

  • Etiology: Rapidly progressive necrotizing soft tissue infection (commonly polymicrobial; can include GAS, Staph aureus, anaerobes, gram negatives)

  • risk factors: DM, immunocompromised state, CKD, obesity, IV drug use, recent surgery/trauma, chronic wounds, peripheral vascular disease

  • initial DATA: ↑WBC, ↑CRP, ↑lactate, hyponatremia, possible AKI; exam with tenderness beyond erythema, edema, bullae, skin discoloration, possible crepitus (late finding)

  • pending DATA: Blood cultures, wound cultures, trend CBC/BMP/CRP/lactate, CT with IV contrast if diagnosis unclear and patient stable

  • MEDS: Vancomycin + Piperacillin-tazobactam 4.5 g q8hr + Clindamycin 900 mg q8hr (Meropenem 1 g q8hr can substitute for Zosyn)

  • COURSE: Rapidly progressive infection concerning for necrotizing fasciitis requiring emergent surgical evaluation and broad-spectrum antibiotics; monitor closely for sepsis/hemodynamic instability

Plan :

  • Immediate surgical consult → urgent OR debridement

  • Consult ID for assistance with antibiotic management and de-escalation recommendations

  • Continue broad-spectrum IV antibiotics initially: Vancomycin + Meropenem + Clindamycin

  • After culture results / ID recommendations: narrow therapy to organism-specific coverage (ex: Cefazolin/nafcillin for MSSA, Penicillin + Clindamycin for GAS, targeted gram-negative/anaerobic coverage if polymicrobial)

  • De-escalate antibiotics per cultures and clinical response

  • Hemodynamic support / sepsis management if indicated

  • Trend lactate, CBC, BMP, CRP

  • Follow blood cultures and wound cultures

  • If diagnosis unclear and patient stable → CT with IV contrast

Note:

  • Definitive diagnosis = surgical exploration showing gray necrotic fascia, “dishwater” fluid, lack of bleeding

  • DDx: cellulitis, abscess, pyomyositis, DVT, compartment syndrome