Necrotizing Fasciitis: Pillars for Improved Patients’ Outcome

Necrotizing fasciitis (NF) is a common soft tissue infection, and it remains a life- and limb-threatening clinical disease. Minor trauma or incomplete surgical intervention and comorbidities are the risk for NF infection. NSAID (non-steroidal anti-inflammatory drug) seems to mask the disease process, sometimes inhibiting pain. Significantly higher pain without obvious skin manifestations and more systemic toxicity should raise a strong suspicion of NF. LRINC (Laboratory Risk Indicator for Necrotizing Fasciitis) score is helpful in the early diagnosis of NF by excluding cellulitis. Further investigations are also useful to diagnose NF, and imaging studies are increasingly used to diagnose NF with increased frequency. NF is classified according to the area involved or the microbes causing the necrotizing fasciitis. NF has a typical pathophysiology. Initially, the microbe gets lodged in fascial layers and causes necrosis and rapid progression within fascial layers causing systemic toxicity; this is called the horizontal spread of infection. The later phase is cutaneous manifestation due to vertical spread and necrotizing infection with thrombosis of vessels supplying the skin. The management includes aggressive medical and surgical therapy. Medical therapy includes early proper antibiotics, resuscitation, correction of coagulopathy, and hydration. The immediate surgical intervention is the bold debridement of necrotic tissue till the wound starts to bleed. Organ supportive care ranges from hemodynamic support to invasive ventilation. As known NF has higher morbidity and mortality, around 20–40% requires amputations. Delayed diagnosis and delayed surgical intervention will increase NF patients’ mortality significantly. Early medical consultation in patients with unhealthy wounds and fever is needed to detect NF early and to prevent the progression to multi-organ dysfunction and shock.