Orthopaedic Knowledge Update®: Musculoskeletal Infection 2 Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

Chapter 27: Necrotizing Fasciitis and Other Complicated Skin and Soft-Tissue Infections

Management of NSTIs Management of NSTIs entails early and thorough surgi cal exploration with débridement of necrotic tissue, along with broad-spectrum empiric antimicrobial therapy and hemodynamic support. Because patients with NSTIs may deteriorate within hours of their presentation, only a clinical suspicion of NSTI is warranted to incite surgical exploration, especially in patients who are immunocom promised, have diabetes mellitus, or have undergone sur gery recently. A clear multidisciplinary approach among surgeons, microbiologists, infectious diseases specialists, pharmacists, and intensivists is fundamental in caring for these complex patients. 8 Surgical Interventions A 2023 review reported that aggressive débridement of all necrotic tissue should not be delayed for any reason as it is a surgical emergency. 38 A systematic review from 2018 reported that the goal of the surgical intervention is to reach healthy viable tissue that is bleeding 39 ( Figure 3 ). A systematic review from 2020 reported that the initial débridement should be performed at the first center to which the patient presents with the suspected diagnosis; this way, control of infection source is achieved more promptly, ideally within 6 hours of presentation to reduce mortality. 40 A 2022 study showed that because prolonged surgical times may be associated with longer intensive care unit and hospital stays in patients with NSTIs, there should be a balance between adequate débridement and shorter surgical time. 41 In fact, débridement and reevalua tion of tissue should be repeated every 1 to 2 days until all necrotic tissue is removed. This could be performed at a referral center that has a multidisciplinary team familiar with the management of complex wounds. Viable skin

and subcutaneous tissue can be salvaged despite invasive débridement when it is focused only on necrosed tissue. Skin grafting and rehabilitation services are required to improve pain, joint mobility, and disfigurement after wide débridement. 42 A 2020 study reported that once necrotic tissue is resected, negative-pressure wound ther apy may be helpful for physiologic wound healing. 43 A surgical consult should occur early when patients have a prosthetic joint to help with the initial débridement and to direct decisions regarding implant removal. 10 In a 2020 review of cases of Fournier gangrene, urinary and fecal diversions may be warranted based on the extent of infection and débridement. 44 In addition, it was reported in 2018 that limb amputation may be needed in cases of severe NSTI, especially if the affected extremity is not viable or expected to be nonfunctional. Amputation performed in patients presenting with hemorrhagic bul lae, peripheral vascular disease, bacteremia, or LRINEC score greater than8 may reduce mortality risk. 45 Antimicrobial Therapy Initial empiric broad-spectrum antimicrobial agents with activity against gram-positive (including methicillin- resistant S aureus [MRSA]), gram-negative, and anaer obic pathogens should be administered after drawing blood cultures. An updated review from 2021 reported that adequate empiric antibiotic combinations include a carbapenem or piperacillin-tazobactam plus vancomycin or daptomycin (antibiotics with activity against MRSA) plus clindamycin (which is an antiribosomal agent active against organisms producing exotoxins as well as other beneficial aspects). 46 A 2023 review determined that deciding whether linezolid can be used instead of clinda mycin in cases where group A Streptococcus is resistant

Section 6: Bone, Joint, and Soft-Tissue Infections

A B FIGURE 3 Polymicrobial (type I) necrotizing fasciitis in a woman with obesity and uncontrolled diabetes mellitus. Photographs were obtained on presentation ( A ) and after surgical exploration and débridement ( B ). Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

297

© 2025 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update ® : Musculoskeletal Infection 2