Necrotizing Fasciitis (quick-hits)

submitted by Amit Kumar, M.D.

Diagnosis:

1) Physical exam

-pain out of proportion of external appearance of skin, crepitus, dish-water foul-smelling fluid; rapidly progressive

 

2) Criteria: LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score

• CRP >/= 150: 4 points
• WBC 15-25: 1 point; >25: 2 points
• Hgb 11-13.5: 1 point; <11: 2 points
• Na <135: 2 points
• Creatinine >1.6: 2 points
• Glucose >180: 1 point

General rule of thumb:

-Score <6: Low risk but not “no risk” (use history, PE, and clinical gestalt)

-Score >6: +NF (PPV of 92% and NPV of 96%)

 

3) Imaging

-CT without contrast (best at assessing for gas within fascial planes)

 

Treatment:

1. Early and aggressive surgical exploration and debridement
   • debridement of all necrotic tissue until healthy, viable tissue is reached
   • reevaluate in OR ~24 hours later, redebride as needed
2. Broad-spectrum empiric antibiotics
   • Acceptable regimen: carbapenem/b-lactam and b-lactamase + clindamycin + anti-MRSA (example: meropenem/zosyn or unasyn + clindamycin + vanc/linezolid/daptomycin)
3. Hemodynamic support
4. +/- hyperbaric oxygen, IVIG?

References:
-UpToDate (https://www.uptodate.com/contents/necrotizing-soft-tissue-infections?source=search_result&search=necrotizing%20fasciitis&selectedTitle=1~101)

-MDCalc (http://www.mdcalc.com/lrinec-score-for-necrotizing-soft-tissue-infection/)

-Picture of CT scan of abdominal wall abscess (http://bariatrictimes.com/necrotizing-fasciitis-of-the-abdominal-wall-after-laparoscopic-roux-en-y-gastric-bypass-by-joanna-r-crossett-md-and-william-v-rice-md/)

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