Management requires immediate surgical debridement, broad-spectrum antibiotics, and intensive care support. Delays significantly increase mortality.

NECROTISING FASCIITIS MANAGEMENT ALGORITHM
===========================================

Patient with suspected necrotising fasciitis
                |
                v
        IMMEDIATE ASSESSMENT
        - Clinical diagnosis (pain out of proportion)
        - LRINEC score
        - Systemic assessment
                |
                +-------------------+-------------------+
                |                   |                   |
        HIGH SUSPICION         UNCERTAIN           LOW SUSPICION
        (Classic signs)         (Atypical)          (Cellulitis?)
                |                   |                   |
        IMMEDIATE SURGERY      Diagnostic         Trial of
        (Do not delay)         exploration        antibiotics +
                                or incision        close monitoring
                                (finger test)

                    SURGICAL MANAGEMENT
                        |
                        +-------------------+-------------------+
                        |                   |                   |
                Initial Debridement    Re-exploration      Reconstruction
                        |                   |                   |
            - Radical excision      - 24-48 hours        - After infection
              of all necrotic       - Continue until      controlled
              tissue                healthy tissue       - Skin grafts
            - Extend to healthy     - May need           - Flaps
              bleeding tissue         amputation         - Delayed closure
            - Send tissue for       - Multiple
              culture                 debridements
            - Leave open            often needed

                    ANTIBIOTIC THERAPY
                        |
                        +-------------------+-------------------+
                        |                   |                  |
                Empiric Therapy         Directed Therapy    Duration
                        |                   |                   |
            - Meropenem 1g tds    - Based on cultures   - Continue until
            - Vancomycin 1g bd    - Narrow spectrum      surgery complete
            - Clindamycin 600mg    when possible         - Usually 7-14 days
              qds (KEY for Strep)                        - May need longer
            - Consider linezolid                         if extensive
              if MRSA suspected

                    SUPPORTIVE CARE
                        |
                        +-------------------+-------------------+
                        |                   |                   |
                Hemodynamic Support    Organ Support      Wound Care
                        |                   |                   |
            - IV fluids            - Renal: Monitor     - VAC therapy
            - Vasopressors if      - Respiratory:        - Regular
              needed                 Ventilation if       dressings
            - Inotropes if           needed             - Monitor for
              cardiac dysfunction   - Coagulation:        extension
                                    Correct DIC

                    COMPLICATIONS MANAGEMENT
                        |
                        v
            - Amputation if limb not salvageable
            - Compartment syndrome: Fasciotomy
            - Toxic shock: IVIG for Strep
            - Multi-organ failure: Supportive care

Surgical Management:

Immediate Debridement:

• Timing: Within hours of diagnosis, not days
• Extent: Radical excision of all necrotic tissue until healthy, bleeding tissue
• Technique: Extend incisions until healthy fascia and muscle
• Tissue: Send for culture and histology
• Wound: Leave open, pack with dressings

Re-exploration:

• Timing: 24-48 hours after initial debridement
• Purpose: Assess for continued necrosis, further debridement
• Frequency: May need multiple debridements (3-5+ common)
• Endpoint: No further necrosis, healthy granulation tissue

Amputation:

• Indication: Limb not salvageable, extensive necrosis
• Timing: Early amputation may be life-saving
• Level: Preserve as much length as possible
• Rate: 15-25% of limb cases require amputation

Reconstruction:

• Timing: After infection controlled, healthy granulation present
• Options: Skin grafts, local flaps, free flaps
• Delayed: Usually weeks to months after initial debridement

Antibiotic Therapy:

Empiric (Immediate):

• Meropenem: 1g IV tds (or imipenem)
• Vancomycin: 1g IV bd (target trough 15-20)
• Clindamycin: 600mg IV qds (KEY - inhibits toxin production in Strep)
• Rationale: Broad coverage for Type 1 and Type 2

Alternative Regimens:

• Piperacillin-tazobactam + vancomycin + clindamycin
• Consider linezolid if MRSA suspected
• Consider metronidazole if anaerobes likely

Directed (After Cultures):

• Narrow spectrum based on culture results
• Continue clindamycin if Group A Strep (toxin inhibition)
• Duration: Usually 7-14 days, may need longer

Supportive Care:

Hemodynamic:

• IV fluids: Aggressive resuscitation, may need 5-10L
• Vasopressors: If hypotension persists (norepinephrine)
• Inotropes: If cardiac dysfunction
• Monitoring: Central line, arterial line, frequent assessment

Organ Support:

• Respiratory: Mechanical ventilation if needed
• Renal: Monitor function, may need dialysis
• Coagulation: Correct DIC, transfuse as needed
• Nutrition: Early enteral nutrition if possible

Wound Care:

• VAC therapy: Negative pressure wound therapy
• Dressings: Regular changes, monitor for extension
• Isolation: Contact precautions

Special Considerations:

IVIG (for Group A Strep):

• Indication: Toxic shock syndrome, severe disease
• Dose: 1-2 g/kg
• Rationale: Neutralizes toxins
• Evidence: Limited, but may be beneficial in severe cases

Hyperbaric Oxygen:

• Controversial: Limited evidence
• May help: In clostridial infections
• Limitations: Requires specialized facility, may delay surgery