treatment

Last edited 04/2020

Early diagnosis and treatment of the condition is important since prognosis decreases sharply with time. Suspect NF especially when the presentation is “not quite right” or the patient is not responding to treatment (1).

Treatment should be delivered by a multidisciplinary team of intensivists, microbiologists and surgeons, preferably including a plastic surgeon (2):

  • mainstay of treatment is surgical management with aggressive debridement, which should be performed as soon as practically possible after immediate resuscitation (3)

  • haemodynamic support.
    • intravenous fluid resuscitation if symptoms or signs of systemic sepsis eg tachycardia, oliguria, hypotension

  • broad-spectrum antibiotics
    • broad-spectrum antibiotics should be commenced immediately to prevent the progression of septic shock
    • e.g. -  benzylpenicillin, flucloxacillin, clindamycin 
    • antibiotic regimes can be changed once the culture results are available
      • - antibiotic regime should be in consultation with infectious diseases specialists (3)
  •  early exploration and aggressive debridement of necrotic tissue,
    • is the cornerstone of treatment
    • wide excision of area down to fascia
    • diagnosis supported by fascia that is poorly adherent to deeper structures and liquifying necrosis; in affected areas the subcutaneous fat can manually be separated from the deep fascia
    • samples of involved and clinically uninvolved fascia taken with clean instruments for:
      • urgent gram stain
      • culture and sensitivity
      • histology eg urgent frozen section; may give rapid clues to nature of infective agent
    • thorough debridement
    • packing of wound with antiseptic-soaked gauze or catheters left in situ for repeated irrigation of area
    • compulsory surgical exploration 24-48 hours later should be carried out to exclude extension of the infectious process (1); this may need to be repeated more frequently if the patient is very toxic
    • regular inspection of wound post-operatively with further debridement if necessary
    • exposed vital structures eg tendons and nerves, should be kept from dessicating by moist dressings; flamazine ointment may be useful for tendons in this respect
    • amputation – may be required in necrotising infections of the extremities

  • nutritional supplementation

  • consider regional reconstruction eg skin grafts, regional flaps or free flaps, once the patient is stabilised and there is no evidence of infection

  • vacuum assisted closure (VAC) therapy:
    • helpful to promote healing as it reduces organism counts and oedema
    • should be changed regularly
    • not a substitute for adequate surgical debridement
    • can temporise the closure of larger wounds but should not be seen as a definitive form of wound closure (1)

  • intravenous immunoglobulins (IVIG) – can be considered as an add-on method  (2)

  • hyperbaric oxygen therapy may be used as an adjunct to treatment but again, it should not be used as an alternative to complete surgical debridement

Reference:

Related pages:

penicillins

erythromycin