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Necrotizing Soft Tissue Infection

I. Background

Necrotizing soft tissue infection (NSTI) is a rapidly progressing, life-threatening infection with significant morbidity and mortality. Prompt recognition, initiation of antibiotics, and surgical debridement are essential for effective management.

II. Guideline

A. Initial Evaluation

  • Labs

    • CBC
    • BMP
    • Lactate
    • CRP
    • Blood cultures

  • Imaging

    • Diagnosis is primarily clinical and confirmed in the operating room
    • CT with IV contrast can support diagnosis in equivocal cases
    • Presence of soft tissue gas is highly specific
    • Absence of gas does not rule out NSTI

  • Initial Antibiotic Therapy

    • First-line: Linezolid + Piperacillin/Tazobactam
    • Severe PCN allergy: Linezolid + Cefepime + Metronidazole

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  • Consultations
    • STAT Emergency General Surgery consultation for trunk NSTI
    • Additional specialty consults as indicated:
      • Urology (perineal/scrotal NSTI)
      • Gynecology (vulvar NSTI)
      • Orthopedics / Hand (extremity NSTI)
      • Plastic Surgery (for reconstruction after infection control)
    • Strongly consider SICU admission postoperatively

B. Surgical Management

  • Early, aggressive debridement within 6 hours
  • Expedite Level 2 OR activation
  • Send intraoperative specimens for gram stain and culture
  • Use skin-sparing technique when feasible; elevate full-thickness and subcutaneous flaps to access necrotic tissue
  • Debride skin only if necrotic
  • Avoid incisions near bony prominences, major vessels, and nerves
  • Plan for second look operation within 24 hours or sooner if patient deteriorates
  • For perineal/perianal involvement: consider diverting colostomy once hemodynamically stable
  • For large wounds:
    • Apply negative pressure wound therapy (VAC)
    • Cleanse with dilute Dakin’s solution between VAC changes
  • Once stable and debridement complete:
    • Close with interrupted sutures, split-thickness skin grafts, or flaps (Plastic Surgery)

C. Ongoing Management

  • Antibiotic Duration

    • Continue systemic antibiotics until ALL of the following:
      • Adequate source control
      • Hemodynamic normalization
      • Afebrile for 48 hours
      • WBC improvement

  • Infectious Disease Consultation

    • Indications:
      • Multidrug-resistant organisms
      • Osteoarticular involvement
      • Per VUMC policy (e.g., S. aureus or Enterococcus bacteremia)

  • Physical & Occupational Therapy

    • Early involvement recommended

III. References

  1. Stevens DL, Bryant AE. N Engl J Med. 2017;377(23):2253–2265.
  2. Stevens DL, et al. Clin Infect Dis. 2014;59(2):147–159.
  3. Hua C, et al. Lancet Infect Dis. 2023;23(3):e81–e94.
  4. Hadeed GJ, et al. J Emerg Trauma Shock. 2016;9(1):22–27.
  5. Zacharias N, et al. Arch Surg. 2010;145(5):452–455.
  6. Duane TM, et al. Surg Infect (Larchmt). 2021;22(4):383–399.
  7. Dorazio J, et al. Open Forum Infect Dis. 2023;10(6):ofad258.
  8. Tom LK, et al. J Am Coll Surg. 2016;222(5):e47–60.

IV. Authors

  • Michael J. Derickson, MD
  • Eddie Blay, MD
  • Kelli Rumbaugh, PharmD, BCPS, BCCCP
  • Jade Flynn, PharmD, BCPS

Date: February 26, 2024

V. Appendix

Refer to institutional documents for visual guides and operative illustrations related to skin-sparing debridement techniques.