Editing Necrotizing fasciitis (section)

==Treatment==
Necrotizing fasciitis is treated with surgical [[debridement]] (cutting away affected tissue).<ref name="CDC2016" /> However, antibiotics should be started as soon as this condition is suspected. Appropriate antibiotic coverage may be changed based on tissue cultures. Additional support should be initiated for those with unstable vital signs and low urine output.<ref name=Hak2014/>

===Surgery===
Aggressive wound debridement should be performed as soon as the diagnosis is made. The affected area may need to be debrided several times, usually once every 12–36 hours.<ref name="CDC2016" /> Large sections of tissue and muscle may need to be removed to prevent the infection from spreading. Amputation may be needed if the infection is too severe.<ref name="CDC2016" />

''En bloc'' debridement (EBd) is most commonly employed in treating NSTIs.<ref name=":3">{{Cite journal |last1=Suijker |first1=Jaco |last2=Zheng |first2=Kang Jing |last3=Pijpe |first3=Anouk |last4=Nasroe |first4=Farha |last5=Vries |first5=Annebeth Meij-de |date=2021-08-01 |title=The Skin-Sparing Debridement Technique in Necrotizing Soft-Tissue Infections: A Systematic Review |url=https://linkinghub.elsevier.com/retrieve/pii/S0022480421001025 |journal=Journal of Surgical Research |language=English |volume=264 |pages=296–308 |doi=10.1016/j.jss.2021.03.001 |issn=0022-4804 |pmid=33845413|url-access=subscription }}</ref>  This involves cutting away the skin overlying all diseased areas at the cost of increased scar formation and potential decreased quality of life post-operatively.<ref name=":3" />  More recently, skin-sparing debridement (SSd) has gained traction, as it resects the underlying tissue and sources of infection while preserving skin that is not overtly necrotic.<ref name=":3" />  However, more studies are needed to examine whether SSd actually accelerates the healing process after surgery.<ref name=":3" />
[[File:Fournier gangrene VSD.webp|thumb|Fournier gangrene and subsequent VSD]]
After the wound debridement, adequate dressings should be applied to promote wound healing.<ref name="Hak2014" /> Wounds are generally packed with wet-to-dry dressings and left open to heal.<ref name="CDC2016" /> In certain cases, vacuum-sealing drainage (VSD) may help the wound heal, especially in Fournier gangrene.

For necrotizing infection of the perineal area (Fournier's gangrene), wound debridement and wound care in this area can be difficult because of the excretory products that often render this area dirty and affect the wound-healing process. Therefore, regular dressing changes with a fecal management system can help to keep the wound at the perineal area clean. Sometimes, [[colostomy]] may be necessary to divert the excretory products to keep the wound at the perineal area clean.<ref name="Hak2014" />

<gallery widths="200px" heights="200px">
File:Open wound after debridement of NF.jpg|Wound after aggressive acute debridement of NF
File:Necrotizing fasciitis left leg debridement.JPEG|Necrotic tissue from the left leg surgically removed
File:Post surgical debridement and skin grafting..jpg|Postsurgical debridement and skin grafting
File:Knee Disarticulation Amputation.jpg|After knee disarticulation amputation
</gallery>

===Antibiotics===
Empiric antibiotics are usually initiated as soon as the diagnosis of NSTI has been made. They are then changed to culture-guided antibiotic therapy. In the case of NSTIs, empiric antibiotics are broad-spectrum, covering gram-positive (including MRSA), gram-negative, and anaerobic bacteria.<ref name="Hu2018">{{cite journal|last1=Hua|first1=C|last2=Bosc|first2=R|last3=Sbidian|first3=E|last4=De Prost|first4=N|last5=Hughes|first5=C|last6=Jabre|first6=P|last7=Chosidow|first7=O|last8=Le Cleach|first8=L|date=31 May 2018|title=Interventions for necrotizing soft tissue infections in adults|journal=The Cochrane Database of Systematic Reviews|volume=2018|issue=5|pages=CD011680|doi=10.1002/14651858.CD011680.pub2|pmid=29851032|pmc=6494525}}</ref> Often, a combination of [[clindamycin]], [[daptomycin]], IV [[vancomycin]], and [[gentamicin]] is used.<ref name="Hak2014" /> Gram-negative coverage may entail the use of [[Quinolone antibiotic|fluoroquinolones]], [[piperacillin/tazobactam]], or [[carbapenem]]s.<ref name="CDC2016" />

Despite multiple studies, there is no consensus on how long antibiotics should be given.<ref name=Hu2018/> Generally, antibiotics are administered until surgeons decide that no further debridement is needed, and the patient no longer shows any systemic signs of infection from a clinical and laboratory standpoint.<ref name="CDC2016" /> Evidence regarding the efficacy of treatment and adverse effects is also unclear.

===Add-on therapy===
* '''[[Hyperbaric oxygen]] (HBO)''': In theory, HBO decreases local inflammation in the wound and bolsters the body's immune response. However, the impact of HBO in patients with NSTIs remains unclear.<ref name=Hu2018/>
* '''[[Intravenous immunoglobulin]] (IVIG)''': IVIG is intended to combat the exotoxins released by ''[[Streptococcus pyogenes|S. pyogenes]]'' [[toxic shock syndrome]] (TSS).<ref name=":4">{{Citation |last1=Evans |first1=Heather Leigh |title=Management of Necrotizing Soft Tissue Infection |date=2020 |work=Evidence-Based Critical Care: A Case Study Approach |pages=697–701 |editor-last=Hyzy |editor-first=Robert C. |url=https://link.springer.com/chapter/10.1007/978-3-030-26710-0_93 |access-date=2024-12-05 |place=Cham |publisher=Springer International Publishing |language=en |doi=10.1007/978-3-030-26710-0_93 |isbn=978-3-030-26710-0 |last2=Napolitano |first2=Lena M. |last3=Bulger |first3=Eileen M. |editor2-last=McSparron |editor2-first=Jakob|url-access=subscription }}</ref>  However, studies have failed to find any effect on patient mortality.<ref name=":4" /> There may also be serious adverse effects with IVIG use.<ref name=Hu2018/>
* '''AB103''': Reltecimod aka AB103 is a new drug that binds to the CD28 T-cell receptor and thus mitigates the effects of bacterial toxins. Studies show that it may decrease the severity of organ failure in NF patients.<ref name=":4" /> However, other studies found no difference in mortality with this therapy.<ref name=Hu2018/>
* '''Supportive therapy''': Intravenous hydration, wound care, anticoagulants to prevent thromboembolic events, pain control, vasopressors, etc. should always be provided to patients when appropriate.<ref name=":5" />