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Surgical management of necrotizing soft tissue infections

Alan D Rogers, MBChB, FC Plast Surg, MMed
Shahriar Shahrokhi, MD, FRCSC, FACS
Section Editor
Marc G Jeschke, MD, PhD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Necrotizing soft tissue infections (NSTIs) are the most severe among the spectrum of skin and soft tissue infections [1]. The presentation is variable with respect to the etiology, anatomic location, and extent of required initial and subsequent debridement, and the manner and complexity of reconstruction. NSTI may involve any or all layers of the skin and soft tissue, including dermis, subcutaneous fat, fascia, and muscle, as well as other structures.

NSTI is challenging to manage successfully because of the rapid onset and extent of the disease process, which is frequently underestimated at initial presentation. Prompt recognition and adequate initial surgical debridement, preferably at the institution to which the patient presented, reduces morbidity and improves survival. Thereafter, interhospital transfer may be required for optimal care, which often requires further aggressive debridement and supportive critical care, sometimes followed by a prolonged and complex process of reconstruction and rehabilitation to regain form and function. Patients with NSTIs are best cared for at a burn center or similar institution with a multidisciplinary environment accustomed to managing complex wounds of this nature and extent.

The operative management and perioperative care of patients with NSTI are reviewed here. The risk factors, clinical features, microbiology, diagnosis, and antimicrobial treatment of NSTI are discussed separately. (See "Necrotizing soft tissue infections".)


Whenever a diagnosis of NSTI is suspected (sepsis, rapid deterioration in clinical condition, necrosis, bullae, or crepitus of the skin) [2], surgical exploration is indicated to perform debridement to the extent that is deemed necessary based upon the appearance of the tissues, or to confirm the diagnosis, if it remains in question (algorithm 1).

Surgery indicated for clinical suspicion — Although patients with NSTI may appear quite well during the early part of their clinical course, deterioration within hours of presentation frequently occurs, with the infection having the potential to cause extensive soft tissue necrosis. As such, a suspicion of NSTI is all that is required to prompt surgical exploration, particularly in high-risk patients (eg, immunocompromised, diabetic, or postsurgical patients) [1,3,4]. Although such high-risk individuals comprise the majority, some of the most severe cases of NSTI have occurred in young patients with no obvious predisposing factors. Occasionally, a history of an upper respiratory tract infection or minor skin infection prior to an inciting trauma may be elicited, but often no such history is forthcoming. (See "Necrotizing soft tissue infections".)

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Literature review current through: Nov 2017. | This topic last updated: Dec 07, 2017.
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