Necrotising fasciitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected necrotising fasciitis, organism unknown

1st line – emergency surgical debridement

Back

1st line –

emergency surgical debridement

Refer the patient immediately to the surgical team; necrotising fasciitis requires rapid debridement of all infected tissues in combination with empirical antibiotic therapy.[2][3][4][20][46]

The infected subcutaneous tissue is devitalised, so expedited surgical removal of all infected tissue, drainage of infected fluids, and removal of infected devices or foreign bodies is critical for successful treatment.[3] Surgical debridement should be performed as soon as possible, but at least within 6-12 hours of hospital admission.[3][15][46][57]
- Delay in surgical debridement (>12 hours after admission) has been associated with the need for a greater number of subsequent debridements, higher incidence of organ failure, and higher mortality.[4][46][56]
Surgical specimens including tissue and fluid should be obtained for microbiological culture.[2][3]
A multidisciplinary approach (including a surgeon, an infectious disease or microbiology specialist, and critical care) is required.[15][53]

While the patient is waiting for surgery, monitor them for systemic toxicity (e.g., signs of end-organ damage), as well as local signs and symptoms of extension of the area of necrotising fasciitis.[4]

Consider the need for additional debridement or alterations in antibiotic or antifungal therapy, based on culture results from subcutaneous tissue or blood, the patient’s clinical condition, and discussion with the multidisciplinary team.[2][3][4][53] See Acute - surgical re-exploration ± debridement.

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Get an early review from the critical care team. Some patients will need critical care support depending on the degree of surgical resection and their physiological state.

Give intensive haemodynamic support with intravenous fluids, and vasoactive drugs if needed.[2][3][4]

Check local protocols for specific recommendations on fluid choice. Evidence from critically ill patients in general (not specifically people with necrotising fasciitis) suggests that there is no difference in benefit between normal saline and a balanced crystalloid (such as Hartmann's solution [also known as Ringer’s lactate] or Plasma-Lyte®), and therefore either choice of fluid is reasonable.[58][59]

Practical tip

Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloremic acidosis.

Also note that use of lactate-containing fluid in a patient with impaired liver metabolism may lead to a spuriously elevated lactate level, so results need to be interpreted with other markers of volume status.

Evidence: Choice of fluids

Evidence from two large randomised controlled trials (RCTs) suggests there is no difference between normal saline and a balanced crystalloid in mortality at 90 days, and therefore either option is a reasonable choice for the resuscitation of critically ill patients.

There has been extensive debate over the choice between normal saline (an unbalanced crystalloid) versus a balanced crystalloid (such as Hartmann’s solution [also known as Ringer’s lactate] or Plasma-Lyte®). Evidence from critically ill patients points to no benefits from using a balanced crystalloid in preference to normal saline. Clinical practice varies widely, so you should check local protocols.

In 2021 to 2022 two large double-blind RCTs were published assessing intravenous fluid resuscitation in intensive care unit (ICU) patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline: the Plasma-Lyte 148 versus Saline (PLUS) trial (53 ICUs in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[58][59]
- In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
- In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
- Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis, or post-surgery. They also found no difference in the risk of AKI.
- In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90-day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[60]
Previous evidence has been mixed.
- One 2015 double-blind, cluster-randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs. Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[61]
- However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs. 11.1%; odds ratio [OR] 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[62]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[63]
- The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
- There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high-quality evidence as assessed by GRADE), AKI (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).

Check your local protocols for choice and dose of vasoactive drugs.
Ensure the patient has adequate analgesia.[3] Morphine is used in practice.

Primary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – empirical antibiotic therapy

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Plus –

empirical antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Start empirical intravenous antibiotic therapy as soon as you have obtained blood cultures.[2][3][35] Urgently discuss choice of antibiotic with an infectious disease or microbiology specialist.

Use high-dose broad-spectrum antibiotics that target the most common aetiologies of:
- Type I infection
  - Anaerobes such as Bacteroides or Peptostreptococcus with a facultative anaerobe such as certain Enterobacterales ( Escherichia coli, Enterobacter, Klebsiella, Proteus), MRSA, or non-group A streptococcus
- Type II infection
  - Group A streptococcus.
Consider local resistance and epidemiological patterns (including extended-spectrum beta-lactamase or carbapenemase-producing organisms).
Appropriate antibiotics include piperacillin/tazobactam, a carbapenem (e.g., meropenem), a cephalosporin (e.g., ceftriaxone), or a fluoroquinolone such as ciprofloxacin (if the patient is allergic to penicillin).
Always add vancomycin, linezolid, tedizolid, or daptomycin for MRSA cover.[3]
Add antibiotics that inhibit toxin production until group A streptococcus involvement is excluded.[3] Evidence for clindamycin is strongest.[2][37]
Fungal pathogens (e.g., Mucorales, Candida) are rare causes of necrotising fasciitis; empirical antifungal agents are not recommended.

Continue empirical antibiotics until the causative organism has been determined. Once these results are available, tailor antibiotic therapy accordingly.

Drug safety alert: Fluoroquinolones

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[64] Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[65][66]

Primary options

piperacillin/tazobactam: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections

meropenem: 0.5 to 1 g intravenously every 8 hours

ceftriaxone: 2 g intravenously every 24 hours

ciprofloxacin: 400 mg intravenously every 8-12 hours

-- AND --

vancomycin: 15-20 mg/kg intravenously every 8-12 hours, maximum 2000 mg/dose

linezolid: 600 mg intravenously every 12 hours

tedizolid phosphate: 200 mg intravenously every 24 hours

daptomycin: 4-6 mg/kg intravenously every 24 hours

-- AND --

clindamycin: 600-2700 mg/day intravenously given in 2-4 divided doses, may increase to 1200 mg every 6 hours in life-threatening infections

ACUTE

type I necrotising fasciitis (polymicrobial)

1st line – surgical re-exploration ± debridement

Back

1st line –

surgical re-exploration ± debridement

Consider the need for additional debridement (following the initial debridement), based on culture results from subcutaneous tissue or blood, the patient’s clinical condition, and discussion with the multidisciplinary team.[2][3][4][53]

Surgical re-exploration to assess the need for further debridement should be performed at least every 12 to 24 hours after the initial debridement.[3] However, re-exploration may be needed sooner in some patients; inform the surgical team urgently if the patient has clinical signs of worsening infection (local or systemic), or worsening laboratory markers (particularly white blood cell count).[3]
Re-exploration should be repeated until the patient has no necrotic tissue remaining.[3]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Get an early review from the critical care team. Some patients will need critical care support depending on the degree of surgical resection and their physiological state.

Give intensive haemodynamic support with intravenous fluids, and vasoactive drugs if needed.[2][3][4]

Check local protocols for specific recommendations on fluid choice. Evidence from critically ill patients in general (not specifically people with necrotising fasciitis) suggests that there is no difference in benefit between normal saline and a balanced crystalloid (such as Hartmann's solution [also known as Ringer’s lactate] or Plasma-Lyte®), and therefore either choice of fluid is reasonable.[58][59]

Practical tip

Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloremic acidosis.

Evidence: Choice of fluids

In 2021 to 2022 two large double-blind RCTs were published assessing intravenous fluid resuscitation in intensive care unit (ICU) patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline: the Plasma-Lyte 148 versus Saline (PLUS) trial (53 ICUs in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[58][59]
- In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
- In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
- Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis, or post-surgery. They also found no difference in the risk of AKI.
- In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90-day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[60]
Previous evidence has been mixed.
- One 2015 double-blind, cluster-randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs. Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[61]
- However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs. 11.1%; odds ratio [OR] 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[62]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[63]
- The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
- There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high-quality evidence as assessed by GRADE), AKI (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).

Check your local protocols for choice and dose of vasoactive drugs.
Ensure the patient has adequate analgesia.[3] Morphine is used in practice.

Primary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – pathogen-targeted antibiotic therapy

Back

Plus –

pathogen-targeted antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Continue empirical antibiotics started in the initial phase (see Suspected necrotising fasciitis) until culture results are known.

Once culture results are available, tailor the patient’s antibiotics to target the causative organism. Always consult an infectious disease or microbiology specialist (this is particularly important if the patient has multi-drug resistant necrotising fasciitis or is allergic to penicillin) and consider local epidemiological patterns.

Necrotising fasciitis is classified according to the underlying pathogen as type I or II.[5]
Type I infection involves aerobic and anaerobic organisms.[3] It is usually seen in older patients or in those with underlying illnesses.[8]

Suitable antibiotic regimens include piperacillin/tazobactam, a carbapenem (e.g., meropenem), a cephalosporin (e.g., ceftriaxone), or a fluoroquinolone such as ciprofloxacin (if the patient is allergic to penicillin).

Stop antibiotic cover for MRSA and group A streptococcus if these are ruled out.

Continue antibiotics until further debridement is no longer necessary, the patient has clinically improved, and fever has resolved for 48 to 72 hours.[3][67]

Drug safety alert: Fluoroquinolones

Primary options

piperacillin/tazobactam: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections

meropenem: 0.5 to 1 g intravenously every 8 hours

ceftriaxone: 2 g intravenously every 24 hours

ciprofloxacin: 400 mg intravenously every 8-12 hours

Consider – MRSA antibiotic cover

Back

Consider –

MRSA antibiotic cover

Additional treatment recommended for SOME patients in selected patient group

Continue vancomycin, linezolid, tedizolid, or daptomycin if MRSA is confirmed.

Continue antibiotics until further debridement is no longer necessary, the patient has clinically improved, and fever has resolved for 48 to 72 hours.[3][67]

Primary options

vancomycin: 15-20 mg/kg intravenously every 8-12 hours, maximum 2000 mg/dose

linezolid: 600 mg intravenously every 12 hours

tedizolid phosphate: 200 mg intravenously every 24 hours

daptomycin: 4-6 mg/kg intravenously every 24 hours

Consider – group A streptococcus antibiotic cover

Back

Consider –

group A streptococcus antibiotic cover

Additional treatment recommended for SOME patients in selected patient group

Continue an antibiotic that inhibits toxin production until group A streptococcus involvement is excluded.[3] Evidence for clindamycin is strongest.[2][37]

Continue antibiotics until further debridement is no longer necessary, the patient has clinically improved, and fever has resolved for 48 to 72 hours.[3][67]

Primary options

clindamycin: 600-2700 mg/day intravenously given in 2-4 divided doses, may increase to 1200 mg every 6 hours in life-threatening infections

type II necrotising fasciitis due to group A streptococcus

1st line – surgical re-exploration ± debridement

Back

1st line –

surgical re-exploration ± debridement

Surgical re-exploration to assess the need for further debridement should be performed at least every 12 to 24 hours after the initial debridement.[3] However, re-exploration may be needed sooner in some patients; inform the surgical team urgently if the patient has clinical signs of worsening infection (local or systemic), or worsening laboratory markers (particularly white blood cell count).[3]
Re-exploration should be repeated until the patient has no necrotic tissue remaining.[3][4]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Get an early review from the critical care team. Some patients will need critical care support depending on the degree of surgical resection and their physiological state.

Give intensive haemodynamic support with intravenous fluids, and vasoactive drugs if needed.[2][3][4]

Check local protocols for specific recommendations on fluid choice. Evidence from critically ill patients in general (not specifically people with necrotising fasciitis) suggests that there is no difference in benefit between normal saline and a balanced crystalloid (such as Hartmann's solution [also known as Ringer’s lactate] or Plasma-Lyte®), and therefore either choice of fluid is reasonable.[58][59]

Practical tip

Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloremic acidosis.

Evidence: Choice of fluids

In 2021 to 2022 two large double-blind RCTs were published assessing intravenous fluid resuscitation in intensive care unit (ICU) patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline: the Plasma-Lyte 148 versus Saline (PLUS) trial (53 ICUs in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[58][59]
- In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
- In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
- Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis, or post-surgery. They also found no difference in the risk of AKI.
- In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90-day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[60]
Previous evidence has been mixed.
- One 2015 double-blind, cluster-randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs. Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[61]
- However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs. 11.1%; odds ratio [OR] 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[62]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[63]
- The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
- There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high-quality evidence as assessed by GRADE), AKI (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).

Check your local protocols for choice and dose of vasoactive drugs.
Ensure the patient has adequate analgesia.[3] Morphine is used in practice.

Primary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – pathogen-targeted antibiotic therapy

Back

Plus –

pathogen-targeted antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Continue empirical antibiotics started in the initial phase (see Suspected necrotising fasciitis) until culture results are known.

Necrotising fasciitis is classified according to the underlying pathogen as type I or II.[5]
Type II infection is most commonly due to group A streptococcus, but can also be due to Staphylococcus aureus.[3]

Clindamycin plus a penicillin is recommended for type II infection due to group A streptococcus.[2]

If the patient has a penicillin allergy, vancomycin monotherapy may be used.

Continue antibiotics until further debridement is no longer necessary, the patient has clinically improved, and fever has resolved for 48 to 72 hours.[3][67]

Primary options

clindamycin: 600-2700 mg/day intravenously given in 2-4 divided doses, may increase to 1200 mg every 6 hours in life-threatening infections

and

benzylpenicillin sodium: 0.6 to 1.2 g intravenously every 6 hours, may increase dose in serious infections, maximum 14.4 g/day

vancomycin: 15-20 mg/kg intravenously every 8-12 hours, maximum 2000 mg/dose

Consider – intravenous immunoglobulin

type II necrotising fasciitis due to Staphylococcus aureus

1st line – surgical re-exploration ± debridement

Back

1st line –

surgical re-exploration ± debridement

Surgical re-exploration to assess the need for further debridement should be performed at least every 12 to 24 hours after the initial debridement.[3] However, re-exploration may be needed sooner in some patients; inform the surgical team urgently if the patient has clinical signs of worsening infection (local or systemic), or worsening laboratory markers (particularly white blood cell count).[3]
Re-exploration should be repeated until the patient has no necrotic tissue remaining.[3][4]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Get an early review from the critical care team. Some patients will need critical care support depending on the degree of surgical resection and their physiological state.

Give intensive haemodynamic support with intravenous fluids, and vasoactive drugs if needed.[2][3]

Check local protocols for specific recommendations on fluid choice. Evidence from critically ill patients in general (not specifically people with necrotising fasciitis) suggests that there is no difference in benefit between normal saline and a balanced crystalloid (such as Hartmann's solution [also known as Ringer’s lactate] or Plasma-Lyte®), and therefore either choice of fluid is reasonable.[58][59]

Practical tip

Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloremic acidosis.

Evidence: Choice of fluids

In 2021 to 2022 two large double-blind RCTs were published assessing intravenous fluid resuscitation in intensive care unit (ICU) patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline: the Plasma-Lyte 148 versus Saline (PLUS) trial (53 ICUs in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[58][59]
- In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
- In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
- Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis, or post-surgery. They also found no difference in the risk of AKI.
- In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90-day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[60]
Previous evidence has been mixed.
- One 2015 double-blind, cluster-randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs. Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[61]
- However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs. 11.1%; odds ratio [OR] 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[62]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[63]
- The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
- There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high-quality evidence as assessed by GRADE), AKI (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).

Check your local protocols for choice and dose of vasoactive drugs.
Ensure the patient has adequate analgesia.[3] Morphine is used in practice.

Primary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – pathogen-targeted antibiotic therapy

Back

Plus –

pathogen-targeted antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Continue empirical antibiotics started in the initial phase (see Suspected necrotising fasciitis) until culture results are known.

Necrotising fasciitis is classified according to the underlying pathogen as type I or II.[5]
Type II infection is most commonly due to group A streptococcus, but can also be due to Staphylococcus aureus.[3]

Use antibiotics that are active against MRSA until cultures confirm susceptibilities; options include vancomycin, linezolid, tedizolid, or daptomycin. Ceftaroline or dalbavancin are also reasonable choices.[2][3] In practice, tigecycline may also be used.

Flucloxacillin or cefazolin may be used if methicillin susceptibility is confirmed.[2]

Continue antibiotics until further debridement is no longer necessary, the patient has clinically improved, and fever has resolved for 48 to 72 hours.[3][67]

Primary options

MRSA

vancomycin: 15-20 mg/kg intravenously every 8-12 hours, maximum 2000 mg/dose

MRSA

linezolid: 600 mg intravenously every 12 hours

MRSA

tedizolid phosphate: 200 mg intravenously every 24 hours

MRSA

daptomycin: 4-6 mg/kg intravenously every 24 hours

MSSA

flucloxacillin: 1-2 g intravenously every 6 hours

MSSA

cefazolin: 1-2 g/day intravenously given in 2-3 divided doses, may increase to 6 g/day given in 3-4 divided doses in severe infections

Secondary options

MRSA

ceftaroline: 600 mg intravenously every 12 hours

MRSA

dalbavancin: 1500 mg intravenously as a single dose; or 1000 mg intravenously as a single dose, followed by 500 mg after 1 week

MRSA

tigecycline: 100 mg intravenously initially, followed by 50 mg every 12 hours

type II necrotising fasciitis due to Vibrio vulnificus

1st line – surgical re-exploration ± debridement

Back

1st line –

surgical re-exploration ± debridement

C onsider the need for additional debridement (following the initial debridement), based on culture results from subcutaneous tissue or blood, the patient’s clinical condition, and discussion with the multidisciplinary team.[2][3][4][53]

Surgical re-exploration to assess the need for further debridement should be performed at least every 12 to 24 hours after the initial debridement.[3] However, re-exploration may be needed sooner in some patients; inform the surgical team urgently if the patient has clinical signs of worsening infection (local or systemic), or worsening laboratory markers (particularly white blood cell count).[3]
Re-exploration should be repeated until the patient has no necrotic tissue remaining.[3][4]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Get an early review from the critical care team. Some patients will need critical care support depending on the degree of surgical resection and their physiological state.

Give intensive haemodynamic support with intravenous fluids, and vasoactive drugs if needed.[2][3][4]

Check local protocols for specific recommendations on fluid choice. Evidence from critically ill patients in general (not specifically people with necrotising fasciitis) suggests that there is no difference in benefit between normal saline and a balanced crystalloid (such as Hartmann's solution [also known as Ringer’s lactate] or Plasma-Lyte®), and therefore either choice of fluid is reasonable.[58][59]

Practical tip

Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloremic acidosis.

Evidence: Choice of fluids

In 2021 to 2022 two large double-blind RCTs were published assessing intravenous fluid resuscitation in intensive care unit (ICU) patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline: the Plasma-Lyte 148 versus Saline (PLUS) trial (53 ICUs in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[58][59]
- In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
- In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
- Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis, or post-surgery. They also found no difference in the risk of AKI.
- In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90-day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[60]
Previous evidence has been mixed.
- One 2015 double-blind, cluster-randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs. Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[61]
- However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs. 11.1%; odds ratio [OR] 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[62]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[63]
- The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
- There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high-quality evidence as assessed by GRADE), AKI (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).

Check your local protocols for choice and dose of vasoactive drugs.
Ensure the patient has adequate analgesia.[3] Morphine is used in practice.

Primary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – pathogen-targeted antibiotic therapy

Back

Plus –

pathogen-targeted antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Continue empirical antibiotics started in the initial phase (see Suspected necrotising fasciitis) until culture results are known.

Type II infection with Vibrio vulnificus is associated with predisposing risk factors including hepatic disease, diabetes mellitus, chronic renal insufficiency, and adrenal insufficiency.[5][9]

Doxycycline plus a cephalosporin (e.g., ceftriaxone) is recommended for the management of necrotising fasciitis due to V vulnificus.[2]

Continue antibiotics until further debridement is no longer necessary, the patient has clinically improved, and fever has resolved for 48 to 72 hours.[3][67]

Primary options

doxycycline: 100 mg intravenously every 12 hours

and

ceftriaxone: 2 g intravenously every 24 hours

type II necrotising fasciitis due to Aeromonas hydrophila

1st line – surgical re-exploration ± debridement

Back

1st line –

surgical re-exploration ± debridement

Surgical re-exploration to assess the need for further debridement should be performed at least every 12 to 24 hours after the initial debridement.[3] However, re-exploration may be needed sooner in some patients; inform the surgical team urgently if the patient has clinical signs of worsening infection (local or systemic), or worsening laboratory markers (particularly white blood cell count).[3]
Re-exploration should be repeated until the patient has no necrotic tissue remaining.[3][4]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Get an early review from the critical care team. Some patients will need critical care support depending on the degree of surgical resection and their physiological state.

Give intensive haemodynamic support with intravenous fluids, and vasoactive drugs if needed.[2][3][4]

Check local protocols for specific recommendations on fluid choice. Evidence from critically ill patients in general (not specifically people with necrotising fasciitis) suggests that there is no difference in benefit between normal saline and a balanced crystalloid (such as Hartmann's solution [also known as Ringer’s lactate] or Plasma-Lyte®), and therefore either choice of fluid is reasonable.[58][59]

Practical tip

Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloremic acidosis.

Evidence: Choice of fluids

In 2021 to 2022 two large double-blind RCTs were published assessing intravenous fluid resuscitation in intensive care unit (ICU) patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline: the Plasma-Lyte 148 versus Saline (PLUS) trial (53 ICUs in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[58][59]
- In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
- In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
- Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis, or post-surgery. They also found no difference in the risk of AKI.
- In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90-day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[60]
Previous evidence has been mixed.
- One 2015 double-blind, cluster-randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs. Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[61]
- However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs. 11.1%; odds ratio [OR] 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[62]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[63]
- The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
- There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high-quality evidence as assessed by GRADE), AKI (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).

Check your local protocols for choice and dose of vasoactive drugs.
Ensure the patient has adequate analgesia.[3] Morphine is used in practice.

Primary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – pathogen-targeted antibiotic therapy

Back

Plus –

pathogen-targeted antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Continue empirical antibiotics started in the initial phase (see Suspected necrotising fasciitis) until culture results are known.

Tailor the patient’s antibiotics according to the culture results, and discussion with an infectious disease or microbiology specialist (particularly if the patient has multi-drug resistant necrotising fasciitis or is allergic to penicillin) and consider local epidemiological patterns.

Necrotising fasciitis is classified according to the underlying pathogen as type I or II.[5]
Type II infection infection with Aeromonas hydrophila is more common in patients with immunosuppression, burns, and trauma in an aquatic setting.[5][10]

Doxycycline plus ciprofloxacin or ceftriaxone are recommended for the management of necrotising fasciitis due to A hydrophila.[2]

Continue antibiotics until further debridement is no longer necessary, the patient has clinically improved, and fever has resolved for 48 to 72 hours.[3][67]

Primary options

doxycycline: 100 mg intravenously every 12 hours

-- AND --

ciprofloxacin: 400 mg intravenously every 8-12 hours

ceftriaxone: 2 g intravenously every 24 hours

type II necrotising fasciitis due to Clostridium

1st line – surgical re-exploration ± debridement

Back

1st line –

surgical re-exploration ± debridement

Surgical re-exploration to assess the need for further debridement should be performed at least every 12 to 24 hours after the initial debridement.[3] However, re-exploration may be needed sooner in some patients; inform the surgical team urgently if the patient has clinical signs of worsening infection (local or systemic), or worsening laboratory markers (particularly white blood cell count).[3]
Re-exploration should be repeated until the patient has no necrotic tissue remaining.[3][4]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Get an early review from the critical care team. Some patients will need critical care support depending on the degree of surgical resection and their physiological state.

Give intensive haemodynamic support with intravenous fluids, and vasoactive drugs if needed.[2][3][4]

Check local protocols for specific recommendations on fluid choice. Evidence from critically ill patients in general (not specifically people with necrotising fasciitis) suggests that there is no difference in benefit between normal saline and a balanced crystalloid (such as Hartmann's solution [also known as Ringer’s lactate] or Plasma-Lyte®), and therefore either choice of fluid is reasonable.[58][59]

Practical tip

Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloremic acidosis.

Evidence: Choice of fluids

In 2021 to 2022 two large double-blind RCTs were published assessing intravenous fluid resuscitation in intensive care unit (ICU) patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline: the Plasma-Lyte 148 versus Saline (PLUS) trial (53 ICUs in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[58][59]
- In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
- In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
- Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis, or post-surgery. They also found no difference in the risk of AKI.
- In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90-day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[60]
Previous evidence has been mixed.
- One 2015 double-blind, cluster-randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs. Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[61]
- However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs. 11.1%; odds ratio [OR] 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[62]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[63]
- The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
- There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high-quality evidence as assessed by GRADE), AKI (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).

Check your local protocols for choice and dose of vasoactive drugs.
Ensure the patient has adequate analgesia.[3] Morphine is used in practice.

Primary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – pathogen-targeted antibiotic therapy

Back

Plus –

pathogen-targeted antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Continue empirical antibiotics started in the initial phase (see Suspected necrotising fasciitis) until culture results are known.

Necrotising fasciitis is classified according to the underlying pathogen as type I or II.[5]
Type II infection with Clostridium can also cause gangrenous necrotising fasciitis.[5] See Gangrene.

Primary options

clindamycin: 600-2700 mg/day intravenously given in 2-4 divided doses, may increase to 1200 mg every 6 hours in life-threatening infections

and

benzylpenicillin sodium: 0.6 to 1.2 g intravenously every 6 hours, may increase dose in serious infections, maximum 14.4 g/day

fungal infection

1st line – surgical re-exploration ± debridement

Back

1st line –

surgical re-exploration ± debridement

Surgical re-exploration to assess the need for further debridement should be performed at least every 12 to 24 hours after the initial debridement.[3] However, re-exploration may be needed sooner in some patients; inform the surgical team urgently if the patient has clinical signs of worsening infection (local or systemic), or worsening laboratory markers (particularly white blood cell count).[3]
Re-exploration should be repeated until the patient has no necrotic tissue remaining.[3][4]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Get an early review from the critical care team. Some patients will need critical care support depending on the degree of surgical resection and their physiological state.

Give intensive haemodynamic support with intravenous fluids, and vasoactive drugs if needed.[2][3][4]

Check local protocols for specific recommendations on fluid choice. Evidence from critically ill patients in general (not specifically people with necrotising fasciitis) suggests that there is no difference in benefit between normal saline and a balanced crystalloid (such as Hartmann's solution [also known as Ringer’s lactate] or Plasma-Lyte®), and therefore either choice of fluid is reasonable.[58] [59]

Practical tip

Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloremic acidosis.

Evidence: Choice of fluids

In 2021 to 2022 two large double-blind RCTs were published assessing intravenous fluid resuscitation in intensive care unit (ICU) patients with a balanced crystalloid solution (Plasma-Lyte) versus normal saline: the Plasma-Lyte 148 versus Saline (PLUS) trial (53 ICUs in Australia and New Zealand; N=5037) and the Balanced Solutions in Intensive Care Study (BaSICS) trial (75 ICUs in Brazil; N=11,052).[58][59]
- In the PLUS study 45.2% of patients were admitted to ICU directly from surgery (emergency or elective), 42.3% had sepsis and 79.0% were receiving mechanical ventilation at the time of randomisation.
- In BaSICS almost half the patients (48.4%) were admitted to ICU after elective surgery and around 68% had some form of fluid resuscitation before being randomised.
- Both found no difference in 90-day mortality overall or in prespecified subgroups for patients with acute kidney injury (AKI), sepsis, or post-surgery. They also found no difference in the risk of AKI.
- In BaSICS, for patients with traumatic brain injury, there was a small decrease in 90-day mortality with normal saline - however, the overall number of patients was small (<5% of total included in the study) so there is some uncertainty about this result. Patients with traumatic brain injury were excluded from PLUS as the authors felt these patients should be receiving saline or a solution of similar tonicity.
One meta-analysis of 13 RCTs (including PLUS and BaSICS) confirmed no overall difference, although the authors did highlight a non-significant trend towards a benefit of balanced solutions for risk of death.[60]
Previous evidence has been mixed.
- One 2015 double-blind, cluster-randomised, double-crossover trial conducted in four ICUs in New Zealand (N=2278), the 0.9% Saline vs. Plasma-Lyte for ICU fluid Therapy (SPLIT) trial, found no difference for in-hospital mortality, AKI, or use of renal-replacement therapy.[61]
- However, one 2018 US multicentre unblinded cluster-randomised trial - the isotonic Solutions and Major Adverse Renal events Trial (SMART), among 15,802 critically ill adults receiving ICU care - found possible small benefits from balanced crystalloid (Ringer’s lactate or Plasma-Lyte) compared with normal saline. The 30-day outcomes showed a non-significant reduced mortality in the balanced crystalloid group versus the normal saline group (10.3% vs. 11.1%; odds ratio [OR] 0.90, 95% CI 0.80 to 1.01) and a major adverse kidney event rate of 14.3% versus 15.4% respectively (OR 0.91, 95% CI 0.84 to 0.99).[62]
One 2019 Cochrane review included 21 RCTs (N=20,213) assessing balanced crystalloids versus normal saline for resuscitation or maintenance in a critical care setting.[63]
- The three largest RCTs in the Cochrane review (including SMART and SPLIT) all examined fluid resuscitation in adults and made up 94.2% of participants (N=19,054).
- There was no difference in in‐hospital mortality (OR 0.91, 95% CI 0.83 to 1.01; high-quality evidence as assessed by GRADE), AKI (OR 0.92, 95% CI 0.84 to 1.00; GRADE low), or organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; GRADE very low).

Check your local protocols for choice and dose of vasoactive drugs.
Ensure the patient has adequate analgesia.[3] Morphine is used in practice.

Primary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Plus – discussion with infectious disease or microbiology specialist and antifungal therapy

Back

Plus –

discussion with infectious disease or microbiology specialist and antifungal therapy

Treatment recommended for ALL patients in selected patient group

Continue empirical antibiotics started in the initial phase (see Suspected necrotising fasciitis) until culture results are known.

Seek advice from an infectious disease or microbiology specialist to determine further treatment, which should be tailored according to the culture results.

Fungal infection is rare and is the result of infection with pathogens such as Mucorales and Candida species. Although necrotising mucormycosis predominantly affects immunocompromised people, it may also occur in immunocompetent individuals.[12][13][14]
Liposomal amphotericin-B is usually the primary treatment option.

Primary options

amphotericin B liposomal: consult specialist for guidance on dose

ONGOING

persistent cosmetic and functional defects after debridement

1st line – reconstructive surgery

Use of this content is subject to our disclaimer

Necrotising fasciitis

Treatment algorithm

suspected necrotising fasciitis, organism unknown

emergency surgical debridement

supportive care

Practical tip

Evidence: Choice of fluids

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

empirical antibiotic therapy

Drug safety alert: Fluoroquinolones

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

type I necrotising fasciitis (polymicrobial)

surgical re-exploration ± debridement

supportive care

Practical tip

Evidence: Choice of fluids

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

pathogen-targeted antibiotic therapy

Drug safety alert: Fluoroquinolones

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

MRSA antibiotic cover

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

group A streptococcus antibiotic cover

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

type II necrotising fasciitis due to group A streptococcus

surgical re-exploration ± debridement

supportive care

Practical tip

Evidence: Choice of fluids

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

pathogen-targeted antibiotic therapy

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

intravenous immunoglobulin

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

type II necrotising fasciitis due to Staphylococcus aureus

surgical re-exploration ± debridement

supportive care

Practical tip

Evidence: Choice of fluids

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options