Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Recognize red flags (pain out of proportion, systemic toxicity, bullae, anesthesia, rapid progression).
- Start broad antibiotics with clindamycin; resuscitate; alert OR immediately.
- Do not delay for imaging if high suspicion; perform wide debridement and obtain cultures.
- Plan for 12–24 h re‑look; escalate ICU care; optimize nutrition and wound care; consider VAC therapy.
Clinical Synopsis & Reasoning
Rapidly progressive infection with severe pain, systemic toxicity, bullae, crepitus, or anesthesia of skin. Do not rely on LRINEC. Start broad IV antibiotics including toxin suppression and obtain emergent surgical debridement with planned re‑explorations.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CT with IV contrast (adjunct) | Extent/gas | Fascial gas, enhancement patterns | Do not delay OR |
| Bedside exam/finger test | Clinical confirmation | ‘Dishwater’ fluid, easy fascial dissection | — |
| Cultures (blood/tissue) | Microbiology | Monomicrobial (GAS) or polymicrobial | Tailor therapy |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Piperacillin‑tazobactam + Vancomycin + Clindamycin | Broad coverage + toxin suppression | Hours | Empiric regimen | Carbapenem as alternative base |
| IVIG (selected severe GAS) | Immunotherapy | Hours | Toxin neutralization (controversial) | Limited evidence |
| Serial surgical debridements | Source control | Immediate‑days | Planned re‑look in 12–24 h | — |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- IDSA SSTI guideline and WSES consensus on NSTI — Link