Efficacy analysis of early incision and drainage on necrotizing fasciitis, a retrospective study

Abstract

Background

Necrotizing fasciitis is a life-threatening infectious disease, and extensive debridement, as the primary surgical approach, poses significant risks for advanced-stage patients. Early incision and drainage is a common treatment for soft tissue infections, while its efficacy as a temporizing strategy in necrotizing fasciitis patients remains unclear.

Methods

This study included 116 necrotizing fasciitis patients who underwent surgical treatment at Zhongda Hospital from 1 Jan 2015 to 28 Feb 2025. Based on their initial surgical approach, patients were divided into the incision and drainage group (48 cases) and the extensive debridement group (68 cases). We collected the demographic data, clinical manifestations, treatment details, and outcomes of all patients, and analyzed through t-tests, Mann-Whitney U tests, and chi-square tests. Binary logistic regression was conducted to assess the outcomes of amputation and mortality rate.

Results

In this study, more patients in the I&D group were man (P = 0.031). A higher proportion of patients in the I&D group presented with anemia (P = 0.035), hypoalbuminemia (P = 0.030), abnormal serum creatinine level(P = 0.029), and were at advanced stage of NF(P = 0.031) on admission. The amputation rate was significantly reduced in the I&D group (P = 0.021). After adjusting for multiple confounders, both early I&D (Amputation: aOR = 0.107, 95%CI: 0.022–0.511. Mortality rate: aOR = 0.172, 95%CI: 0.032–0.924.) and higher albumin level (Amputation: aOR = 0.838, 95%CI: 0.724–0.97. Mortality rate: aOR = 0.71, 95%CI: 0.599–0.902.) were associated with a significant reduction in the risks of amputation and mortality rate in NF patients.

Conclusion

Early incision and drainage was associated with a lower risk of amputation and mortality in necrotizing fasciitis patients, offering an effective temporizing strategy to improve prognosis, particularly for those with poor nutritional status.

Introduction

Necrotizing fasciitis (NF) is a life-threatening infectious disease characterized by extensive necrosis of deep tissues [1], primarily involving damage of fascia, tendons and muscles [2]. Epidemiological data indicates an annual incidence of 13.97–18.47 cases per 100,000 population in Thailand [3, 4], and 0.18-15 cases per 100,000 population in other regions [5–7]. NF can be caused by multiple factors, such as localized trauma, surgical wounds, ingestion of raw or undercooked seafood and insect bites [8, 9]. The disease progresses rapidly, while the mortality rate remains at a high level of 20–30% over the past twenty years [10]. Current evidence on the efficacy and safety of NF interventions remains limited globally [11]. However, according to clinical guidelines, early surgery after diagnosis, along with prompt and empirical broad-spectrum antimicrobial therapy covering both aerobic and anaerobic bacteria has been proven effective in improving patient outcomes. The recommended surgical protocol is extensive debridement, which completely excises all necrotic and devitalized skin, subcutaneous tissues, muscles and tendons until healthy and well-vascularized tissue is exposed [12]. During the prodromal phase, NF patients often exhibit nonspecific cutaneous manifestations, leading to misdiagnosis as other soft tissue infections like cellulitis, causing delays in surgical timing. NF clinical course progresses rapidly, and some patients may develop hemodynamic instability or multiple systemic organ failure within hours, increasing both anesthetic and surgical risks. Additionally, accurate identification and complete removal of necrotic tissues during surgery prove challenging [13], with potential massive bleeding that may exacerbate circulatory compromise and increase mortality risk. For patients with equivocal early signs or those unable to tolerate extensive debridement, early incision and drainage(I&D) has been proposed as a bridging treatment in some studies, while literature evaluating its efficacy remains scarce [14–16]. This article focused on the surgical protocol involving early I&D under local anesthesia followed by extensive debridement within 24 h. We retrospectively analyzed data from patients who underwent surgery for NF at Zhongda hospital over the past ten years, and evaluated the therapeutic effects of early I&D on NF.

Materials and methods

Data sources

This was a retrospective study. We collected data from 156 NF patients who were hospitalized at Zhongda Hospital, Southeast University between January 2015 and February 2025 using the Hospital Information System (HIS). This study was approved by the Institutional Review Board of Zhongda Hospital, Southeast University.

Inclusion criteria: (1) Diagnosed with necrotizing fasciitis; (2) Underwent at least one surgery for NF. Exclusion criteria: (1) Combined with other life-threatening conditions (e.g. severe pancreatitis, aortic dissection etc.) that constituted the principal cause of death; (2) Combined with progressive severe systemic diseases (e.g. decompensated cirrhosis, chronic kidney disease stage 4–5), or active chronic diseases deemed life-threatening by investigators; (3) Data missing or irreparable. A total of 116 patients were ultimately included and divided into two groups based on their surgical protocol. 48 patients underwent early I&D and the remaining 68 patients underwent extensive debridement.

Diagnostic criteria [17]: (1) ①Positive finger sweep test: The localized subcutaneous tissue and fascia layer can be easily separated by fingers in the surgical exploration and lack of bleeding can be observed; ②Severe gray tissues necrotizing, abundant foul-smelling purulent secretion flowing out, and the necrosis extend beyond the boundary of the skin lesion; (2) Clinical stages of NF: ①Early stage: fever, pain, localized erythema, warmth, tenderness; ②Intermediate stage: skin swelling, skin induration, skin fluctuation sensation; ③Advanced stage: hemorrhagic bullae, crepitus, skin necrosis with dusky discoloration.

Treatment protocols

The extensive debridement group

Extensive debridement carried out immediately after diagnosis. Under general anesthesia, an appropriate incision based on the lesion location was made layer by layer and adequately extended until the healthy tissue was exposed. Then necrotic skin, subcutaneous tissue, fascia, and muscle were thoroughly assessed and completely resected during the surgery [18]. After complete hemostasis, the wound was thoroughly irrigated with iodophor and hydrogen peroxide, and covered with sufficient mupirocin ointment. Repeat debridement may be performed depending on wound recovery status. Meanwhile, all patients promptly received empirical broad-spectrum antimicrobial therapy according to guideline recommendations. Treatment efficacy is assessed every 48–72 h. Antibiotics should be adjusted promptly based on pathogen culture results until infection resolution.

The I&D group

Early I&D carried out immediately after diagnosis. After localized disinfection and anesthesia, a small incision is made at the center of the abscess for drainage and decompression, and extending the incision along the skin tension lines. Blunt dissection was performed with fingers. Following the abscess drained, the wound was thoroughly irrigated with sterile normal saline solution until the effluent clearance [19]. After putting a gauze strip or drainage tube for continuous drainage, the wound was covered with sterile dressing and secured. Strict aseptic technique was maintained throughout the surgery. An assessment of wound was necessary within 12–24 h after surgery, followed by extensive debridement. The remaining treatment protocols were consistent with those in the extensive debridement group.

Postoperative wound care protocol

Two standardized postoperative wound care protocols were available for NF patients according to the location of the wound, wound cavity size, and patients’ financial means. Wound conditions or characteristics of drainage were recorded daily. All patients were managed according to the above protocol.

1. VAC Therapy: Indicated for patients with large wound cavities and adequate financial means. A VAC therapy device was used to cover the wound with a negative pressure of -125 to -150 mmHg. Saline was continuously irrigated to remove necrotic tissue and secretions for 24 to 48 h.

2. Daily dressing change and packing therapy: Indicated for patients with shallow wound cavities, wounds located in special anatomical sites (e.g., head and neck), or limited financial means. During dressing change, the wound was fully exposed, gently irrigated with saline, packed with iodoform gauze and finally covered with multi-layer sterile gauze for fixation.

Antibiotic protocol

Before the pathogen is identified, empirical antimicrobial therapy is initiated. Once a specific pathogen is confirmed, treatment is switched to targeted antibiotics. The common pathogen category and recommended antibiotic regimens are detailed in Table 1 (Table 1). Some patients may have presented with concurrent renal insufficiency, in which case the antibiotic dosages were adjusted in accordance with the official package inserts of the medications. The duration of antibiotic therapy was promptly modified based on the patients’ infection markers, local symptoms, drug resistance profiles, and serum drug concentrations [1].

Table 1.

Antibiotic protocol

Pathogen Category	Recommended Antibiotic Regimen	Adult Dosage (Specific)
Polymicrobial Infection	Piperacillin-Tazobactam + Nitroimidazole	Piperacillin-Tazobactam 4.5 g q8h/q6h, IV Ornidazole/Levornidazole 0.5 g q12h, IV
Multidrug-Resistant Gram-Negative Bacilli	Carbapenem + Cefoperazone-Sulbactam / Polymyxin	Imipenem/Meropenem 1 g q8h, IV Polymyxin 1 million units q12h, IV Cefoperazone-Sulbactam 3 g q8h, IV
Klebsiella pneumoniae	Piperacillin-Tazobactam / Carbapenem + Quinolone	Piperacillin-Tazobactam 4.5 g q8h/q6h, IV Meropenem 1 g q8h, IV Levofloxacin 0.5 g qd, IV
Anaerobes	Nitroimidazole + Cefoxitin Sodium / Piperacillin-Tazobactam	Nitroimidazole 0.5 g q12h, IV Cefoxitin Sodium 2 g bid, IV
Methicillin-Resistant Staphylococcus aureus, Drug-Resistant Enterococcus	Linezolid / Vancomycin + Carbapenem	Linezolid 0.6 g q12h, IV Vancomycin 1 g q12h, IV Imipenem 1 g q8h, IV
Streptococcus spp.	Penicillin G Sodium + Clindamycin / Nitroimidazole	Penicillin G Sodium 3.2–8 million units q8h, IV Clindamycin 0.6–0.9 g q8h, IV Ornidazole 0.5 g q12h, IV
Staphylococcus spp. Corynebacterium striatum	Cefoxitin Sodium / Piperacillin-Tazobactam + Vancomycin	Cefoxitin Sodium 2 g bid, IV Piperacillin-Tazobactam 4.5 g q8h, IV Vancomycin 1 g q12h, IV
Clostridium spp.	Penicillin G Sodium + Ornidazole + Piperacillin-Tazobactam	Penicillin G Sodium 4.8 million units q8h, IV Ornidazole 0.5 g q12h, IV Piperacillin-Tazobactam 4.5 g q8h, IV
Candida spp.	Antifungals	Fluconazole 200 mg qd, IV Voriconazole 200 mg q12h, IV Caspofungin Acetate 50 mg qd, IV

q6/8/12 h: every 6/8/12 hours; qd: once daily; bid: twice daily; IV: intravenous injection

Data collection

This study collected the following data through the HIS and Laboratory Information System. (1) Demographics characteristics: gender, age, medical history, affected site, disease stage, admission vital signs; (2) Laboratory tests: ①Inflammatory parameters: white blood cell count(WBC), neutrophil count(NEUT), neutrophil to lymphocyte ratio(NLR), fibrinogen(Fib);②Fibrinolytic function parameters: platelet (PLT), prothrombin Time (PT);③Nutritional and metabolic parameters: red blood cell count (RBC), hemoglobin (Hb), blood glucose (Glu), albumin (Alb), red cell distribution width (RDW);④Electrolyte and renal function parameters: serum sodium (Na⁺), serum potassium (K⁺), serum creatinine (Scr). The diagnostic thresholds were defined as follows: Hb < 110 g/L for anemia, Na⁺ <135 mmol/L for hyponatremia, K⁺<3.5 mmol/L for hypokalemia, Scr > 106µmol/L for abnormal serum creatinine, Glu > 7.1 mmol/L for hyperglycemia, Alb < 35 g/L for hypoalbuminemia, and PT > 15.0 s for abnormal coagulation time; (3) Treatments: first surgery timing, total number of surgeries, total ICU stay, total hospital stay, the use of VAC(vacuum-assisted closure) therapy; (4) Outcomes: postoperative complications, amputation rate, mortality rate.

Statistical analysis

This study used IBM SPSS Statistics 27 for statistical analysis. Normally distributed quantitative data was presented as mean ± standard deviation (±s) and analyzed using independent-sample t test. Non-normally distributed quantitative data was expressed as M(Q1,Q3)(Median (Lower Quartile, Upper Quartile)) and analyzed using Mann-Whitney U test. Categorical data was described as n(%) and analyzed by chi-square test. Binary logistic regression analysis was performed to assess the independent effect of early I&D on the risks of amputation and mortality rate. P-value < 0.05 was considered statistically significant.

Results

Comparison of demographics characteristics between the I&D group and the extensive debridement group

All patients were adults with a median age of 58.20 years, including 68 males and 48 females. There more male patients in the I&D group. Hypertension (41.4%), diabetes (36.2%) and malignant tumors (20.7%) were the most common previous medical history(PMH). NF mostly developed secondary to traumatic injury, chronic wounds or postoperative infection, and more patients in the I&D group developed the disease under no obvious predisposing causes. The limbs were the most common sites of NF involvement, followed by the perineum. Compared with early and intermediate stage patients, more patients at advanced stage received early I&D surgery(P = 0.029). We found no significant differences between two groups in terms of age and PMH (Table 2).

Table 2.

Comparison of demographics characteristics between I&D group and extensive debridement group

	All cases (n = 116)		Initial Surgical Approach		t/Z/X2	P
			I&D group (n = 48)	Extensive Debridement group(n = 68)
Age	58.20 ± 16.14		59.00 ± 13.78	57.63 ± 17.70	0.448	0.655
≥601	60(51.7%)		24(50.0%)	36(52.9%)	0.097	0.755
<60	56(48.3%)		24(50.0%)	32(47.1%)
Gender  (male: female)	68:48		34:14	34:34	5.035	0.031
Chronic Disease
Numbers	2.0(1.0,3.0)		2.0(1.0,3.0)	2.0(1.0,3.0)	1537.0	0.584
Cerebral ischemic stroke	18(15.5%)		9(18.8%)	9(13.2%)	0.653	0.419
Hypertension	48(41.4%)		19(39.6%)	29(42.6%)	0.109	0.741
Diabetes	42(36.2%)		20(41.7%)	22(32.4%)	1.057	0.304
Malignant tumor	24(20.7%)		8(16.7%)	16(23.5%)	0.808	0.369
Chronic liver disease	4(3.4%)		4(8.3%)	0(0.0%)	3.633	0.057
Drinking	4(3.4%)		2(4.2%)	2(2.9%)	0.000	1.000
Causes of NF
Trauma	48(41.4%)	14(29.2%)		34(50.0%)	17.001	< 0.001
After the surgery	19(16.4%)	6(12.5%)		13(19.1%)
No obvious cause	34(29.3%)	24(50.0%)		10(14.7%)
Long-term immobilization or chronic wound	15(12.9%)	4(8.3%)		11(16.2%)
Affected area1,*
Limbs	71(59.2%)	23(46.9%)		48(67.6%)	6.031	0.108
Torso	14(11.7%)	6(12.2%)		8(11.3%)
Perineum	25(20.8%)	14(28.6%)		11(15.5%)
Head and neck	10(8.3%)	6(12.2%)		4(5.6%)
NF Stages
Early stage	60(51.7%)	18(37.5%) a		42(61.8%) a	7.090	0.029
Intermediate stage	34(29.3%)	17(35.4%) a, b		17(25.0%) a, b
Advanced stage	22(19.0%)	13(27.1%) b		9(13.2%) b

1: Fisher’s exact test

Bold text: P < 0.05

*: Six patients had multiple injuries, which were classified into different affected areas according to their location of onset

a.b: There was a significant difference in the proportion of NF patients at early stage and advanced stage between the two groups

Comparison of clinical characteristics between I&D group and extensive debridement group

Laboratory results showed that most patients had significant hypoalbuminemia (61.2%), anemia (50.9%) and hyperglycemia (45.7%) when admission. The proportion of patients with abnormal Scr (P = 0.029), anemia (P = 0.035) and hypoalbuminemia (P = 0.030) was significantly higher in the I&D group than in the extensive debridement group. No significant differences were observed in admission vital signs or other laboratory tests between the two groups, although inflammatory parameters were slightly elevated in the I&D group. (Table 3)

Table 3.

Comparison of clinical characteristics between I&D group and extensive debridement group

	All cases (n = 116)	Initial Surgical Approach		t/Z/X2	P
		I&D group (n = 48)	Extensive Debridement group(n = 68)
Temperature (°C)	36.50(36.40,36.80)	36.50(36.40,36.95)	36.50(36.50,36.60)	-0.070	0.945
MAP (mmHg)	92.83 ± 14.39	89.76 ± 11.79	94.99 ± 15.70	-1.949	0.054
Breath	18.0(16.0,20.0)	20.0(17.5,20.0)	18.0(16.0,20.0)	-1.428	0.153
Heart rate	88.63 ± 19.78	91.06 ± 20.97	86.91 ± 18.87	1.114	0.268
RBC (×10^12/L)	3.815(3.185,4.270)	3.50(3.19,4.14)	3.91(3.19,4.34)	0.945	0.345
WBC (×10^9/L)	10.47 ± 6.22	11.42 ± 7.04	9.79 ± 5.53	1.388	0.168
Platelets (×10^9/L)	226.63 ± 109.11	213.10 ± 92.57	236.18 ± 119.16	-1.123	0.264
NEUT (×10^9/L)	6.64(4.36,11.83)	7.58(4.10,14.26)	6.50(4.40,10.40)	-0.762	0.446
NLR (%)	6.25(3.25,17.36)	7.48(3.21,20.91)	6.12(3.28,11.24)	-0.835	0.404
RDW (%)	13.75(12.83,15.10)	13.90(13.05,15.25)	13.70(12.80,14.90)	-0.407	0.684
FIB-C (g/L)	4.56 ± 1.32	4.47 ± 1.22	4.62 ± 1.39	-0.568	0.571
Scr (µmol/L)	68.5(53.3,96.8)	81.0(57.5,107.0)	64.0(50.0,87.0)	-2.187	0.029
Anemia	59(50.9%)	30(62.5%)	29(42.6%)	4.437	0.035
Hyponatremia	33(28.4%)	12(25.0%)	21(30.9%)	0.478	0.489
Hypokalemia	24(20.7%)	10(20.8%)	14(20.6%)	0.001	0.974
Abnormal Scr	25(21.6%)	11(22.9%)	14(20.6%)	0.090	0.764
Hyperglycemia	53(45.7%)	23(47.9%)	30(44.1%)	0.164	0.686
Hypoproteinemia	71(61.2%)	35(72.9%)	36(52.9%)	4.729	0.030
Abnormal PT	13(11.2%)	6(12.5%)	7(11.2%)	0.138	0.711

Bold text: P < 0.05

Comparison of treatments between I&D group and extensive debridement group

50.9% patients were able to undergo surgical intervention within 24 h after admission, with an average of 2 extensive debridement procedures. 34.5% patients required ICU admission. The mean ICU stay was 3.79 ± 7.76 days and total hospital stay was 29.34 ± 18.46 days. No significant difference was found in treatment course between two groups. (Table 4)

Table 4.

Comparison of treatments between I&D group and extensive debridement group

	All cases (n = 116)	Initial Surgical Approach		t/Z/X2	P
		I&D Group (n = 48)	Extensive debridement group(n = 68)
first surgery timing (within 24 h)	59(50.9%)	28(58.3%)	31(45.6%)	1.829	0.176
ICU admission	40(34.5%)	21(43.8%)	19(27.9%)	3.113	0.078
Total ICU stay(days)	0(0,3.00)	1(0,5.75)	0(0,3.00)	−1.244	0.214
Total hospital stay(days)	29.34 ± 18.46	30.27 ± 18.95	28.68 ± 18.22	0.457	0.649
Total number of surgeries	2.0(1.0,4.0)	2(1,3)	3(1,4)	1.811	0.070
VAC use	81(69.8%)	30(62.5%)	51(75.0%)	2.087	0.149

Comparison of outcomes between I&D group and extensive debridement group

Septic shock (20.7%), sepsis (25.0%), and acute kidney injury (7.8%) were the most common postoperative complications. The I&D group showed significantly higher risk of postoperative sepsis (P = 0.029). A total of 18 patients (15.5%) underwent amputation or scrotal/penile resection, among whom 15 patients had not received early I&D surgery. The amputation rate was significantly higher in the extensive debridement group than that in the I&D group (P = 0.021). (Table 5)

Table 5.

Comparison of outcomes between I&D group and extensive debridement group

	All cases (n = 116)	Initial Surgical Approach		t/Z/X2	P
		I&D Group (n = 48)	Extensive debridement group(n = 68)
Septic shock	24(20.7%)	12(25.0%)	12(17.6%)	0.927	0.336
Sepsis	29(25.0%)	17(35.4%)	12(17.6%)	4.739	0.029
Acute kidney injury	9(7.8%)	4(8.3%)	5(7.4%)	0.000	1.000
Other complications	11(9.5%)	6(12.5%)	5(7.4%)	0.372	0.542
RBC change (×10^12/L)	-0.27(-0.47,-0.13)	-0.28(-0.54,-0.15)	-0.24(-0.47,-0.12)	0.449	0.654
Hb change (g/L)	-7.5(-15.5,-3.25)	-7.0(-16.25,-3.0)	-8.0(-15.5,-4.0)	-0.480	0.631
Platelets change (×10^9/L)	-11(-39,8)	-14.5(-42.5,4.5)	-10.5(-32.0,12.5)	1.256	0.209
PT change (s)	-0.2(-0.8,0.3)	-0.2(-0.76,0.5)	-0.25(-0.9,0.18)	-0.909	0.363
APTT change (s)	-0.39(-1.68,1.35)	-0.34(-2.3,1.4)	-0.45(-1.48,1.18)	0.118	0.906
Blood transfusion	28(24.1%)	16(33.3%)	12(17.6%)	3.781	0.052
Administer vasoactive drugs	28(24.1%)	15(31.3%)	13(19.1%)	2.131	0.144
Amputation	18(15.5%)	3(6.3%)	15(22.1%)	5.364	0.021
Mortality rate	13(11.2%)	5(10.4%)	8(11.8%)	0.051	0.821

Bold text: P < 0.05

RBC, Hb, platelets, PT and APTT changes were calculated as postoperative value minus preoperative value

Binary logistic regression analysis on amputation and mortality rate

Multivariate binary logistic regression analysis revealed that early I&D(aOR = 0.016, 95%CI: 0.026–0.524) and higher albumin levels(aOR = 0.86, 95%CI: 0.757–0.976) were significant protective factors against amputation for NF patients. Concurrently, early I&D (aOR = 0.172, 95%CI: 0.033–0.905) and higher albumin levels (aOR = 0.726, 95%CI: 0.593–0.889) were also associated with reduction in mortality risk. Variables including NEUT, anemia, NLR, abnormal PT, diabetes and NF stage showed no significant association with either outcome (P > 0.05) (Table 6).

Table 6.

Multivariate binary logistic regression analysis on amputation and mortality rate

Variables	B	SE	Wald	P	aOR(95%CI)
Outcome: amputation
I&D(Surgical Approach)	-2.233	0.797	7.847	0.005	0.107(0.022–0.511)
Albumin(g/L)	-0.177	0.075	5.576	0.018	0.838(0.724–0.97)
NEUT (×10^9/L)	0.043	0.038	1.264	0.261	1.044(0.968–1.126)
Anemia	-0.498	0.695	0.513	0.474	0.608(0.156–2.372)
NLR (%)	-0.027	0.02	1.864	0.172	0.974(0.937–1.012)
Abnormal PT	0.613	0.991	0.382	0.536	1.846(0.264–12.886)
Diabetes	-0.39	0.642	0.369	0.544	0.677(0.192–2.383)
Early stage (Advanced stage)	1.72	1.05	2.681	0.102	5.584(0.713–43.75)
Intermediate stage (Advanced stage)	1.642	1.038	2.505	0.114	5.167(0.676–39.492)
Outcome: mortality rate
I&D(Surgical Approach)	-1.758	0.856	4.212	0.04	0.172(0.032–0.924)
Albumin(g/L)	-0.343	0.122	7.871	0.005	0.71(0.559–0.902)
NEUT (×10^9/L)	0.084	0.064	1.732	0.188	1.087(0.96–1.232)
Anemia	0.859	1.001	0.736	0.391	2.361(0.332–16.789)
NLR (%)	-0.015	0.02	0.536	0.464	0.985(0.947–1.025)
Abnormal PT	-0.949	0.945	1.007	0.316	0.387(0.061–2.469)
Diabetes	0.492	0.891	0.305	0.581	1.636(0.285–9.379)
Early stage(Advanced stage)	-0.908	1.309	0.481	0.488	0.403(0.031–5.249)
Intermediate stage (Advanced stage)	1.959	0.999	3.843	0.05	7.092(1.00-50.283)

B: regression coefficient, SE: standard error, aOR: adjusted odds ratio, CI: confidence interval

Bold text: P < 0.05

Discussion

The study revealed a higher proportion of male patients in the I&D group compared to females. This group also showed greater prevalence of abnormal Scr levels, anemia, and hypoalbuminemia, with more patients presenting at advanced NF stages at admission. There were no significant differences between the two groups in terms of the proportion of patients who underwent surgery within 24 h, length of hospital stay, and other relevant indicators. Although the incidence of sepsis was significantly higher in the I&D group, fewer of these patients progressed to septic shock. The amputation rate was reduced in the I&D group, while mortality rates showed no significant difference. Binary logistic regression analysis revealed that early I&D was associated with a lower risk of amputation and mortality, and higher albumin levels were associated with lower mortality in NF patients.

NF, as a severe skin and soft tissue infection, often proves fatal when uncontrolled infection progresses to sepsis or septic shock. Kao et al. [20] demonstrated that NF patients with sepsis faced 3.39-fold higher mortality than others. Several studies have identified hemoglobin and albumin levels as critical prognostic markers for assessing inflammatory status and mortality risk in septic patients [21, 22]. In our study, patients in the I&D group exhibited higher rates of anemia and hypoalbuminemia at admission compared to the extensive debridement group, which may explain the higher sepsis incidence. However, fewer patients in this group progressed to septic shock. This finding suggests that the I&D surgery provided effective infection control, preventing the most critical deterioration. Higher inflammatory parameters such as NLR and RDW are associated with increased sepsis mortality [23], but no significant difference in these markers was found between the two groups.Given the small sample size inherent to this single-center retrospective study, we consider that future prospective studies with larger cohorts are warranted to verify the potential correlation between these inflammatory markers and clinical outcomes in NF patients.

Amputation serves as a critical intervention to control the spread of infection in the extremities NF. When NF patients present with uncontrollable, life-threatening limb infections or when limb function is deemed irreparable, amputation can effectively halt the further progression of infection. Ramin et al. previously reported two cases where early amputation was life-saving [24]. A multicenter study in Texas reported a 13% amputation rate during hospitalization for NF patients, predominantly involving lower limbs [20]. This study found that early I&D reduced the risk of amputation, and this association remained consistent after adjusting for various confounding variables. One possible explanation for the higher amputation rate in extensive debridement group may be that persistent infection can exacerbate local toxin release, promote microthrombosis, and impair healing, thereby accelerating necrosis of fascial and muscle tissues [25–27]. Early I&D can be considered as a rational strategy for achieving local infection control in critically ill NF patients. However, the clinical application of amputation is subject to multiple factors, including patient willingness, financial status, and the infection location, which were not further investigated in our study. The potential protective effect of amputation against mortality in NF patients requires further validation through prospective, large-scale studies. Such research would provide higher-level evidence to guide precise management strategies for patients with extremity NF.

No significant decline in NF mortality has been observed over the past ten years, with in-hospital mortality consistently remaining at 12–14% [28, 29]. Surgical timing is emphasized in current treatment protocols, because mortality rates are reduced when surgery occurs within 6–12 h of admission [30, 31]. NF progresses rapidly, and extensive debridement surgery necessitates even closer multidisciplinary collaboration. Evidence indicates that patients achieve better treatment outcomes in high-volume centers [32, 33]. However, this may increase the mortality risk for those unable to access tertiary general hospitals promptly. In contrast, early I&D can achieve effective local decompression and drainage, demand less technical expertise, and cause minimal trauma, allowing for much faster intervention. Hong et al. compared outcomes of patients with advanced Vibrio NF complicated by sepsis who underwent early I&D or extensive debridement, and found significantly lower mortality in the I&D group [14]. Although no significant difference in mortality was observed between the two groups, the poorer baseline status of the I&D group confounded this comparison. After adjusting for factors including infection severity and nutritional status, early I&D was independently associated with a lower risk of mortality. Given that the I&D group achieved comparable mortality despite worse nutritional status and more severe infections, early I&D appears to serve as a temporizing strategy for critically ill NF patients who are poor candidates for extensive debridement surgery. This approach aligns with current guidelines for the management of patients with sepsis, which recommend minimally invasive interventions for hemodynamically unstable patients [34]. The nutritional status and NF stage are also considered as important factors influencing mortality in NF patients.

This retrospective study, with data collected from HIS, had a relatively small sample size. Besides, as a single-center study, potential selection and information biases were unavoidable. The conclusions of this study are primarily applicable to hospitals with established referral capabilities. In addition to surgical intervention, antibiotic therapy and wound care are components of NF management. Although enrolled patients received standardized anti‑infective and nursing care protocols at our institution, nuances in implementation could exist. As a retrospective study and given the considerable heterogeneity in causative microbiology among NF patients, we documented rather than controlled therapeutic variables, so some confounding factors are unavoidable. Given that there was no standardized decision-making protocol of surgical approach after admission, the determination was made by the medical team’s comprehensive assessment of the patient’s condition. As a result, the treatment allocation was non-randomized, leading to significant differences in baseline characteristics between the two groups. Patients in the I&D group generally presented with more advanced disease stages and poorer nutritional status. To mitigate this bias, we performed binary logistic regression analysis adjusting for key confounders, including disease stage, nutritional status, infectious parameters, and comorbidities. However, a high possibility of residual confounding remains. A direct comparison with an ideal control group of “patients with similar baseline severity who did not undergo early I&D” was not feasible, as withholding surgical intervention in such critically ill patients would be clinically and ethically unjustifiable. Despite these limitations, the fact that the I&D group achieved outcomes comparable to the extensive debridement group despite their initial disadvantage suggests that this intervention may hold significant clinical value. Especially for NF patients with poor conditions or those who cannot undergo timely extensive debridement surgery, early I&D represents an alternative bridging treatment option. Future prospective, multi-center studies are warranted to confirm and expand these results.

Extensive debridement remains the standard surgical approach for NF patients, but severe cases often experience delayed intervention due to poor tolerability. This study demonstrates that early incision and drainage significantly reduced amputation risk and mortality rate, offering a potential bridging or temporizing strategy to improve prognosis for those with poor nutritional status and advanced-stage NF. Given that current research evaluating efficacy of early I&D lacks, our study provides valuable data support and evidence-based guidance for clinical decision-making in severe NF management.

Recommended patient groups for early I&D

1. Early I&D may be warranted in patients presenting with the following criteria:

   • (A)
     The diagnosis of NF is confirmed, but the patient is in a critical condition and unable to tolerate surgery. Or the patient is able to tolerate surgery, but timely extensive debridement cannot be performed (e.g., due to the inaccessibility of a surgical facility or lack of operating room availability).
   • (B)
     When patients present with significant local symptoms (e.g., erythema, swelling, severe pain) and NF is highly suspected but not yet confirmed, early I&D may be performed to alleviate symptoms and obtain samples for etiological analysis, thereby guiding subsequent antibiotic therapy.

• 2.Patient Populations Recommended for Early I&D:
  • A.
    Patients presenting with septic shock or severe metabolic disorders; such patients are unable to tolerate surgery. Early I&D should be performed to control the source of infection, thereby gaining time for resuscitation and hemodynamic stabilization in preparation for subsequent extensive surgery.
  • B.
    Patients who reside too far from a comprehensive hospital to access prompt treatment, or critically ill patients admitted initially to a hospital lacking the capacity for radical extensive debridement, may undergo early I&D as an initial intervention.
  • C.
    Patients with an unclear diagnosis: Patients whose clinical manifestations cannot reliably distinguish severe cellulitis/abscess from early-stage NF, requiring surgical exploration to confirm the diagnosis.
  • D.
    Patients with severe pain disproportionate to clinical signs: Patients with this specific symptom should be prioritized for evaluation and, if appropriate, undergo early I&D.
  • E.
    Elderly Patients(over 65 years old): Older adults may have atypical presentations; thus, any sign of localized infection accompanied by systemic symptoms should prompt consideration for early intervention.

Abbreviations

NF

necrotizing fasciitis

I&D

incision and drainage

HIS

Hospital Information System

WBC

white blood cell count

NEUT

neutrophil count

NLR

neutrophil-to-lymphocyte ratio

Fib

fibrinogen

PLT

platelet

PT

prothrombin time

RBC

red blood cell count

Hb

hemoglobin

Glu

blood glucose

Alb

albumin

RDW

red cell distribution width

Na+

serum sodium

K+

serum potassium

Scr

serum creatinine

PMH

previous medical history

Author contributions

GFF, MSL, ZX Chai and FYC were responsible for the study conception and supervision. WL and LX conducted the data collection and curation. ZX Chen, FYC and ZX Chai performed the data analysis and literature integrating. ZX Chai and Dachun Chen drafted the manuscript. MFQ critically reviewed and revised the first draft.

Funding

Jiangsu Provincial Traditional Chinese Medicine Science and Technology Development Plan Project, Grant No. MS2024137. This project is presided over by Dachun Chen, the co-first author of this study. It has provided crucial support and assistance throughout the entire research process, laying a solid foundation for the smooth completion of this retrospective study on necrotizing fasciitis.

Data availability

The dataset supporting the conclusions of this article is included within the article.

Declarations

Ethics approval and consent to participate

The study was established, according to the ethical guidelines of the Declaration of Helsinki, and was approved by IEC for Clinical Research of Zhongda Hospital Southeast University (Approval Number 2025ZDSYLL174-P01). The requirement for informed consent was waived by the ethics committee because this was a retrospective study using de-identified data from hospital records and involved no more than minimal risk to participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.