What's new in emergencies, trauma and shock? The tortuous path in the management of necrotizing fasciitis: Is early surgical intervention critical?

Necrotizing fasciitis is an infection of the subcutaneous tissue with high rates of mortality and morbidity. Surgical exploration and debridement play key roles in the management of this condition. Unfortunately, the diagnosis can be tricky and often gets delayed, which may lead to a late intervention that can affect various outcomes. This is reflected in wide variations of mortality described in the literature.[1] Numerous scores have been proposed for early diagnosis, such as the Laboratory Risk Indicator for Necrotizing Fasciitis,[2] but their objectivity has been questioned. The diagnosis of necrotizing fasciitis is still clinical, but there are subjective biases in “pain out of proportion,” and laboratory markers such as C-reactive protein level are helpful but only complementary.[3,4] Nonetheless, progress has been made, particularly in understanding the surgical aspects of management of necrotizing fasciitis, and the recent literature shows a decline in mortality trends.[5] Early surgical intervention is associated with improved survival in many studies; however, those studies differ in defining “early” intervention.[1,6,7] Moreover, a multicenter analysis of a large patient population concludes to the contrary.[8]

In this current issue of Journal of Emergencies, Trauma, and Shock, Hadeed et al. describe their experience with early surgical intervention in necrotizing soft tissue infection.[9] This is a retrospective, single-center analysis of patients diagnosed with necrotizing fasciitis who underwent surgical intervention. While it is known from previous investigations that early intervention improves outcome, the timing of “early” has often varied. In their study, Hadeed et al. have attempted to standardize terminology by defining “early intervention” as less than four hours. In fact, the median time to surgery after confirming the diagnosis was three hours in the early intervention group. The principal outcome difference with this earlier intervention was shorter intensive care unit length of stay and shorter hospital length of stay. These findings are largely in conformity with a previously published retrospective analysis.[7] Notwithstanding, no significant mortality difference existed between the two treatment groups in the study by Hadeed et al., unlike the previously published reports.[1,6,7] The overall mortality rate in this study was also lower than described in the literature, although considerable heterogeneity exists in this regard.[5,6,7] This was in spite of the fact that nearly half of the patients had necrotizing fasciitis involving a lower extremity, which entails a higher mortality rate.[5]

This study, however, is a retrospective analysis with its inherent biases and shortcomings. While the authors are commended for comparing the co-morbidities between the two groups that can affect outcomes there are several other variables which would impact the postoperative events. The likelihood of selection bias is always lurking a round the corner in this scenario. The surgical techniques, including the extent of debridement, pre- and postoperative use of antibiotics, wound therapy, and other resuscitative measures may affect clinical outcomes as well. It is also unclear how the initial diagnosis was reached before early intervention. Curiously, the investigators indicate no particular clinical sign or laboratory parameter as a useful predictor for early diagnosis. However, this study was not necessarily designed to explore that observation. Another interesting aspect of the present investigation is the definition of the timing of intervention. The time to intervention from symptom onset or hospital admission may be more relevant for an outcome analysis than the time from diagnosis to surgery. This may account for the nonsignificant difference in mortality between the two groups, besides sample size.

This study adds to our understanding from previous analyses that early intervention probably improves outcomes in necrotizing fasciitis, in spite of some conflicting evidence. This study also reinforces the fact that a validated definition of “early” needs to be established. At present there is enough equipoise in this regard that an adequately powered prospective trial with outcome analysis is urgently needed. Until then, the diagnosis and management of necrotizing fasciitis will remain an enigma that will continue to baffle physicians and surgeons in the foreseeable future.