Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician



      Skin and soft tissue infections are common emergency department (ED) presentations. These infections cover a wide spectrum of disease, from simple cellulitis to necrotizing fasciitis. Despite the commonality, a subset of skin and soft tissue infections known as necrotizing soft tissue infections (NSTIs) can cause significant morbidity and mortality.


      This review evaluates the current evidence regarding the presentation, evaluation, and management of NSTI from the ED perspective.


      NSTIs are commonly missed diagnoses. History and physical examination findings are inconsistent, and the risk factors for this high mortality disease are common amongst ED populations. Laboratory evaluation and the Laboratory Risk in Necrotizing Fasciitis (LRINEC) score is helpful but is insufficient to rule out the disease. Imaging modalities including ultrasound, computed tomography, and magnetic resonance imaging are highly sensitive and specific, but may delay definitive management. The gold standard for diagnosis includes surgical exploration. Surgical intervention and empiric broad-spectrum antibiotic coverage are the foundations of treatment. Adjuvant therapies including hyperbaric oxygen and intravenous immunoglobulin have not yet been proven to be beneficial or to improve outcome.


      NSTIs are associated with significant morbidity and mortality. Knowledge of the history, examination, evaluation, and management is vital for emergency clinicians.


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        • Morgan E
        • Hohmann S
        • Ridgway JP
        • Daum RS
        • David MZ.
        Decreasing incidence of skin and soft-tissue infections in 86 US emergency departments, 2009-2014.
        Clin Infect Dis. 2019; 68: 453-459
        • Miller LG
        • Eisenberg DF
        • Liu H
        • et al.
        Incidence of skin and soft tissue infections in ambulatory and inpatient settings, 2005–2010.
        BMC Infect Dis. 2015; 15: 362
        • Esposito S
        • Bassetti M
        • Concia E
        • et al.
        Diagnosis and management of skin and soft-tissue infections (SSTI). A literature review and consensus statement: an update.
        J Chemother. 2017; 29: 197-214
        • Soltani AM
        • Best MJ
        • Francis CS
        • Allan BJ
        • Askari M
        • Panthaki ZJ.
        Trends in the incidence and treatment of necrotizing soft tissue infections: an analysis of the National Hospital Discharge Survey.
        J Burn Care Res. 2014; 35: 449-454
        • Misiakos EP
        • Bagias G
        • Patapis P
        • Sotiropoulos D
        • Kanavidis P
        • Machairas A.
        Current concepts in the management of necrotizing fasciitis.
        Front Surg. 2014; 1: 36
        • Peetermans M
        • de Prost N
        • Eckmann C
        • Norrby-Teglund A
        • Skrede S
        • De Waele JJ.
        Necrotizing skin and soft-tissue infections in the intensive care unit.
        Clin Microbiol Infect. 2020; 26: 8-17
        • Goh T
        • Goh LG
        • Ang CH
        • Wong CH.
        Early diagnosis of necrotizing fasciitis.
        Br J Surg. 2014; 101: e119-e125
        • Fernando SM
        • Tran A
        • Cheng W
        • et al.
        Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging, and LRINEC score: a systematic review and meta-analysis.
        Ann Surg. 2019; 269: 58-65
        • Montravers P
        • Snauwaert A
        • Welsch C.
        Current guidelines and recommendations for the management of skin and soft tissue infections.
        Curr Opin Infect Dis. 2016; 29: 131-138
        • Kaul R
        • McGeer A
        • Low DE
        • Green K
        • Schwartz B.
        Population-based surveillance for group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study.
        Am J Med. 1997; 103: 18-24
        • Stevens DL
        • Bryant AE.
        Necrotizing soft-tissue infections.
        N Engl J Med. 2018; 378: 971
        • Thom C
        • Warlaumont M.
        A necrotizing fasciitis fake out on point-of-care ultrasound–watch the shadow.
        J Emerg Med. 2017; 52: 523-526
        • Shiroff AM
        • Herlitz GN
        • Gracias VH.
        Necrotizing soft tissue infections.
        J Intensive Care Med. 2014; 29: 138-144
        • Garcia NM
        • Cai J.
        Aggressive soft tissue infections.
        Surg Clin North Am. 2018; 98: 1097-1108
        • Bonne SL
        • Kadri SS.
        Evaluation and management of necrotizing soft tissue infections.
        Infect Dis Clin North Am. 2017; 31: 497-511
        • Liu TJ
        • Tai H-C
        • Chien K-L
        • Cheng N-C.
        Predisposing factors of necrotizing fasciitis with comparison to cellulitis in Taiwan: a nationwide population-based case-control study.
        J Formos Med Assoc. 2020; 119: 18-25
        • Lin T-Y
        • Ou C-H
        • Tzai T-S
        • et al.
        Validation and simplification of Fournier's gangrene severity index: simplified index for Fournier's gangrene.
        Int J Urol. 2014; 21: 696-701
        • Chen K-CJ
        • Klingel M
        • McLeod S
        • Mindra S
        • Ng VK.
        Presentation and outcomes of necrotizing soft tissue infections.
        Int J Gen Med. 2017; 10: 215-220
        • Lee JW
        • Immerman SB
        • Morris LGT.
        Techniques for early diagnosis and management of cervicofacial necrotising fasciitis.
        J Laryngol Otol. 2010; 124: 759-764
        • Hua C
        • Bosc R
        • Sbidian E
        • et al.
        Interventions for necrotizing soft tissue infections in adults.
        Cochrane Database Syst Rev. 2018; 5CD011680
        • Sin F
        • Yuen M
        • Lam K
        • Wu C
        • Tung W.
        A retrospective review of patients with necrotizing fasciitis presenting to an emergency department in Hong Kong.
        Hong Kong J Emerg Med. 2002; 9: 10-17
        • Mitchell A
        • Williams A
        • Dzendrowskyj P.
        Necrotising fasciitis: an 8.5-year retrospective case review in a New Zealand intensive care unit.
        Crit Care Resusc. 2011; 13: 232-237
        • Gönüllü D
        • Ilgun AS
        • Demiray O
        • et al.
        The potential prognostic significance of the Laboratory Risk Indicator for the Necrotizing Fasciitis (LRINEC) score in necrotizing fasciitis.
        Chirurgia (Bucur). 2019; 114: 376-383
        • Latifi R
        • Patel AS
        • Samson DJ
        • et al.
        The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections.
        Eur J Trauma Emerg Surg. 2019; 45: 919-926
        • Wilson MP
        • Schneir AB.
        A case of necrotizing fasciitis with a LRINEC score of zero: clinical suspicion should trump scoring systems.
        J Emerg Med. 2013; 44: 928-931
        • Yen Z-S
        • Wang H-P
        • Ma H-M
        • Chen S-C
        • Chen W-J.
        Ultrasonographic screening of clinically-suspected necrotizing fasciitis.
        Acad Emerg Med. 2002; 9: 1448-1451
        • Wysoki MG
        • Santora TA
        • Shah RM
        • Friedman AC.
        Necrotizing fasciitis: CT characteristics.
        Radiology. 1997; 203: 859-863
        • Martinez M
        • Peponis T
        • Hage A
        • et al.
        The role of computed tomography in the diagnosis of necrotizing soft tissue infections.
        World J Surg. 2018; 42: 82-87
        • Schmid MR
        • Kossmann T
        • Duewell S.
        Differentiation of necrotizing fasciitis and cellulitis using MR imaging.
        AJR Am J Roentgenol. 1998; 170: 615-620
        • Hopkins KL
        • Li KC
        • Bergman G.
        Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes.
        Skeletal Radiol. 1995; 24: 325-330
        • Hakkarainen TW
        • Kopari NM
        • Pham TN
        • Evans HL.
        Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes.
        Curr Probl Surg. 2014; 51: 344-362
        • Kehrl T.
        Point-of-care ultrasound diagnosis of necrotizing fasciitis missed by computed tomography and magnetic resonance imaging.
        J Emerg Med. 2014; 47: 172-175
        • Shyy W
        • Knight RS
        • Goldstein R
        • Isaacs ED
        • Teismann NA.
        Sonographic findings in necrotizing fasciitis: two ends of the spectrum.
        J Ultrasound Med. 2016; 35: 2273-2277
        • Testa A
        • Giannuzzi R
        • De Biasio V.
        Case report: role of bedside ultrasonography in early diagnosis of myonecrosis rapidly developed in deep soft tissue infections.
        J Ultrasound. 2016; 19: 217-221
        • Lin C-N
        • Hsiao C-T
        • Chang C-P
        • et al.
        The relationship between fluid accumulation in ultrasonography and the diagnosis and prognosis of patients with necrotizing fasciitis.
        Ultrasound Med Biol. 2019; 45: 1545-1550
        • Hadeed G
        • Smith J
        • O'Keeffe T
        • et al.
        Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: a single academic center experience.
        J Emerg Trauma Shock. 2016; 9: 22-27
        • Stevens DL
        • Bisno AL
        • Chambers HF
        • et al.
        Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.
        Clin Infect Dis. 2014; 59: e10-e52
        • Amphotericin B (Lipid Complex) (Lexi-Drugs)
        2021 (Available at:)
        • Levett DZ
        • Bennett MH
        • Millar I.
        Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Emergency and Critical Care Group.
        ed. Cochrane Database Syst Rev. 2015; 1CD007937
        • Kadri SS
        • Swihart BJ
        • Bonne SL
        • et al.
        Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock: a propensity-score matched analysis from 130 US hospitals.
        Clin Infect Dis. 2017; 64: 877-885
        • Wang T-L
        • Hung C-R.
        Role of tissue oxygen saturation monitoring in diagnosing necrotizing fasciitis of the lower limbs.
        Ann Emerg Med. 2004; 44: 222-228
        • Singer M
        • Deutschman CS
        • Seymour CW
        • et al.
        The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
        JAMA. 2016; 315: 801-810
        • Martínez ML
        • Ferrer R
        • Torrents E
        • et al.
        Impact of source control in patients with severe sepsis and septic shock.
        Crit Care Med. 2017; 45: 11-19
        • McHenry CR
        • Piotrowski JJ
        • Petrinic D
        • Malangoni MA.
        Determinants of mortality for necrotizing soft-tissue infections.
        Ann Surg. 1995; 221: 558-565
        • Freischlag JA
        • Ajalat G
        • Busuttil RW.
        Treatment of necrotizing soft tissue infections. The need for a new approach.
        Am J Surg. 1985; 149: 751-755
        • Bucca K
        • Spencer R
        • Orford N
        • Cattigan C
        • Athan E
        • McDonald A.
        Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study: early diagnosis and treatment of NF.
        ANZ J Surg. 2013; 83: 365-370