Essentials in the management of necrotizing soft-tissue infections.

Necrotizing soft-tissue infections (NSTI) are rare but severe diseases with rapid progression. Rates of mortality and morbidity are high and early diagnosis, immediate surgical intervention and antibiotic treatment are essential to improve prognosis. Thus, our commentary emphasizes important information in the management of NSTI. We describe the essentials in the management of necrotizing soft-tissue infections. Six essentials were identified: 1. Necrotizing soft-tissue infections (NSTI) are primarily diagnosed clinically; pain out of proportion, rapid progression of skin infection and systemic signs should alert clinicians. 2. Early diagnosis can be rather delayed by several factors such as absence of fever, significant cutaneous manifestations, elevation of inflammatory parameters, systemic signs, and non-specific imaging tests. 3. NSTI can occur both in the elderly or patients with underlying diseases after major trauma (usually polymicrobial Gram-negative and Gram-positive pathogens) but also in healthy patients after minor trauma (often monomicrobial; most common among Gram-positive organisms: group A Streptococcus). 4. Immediate and radical debridement (incl. re-debridement after 24 h) remains the cornerstone of surgical therapy. 5. Empirical broad-spectrum antimicrobial treatment has to be administered shortly after admission. After isolation of the causative bacteria therapy should be tailored. 6. The value of adjunctive measures (hyperbaric oxygen therapy, intravenous immunoglobulines) is uncertain and their routine use cannot be recommended. Further efforts should be undertaken to increase the awareness for and the adherence to the essentials in the management of necrotizing soft-tissue infections.