Progressive necrotizing surgical infections--a unified approach

Four types of progressive necrotizing surgical infections have been described, based on the type of infecting organism, the type and depth of soft tissue penetration and clinical findings, and the type of surgical therapy recommended, e.g., necrotizing fasciitis, clostridial cellulitis. A mortality rate of up to 50% continues to be reported. An experience with 20 such cases indicates that there is a considerable overlap in clinical-physical findings and bacteriology such that classification schemes are confusing and lead to treatment delays and the use of inappropriate therapy. The infections all seem to be variations of the same disease process, a spreading, necrotizing infection. Of the 20 cases, four were treated with antibiotics and delayed (1 to 3 days) excision of necrotic tissue with 75% deaths; four cases received antibiotics and multiple surgical incisions with 100% deaths. The other 12 cases were treated with a unified approach of resuscitation, antibiotics (penicillin, clindamycin, tobramycin), immediate surgical excision (3 to 4 hours) of all necrotic tissue, aggressive nutritional support, and early skin coverage, with an 8.3% mortality. We conclude that there seems to be no need to classify necrotizing infections into different types. Recognizing them as the same disease process and treating them with a unified approach resulted in a significant reduction in mortality.