Implementation of a Standardized Management Protocol Improved the Survival of Patients with Necrotizing Fasciitis

Abstract

Necrotizing fasciitis (NF) is a life-threatening soft tissue infection requiring urgent interventions. This study aimed to investigate the effect of implementation of a standardized management protocol on the outcome of NF patients admitted to the intensive care unit. We initiated a management protocol for NF patients in 2012 at our institution. The protocol consisted of early surgical intervention, initial board-spectrum antibiotic regimen, daily wound inspection, repeated debridement, and inter-professional collaboration. Herein, we reviewed the NF cases admitted between 2005 and 2018 and compared their clinical features and outcome before and after the protocol implementation. All of the NF cases underwent were confirmed by intraoperative findings. We included 134 NF patients before (2005 to 2011, n = 62) and after (2013 to 2018, n = 72) the protocol implementation. The baseline patient profile from these two periods were largely similar, except that after protocol implementation, more patients presented with erythema (64.5% vs 84.7%) and a higher C-reactive protein level (65.5% vs 85.5%) on admission. Notably, the day 28-censored mortality was significantly lower after protocol implementation (40.3% vs 13.9%). By analyzing the 28-day mortality with univariate and multivariate model, initial presentation with neutropenia was identified as a risk factor [hazard ratio (HR) = 8.45, 95% confidence interval (CI) = 1.76-40.6], while protocol implementation (HR = 0.27, 95% CI = 0.11-0.71) was a protective factor. A multidisciplinary bundle care protocol for NF including board-spectrum empirical antibiotic regimen and inter-professional collaboration was feasible, which was associated with improved overall and 28-day survival.