Necrotizing soft tissue infections (NSTIs) are fulminant infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Delay in diagnosing and treating these infections increases the risk of mortality. Early and aggressive surgical debridement with support for the failing organs significantly improves the survival. Although there are different forms of NSTIs like Fournier’s gangrene or clostridial myonecrosis, the most important fact is that they share common pathophysiology and principles of treatment. The current paper summarizes the pathophysiology, clinical features, the diagnostic workup required and the treatment principles to manage these cases. 1. Introduction Necrotizing soft tissue infections (NSTIs) are fulminant infections of any layer of the soft tissue compartment associated with widespread necrosis, systemic toxicity and a high mortality rate if not treated early. These infections were first described by Jones in 1871 and at that time they were termed “hospital gangrene” [1]. The term “necrotizing soft tissue infections” has been emphasized to encompass all necrotizing infections and advocate an approach to all of them that uses the same principles for diagnostic and treatment strategies [2]. 2. The Current Scenario The incidence of NSTIs in the United States of America is estimated to be around 500–1500 cases per year [3]. The mortality rates have been reported to be around 25%, although it is higher in some studies [4]. 3. Classification of NSTIs The Food and Drug Administration (FDA) has classified skin and soft tissue infections in to two categories, namely, the complicated infections [5, 6]. Based on the microbiological characteristics, NSTIs are broadly classified into three types. Type I Infections. Type I infections are the most common forms accounting for 80% or more of all the NSTIs, for example, Fournier’s gangrene and Ludwig’s angina [7]. These are mostly polymicrobial infections having a combination of aerobes, anaerobes and facultative aerobes/anaerobes. The common aerobic species isolated from these infections are streptococci, staphylococci, enterococci, and the family of gram-negative rods. Bacteroides species are the most common anaerobes involved. Type II Infections. Type II infections are usually mono-microbial and usually follow a minor injury accounting for 10–15% of all NSTIs [8, 9]. Common organisms involved are the Group A beta-hemolytic streptococcus or the S. aureus. Type III Infections. These account for less than 5% of all NSTIs and clostridial gas forming
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