› IV fluid resuscitation
› Crystalloid 30 mL/kg bolus for septic shock
› Balanced crystalloid preferred (Ringer's lactate or PlasmaLyte)
› Reassess after each bolus for fluid responsiveness
› Vasopressors for fluid-refractory shock
› Norepinephrine 0.01–3 mcg/kg/min IV infusion as first-line vasopressor
› Titrate to MAP > 65 mmHg
› Central venous or large peripheral access preferred
› Vasopressin 0.03–0.04 units/min as adjunct if norepinephrine > 0.25 mcg/kg/min
› Hydrocortisone 200 mg/day IV if vasopressor-refractory septic shock
Empiric antibiotic therapy
› First-line broad-spectrum regimen (IDSA guidelines)
› Vancomycin 30 mg/kg/day IV in 2 divided doses
› Adjust for renal function; target trough 15–20 mg/L or AUC/MIC 400–600
› Covers MRSA and gram-positive organisms
› Piperacillin-tazobactam 3.375 g IV q6–8h
› Extended infusion over 4 hours preferred for PK/PD optimization
› Covers gram-negative rods and anaerobes
› Carbapenem alternative
› Meropenem 1 g IV q8h if MDR organism concern or penicillin allergy
› Covers broad gram-negative, gram-positive, and anaerobic spectrum
› OR ceftriaxone 2 g IV q24h PLUS metronidazole 500 mg IV q8h
› Clindamycin addition for toxin suppression
› Clindamycin 600–900 mg IV q8h if toxic shock syndrome suspected
› Mechanism: inhibits ribosomal exotoxin production
› Used with, not instead of, beta-lactam therapy
› Antifungal coverage
› Micafungin 100 mg IV q24h for immunocompromised patients
› Candida species increasingly identified and associated with worse outcomes
› Consider empirically in diabetics with poorly controlled glucose
› Antibiotic de-escalation
› Guided by intraoperative tissue culture results
› Typically 7–14 days total; duration guided by clinical response
› Emergent radical surgical debridement
› Single most important determinant of outcome
› Debride all necrotic tissue to bleeding, viable margins
› Intraoperative "finger test": lack of tissue resistance to blunt finger dissection along fascial plane confirms necrotizing fasciitis
› Obtain deep tissue cultures (aerobic, anaerobic, fungal) intraoperatively
› Planned return to OR
› Return within 24 hours for wound re-evaluation
› Average 3 debridements per patient per series
› Continue until wound is clean and all necrotic tissue removed
› Orchiectomy
› Only if testicular viability is in question after intraoperative assessment
› Testes usually spared due to independent blood supply
› Fecal diversion
› Consider colostomy or fecal management system for sphincter involvement, fecal incontinence, or ongoing wound contamination
› Colostomy has not been shown to reduce mortality; carries its own morbidity
› Non-invasive fecal management systems (e.g., Flexi-Seal) should be tried first
› Suprapubic cystostomy
› Indicated for urethral disruption or extensive penile debridement requiring urinary diversion
› Negative pressure wound therapy (NPWT/VAC)
› Promotes granulation tissue formation; removes exudate and reduces bacterial burden
› Initiate after wound is stable following serial debridements
› Not a substitute for surgical debridement
› Hyperbaric oxygen therapy (HBOT)
› Meta-analyses suggest lower mortality; evidence limited to observational studies
› IDSA recommends against; other guidelines suggest consideration
› HBOT must never delay surgery
› Typical protocol: 100% O2 at 2–3 atmospheres for 90 minutes, 2 sessions/day
Glycemic and metabolic management
› Insulin therapy
› Target glucose 7.8–10 mmol/L in ICU
› Insulin infusion protocol for uncontrolled hyperglycemia
› Avoid hypoglycemia < 4.0 mmol/L
› Nutritional support
› Early enteral nutrition within 24–48 hours post-stabilization
› High-protein diet to support wound healing
› Dietitian involvement for caloric target calculation
› Reconstructive options after wound is clean
› Split-thickness skin grafts for large defects
› Local or regional flaps for complex anatomic areas
› Average time to complete wound healing approximately 4.8 months
› Plastic and reconstructive surgery involvement
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