Consensus on the diagnosis and treatment of adult necrotizing fasciitis (2025 edition)
Chinese expert group · 2025 · China
Source and licence
- Authors
- Ling Zhou, Haisheng Li, Gaoxing Luo et al.
- Title
- Consensus on the diagnosis and treatment of adult necrotizing fasciitis (2025 edition)
- Journal
- Burns & Trauma, 2025
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC12225674
Licence statement of the original publication
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Clinical question 1: overview of necrotizing fasciitis
- Recommendation 1(highly recommended): NF is a rare yet extremely severe purulent soft tissue infection. NF primarily spreads rapidly along the fascial plane and typically involves the subcutaneous tissue, superficial fascia, and deep fascia, while sparing the muscular layer. NF has an acute onset and progresses rapidly, usually accompanied by systemic symptoms of infection and toxicity. NF is characterized by a low incidence but high mortality rate. Individuals with compromised immune function are particularly susceptible to this type of infectionevidence level: high
Clinical question 2: diagnosis of necrotizing fasciitis
- Recommendation 2(highly recommended): Early diagnosis is crucial for reducing the mortality rate of NF. A comprehensive evaluation of the patient’s susceptibility factors, medical history, characteristic clinical manifestations, and finger test results is recommended. In addition, diagnostic tools, such as the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, Site other than the lower limb, Immunosuppression, Age, Renal impairment, and Inflammatory markers (SIARI) score, and Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF) score, should be used in combination to assist in early risk identification and diagnosisevidence level: high
- Recommendation 3(highly recommended): It is suggested that CT scans be the first choice for emergency screening, that point-of-care ultrasound be used for rapid diagnosis, and that MRI be utilized as an auxiliary diagnostic tool during stable phases. Surgical exploration and pathological examination are the gold standards for confirmation, while multiple microbiological cultures are used to identify pathogens. The use of X-ray is not recommendedevidence level: high
Clinical question 3: general treatment of necrotizing fasciitis
- Recommendation 4(highly recommended): In cases where NF is highly suspected, surgical exploration should be conducted without delay. Concurrently, active measures must be taken to ensure stability of respiration, circulation, and overall homeostasisevidence level: moderate
Clinical question 4: antimicrobial therapy for necrotizing fasciitis
- Recommendation 5(highly recommended): In the anti-infective treatment of NF, when the causative pathogens are not yet identified, early empirical administration of sufficient and appropriate broad-spectrum antimicrobial agents is recommended. This should be guided by epidemiological data and rapid Gram stain results to ensure coverage of both aerobic and anaerobic bacteria. The antimicrobial regimen should be promptly adjusted on the basis of pathogen identification and dynamic changes in infection markersevidence level: high
Clinical question 5: surgical treatment of necrotizing fasciitis
- Recommendation 6(highly recommended): Incision, debridement, and drainage are essential components of emergency treatment for NF. Surgery should be performed promptly when fluctuance or significant necrotic areas are detected on the skin. During the procedure, methylene blue can be used to mark necrotic tissues, and multiple samples should be obtained for microbiological analysis. The initial surgery should be swift, straightforward, and thorough, with an emphasis on opening subcutaneous cavities and avoiding excessive debridement that may complicate subsequent wound repair. Subsequent debridement should be repeated until all the necrotic tissues are completely removedevidence level: high
- Recommendation 7(weakly recommended): Following thorough debridement, negative pressure wound therapy (NPWT) may be utilized to facilitate wound healing. However, NPWT should be applied cautiously in cases of confirmed anaerobic infection. In such instances, the use of antimicrobial dressings for wound care is recommended as an alternativeevidence level: moderate
- Recommendation 8(highly recommended): Amputation should be considered with caution. The main indications include uncontrollable and life-threatening limb infections or when limb function is beyond salvage. However, the decision and timing of surgery should be based on a comprehensive assessment of the patient's overall clinical statusevidence level: moderate
- Recommendation 9(highly recommended): When treating Fournier's gangrene (FG), it is crucial to evaluate underlying anorectal conditions, such as anal fistulas. During surgical debridement, meticulous care should be taken to preserve the testes unless severe infection or clear necrosis is present. Injury to the rectum, anal canal, and anal sphincter must be avoided. Strict perioperative management of bowel and bladder function is essential to prevent wound contamination. Fasting and parenteral nutrition support may be indicated if necessaryevidence level: moderate
- Recommendation 10(weakly recommended): Wound reconstruction is a core therapeutic goal in the management of NF, and it should be performed once the local infection is controlled, the wound bed is adequately prepared, and the patient’s overall condition is stable. The choice of reconstruction method depends on the wound characteristics and may include direct closure, skin grafting, or flap transfer. For complex wounds with exposed bone or tendons or those involving sinus tracts, reconstruction can be enhanced with the use of certain materials, such as antibiotic-loaded cement spacers, platelet-rich plasma (PRP), or artificial dermal scaffoldsevidence level: moderate
Clinical question 6: adjuvant therapy for necrotizing fasciitis
- Recommendation 11(highly recommended): For patients with impaired consciousness, respiratory failure, or NF involving the face and neck, close monitoring of local edema and respiratory status is essential. When necessary, a prophylactic artificial airway should be established. Respiratory support measures, including oxygen therapy, assisted ventilation, or mechanical ventilation, should be applied in a stepwise manner on the basis of oxygenation and pulmonary statusevidence level: low
- Rationale: Airway management is critical for patients with NF of the neck, as this disease can cause cervical edema and tissue necrosis, significantly increasing the difficulty of tracheal intubation. Studies have demonstrated that for patients with mild (Grade 1) or moderate (Grade 2) respiratory distress, short-term corticosteroid therapy (e.g. 10 mg of dexamethasone) combined with early surgical debridement and drainage can often avoid the need for tracheostomy. However, for those with severe (Grade 3) respiratory distress, tracheostomy should be performed immediately if corticosteroid therapy is ineffective. In cases where patients have concurrent pulmonary infections and poor oxygenation, a stepwise respiratory support strategy, including oxygen therapy, assisted ventilation, or mechanical ventilation, may be considered. For patients with neck NF requiring long-term airway management, tracheostomy is generally preferred over orotracheal or nasotracheal intubation because tracheostomy is safer, more secure, and reduces the risk of complications [93–95].
- Recommendation 12(highly recommended): High-dose corticosteroids are not recommended. Intravenous immunoglobulin (IVIG) may be considered for immune supportive therapy; however, its potential risk of renal injury should be carefully monitoredevidence level: moderate
- Recommendation 13(highly recommended): Following confirmation of the etiology, a tiered pain management strategy is recommended. Patients with NF are at high risk for deep vein thrombosis (DVT); therefore, a tiered DVT prophylaxis strategy is advisedevidence level: low
- Recommendation 14(weakly recommended): For patients with NF who have stable systemic conditions and can be safely transported, hyperbaric oxygen therapy (HBOT) is recommendedevidence level: high
- Recommendation 15(highly recommended): Early initiation and continuous implementation of individualized comprehensive rehabilitation and psychological therapy are recommended throughout the entire treatment process. Nutritional support should also be integrated across the full treatment cycleevidence level: moderate
Abstract
Necrotizing fasciitis (NF) is a disease characterized by severe infection of the skin and its underlying soft tissues as the initial symptom. NF is known for its difficulty in early diagnosis and rapid progression. If not treated promptly, NF can quickly evolve into systemic infection, sepsis, and multiple organ failure, and it may even lead to patient death. Currently, many controversies and challenges remain in clinical practice for the diagnosis and treatment of NF. To promote the standardization of NF diagnosis and treatment, Chinese Burn Association, Editorial Board of the Chinese Journal of Burns and Wounds, and Burn Medicine Branch of China International Exchange and Promotion Association for Medical and Health Care, based on the latest relevant guidelines, literature, and clinical practice experience and in accordance with the principles of evidence-based medicine, have jointly developed the Consensus on the Diagnosis and Treatment of Adult Necrotizing Fasciitis (2025 Edition) through repeated discussion and voting. This consensus aims to provide scientific and standardized guidance for clinical diagnosis and treatment.
Contents of the original publication
The section headings of the original.
- Background
- Methods
- Registration and planning
- Development team and process
- Clinical questions and literature search
- Evidence grading and recommendation formulation
- Consensus formation
- Clinical questions and recommendations
- Clinical question 1: overview of necrotizing fasciitis
- Clinical question 2: diagnosis of necrotizing fasciitis
- Clinical question 3: general treatment of necrotizing fasciitis
- Clinical question 4: antimicrobial therapy for necrotizing fasciitis
- Clinical question 5: surgical treatment of necrotizing fasciitis
- Clinical question 6: adjuvant therapy for necrotizing fasciitis
- Conclusion
- Contributor Information
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