Intended for healthcare professionals

Practice Easily Missed?

Necrotising fasciitis

BMJ 2020; 369 doi: (Published 27 April 2020) Cite this as: BMJ 2020;369:m1428
  1. Jason Diab, surgical registrar,
  2. Aiveen Bannan, infectious disease consultant,
  3. Timothy Pollitt, general surgeon
  1. Port Macquarie Base Hospital, Port Macquarie, New South Wales, Australia
  1. Correspondence to J Diab
  2. This is one of a series of occasional articles highlighting conditions that may be more common than many doctors realise or may be missed at first presentation. The series advisers are Anthony Harnden, professor of primary care, Department of Primary Care Health Sciences, University of Oxford, and Dr Kevin Barraclough, School of Social and Community Medicine, University of Bristol. To suggest a topic for this series, please email us at practice{at}

What you need to know

  • Necrotising fasciitis can present with non-specific signs that evolve rapidly over time, with life threatening consequences

  • Disproportionate pain is a serious sign that warrants urgent surgical referral and intervention

  • Understanding the epidemiological risk factors, and timely laboratory and imaging assessments can increase confidence in the diagnosis, but necrotising fasciitis remains a clinical diagnosis that can be supported by ongoing reviews from medical and surgical teams

  • Successful treatment consists of resuscitation, intravenous antibiotics, and immediate referral to surgical care for aggressive debridement

A 36 year old indigenous Australian woman presents to her general practitioner with non-tender swelling on her flank and no other symptoms (including no fevers or chills). Her medical history includes type 2 diabetes mellitus, hypertension, dyslipidaemia, obesity, and chronic kidney disease. She is given oral antibiotics for presumed cellulitis but does not take them. Five days later, she presents to hospital with progressive generalised abdominal pain, soft tissue swelling, and fever. She is treated with broad spectrum antibiotics (meropenem, vancomycin, and clindamycin), fluid resuscitation, and electrolyte replacement. Her abdomen has several focuses of necrosis, generalised tenderness, and soft tissue induration extending to the bilateral subcostal margins (fig 1). She is taken urgently to theatre for aggressive surgical debridement and resuscitation.

What is necrotising fasciitis?

Necrotising fasciitis is a rare but serious infection of the subcutaneous tissues and fascia of the skin. The condition has an average mortality rate of 20.6%1 and is a surgical emergency. It can occur anywhere on the body, but most commonly at the perineum (36%), lower extremities (15.2%), postoperative wounds (14.7%), as well as in the abdomen, oral cavity, and neck.2 Necrotising fasciitis spreads rapidly with little muscle sparing3 and often leads to sepsis. If not treated promptly, it has high morbidity and mortality. Prompt diagnosis and surgery are the cornerstones of therapy to reduce …

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