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id.necrotising-fasciitis.core.v1PRODUCTION
id.necrotising-fasciitis.core.v1

Necrotising fasciitis / Fournier’s gangrene / gas gangrene

infectious_diseaseacuteadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm necrotising fasciitis / Fournier / gas gangrene scope per Stevens IDSA SSTI 2014 + WSES/SIS-E 2018 — surgical emergency; differentiate from severe cellulitis without NF (Stevens IDSA 2014; Wong 2003)

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scope confirmed: cellulitis with cardinal NF features OR LRINEC ≥ 6 OR clinical suspicion meeting T_treat surgical

Patient inputs (31)

Type I polymicrobial NF risk + Fournier risk + glycaemic control (Stevens IDSA 2014)

Broader pathogen spectrum + lower threshold; transplant / neutropenic / AIDS / chemo (Stevens IDSA 2014)

Type III Vibrio vulnificus pathway; doxycycline + cefotaxime (Horseman J Infect 2011)

Sepsis screening + SIRS / qSOFA component (Stevens IDSA 2014; SSC 2026)

LRINEC component (>15 = 1pt; >25 = 2pt); SIRS criterion (Wong CCM 2004)

LRINEC component (11-13.5 = 1pt; <11 = 2pt) (Wong CCM 2004)

LRINEC component (<135 = 2pt) (Wong CCM 2004)

LRINEC component (>1.6 = 2pt); pip-tazo + vanco + cefotaxime renal dosing; AKI from sepsis (Wong CCM 2004; Rybak 2020)

LRINEC component (>180 = 1pt); DKA from sepsis + Type IV Mucor risk (Wong CCM 2004; Stevens IDSA 2014)

LRINEC component (>150 mg/L = 4pt; the heaviest weighted item) (Wong CCM 2004)

Shock state + tissue ischaemia; SSC 2026 sepsis bundle (Singer JAMA 2016; SSC 2026)

Identify Type II Strep pyogenes / Clostridium / S. aureus; before first antibiotic dose unless shock (Stevens IDSA 2014)

Septic shock + Streptococcal TSS recognition; ICU + IVIG threshold (Stevens IDSA 2014; SSC 2026)

qSOFA / SIRS component; shock recognition (SSC 2026)

Cardinal early NF sign; LR+ ≈5-8 (Wong 2003; Stevens IDSA 2014)

Gas-forming / late NF signs; LR+ ≈9-10 (Stevens IDSA 2014)

Border extension >1 cm/h is cardinal; mark border for trend (Stevens IDSA 2014; WSES/SIS-E 2018)

Bedside immediate; subcutaneous gas LR+ ≈9 for gas-forming NF (Stevens IDSA 2014)

Fascial gas + fluid + edema LR+ ≈8; do NOT delay surgery when clinically suspected (Stevens IDSA 2014; WSES/SIS-E 2018)

Deep-fascial T2 hyperintensity + enhancement LR+ ≈10; operator + bed availability variable (Stevens IDSA 2014)

Bedside, rapid, low cost; useful for fluid + gas in equivocal cases (Stevens IDSA 2014)

Type II Strep pyogenes risk + OUD linkage; route to psych.opioid_use_disorder.core.v1 (Stevens IDSA 2014)

Type III Aeromonas pathway; cipro + ceftriaxone (Stevens IDSA 2014)

Vibrio vulnificus predisposition + mortality >50%; Type III recognition (Horseman J Infect 2011)

Type II / IV / post-op NF risk (Stevens IDSA 2014)

Pediatric Type II Strep pyogenes NF + STSS classic association (AAP 2018)

Fournier’s gangrene phenotype — Type I polymicrobial; diverting colostomy consideration (Stevens IDSA 2014)

Identify pathogen + susceptibility; intra-op tissue is gold standard (Stevens IDSA 2014; WSES/SIS-E 2018)

Sepsis-induced DIC monitoring; pre-op coagulation; massive transfusion preparation (SSC 2026)

qSOFA component (Singer JAMA 2016; SSC 2026)

Late-stage fascial nerve destruction; LR+ ≈12 (Stevens IDSA 2014)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningnf_at_diagnosis_emergent_surgery
    Clinical NF diagnosis (cardinal signs: pain out of proportion + hemorrhagic bullae OR crepitus OR rapid extension OR anaesthesia of involved skin) — STAT surgical activation within 1 h; mortality doubles per 6 h delay to OR (Stevens IDSA 2014; WSES/SIS-E 2018; Bilton AmJSurg 1998)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningstreptococcal_toxic_shock_syndrome
    Type II NF + shock + multi-organ failure — STSS toxin-mediated syndrome; clindamycin toxin suppression essential; IVIG Class IIa per Stevens IDSA 2014 (Darenberg 2003 RCT trend; Linnér 2014 observational OR 0.30); minimum 21 d duration for persistent toxemia (Stevens IDSA 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningclostridial_myonecrosis_gas_gangrene
    C. perfringens (post-traumatic) or C. septicum (spontaneous; colon-cancer-associated) myonecrosis + crepitus + hemorrhagic bullae + "dishwater" exudate + profound toxemia — penicillin G + clindamycin + emergent debridement; HBO transfer consideration if available; colonoscopy mandatory once stable for spontaneous C. septicum (Stevens IDSA 2014; Shupak 1995)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningvibrio_vulnificus_after_salt_water_exposure
    Type III NF after seawater / raw oyster exposure OR cirrhosis with rapid-progression cellulitis — doxycycline + cefotaxime first-line; mortality > 50% if shock; surgical debridement + ICU + empiric within 1 h essential (Horseman J Infect 2011; Stevens IDSA 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfournier_gangrene_perineal_genital
    Perineal / genital / perianal NF — almost always Type I polymicrobial; diabetes + obesity + immunocompromise predispose; emergent debridement + broad-spectrum + diverting colostomy considered for perineal extension; urology + colorectal surgery consultation (Stevens IDSA 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnf_with_septic_shock_routes_to_sepsis_core
    NF + septic shock + multi-organ failure — routes bidirectionally to id.sepsis.core.v1 for SSC 2026 Hour-1 bundle + vasopressor management + ICU; surgical-source carryover maintained (SSC 2026; Stevens IDSA 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremonomicrobial_strep_pyogenes_with_clindamycin
    Type II monomicrobial Strep pyogenes (± S. aureus) NF — clindamycin essential for ribosomal toxin suppression (Eagle effect; Stevens JID 1988); macrolide alone is NOT acceptable; clindamycin-resistance in S. pyogenes rising regionally (Stevens IDSA 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelrinec_score_above_6
    LRINEC ≥ 6 in patient with cellulitis or suspected SSTI — high suspicion for NF (LR+ ≈10 in Wong 2004 derivation cohort); do NOT delay surgical exploration for further imaging or labs; surgical clinical judgement always overrides (Wong CCM 2004; Bechar 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepolymicrobial_diabetic_or_immunocompromised
    Type I polymicrobial NF in diabetic or immunocompromised host — broaden anaerobic coverage; aggressive glycemic control; Fournier risk; lower OR threshold + lower second-look threshold; ID + endocrine consultation (Stevens IDSA 2014; IDSA Lipsky 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepost_op_persistent_necrosis_repeat_debridement
    Post-op (first debridement) persistent necrosis at second-look 24-48 h — mandatory repeat OR if necrosis advancing; antibiotics adjunct only; consider broaden empirics + reassess pathogen + tertiary debridement (Stevens IDSA 2014; WSES/SIS-E 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

NF empiric — piperacillin-tazobactam + vancomycin + clindamycin within 1 h (Stevens IDSA 2014; WSES/SIS-E 2018)
axis: nf_empiric_broad_spectrum
Selected axis "NF empiric — piperacillin-tazobactam + vancomycin + clindamycin within 1 h (Stevens IDSA 2014; WSES/SIS-E 2018)" by default fallback (first axis)
  • piperacillin-tazobactam
    first line
    penicillin_beta_lactamase_inhibitor
    4.5 g IV q6h (extended infusion 4 h preferred in shock) • IV • q6h
    triggers: empiric_nf_polymicrobial, type_I_polymicrobial, fournier_gangrene, diabetic_foot_nf, post_op_nf
    Stevens IDSA 2014 — broad Gram-positive + Gram-negative + anaerobe + Pseudomonas; extended infusion for time-dependent killing; renal adjust CrCl < 40
    rxcui 74169
  • vancomycin
    first line
    glycopeptide
    25-30 mg/kg IV load × 1 → 15-20 mg/kg IV q8-12 h targeting AUC24 400-600 mg·h/L • IV • q8-12h (AUC-titrated)
    triggers: empiric_nf, mrsa_coverage, type_II_strep_aureus_coverage
    Stevens IDSA 2014 + Rybak ASHP/IDSA 2020 — covers MRSA + CoNS + most Enterococcus; AUC-targeted dosing 2026 standard (PMID 32191793)
    rxcui 11124
  • clindamycin
    first line
    lincosamide
    900 mg IV q8h • IV • q8h
    triggers: empiric_nf, type_II_strep_pyogenes_toxin_suppression, clostridial_toxin_suppression, eagle_effect_inhibition
    Stevens IDSA 2014 — 50S ribosomal toxin suppression for Type II Strep pyogenes + Type III Clostridium (Eagle effect; Stevens JID 1988 PMID 3292661); critical — do NOT use macrolide alone; clindamycin-resistance in S. pyogenes rising regionally
    rxcui 2582
  • meropenem
    contraindication substitute
    carbapenem
    1 g IV q8h (2 g IV q8h for severe / immunocompromised / CNS extension) • IV • q8h
    triggers: pip_tazo_severe_allergy, esbl_risk, severe_immunocompromised, carbapenem_preference
    Stevens IDSA 2014 — replaces pip-tazo when ESBL risk or carbapenem preferred; broad-spectrum; pair with vanco + clindamycin; seizure risk in elderly + renal
    rxcui 29561
  • imipenem-cilastatin
    contraindication substitute
    carbapenem
    500-1000 mg IV q6h • IV • q6h
    triggers: pip_tazo_severe_allergy, esbl_risk, meropenem_unavailable
    Stevens IDSA 2014 — equivalent carbapenem alternative; pair with vanco + clindamycin
    rxcui 34482

ed playbook — drug actions (5)

  1. 1. piperacillin-tazobactam
    rxcui 74169
    4.5 g IV (extended infusion 4 h preferred in shock) • IV • q6h
    trigger: Empiric within 1 h of recognition; after ≥ 2 cultures unless septic shock (Stevens IDSA 2014; Kumar CCM 2006)
    Broad Gram-positive + Gram-negative + anaerobe + Pseudomonas coverage
  2. 2. vancomycin
    rxcui 11124
    25-30 mg/kg IV load × 1 • IV • q8-12h AUC-titrated
    trigger: Empiric within 1 h — MRSA + CoNS coverage (Stevens IDSA 2014; Rybak 2020)
    AUC 400-600 target per Rybak ASHP/IDSA 2020
  3. 3. clindamycin
    rxcui 2582
    900 mg IV • IV • q8h
    trigger: Empiric within 1 h — toxin suppression for Type II Strep + Type III Clostridium (Stevens IDSA 2014; Stevens JID 1988)
    Eagle effect ribosome-targeted toxin shutoff; CRITICAL adjunct
  4. 4. doxycycline + cefotaxime (Vibrio-suspected)
    rxcui 3640
    Doxycycline 100 mg IV BID + cefotaxime 2 g IV q8h • IV • BID / q8h
    trigger: Seawater / raw oyster exposure / cirrhosis (Horseman J Infect 2011)
    Type III Vibrio vulnificus first-line; replaces or supplements pip-tazo
  5. 5. IVIG (STSS suspected)
    rxcui 1426680
    1 g/kg IV day 1 → 0.5 g/kg IV days 2-3 • IV • daily × 3
    trigger: Type II NF + shock / multi-organ failure / STSS (Stevens IDSA 2014 Class IIa; Linnér 2014)
    Toxin neutralisation; OR 0.30 for mortality benefit in observational cohort

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Pain out of proportion to skin findings — cardinal early NF sign; LR+ ≈5-8 (Stevens IDSA 2014; Wong 2003); Rapidly extending erythema (>1 cm/h) + systemic toxicity (Stevens IDSA 2014; WSES/SIS-E 2018); Hemorrhagic bullae, crepitus, "dishwater" exudate, anaesthesia of involved skin (Stevens IDSA 2014 — cardinal mid-late signs).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Necrotising fasciitis / Fournier’s gangrene / gas gangrene** (id.necrotising-fasciitis.core.v1).
Phenotype framing: Distinguish NF from severe cellulitis (parent dossier), erysipelas, pyomyositis, compartment syndrome, deep abscess, gas gangrene without NF, TSS without NF, DVT mimicker, spider envenomation (Loxosceles), severe contact dermatitis (Stevens IDSA 2014; Wong 2003)
Scope: Confirm necrotising fasciitis / Fournier / gas gangrene scope per Stevens IDSA SSTI 2014 + WSES/SIS-E 2018 — surgical emergency; differentiate from severe cellulitis without NF (Stevens IDSA 2014; Wong 2003)

No severity triggers fired against current inputs.

Plan

Regimen axis: **NF empiric — piperacillin-tazobactam + vancomycin + clindamycin within 1 h (Stevens IDSA 2014; WSES/SIS-E 2018)**.
1. piperacillin-tazobactam 4.5 g IV q6h (extended infusion 4 h preferred in shock) IV q6h (penicillin_beta_lactamase_inhibitor, first line) — Stevens IDSA 2014 — broad Gram-positive + Gram-negative + anaerobe + Pseudomonas; extended infusion for time-dependent killing; renal adjust CrCl < 40
2. vancomycin 25-30 mg/kg IV load × 1 → 15-20 mg/kg IV q8-12 h targeting AUC24 400-600 mg·h/L IV q8-12h (AUC-titrated) (glycopeptide, first line) — Stevens IDSA 2014 + Rybak ASHP/IDSA 2020 — covers MRSA + CoNS + most Enterococcus; AUC-targeted dosing 2026 standard (PMID 32191793)
3. clindamycin 900 mg IV q8h IV q8h (lincosamide, first line) — Stevens IDSA 2014 — 50S ribosomal toxin suppression for Type II Strep pyogenes + Type III Clostridium (Eagle effect; Stevens JID 1988 PMID 3292661); critical — do NOT use macrolide alone; clindamycin-resistance in S. pyogenes rising regionally
4. meropenem 1 g IV q8h (2 g IV q8h for severe / immunocompromised / CNS extension) IV q8h (carbapenem, contraindication substitute) — Stevens IDSA 2014 — replaces pip-tazo when ESBL risk or carbapenem preferred; broad-spectrum; pair with vanco + clindamycin; seizure risk in elderly + renal
5. imipenem-cilastatin 500-1000 mg IV q6h IV q6h (carbapenem, contraindication substitute) — Stevens IDSA 2014 — equivalent carbapenem alternative; pair with vanco + clindamycin

Setting playbook (ed) — Recognise NF within minutes — pain out of proportion, rapid extension, hemorrhagic bullae, crepitus, anaesthesia, sepsis with skin source. STAT surgical activation within 1 h of recognition. Empiric pip-tazo + vancomycin + clindamycin within 1 h. Do NOT delay surgery for imaging when clinically suspected. (Stevens IDSA 2014; WSES/SIS-E 2018)
6. piperacillin-tazobactam 4.5 g IV (extended infusion 4 h preferred in shock) IV q6h — Empiric within 1 h of recognition; after ≥ 2 cultures unless septic shock (Stevens IDSA 2014; Kumar CCM 2006) (Broad Gram-positive + Gram-negative + anaerobe + Pseudomonas coverage)
7. vancomycin 25-30 mg/kg IV load × 1 IV q8-12h AUC-titrated — Empiric within 1 h — MRSA + CoNS coverage (Stevens IDSA 2014; Rybak 2020) (AUC 400-600 target per Rybak ASHP/IDSA 2020)
8. clindamycin 900 mg IV IV q8h — Empiric within 1 h — toxin suppression for Type II Strep + Type III Clostridium (Stevens IDSA 2014; Stevens JID 1988) (Eagle effect ribosome-targeted toxin shutoff; CRITICAL adjunct)
9. doxycycline + cefotaxime (Vibrio-suspected) Doxycycline 100 mg IV BID + cefotaxime 2 g IV q8h IV BID / q8h — Seawater / raw oyster exposure / cirrhosis (Horseman J Infect 2011) (Type III Vibrio vulnificus first-line; replaces or supplements pip-tazo)
10. IVIG (STSS suspected) 1 g/kg IV day 1 → 0.5 g/kg IV days 2-3 IV daily × 3 — Type II NF + shock / multi-organ failure / STSS (Stevens IDSA 2014 Class IIa; Linnér 2014) (Toxin neutralisation; OR 0.30 for mortality benefit in observational cohort)

Non-pharmacologic actions:
- STAT general surgery (or urology for Fournier; ENT for cervical; trauma surgery for extremity) activation within 1 h of recognition (Stevens IDSA 2014; WSES/SIS-E 2018)
- Do NOT delay surgical exploration for imaging when clinically NF (Stevens IDSA 2014)
- Sepsis bundle in parallel (SSC 2026): 30 mL/kg crystalloid for hypotension / lactate > 4; norepinephrine to MAP ≥ 65; lactate q2-4h
- Mark border with skin marker every 30 min in ED to document rate of extension (Stevens IDSA 2014; WSES/SIS-E 2018)
- For IDU patient: initiate OUD-linkage discussion + harm-reduction counseling; route to psych.opioid_use_disorder.core.v1 (Stevens IDSA 2014)
- For Fournier: urology + colorectal surgical consultation; discuss diverting colostomy for perineal extension (Stevens IDSA 2014)
- Tetanus prophylaxis if not up to date + traumatic NF (CDC ACIP 2026)

AVOID / contraindication checks:
- Surgery is cure antibiotics adjunct (Stevens IDSA 2014)
- No imaging delay when clinically suspected (Stevens IDSA 2014; WSES/SIS E 2018)
- Mandatory second look 24 48h (Stevens IDSA 2014; WSES/SIS E 2018)
- Vanco auc monitoring 400 600 (Rybak 2020 PMID 32191793)
- Clindamycin c diff counsel (Stevens IDSA 2014; DailyMed clindamycin)
- Pip tazo renal adjust CrCl lt 40 (DailyMed pip tazo)
- Meropenem seizure risk cns elderly renal (DailyMed meropenem)
- Blood cultures x2 before abx unless shock (Stevens IDSA 2014)
- Mark border with skin marker at presentation (Stevens IDSA 2014; WSES/SIS E 2018)

Monitoring

Regimen monitoring:
- surgical response within 1h target (Stevens IDSA 2014; WSES/SIS-E 2018)
- mandatory second look at 24 48h (Stevens IDSA 2014)
- vanco AUC q3 5d target 400 600 (Rybak 2020)
- repeat blood cultures q48 72h until clearance (Stevens IDSA 2014)
- wound culture from each debridement (Stevens IDSA 2014)
- creatinine daily during induction then 3x weekly (Rybak 2020; DailyMed)
- lactate q4h until clearance (SSC 2026)
- duration ge 14d minimum extended to 21d for STSS or persistent toxemia (Stevens IDSA 2014)

Setting (ed) monitoring:
- Vitals q15 min until disposition (Stevens IDSA 2014; SSC 2026)
- Lactate q2 h until clearance (SSC 2026)
- Border extension q30 min (Stevens IDSA 2014; WSES/SIS-E 2018)

Follow-up plan: Physical / occupational rehab; plastic / reconstructive surgery for closure / grafting / amputation prosthesis; psychological sequelae after disfiguring debridement; OUD linkage if IDU; addiction medicine consult; diabetes optimisation; colon-cancer workup for C. septicum; community follow-up (Stevens IDSA 2014; AAP 2018)
- Close-out criterion: rehab + reconstructive plan + OUD linkage (if IDU) + colon workup (if C. septicum) scheduled

Monitoring phase: Mandatory second-look at 24-48 h (Stevens IDSA 2014); tertiary debridement if necrosis advancing; daily exam + dressing change + culture from each debridement; lactate / SOFA / vasopressor trend; AKI monitoring (vanco AUC, cefotaxime renal); clostridial → colon workup once stable for C. septicum (Stevens IDSA 2014; Rybak 2020)

Disposition

Current setting: ed — Recognise NF within minutes — pain out of proportion, rapid extension, hemorrhagic bullae, crepitus, anaesthesia, sepsis with skin source. STAT surgical activation within 1 h of recognition. Empiric pip-tazo + vancomycin + clindamycin within 1 h. Do NOT delay surgery for imaging when clinically suspected. (Stevens IDSA 2014; WSES/SIS-E 2018)

Disposition criteria:
- All NF patients admitted — typically ICU for shock / pre-shock / Fournier with diversion / large debridement / STSS / Vibrio Type III + cirrhosis; ward + ID consult for hemodynamic stability after second-look; NEVER discharged from ED (Stevens IDSA 2014; WSES/SIS-E 2018)

Escalation triggers (move to higher acuity):
- qSOFA ≥ 2 + hypotension + lactate > 2 → ICU; SSC Hour-1 bundle + emergent surgery (Stevens IDSA 2014; SSC 2026)
- Cardiogenic / vasoplegic shock — IVIG + emergent surgery + ICU (Stevens IDSA 2014)
- Rapid extension > 1 cm / h — emergent OR within 1 h (Stevens IDSA 2014; WSES/SIS-E 2018)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Clinical NF diagnosis (cardinal signs: pain out of proportion + hemorrhagic bullae OR crepitus OR rapid extension OR anaesthesia of involved skin) — STAT surgical activation within 1 h; mortality doubles per 6 h delay to OR (Stevens IDSA 2014; WSES/SIS-E 2018; Bilton AmJSurg 1998)
- [LIFE_THREATENING] Type II NF + shock + multi-organ failure — STSS toxin-mediated syndrome; clindamycin toxin suppression essential; IVIG Class IIa per Stevens IDSA 2014 (Darenberg 2003 RCT trend; Linnér 2014 observational OR 0.30); minimum 21 d duration for persistent toxemia (Stevens IDSA 2014)
- [LIFE_THREATENING] C. perfringens (post-traumatic) or C. septicum (spontaneous; colon-cancer-associated) myonecrosis + crepitus + hemorrhagic bullae + "dishwater" exudate + profound toxemia — penicillin G + clindamycin + emergent debridement; HBO transfer consideration if available; colonoscopy mandatory once stable for spontaneous C. septicum (Stevens IDSA 2014; Shupak 1995)

Citations

- Stevens IDSA SSTI 2014 (Stevens, CID 2014 PMID 24973422) + WSES/SIS-E SSTI 2018 (Sartelli, World J Emerg Surg 2018 PMID 30564282) — co-canonical US + global surgical guidance. Supplemented by Wong LRINEC (CCM 2004 PMID 15241098), Eagle effect / Stevens clindamycin (Stevens JID 1988 PMID 3292661), Darenberg IVIG RCT (CID 2003 PMID 12884156), Linnér IVIG cohort (CID 2014 PMID 24928291), Horseman Vibrio (Int J Infect Dis 2011 PMID 21177133), Rybak ASHP/IDSA Vanco AUC 2020 (PMID 32191793), Bechar LRINEC meta (Ann R Coll Surg Engl 2017 PMID 28462647), Kumar antibiotic-delay (CCM 2006 PMID 16625125). [PMID:24973422](https://pubmed.ncbi.nlm.nih.gov/24973422/)
- Cited evidence (PMID 30564282) [PMID:30564282](https://pubmed.ncbi.nlm.nih.gov/30564282/)
- Cited evidence (PMID 15241098) [PMID:15241098](https://pubmed.ncbi.nlm.nih.gov/15241098/)
- Cited evidence (PMID 3292661) [PMID:3292661](https://pubmed.ncbi.nlm.nih.gov/3292661/)
- Cited evidence (PMID 12884156) [PMID:12884156](https://pubmed.ncbi.nlm.nih.gov/12884156/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Stevens IDSA SSTI 2014 (Stevens, CID 2014 PMID 24973422) + WSES/SIS-E SSTI 2018 (Sartelli, World J Emerg Surg 2018 PMID 30564282) — co-canonical US + global surgical guidance. Supplemented by Wong LRINEC (CCM 2004 PMID 15241098), Eagle effect / Stevens clindamycin (Stevens JID 1988 PMID 3292661), Darenberg IVIG RCT (CID 2003 PMID 12884156), Linnér IVIG cohort (CID 2014 PMID 24928291), Horseman Vibrio (Int J Infect Dis 2011 PMID 21177133), Rybak ASHP/IDSA Vanco AUC 2020 (PMID 32191793), Bechar LRINEC meta (Ann R Coll Surg Engl 2017 PMID 28462647), Kumar antibiotic-delay (CCM 2006 PMID 16625125). — PMID:24973422
  • Cited evidence (PMID 30564282) — PMID:30564282
  • Cited evidence (PMID 15241098) — PMID:15241098
  • Cited evidence (PMID 3292661) — PMID:3292661
  • Cited evidence (PMID 12884156) — PMID:12884156