Necrotizing fasciitis: An indication hyperbaric oxygenation therapy? for Avi Shupak, MD, Oren Shoshani, MD, Ilan Goldenberg, MD, Ami Barzilai, MD, Ron Moskuna, MD, and Shimon Bursztein, MD,t Haifa, Israel Background. The accepted treatment protocol for necrotizing fasciitis (NF) consists of extensive surgery and wide spectrum antibiotics. Hyperbaric oxygenation (HBO) has been recommended as adjuvant therapy for NF, improving patient mortality and outcome. However, the beneficial effect of HBO for NF remains controversial. Methods. A retrospective evaluation of treatment outcome in 37 patients treated for NF between 1984 and 1993 was carried out. The mortality rate, morbidity criteria, and risk factors for grave prognosis were compared between a group of 25 patients who received HBO as part of their treatment protocol and a group of the remaining 12 patients treated by surgical excision and antibiotics alone. Results. The two groups werefound to be similar with regard to age, gender, the incidence of individual risk factors for ominous prognosis, and the Acute Physiology and Chronic Health Evaluation (APACHE) II scorefor disease's severity on presentation. The mortality rate among the HBO-treated patients was 36 %, as opposed to 25 % in the non-HBO group. The mean number of surgical dibridements required per patient was significantly higher in the HBO group: 3.3 compared with 1.5 in the non-HBO-treated patients. Although the average length of hospitalization for survivors was shorter for the HBO group, the difference between the groups did not reach statistical significance. Conclusions. The results of this study cast doubt on the suggested advantage of HBO in reducing patient mortality and morbidity when used as adjuvant therapy for NF. (SURGERY1995;118:873-8.) From the Israel Naval Medical Institute, IDP, and the Department of Surgery A, Department of Plastic and ReconstructiveSurgery, and Department of Intensive Care, Rambam Medical Center, Haifa, Israel NECROTIZING FASCIITIS (NF) is a relatively rare infection characterized by rapidly progressing necrosis of fascia and subcutaneous fat with subsequent necrosis of the overlying skin. Muscle involvement is minimal or non- existent. Systemic toxicity is common and may be accompanied by altered mental status. The disease is generally associated with minor trauma or a surgical procedure, whereas the de novo onset of necrotizing fasciitis has been reported mainly in immune-compro- mised and diabetic patients, l' 2 Tissue cultures usually exhibit a mixture of aerobic and anaerobic bacteria, including streptococci group A, gram-negative bacilli, anaerobic gram-positive cocci, and bacteroides species. ~7 The extent of the disease may not always be recognized initially, because the infection spreads along subdermal fascial planes with minimal or no skin involvement. Although various diagnostic pro- cedures--including plane x-ray, computed tomogra- phy, and frozen section biopsy--have been suggested Accepted for publication Feb. 14, 1995. Reprint requests: Avi Shupak, MD, The Israel NavalMedical Institute, P.O. Box 8040, Haifa 31080, Israel. tDeceased. Copyright 91995 by Mosby-YearBook, Inc. 0039-6060/95/$5.00 + 0 11/56/64388 for early and accurate diagnosis, 8 a high level of clinical awareness is still the main diagnostic toolfi Early diag- nosis and prompt commencement of broad spectrum antibiotics and radical surgical excision are critical for a successful outcome in this serious condition. 9q2 Despite the general acceptance of this approach to treatment, the mortality rate of 20% to 40% has remained constant since necrotizing fasciitis was first reported by Meleney in 1924. 3, 5. l 1-13 A number of clin- ical studies have suggested that the outcome of patients with necrotizing fasciitis may be improved by hyperbaric oxygenation (HBO).4' 14-20 Although necrotizing fascii- tis has been recommended by the Undersea and Hyperbaric Medical Society as a definite indication for HBO,21.22 several reports have raised doubts about its efficacy in improving mortality and morbidity. 6, 12, 2~, 24 The purpose of this study was to evaluate the benefit of adjuvant HBO therapy in necrotizing fasciitis by comparing the outcome of HBO- and non-HBO-treat- ed patients admitted to our institute during the past 10 years. PATIENTS AND METHODS The medical records of 37 patients treated for necro- tizing fasciitis between 1984 and 1993 were evaluated SURGERY 873