Necrotizing soft tissue infections (NSTI) have been recognized for millennia and continue to impose considerable burden on both patient and society in terms of morbidity, death, and the allocation of resources. With improvements in the delivery of critical care, outcomes have improved, although disease-specific therapies are lacking. The basic principles of early diagnosis, of prompt and broad antimicrobial therapy, and of aggressive debridement have remained unchanged. Clearly novel and new therapeutics are needed to combat this persistently lethal disease. This review emphasizes the pillars of NSTI management and then summarizes the contemporary evidence supporting the incorporation of novel adjuncts to the pharmacologic and operative foundations of managing this disease.

Objectives Single center experience has shown that American College of Surgeons (ACS) trauma verification can improve outcomes. The current objective was to compare mortality between ACS verified and State designated centers in a national sample. Methods Subjects ≥16yr from ACS verified or State designated level I and II centers were identified in the NTDB 2007–08. A predictive mortality model was constructed using TQIP methodology. Imputation was used for missing data. Probability of mortality in the model determined expected deaths. Observed to expected (O/E) mortality ratios with 90%CI and outliers (90%CI above or below 1.0) were compared across ACS and State level I and II centers. The mortality model was repeated with ACS vs. State included. Results There were 900,274 subjects. The model had an AUC of 0.92 to predict death. Level I ACS centers had a lower median O/E ratio than State (0.95 [IQR 0.82–1.05] vs 1.02 [0.87–1.15], p<0.01), with no difference in level II centers. Level II State centers had more high O/E outliers (Table). ACS verification was an independent predictor of survival in level II centers (OR 1.26; 95%CI 1.20–1.32, p<0.01), but not in level I centers (p=0.84). Conclusions Level II centers have a disproportionate number of high mortality outliers and ACS verification is a predictor of survival. Level I ACS centers have lower O/E ratios overall but no difference in outliers. ACS verification appears beneficial. This data suggests that level II centers benefit most, and promoting level II ACS verification may be an opportunity for improved outcomes. Level of Evidence: III

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