Hyperbaric Oxygen Therapy As Adjunctive Treatment in Necrotizing Soft Tissue Infections, Osteomyelitis and Invasive Fungal Infections: A Systematic Review

Necrotizing soft tissue infections (NSTIs), chronic osteomyelitis, and invasive fungal infections remain challenging conditions associated with substantial morbidity and mortality despite advances in antimicrobial therapy and surgical management. Hyperbaric oxygen therapy (HBOT) has been proposed as an adjunctive treatment; however, its clinical effectiveness remains uncertain. This systematic review aimed to evaluate the available evidence regarding the impact of HBOT when added to standard care in patients with NSTIs, osteomyelitis, and invasive fungal infections. The available literature consists predominantly of observational studies and case series investigating NSTIs, chronic osteomyelitis, and, to a lesser extent, invasive fungal infections. Across these conditions, HBOT was frequently associated with improved clinical outcomes, including infection control, wound healing, limb preservation, and reduced mortality. However, the certainty of evidence was generally low to very low according to GRADE assessments, reflecting methodological limitations, risk of bias, and substantial heterogeneity among studies and treatment protocols. Current evidence suggests that HBOT may provide clinical benefit as an adjunct to standard treatment in selected patients with NSTIs, chronic osteomyelitis, and invasive fungal infections. Nevertheless, the available evidence is derived mainly from observational studies and should be interpreted with caution. Further high-quality prospective studies are required to clarify the magnitude of benefit, identify the patient populations most likely to benefit, and support the development of standardized treatment protocols.