Necrotizing Fasciitis


Article Author:
Heather Wallace
Abdul Waheed


Article Editor:
Thomas Perera


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/4/2019 1:40:56 AM

Introduction

Necrotizing fasciitis is a subset of the aggressive skin and soft tissue infections (SSTIs) that cause necrosis of the muscle fascia and subcutaneous tissues. This infection typically travels along the fascial plane, which has a poor blood supply, leaving the overlying tissues initially unaffected, potentially delaying diagnosis and surgical intervention. The infectious process can rapidly spread causing infection of the fascia, peri-fascial planes, and cause secondary infection of the overlying and underlying skin, soft tissue, and muscle.[1][2][3]

Etiology

Necrotizing fasciitis is typically an acute process occurring rapidly over several days. It is a direct sequela of bacterial infection introduced through a break in the skin’s integrity in approximately 80% of all cases. Gram-positive cocci specifically strains of Staphylococcus aureus and Streptococci are responsible for the majority of these single site source infections. Polymicrobial infections occur as well because of a combination of gram-negative and anaerobic involvement.[4][5]

Epidemiology

Necrotizing fasciitis affects about 0.4 in every 100,000 people per year in the United States. In some areas of the world, it is as common as one in every 100,000 people.[6][7]

Pathophysiology

The infection rapidly transits the muscle fascia. After several days the overlying skin, which appears unaffected initially, will transition to an erythematous, reddish-purple to bluish-gray hue. The texture of the skin will become indurated, swollen, shiny, and feel warm in temperature. At this stage, the skin is exquisitely tender to palpation and can also be painful out of proportion to presenting symptoms. Skin breakdown will begin in 3 to 5 days and is accompanied by bullae and cutaneous gangrene. Pain is reduced in the affected area secondary to thrombosed small vessels and destruction of the superficial nerves in the subcutaneous tissues. Advanced stages of the infection are characterized by systemic symptoms such as fever, tachycardia, and sepsis.[8]

Histopathology

Tissue obtained from the operating room after debridement will usually show extensive superficial fascial necrosis. The majority of small and medium-size blood vessels will be thrombosed. Aggregates of neutrophils will be observed in the fascia and subcutaneous tissues. Small vessel vasculitis and extensive fat necrosis will also be evident. All the glands in the dermis and subcutaneous tissues will be necrotic as well. Gram stain will show clusters of various types of microorganisms.

History and Physical

Necrotizing infections are more commonly present with excruciating pain out of proportion to presenting symptoms and systemic septic signs than non-necrotizing infections.

Physical findings of necrotizing soft tissue infections may include tenderness to palpation beyond the erythematous border, crepitus, and cellulitis. The presence of bullae, ecchymotic changes to the skin, and dysesthesia or paresthesia should also be treated as a necrotizing infection.

Evaluation

Any rapidly progressing skin or soft tissue infection should be managed aggressively due to the difficulty in differentiating non-necrotizing from necrotizing skin and soft tissue infections.[9][10][11]

The Laboratory Risk Indicator for Necrotizing Infection (LRINEC) Score was developed in a 2004 report to distinguish NSTIs from other severe soft tissue infections. The scoring system is hinged on abnormalities in six independent variables:

C-reactive protein, mg/L

  • Less than 150 (0)
  • More than 150 (4)

Total white cell count (WBC), cells/mm

  •  Less than 15 (0)
  •  15 to 25 (1)
  •  More than 25 (2)

Hemoglobin, g/dl

  •  More than 13.5 (0)
  •  11 to 13.5 (1)
  •  Less than 11 (2)

Sodium, mmol/L

  • 135 or greater  (0)
  • Less than 135 (2)

Creatinine, mg/dL

  • 1.6 or less (0)
  • More than 1.6 (2)

Glucose, mg/dL

  • 180 or less (0)
  • More than 180 (1)

A score of six has a positive predictive value of 92% and negative predictive value of 96%. A score of eight or greater represents a 75% risk of a necrotizing infection.

Diagnosis of NSTIs is still primarily a clinical one. Imaging may be useful in providing data when the diagnosis is uncertain. The most common plain film finding is similar to cellulitis with increased soft tissue thickness and opacity. Computed tomography (CT) has greater sensitivity than plain film in identifying necrotizing soft tissue infections.

Treatment / Management

These patients are extremely ill and should be transferred immediately to the intensive care unit. The sepsis causes refractory hypotension and diffuse capillary leak. Thus the patient will need aggressive resuscitation with fluids and use of inotropes to maintain blood pressure. The patient must be kept NPO (nothing by mouth) until seen by the surgeon. Nutrition is vital but only after surgery has been completed. Enteral feedings should be started as soon as the patient is hemodynamically stable. The enteral feedings may help offset the massive negative protein balance that occurs as a result of catabolism.[5][12][13]

Key concepts for treatment/management of skin and soft-tissue infections are:

  1. Early diagnosis and differentiation between necrotizing and non-necrotizing SSTIs

  2. The early launch of appropriate empiric antibacterial coverage (wide-spectrum)

  3. Adequate control of infection sources such as aggressive surgical intervention for abscess drainage and debridement of necrotizing soft tissue infections (NSTIs)

  4. Identification of infection-causing pathogen and applicable adjustment of antimicrobial coverage.

Antimicrobial therapy of necrotizing fasciitis is as follows:

  1. Linezolid 600 mg twice per day, AND
  2. Piperacillin/Tazobactam 4/0 to 5g LD infused in 30 min then 16/2 g qd by CI OR Daptomycin 6 mg/kg qd, AND
  3. Piperacillin/Tazobactam 4/0 to 5g LD infused in 30 min then 16/2 g qd by CI AND Clindamycin 600 mg to 900 mg four times per day.

Surgery

The treatment of necrotizing fasciitis is surgery and no time should be wasted calling for a surgical consult. The earlier the surgery is undertaken the better the outcome.

The surgery requires extensive, wide debridement of all necrotic tissues. In some cases, a second-look surgery may also be required. Early surgery may help minimize tissue loss and eliminate the need for amputation of a gangrenous extremity. With wide debridement, the wounds need to be left open and are packed with wet gauze. Daily dressing changes are mandatory. As long as the necrotic tissue is removed, the patient's recovery is faster. A great deal of surgical judgment is required when faced with normal appearing tissue which is not frankly necrotic. In most cases, if there is any doubt about viability, the tissues should be removed. In most cases, hemodynamic stability is restored once the necrotic tissue and pus are removed. The patient should be kept intubated and monitored in a critical care unit.  In some patients, daily surgical debridement may be required. During the surgery, meticulous attention should be paid to hemostasis.

Soft-tissue Reconstruction

Once all the necrotic tissue is removed and there is evidence of granulation tissue, the plastic surgeon should be consulted. In most cases, primary closure is not possible and hence the plastic surgeon may be required to reconstruct the soft tissues and close the wound with a muscle flap. If there is no adequate natural skin available for a skin graft, then one may need to use artificial skin.

Another method of treatment includes the use of hyperbaric oxygenation. While the literature does suggest this modality can be used, most of these patients are in the intensive care unit attached to a variety of medical equipment, thus making the journey to the hyperbaric oxygen therapy facility difficult. For small wounds, hyperbaric oxygen therapy may be effective, but for large wounds, there is no evidence that this therapy improves healing or prolongs life. Finally, it should be noted that hyperbaric oxygen therapy is an adjunctive treatment and not a substitute for surgical debridement.

Differential Diagnosis

  • Cellulitis
  • Testicular torsion
  • Toxic shock syndrome

Pearls and Other Issues

Necrotizing fasciitis is a life-threatening disorder which carries a mortality ranging from 20% to 80%. Risk factors for adverse outcomes include advanced age, resistant organism, delay in therapy, multiorgan failure, and infection site.

Enhancing Healthcare Team Outcomes

Necrotizing is a life-threatening disorder with a very high mortality rate. Any delay in diagnosis or treatment usually results in a poor outcome. The disorder is best managed by a team of healthcare professionals that includes a urologist, general surgeon, an infectious disease expert, intensivist, nephrologist, and radiologist. The role of the nurse and pharmacist is also of critical importance. The nurse is often the first to recognize that the patient is critically ill or in pain. The patient should be kept NPO, hydrated and immediately covered with broad-spectrum antibiotics. The pharmacist should check cultures and ensure that the right antibiotics are used to cover the offending organism. The stoma nurse should be consulted because many of these patients also need a fecal diversion to prevent contamination of the perineum. These patients are best managed in the ICU until signs of toxicity diminish. Only through a systemic approach with close collaboration can the mortality of this condition be lowered. [1][14][15](Level V)

Outcomes

Necrotizing fasciitis is a serious disorder that carries a mortality rate of anywhere from 30-90%. The mortality ultimately depends on patient age, type of organism, the speed of diagnosis and treatment and patient comorbidity. The worst prognosis is in patients with specific streptococcal strains. Other factors that adversely affect prognosis include loss of consciousness, respiratory distress, renal failure, and ARDs. Survival is best for patients who have an immediate radical debridement, hydration, and broad-spectrum antibiotics. Even after treatment, survivors of the disorder tend to have a shorter lifespan than age-matched controls. [16][17](Level V)


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Necrotizing Fasciitis - Questions

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A patient undergoes an open appendectomy and 4 days later presents with a wound with diffuse erythema and clear watery discharge. He has a high-grade fever, and the wound develops a margin of diffuse erythema, necrosis, bullae, and clear watery discharge. What is the most likely cause?



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A patient suffers a bullet wound to the abdomen and undergoes emergency surgery. After surgery, there is extensive necrotizing fasciitis of the anterior abdominal wall. Which of the following is true about this condition?



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A patient arrives at the emergency department after having been on the beach for the past 3 days. Ten hours before his arrival, he observed a tiny puncture wound on the sole of the right foot. Over the past 6 hours, he has noticed that the foot is painful, swollen, and red, and he has both fevers and chills. Examination reveals a red, swollen foot with blisters but no crepitus. Radiological studies appear normal but the white blood cell count is 18 cells/mm3. Which of the following is most appropriate for the management of this patient?



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A previously healthy 55-year-old male with non-insulin dependent diabetes mellitus presents with neck swelling, 10 out of 10 pain, and fever. He states that he has a small lesion on the side of his neck, which has progressively increased in size. On examination, he has a temperature of 102.2F and a white blood cell count of 22,000 cells/mm3. The pain is not easily controlled with multiple doses of pain medication. In addition to antibiotics, the management of this patient includes which of the following?



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A patient presents with pain in her left calf. She looks ill and is febrile and tachycardic. Her calf is tender to touch, and there is mild crepitus. What is the next step?

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An adult male presents 48 hours after cutting his hand with fever, chills, and extreme pain. On physical, he has marked redness and purple bullae around the area of the wound with putrid discharge and decreased sensation in his hand. The next step in his management is?



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A patient presents with fever, chills, and extreme pain 48 hours after cutting his hand. His hand is purplish in color with bullae, putrid discharge, and decreased sensation. In addition to starting empiric antibiotics, what is the most appropriate management of this patient?

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A 65-year-old female presents 36 hours after cutting her hand. She complains of fever, chills, and extreme pain. Exam reveals progressive redness from the area of the wound, a purplish hand with bullae, putrid discharge, and decreased sensation in his hand. What is the next step in treatment?



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Which of the following infections in patients with lymphedema needs surgical exploration?



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Which bacteria is most commonly found in cultures of necrotizing fasciitis?



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When suspecting necrotizing fasciitis what is the best imaging to obtain prior to consulting surgery?



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The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINF) score is the most well-known system for differentiating necrotizing fasciitis from other infections. Which of the following elements are not part of this score?



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Clindamycin is often added to antibiotic coverage for necrotizing fasciitis which includes carbapenems or combinations like vancomycin with piperacillin/tazobactam. Why is clindamycin is used to treat necrotizing fasciitis?



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The gold standard of diagnosis of necrotizing fasciitis is usually determined in the operating room. Diagnostic signs include “dishwater” discharge and necrosis. What other sign is seen?



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Necrotizing Fasciitis - References

References

Kim YH,Ha JH,Kim JT,Kim SW, Managing necrotising fasciitis to reduce mortality and increase limb salvage. Journal of wound care. 2018 Sep 1     [PubMed]
Hite M,McCrae AL,Privette A, Fungal Necrotizing Fasciitis after Penetrating Trauma. The American surgeon. 2018 Aug 1     [PubMed]
Lange JH,Cegolon L, Comment on: Early clinical manifestations of vibrio necrotising fasciitis. Singapore medical journal. 2018 Aug     [PubMed]
Heijkoop B,Parker N,Spernat D, Fournier's gangrene: not as lethal as previously thought? A case series. ANZ journal of surgery. 2018 Sep 2     [PubMed]
Erichsen Andersson A,Egerod I,Knudsen VE,Fagerdahl AM, Signs, symptoms and diagnosis of necrotizing fasciitis experienced by survivors and family: a qualitative Nordic multi-center study. BMC infectious diseases. 2018 Aug 28     [PubMed]
Khalid M,Junejo S,Mir F, Invasive Community Acquired Methicillin-Resistant Staphylococcal Aureus (CA-MRSA) Infections in Children. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2018 Sep     [PubMed]
Fernando SM,Tran A,Cheng W,Rochwerg B,Kyeremanteng K,Seely AJE,Inaba K,Perry JJ, Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis. Annals of surgery. 2018 Apr 18     [PubMed]
Fais P,Viero A,Viel G,Giordano R,Raniero D,Kusstatscher S,Giraudo C,Cecchetto G,Montisci M, Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges. International journal of legal medicine. 2018 Sep     [PubMed]
Yaşar NF,Uylaş MU,Badak B,Bilge U,Öner S,İhtiyar E,Çağa T,Paşaoğlu E, Can we predict mortality in patients with necrotizing fasciitis using conventional scoring systems? Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma     [PubMed]
Ballesteros-Betancourt JR,García-Tarriño R,Ríos-Guillermo J,Rodriguez-Roiz JM,Camacho P,Zumbado-Dijeres A,Domingo-Trepat A,Llusá-Pérez M,Combalia-Aleu A,García-Ramiro S,Soriano-Viladomiu A, Necrotizing fasciitis attended in the Emergency Department in a tertiary Hospital: Evaluation of the LRINEC scale. Revista espanola de cirugia ortopedica y traumatologia. 2017 Jul - Aug     [PubMed]
Bonne SL,Kadri SS, Evaluation and Management of Necrotizing Soft Tissue Infections. Infectious disease clinics of North America. 2017 Sep     [PubMed]
Semenič D,Kolar P, Fournier's Gangrene Does Not Spare Young Adults. Wounds : a compendium of clinical research and practice. 2018 Jul     [PubMed]
Abass-Shereef J,Kovacs M,Simon EL, Fournier's Gangrene Masking as Perineal and Scrotal Cellulitis. The American journal of emergency medicine. 2018 Sep     [PubMed]
Baraket O,Triki W,Ayed K,Hmida SB,Lahmidi MA,Baccar A,Bouchoucha S, [Therapeutic factors affecting the healing process in patients with gangrene of the perineum]. The Pan African medical journal. 2018     [PubMed]
Ioannidis O,Kitsikosta L,Tatsis D,Skandalos I,Cheva A,Gkioti A,Varnalidis I,Symeonidis S,Savvala NA,Parpoudi S,Paraskevas GK,Pramateftakis MG,Kotidis E,Mantzoros I,Tsalis KG, Fournier's Gangrene: Lessons Learned from Multimodal and Multidisciplinary Management of Perineal Necrotizing Fasciitis. Frontiers in surgery. 2017     [PubMed]
Ray-Zack MD,Hernandez MC,Younis M,Hoch WB,Soukup DS,Haddad NN,Zielinski MD, Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection. The journal of trauma and acute care surgery. 2018 Jun     [PubMed]
Gawaziuk JP,Strazar R,Cristall N,Logsetty S, Factors predicting health-related quality of life following necrotizing fasciitis. Journal of plastic, reconstructive     [PubMed]

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