Epidemiology

Risk factors for infection include an immunocompromised or elderly state, diabetes mellitus, alcoholism, chronic renal failure, peripheral vascular disease, injection drug use,

TABLE 5 Necrotizing Fasciitis: Key Points

Overview

NF is a rare, life-threatening, soft-tissue infection characterized by rapidly spreading inflammation and necrosis of the skin, subcutaneous fat, and fascia

After an incubation period of 1-4 days, an acute onset of symptoms with moderate to marked toxemia, a putrid discharge, and pain out of proportion to the physical examination findings

Pathophysiology of NF

Clinical manifestations include extensive dissection and necrosis of the superficial and often the deep fascia. The infection undermines adjacent tissue and leads to marked systemic toxicity

Thrombosis of subcutaneous blood vessels leads to necrosis of the overlying skin

Most cases of fasciitis follow surgery or minor trauma. The highest incidence is seen in patients with small vessel diseases such as diabetes mellitus

When careful bacteriologic techniques are used, anaerobes, particularly Peptostreptococcus, Bacteroides, and Fusobacterium species, are found in 50-60% of cases. Aerobic organisms, especially Streptococcus pyogenes, Staphylococcus aureus, and members of the Enterobacteriaceae have also been isolated

Most infections are mixed aerobic-anaerobic infections, but a type of NF caused solely by S. pyogenes has been reported and is referred to by the lay press as "flesh eating bacteria"

Symptomatology (by location of infection)

Initial local pain is replaced by numbness or analgesia as the infection involves the cutaneous nerves

Clinically, the hallmarks of mixed aerobic-anaerobic soft tissue infections are tissue necrosis, a putrid discharge, gas production, the tendency to burrow through soft tissue and fascial planes, and the absence of classic signs of tissue inflammation

Diagnosis

A Gram stain of tissue fluid and blood cultures should be obtained to assist in guiding antibiotic therapy

Radiologic testing may detect air within the tissue, highly suggestive of NF

Treatment

Treatment includes broad-spectrum antibiotic coverage, nutritional supplements, hemodynamic support, wound care, and prompt surgical debridement

Prognosis

Untreated, NF has been noted to have an extremely high mortality rate, ranging from 80-100%, and even with rapid intervention and treatment, mortality remains approximately 30-50%

Abbreviation: NF, necrotizing fasciitis.

postpartum patients, or a combination of these factors (16). The unifying thread among these risk factors appears to be a compromised fascial blood supply coupled with the introduction of exogenous microbes. However, various studies have reported that 13% to 31% of patients were previously healthy individuals with no identifiable risk factors (15). The incidence of NF in adults has been reported to be 0.40 cases per 100,000 population, while the incidence in children is 0.08 cases per 100,000 population (16).

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