Necrotizing Fasciitis

Introduction
Necrotizing fasciitis is a life threatening infection
that spreads along soft tissue planes
Risk factors
immune suppression
diabetes
AIDS
cancer
bacterial introduction
IV drug use
hypodermic therapeutic injections
insect bites
skin abrasions
abdominal and perineal surgery
other host factors
obesity
Associated conditions
cellulitis
overlying cellulitis may or may not be present
Prognosis
life threatening infection
mortality rate of 32%
mortality correlates with time to surgical intervention

Classification
Necrotizing Fasciitis Classification
Type Organism Characteristics
Type 1 Polymicrobial Most common (80-90%)
Typical 4-5 aerobic and anaerobic species Seen in immunosuppressed (diabetics
cultured: and cancer patients)
non-Group A Strep Postop abdominal and perineal
anaerobes including Clostridia infections
facultative anaerobes
enterobacteria
Synergistic virulence between organisms
Type 2 Monomicrobial 5% of cases
Group A -hemolytic Streptococci is most Seen in healthy patients
common organism isolated Extremities
Type 3 Marine Vibrio vulnificus Marine exposure
(gram negative rods)
Type 4 MRSA

Presentation
Symptoms
early
localized abscess or cellulitis with rapid progression
 minimal swelling
no trauma or discoloration
late findings
severe pain
high fever, chills and rigors
tachycardia
Physical exam
skin bullae
discoloration
ischemic patches
cutaneous gangrene
swelling, edema
dermal induration and erythema
subcutaneous emphysema (gas producing organisms)

Imaging

Radiographs
not required for diagnosis or treatment

Differentials

Gas gangrene

Studies
Biopsy
indications
emergent frozen section can confirm diagnosis in early cases
technique
take 1x1x1cm tissue sample
can be performed at bedside or in operating room
surgical intervention should not be delayed to obtain
histological findings
necrosis of fascial layer
microorganisms within fascial layer
PMN infiltration
fibrinous thrombi in arteries and veins and necrosis of arterial and venous
walls
LRINEC Scoring system
score > 6 has PPV of 92% of having necrotizing fasciitis
CRP (mg/L)
150: 4 points
WBC count (103/mm3)
<15: 0 points
1525: 1 point
>25: 2 points
Hemoglobin (g/dL)
>13.5: 0 points
 1113.5: 1 point
<11: 2 points
Sodium (mmol/L)
<135: 2 points
Creatinine (umol/L)
>141: 2 points
Glucose (mmol/L)
>10: 1 point

Treatment
Operative
emergency radical debridement with broad-spectrum IV antibiotics
indications
whenever suspicion for necrotizing fasciitis
operative findings
liquefied subcutaneous fat
dishwater pus
muscle necrosis
venous thrombosis
technique
hemodynamic monitoring with systemic resuscitation is critical
hyperbaric oxygen chamber if anaerobic organism identified
antibiotics
initial antibiotics
start empirically with penicillin, clindamycin, metronidazole,
and an aminoglycoside
definitive antibiotics
penicillin G
for strep or clostridium
imipenem or doripenem or meropenem
for polymicrobial
add vancomycin or daptomycin
if MRSA suspected
amputation
indications
low threshold for amputation when life threatening

(OBQ12.136) A 16-year-old male presents to the emergency department one day after scratching
his leg on a piece of scrap metal. He reports a progressive rash on his leg that has advanced over the
last several hours. In the emergency room his temperature is 102.8 degrees and his systolic blood
pressure is 98 mmHg. On physical exam the clinical finding shown in Figure A is found. What
would be the most appropriate next step in treatment. Review Topic
FIGURES: A

1. MRI
2. Biopsy with urgent frozen section in the operating room
3. Needle aspiration
4. CT
5. Ultrasound

Figure A Illustration A

PREFERRED RESPONSE 2
The clinical presentation is consistent with early necrotizing fasciitis. A biopsy with a frozen section
is effective at rapidly confirming an early diagnosis. If the biopsy is performed in the operating
room, and is positive, then their will be minimal time delays in performing the required radical
debridement.

Necrotizing fasciitis is characterized by hypotension, ascending rash, bullae and fevers. Skin
abrasions, prior surgical intervention, and any cause of open wounds in the skin are all risk factors
for the condition. The most common cultures are polymicrobial. The management consists of
immediate IV antibiotics and emergent surgical debridement. Initial IV antiobiotics should be
broad-spectrum to include penicillin, an aminoglycoside, clindamycin, and metronidazole.

Ozalay et al. analyzed the clinical presentation and factors associated with mortality in a
retrospective study of 22 patients with necrotizing fasciitis. They noted that chronic liver disease
and diabetes are common risk factors and they reiterate that early and aggressive debridement is the
primary treatment.

McCarthy et al. review the etiology, presentation, diagnosis, and treatment of necrotizing fasciitis,
noting that biopsy is the only method to definitively diagnose the condition.

Figure A is a clinical radiograph showing early necrotizing fasciitis. Illustration A is a clinical

photograph of a lower extremity with necrotizing fasciitis and the classic signs of bullae, tracking
erythema, and swelling.

Incorrect Answers:
Answer 1 and 4: Although MRI and CT scans are useful adjuncts to demonstrate edema in the soft
tissue it does not provide the definitive diagnosis.
Answer 3: Needle aspiration has no use in the diagnosis of necrotizing fasciitis.
Answer 5: Ultrasound would be helpful if an abscess was suspected.

Illustrations: A

(OBQ10.89) Poor outcomes with necrotizing fasciitis have been associated with which of the
following factors? Review Topic

1. Pre-existing cardiac dysfunction

2. Polymicrobial infection
3. Use of hyperbaric oxygen
4. Intravenous drug abuse
5. Delay in time to diagnosis

PREFERRED RESPONSE 5
Necrotizing fasciitis is a uncommon soft-tissue infection, characterized by widespread fascial
necrosis. It is most commonly a polymicrobial infection, with group A -hemolytic streptococci the
most common bacteria reported. Treatment includes emergent aggressive debridement of all
involved tissues and immediate empiric antibiotics covering aerobic, anaerobic, gram positive and
gram negative bacteria.

The two referenced studies are excellent review articles on diagnosis and treatment of this entity.
Bellapianta et al discuss that the key to treatment involve timely diagnosis, broad-spectrum
antibiotic therapy, and aggressive surgical dbridement.

(OBQ04.217) A 52-year-old diabetic male sustained minor blunt trauma to his left thigh 10 hours
prior to presentation. He initially complained of extreme thigh pain with erythema and swelling but
rapidly developed bullae and worsening erythema over the affected area along with fever and
tachycardia. A clinical photo is shown in Figure A. What clinical factor has been shown to reduce
mortality when treating this pathology? Review Topic
FIGURES: A
1. Presence of MRI findings
2. Administration of pressors
3. Decreasing time from admission to surgery
4. Immediate identification of causative
organism
5. Location of injury

Figure A

PREFERRED RESPONSE 3
The clinical presentation and image shown in Figure A are consistent with necrotizing fasciitis. The
most common pathogen is group A Streptococcus, but polymicrobial infection with Gram-positive,
Gram-negative, aerobic, and anaerobic bacteria is not uncommon. Necrotizing fasciitis is a surgical
emergency and prompt aggressive dbridement of all necrotic tissue is critical for survival.

Wong et al demonstrated that early operative debridement (<24 hours) improved the survival rate.
The mortality associated with this condition has remained high, with a reported cumulative
mortality rate of about 20% in this particular study.

Fontes et al suggest in their review article that early diagnosis and treatment are imperative because
necrotizing infections typically spread rapidly and can result in multiple-organ failure, adult
respiratory distress syndrome, and death.

(OBQ04.264) A 56-year-old diabetic male presents to the emergency department by ambulance

after developing high-grade fevers, malaise, and altered mental status. Upon presentation, he is
found to be hypotensive and initial labs show an elevated WBC with a profound left shift. Figure A
shows skin manifestations confined to the foot at initial presentation. He is started on broad
spectrum antibiotics. Upon follow-up exam 3 hours later his clinical condition deteriorates (Figure
B) and he is taken to the operating room for surgical debridement. In a bacterial culture, what would
be the most common single isolate for this condition? Review Topic
FIGURES: A B

1. Staphylococcus aureus
2. Staphylococcus epidermidis
3. Group A streptococcus
4. Enterobacteriaceae
5. Pseudomonas

PREFERRED RESPONSE 3
The above clinical vignette is describing necrotizing fasciitis. Necrotizing fasciitis is a rare and
often fatal soft-tissue infection that requires high clinical suspicion and prompt administration of
broad-spectrum antibiotics and aggressive surgical debridement (illustrations A). Fontes et al found
that although polymicrobial infections including gram-positive, gram-negative, aerobic, and
anaerobic bacteria were found most commonly in necrotizing fasciitis, Group A streptococcus was
the most common bacterial isolate. Wong et al also found the most isolated organism to be group A
streptococcus. In their study, the highest associated medical comorbidity was diabetes mellitus
(71%). They found that delay in surgery of more than 24 hours was correlated with increased risk of
death.

Illustrations: A