Haran Devakumar L6HVB

The problem of the effects of Necrotizing Fasciitis on human beings

Necrotizing fasciitis is a rare progressive skin infection that destroys the skin and underlying tissue. It is a fatal disease caused by certain kinds of bacteria that have been grouped into 3 types. Type 1 is polymicrobial, type 2 is group A streptococcal and type 3 is gangrene. The most common disease-causing bacteria is Group A streptococcus, also known as GAS that normally causes strep throat. Furthermore, certain conditions can predispose patients to Necrotizing Fasciitis such as diabetes mellitus, immunosuppressive medications, and AIDS (1). Necrotizing fasciitis is contracted when any of the three types of bacteria enter the body through a cut, abrasion or hole in the skin. Alternatively, since the bacteria travel within respiratory droplets, the infection can also be caught by close contact, for example by coughing near someone. These entrance sites can be extremely small, like a needle prick, or as large as a surgical incision. After entering, they quickly reproduce and synthesise the production of toxins such as Exotoxin A. Exotoxin A triggers an inflammatory response in the body which causes the production of cytokines, such as tumour necrosis factor, to be released. These cytokines increase the synthesis of nitrous oxide and oxygen-free radicals, which ultimately contribute to the necrosis of affected tissues (2). Furthermore, the toxins interfere with the blood flow to the tissue, causing material within the tissue to break down, which leads to widespread effects, such as shock and weakening of the immune system, by inhibiting phagocytosis. It can spread through the human tissue at a rate of 3cm per hour, leaving the infected tissue behind to become gangrenous. Overall, these biological effects demonstrate Necrotizing Fasciitis life-threatening potential and its difficulty to treat (3).

Haran Devakumar L6HVB

(4) Figure 1 - Before Necrotizing Fasciitis After Necrotizing

This can be seen in these two illustrations. The left diagram represents a healthy persons tissue, whereas the illustration on the right depicts a person affected by necrotizing fasciitis. As you can see, the bacteria have caused the destruction of the epidermis, dermis and subcutaneous tissue tissue. This induces oedema and further reduces blood flow by allowing plasma to escape into the extravascular space (outside the vessels). As a result, this prevents the body from healing the damaged tissue. Therefore, this diagram highlights the extensive damage caused by the disease and why it is such a grave threat
Fasciitis

The condition goes through three different phases. Firstly, there are initial effects, which are felt within 24 hours of the bacteria entering the body. The patient will have a fever, feel nauseous, want to vomit and have a headache. Furthermore, the pain felt by the patient will be much greater than one would expect from a small wound or injury. However, the problem of necrotizing fasciitis is that these symptoms are often related to flu and, therefore, can lead to misdiagnosis (5). After 36-48 hours, the progressive effects are felt, whereby the site of infection will become swollen and will turn a dark purple colour. Blisters will form and they will appear like a rash. Finally, the final effects are felt whereby the infection spreads over the whole body and it becomes apparent that the patient is suffering from Necrotizing Fasciitis. Only then is the presentation of the condition more clear and the doctors can clearly diagnose the patient. The patient may even go into systematic shock due to the dangerously high level of toxins that have been released by the bacteria. Systematic shock is when the bodys bloody pressure drops at an alarming rate and the person suffers from hypotension, causing them to possibly become unconscious. Thus, systematic shock will increase the difficulty of saving the patients life. Overall, these symptoms portray the severe pain suffered by patients of Necrotizing Fasciitis.

Why is Necrotizing Fasciitis an issue to human beings?

A vast majority of Necrotizing Fasciitis cases are misdiagnosed because none of the symptoms are exclusive to the condition itself, and therefore many doctors do not consider Necrotizing Fasciitis. Despite the disease increasing worldwide, it is still considered uncommon, so many patients are misdiagnosed. As a result, in some extreme conditions, the mortality rate can reach as high as 70% because of late presentation (6). However, late presentation is sometimes not enough for some patients, who die within 18 hours of contracting the disease. Furthermore, The Centres for Disease Control and Prevention in the U.K. reported that in 1996, there were estimates of 500-1500 cases of Necrotizing Fasciitis per year (6). This figure includes patients that suffer life-long effects such as lost

Haran Devakumar L6HVB limbs from amputation, but more importantly hundreds that died from the disease. On average, the mortality rate for necrotizing fasciitis is as high as 25% worldwide (8).

Main Solution
The main solution for Necrotizing Fasciitis is to perform surgical debridement as soon as possible. Surgical debridement is a type of surgery that uses various instruments, such as a scalpels and scissors, to cut necrotic (dead) tissue from the infected wound, where the bacteria are located. The surgeon begins with flushing the area infected with saline (saltwater) solution, and then applies a local anaesthesia to the edges of the wound, in order to minimize the pain (9). Then the surgeon uses forceps to get hold of the devitalized tissue and gradually removes it using a scalpel or scissors, shown (10) Figure 2 - method of by A on the illustration. Devitalised tissue acts Surgical Debridement as a culture medium that promotes bacterial growth and the spread of infection. Therefore, removing tissue, which is heavily contaminated with dirt and bacteria, prevents any further infection. In addition, as debridement progresses, cytokine (toxin) release reduces and the patient usually becomes hemodynamically more stable, which means the patient is significantly more protected from anymore invasive organisms (11).

Effectiveness of Surgical Debridement

In terms of effectiveness, the Hong Kong Medical Journal made a report on the epidemiology of management for necrotizing fasciitis. The report included a US study, which indicated that aggressive surgical debridement from the outset is associated with a mortality rate of 4.2%, as opposed to 38% after delayed treatment. Similar results were collected in a Singaporean study and a Taiwanese study (early debridement conferred a lower mortality than after delayed operations: 26% vs. 36%) (12). This data illustrates the vast impact that early surgical debridement can have on a patient because it can reduce the mortality rate drastically. In addition, surgical debridement is extremely effective in leading to quicker healing of the wound because it excises only the affected tissues and is particularly direct in removing the bacteria, thus leading to a shorter hospital stay for the patient compared to other solutions. Therefore, it is the most effective solution in terms of preventing the infection from spreading any further whilst also improving the healing process.

Implications of Surgical Debridement

Haran Devakumar L6HVB There are a few implications to the surgery. Firstly, there is a social cost involved because after surgical debridement, the skin is removed, leaving behind a vast amount of raw material open to infection: skin grafting is needed in order to replace the skin. Skin grafting forces the patient to require a lengthy period of recovery, which is often accompanied by anxiety and depression. This is because the patient is worried about their future and how their body might turn out (13). Another social cost produced from the surgery is extreme agony for the patient because the wound is extremely painful after debridement. In addition, the patient might need to undergo extensive debridement in order to fully control the infection and prevent it from spreading further, therefore the volume of pain felt by the patient will increase (14). Another implication of the solution is that although the procedure itself is quick, the recovery time is not. The average length of stay for patients recovering from necrotizing fasciitis is 11 days in a High Dependency Unit. Therefore, this puts an economical cost on the NHS because High Dependency Units cost roughly 700 per bed per day in an Adult High Dependency Unit in the UK. These beds are very expensive and are a limited resource because they provide specialized monitoring equipment, a high degree of medical expertise and constant access to highly trained nurses (usually one nurse for each bed) (15).

Advantages and Disadvantages:

Surgeons have the ability to remove specific sections of devitalized tissue from the wound bed and preserve as much healthy tissue as possible, whereas hyperbaric oxygen therapy or antibiotics cannot excise dead tissue. This is essential in order to promote wound healing. However, the greatest advantage of surgical debridement is the speed devitalized tissue can be removed, thus preventing any further progression of infection. Normally, patients suffering from necrotizing fasciitis are admitted into A&E and are in need of being operated on urgently. Surgical debridement allows surgeons to immediately prevent any further infection by excising dead tissue at a fast rate. In conclusion, surgical debridement is the best possible method of treating necrotizing fasciitis when time is limited (16). Surgical debridement does carry numerous risks with it as well. For example, it is possible that underlying tendons, blood vessels or other structures may be damaged during surgical debridement. Surface bacteria may also be introduced deeper into the body and the bloodstream during the operation, causing infection and worsening the healing process (17). Furthermore, surgical debridement causes the patient much more pain compared to other treatments, and for a

Haran Devakumar L6HVB much longer period of time because multiple debridements are required. Another disadvantage of the surgery is that it cannot be performed without placing the patient under general anaesthesia. General anaesthesia can cause complications, such as allergic reactions to certain anaesthetic agents it contains. Experts estimate that a complication occurs to 1 person in every 14,000 (18). However, the main disadvantage is that surgical debridement leaves behind a vast amount of raw material, which forces the patient to undergo skin grafting. As mentioned before, skin grafting places the patient in a state of anxiety and worry because their physical appearance will be changed forever.

Alternative Solutions
One alternative solution to treat necrotizing fasciitis is hyperbaric oxygen therapy. This treatment places the patient in a specially designed chamber, which is similar to the decompression chambers used by deep-sea divers in order to avoid decompression sickness (the bends). In this instance, the chamber is filled with oxygen at a much higher pressure than the normal level of oxygen in the atmosphere, hence making it hyperbaric. The benefit of this higher pressure is that high levels of oxygen can now be dissolved into the blood stream, thus resulting in more oxygen reaching the gangrenous (dead) regions, which prevents the bacteria from causing any further infection. This is because bacteria cannot survive in an oxygen-rich atmosphere. Overall, this treatment is especially useful in reducing a patients risk of amputation whilst also causing less pain (19). Another alternative solution is antimicrobial therapy, which is given alongside surgical debridement. A combination of intravenous antibiotic drugs like Penicillin, Clindamycin and Vancomycin are given immediately. These are used to provide broad bacterial coverage whilst a tissue sample is taken and the actual infecting bacteria are identified. Once the bacteria are identified, they can be categorized into one of the three different types: gram-positive, gram-negative and anaerobic bacteria. Then various antibiotics can be given to target the particular type of bacteria. For example, Penicillin and Gentamicin are given to tackle gram-negative and gram-positive organisms (aerobic infection), whereas Metronidazole is given to combat anaerobic infection (20).

Bibliography
(1) Author: Charles Davis; Title: Necrotizing Fasciitis: Publication:
http://www.medicinenet.com/necrotizing_fasciitis/article.htm; Date accessed: 20/03/11. (2) Author: Richard Salcido and Chulhyun Ahn; Title: Advances in Skin and Wound care; Publication: The Journal for Prevention and Healing; Date

Haran Devakumar L6HVB

03/2007; Date accessed: 20/02/11.

(3) Author: Linda Vorvick, Daniel Levy; Title: Necrotizing soft tissue
infection; Publication: PubMed Health; Date 12/2007; Date accessed: 20/02/11.

(4) Author: Frank Corl; Title: Necrotizing Fasciitis; Publication:

http://microbewiki.kenyon.edu/index.php/Necrotizing_Fasciitis_(flesh_e ating_bacteria); Date accessed: 15/03/11.

(5) Author: Donna and Jack; Title: Necrotizing Fasciitis; Publication:

http://www.nnff.org/nnff_factsheet.htm; Date: 06/12/05; Date accessed: 25/02/11.

(6) Author: Jane M. Anderson; Title: Necrotizing Fasciitis an uncommon

disease, frequently misdiagnosed; Publication: http://www.accessmylibrary.com/article-1G1-121416627/necrotizingfasciitis-uncommon-disease.html; Date accessed: 20/03/11.

(7) Author: BBC; Title: Killer Flesh-eating Bacteria; Publication:

http://www.bbc.co.uk/dna/h2g2/A907481; Date accessed: 15/03/11.

(8) Author: Amanda Hu; Title: the Case of Necrotizing Fasciitis; Publication:
Journal of Young Investigators; Date: Vol. 5 2010.

(9) Author: Susan Mendez-Eastman; Title: Wound Procedures; Publication:

http://www.wounds1.com/care/procedure20.cfm/19; Date accessed: 25/02/11.

(10) Author: Precise Medical Demonstrative Evidence; Title: Infected Left Ankle
Wound with Surgical Debridement and Drainage; Publication: http://preciselaw.medicalillustration.com/generateexhibit.php?ID=71241&TC=&A=59501; Date accessed: 15/03/11.

(11)

Author: Lee A. Fleisher; Title: Anaesthesia and Uncommon Diseases; Publication: Esevier Health Sciences; Date: 10/2005. (12) Author: Jason Cheung, Boris Fung; Title: A review of necrotizing fasciitis in the extremities; Publication: Hong Kong Medical Journal; Date: Vol. 15, No. 1, 02/2009.

(13)

Author: Michelle Kerns; Title: Necrotizing Fasciitis effects; Publication: http://www.ehow.com/about_5554828_necrotizing-fasciitis-effects.html; Date accessed: 24/02/11.

(14)

Author: Steven E. Doerr; Title: Necrotizing Fasciitis; Publication: http://www.emedicinehealth.com/necrotizing_fasciitis/page3_em.htm; Date accessed: 20/03/11. (15) Author: Dr S. Das; Title: an interview with Dr S. Das, consultant surgeon; Location: Hillingdon Hospital; Date: 20/02/11.

(16) Author: Richard H. Camer, Monique Laberge; Title: Debridement;

Publication: http://www.surgeryencyclopedia.com/Ce-Fi/Debridement.html; Date accessed: 24/02/11.

Haran Devakumar L6HVB (17) Author: Wound Care Information Network; Title: Surgical Debridement;
Publications: http://www.medicaledu.com/debridhp.htm; Date accessed: 15/03/11.

(18) Author: NHS; Title: Anaesthetic, general; Publication:

http://www.nhs.uk/conditions/anaesthetic-general/Pages/Definition.aspx; Date accessed: 20/03/11.

(19) Author: Jennifer Trent, Robert Kirsner; Title: Necrotizing Fasciitis;

Publication: http://www.medscape.com/viewarticle/444061_7; Date accessed: 25/02/11.

(20) Author: Lisabetta Divita; Title: Antibiotics for Necrotizing Fasciitis;

Publication: http://www.livestrong.com/article/86723-antibiotics-necrotizingfasciitis/; Date accessed: 19/03/11.

Evaluation of validity of Source (7) The mortality rate of 25% was collected from an article in the Journal of Young Investigators (7). Amanda Hu, from the University of Toronto Medical School, wrote the article. Her methods of collecting data were reliable because her sole aim was to investigate the dangers of Necrotizing Fasciitis. Therefore, she has no reason to be biased or unjust. The article was also peer reviewed by doctors at the Toronto Medical School. Peer Review is a process in which the article is evaluated before it is published. This is normally carried out by respected members in the field and helps to maintain or enhance the quality of the article. More importantly, it discourages cronyism (favouritism shown to friends and family) and obtains an unbiased evaluation. Therefore, I think the results are reliable because these people have great expertise in this particular field and would know the facts behind Necrotizing Fasciitis. Furthermore, when I cross-referenced this source with source (6) and (12), I found that the mortality rate was also calculated at 25%, which means the data is accurate. In conclusion, I

Evaluation of validity of Source (17) Haran Devakumar L6HVB In source (17), Lisabetta Divita explains antibacterial therapy, one of the alternative solutions. She is a physician who was exposed to all facets of the medical field during her training. Her writings are currently featured in prominent medical magazines and various online publications. She holds a doctorate in medicine, a master's in biomedicine, and a Bachelor of Science in biology from Boston College. Therefore, I believe she is unbiased because she is a respected member of the medical industry and so her reputation is on the line. Furthermore, the data is accurate because she witnessed antibacterial therapy being given to a Necrotizing Fasciitis patient during her period as a medical student. In addition, this article was peer reviewed, which means it is reliable because specialists in this field agree with her. Furthermore, I interviewed Dr S.Das (5), who treats the disease at Hillingdon Hospital. He agreed with the article and said that when patients suffering from necrotizing