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Necrotizing fasciitis

Necrotizing soft tissue infections

  • group of infections in which the principle focus of infection is within the deep dermis, adipose tissue and subcutaneous fascia. Hallmark of the infection is extensive necrosis accompanying cellulitis.

  • clinical course often rapid

  • patient usually severely ill and toxic

  • predisposing factors include diabetes, trauma, previous surgery and infection

Pathology

  • extent of infection very variable. May be bound by fascia or may extend to involve muscle and deep vessels

  • bacteria isolated varies from series to series. Seem to fall into several different types including:
    • clostridial gangrene
    • necrotizing cellulitis or fasciitis due to streptococci or other bacteria
    • progressive bacterial synergistic gangrene
    • gangrenous cellulitis due to other pathogens such as Pseudomonas spp or zygomycete fungi (mucormycosis). Mainly immunocompromised patients

Progressive synergistic gangrene

- usually seen in association with abdominal or other surgery, usually where there is contamination of the wound by leakage of bowel contents
- may occur without any apparent injury to skin surface
- organisms vary but microaerophilic strep., Bacteroides spp or other anaerobes as well as Gm -ves are found
- wound becomes extended with surrounding necrosis and oedema and the patient becomes unwell and toxic
- rapid deterioration occurs with wound dehiscence and toxaemia
- difficult to diagnose bacteriologically
- treat with wound exploration and debridement and high dose penicillin

Diabetic foot infection

  • combination of neuropathy and vasculopathy predisposes to the condition
  • infection by multiple organisms

Further reading

Ahrenholz DH, Necrotizing fasciitis and other soft tissue infections. In Rippe JM, Irwin RS, Fink MP, Cerra FB (eds), Intensive Care Medicine, 3rd ed. Little Brown & Co., Boston, 1996, pp 1756-64

Joynt GM, Gomersall CD, Lyon DJ. Necrotising fasciitis of the extremities caused by Vibrionaceae: experience in a Hong Kong tertiary hospital. Hong Kong Med J 1999;5:63-8

Lipman J. Severe soft tissue infections.In Oh TE (ed), Intensive Care Manual, 4th Ed., Butterworth Heinemann, Oxford, 1997, pp 552-6


©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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