Necrotizing Fasciitis 953

• 
Clostridial cellulitis: Caused by Clostridium WORKUP
BASIC INFORMATION perfringens associated with local trauma or
surgery and crepitus caused by gas produc-
• Diagnosis of necrotizing fasciitis generally
requires incision and probing. In patients with
N
DEFINITION tion; generally noted in the skin, with deeper necrotizing fasciitis, there is no resistance to
Necrotizing fasciitis (NF) is a rapidly spread- tissues generally spared. probing subcutaneously, and there is fascial
ing bacterial infection of the deep fascia, with plane involvement.
PHYSICAL FINDINGS • Laboratory tests:
associated inflammation, leading to necrosis
of subcutaneous tissue planes. This infection Minor skin trauma, toxic-appearing patient: 1. The laboratory risk indicator for nec-
can occur in wounds from trauma or surgical • Open skin wound rotizing fasciitis (LRINEC) consists of
wounds or can be spontaneous or idiopathic. • Severe pain at injury or surgical site the following 6 variables. When present
There are two clinical types, both of which carry • Fever, confusion, weakness, diarrhea the reported positive predictive value
a high rate of morbidity and mortality. • Early skin erythema, quickly spreading in is 92%: Complete blood cell count
hours to days

and Disorders
Diseases
(CBC) with differential (leukocytosis
SYNONYMS • Skin redness changes to purple discoloration [WBC >15,000], anemia [Hb <13.5]),
NF • Gangrenous skin changes may develop elevated CRP (≥15 mg/dl), hyponatre-
Soft tissue gangrene • Loosening of skin and subcutaneous skin mia (sodium <135 mEq/L), elevated
Flesh-eating bacteria in association with deep fascial necrosis creatinine (>1.6 mg/dl), hyperglycemia
Fournier’s gangrene (Fig. 1). “Woody” induration and crepitus of (glucose >180 mg/dl).
Hemolytic streptococcal gangrene
• 
involved area are characteristics
Muscle involvement, thrombosis of blood
2. Cultures of skin, soft tissue, or debrided
tissue, aerobically and anaerobically.
I
ICD-10CM CODE vessels, and myonecrosis may develop Blood cultures are positive in 60% of
M72.6 Necrotizing fasciitis • Bullae and gas formation at site patients with type II infections and 20%
with type I infections.
ETIOLOGY • Imaging:
EPIDEMIOLOGY & • NF usually arises from skin damage or
DEMOGRAPHICS 1.  Radiographs may show subcutaneous
trauma. Risk is increased with presence gas in fascial planes (Fig. 2).
PREDOMINANT SEX: Male > female. of comorbidities (DM, cancer, liver disease, 2. Computed tomography (CT) or magnetic
PREDOMINANT AGE: 6 to 50 yr; less common immunosuppression) resonance imaging (MRI) may be helpful
in children. • Polymicrobial: Mixture of anaerobes and aer- because they can detect gas in the tis-
obic enteric gram-negative rods sues. MRI with contrast is more sensitive
EPIDEMIOLOGY • Group A streptococci (S. pyogenes) than CT.
Invasive group A Streptococcus infection occurs • S. aureus
at a rate of 3.5 cases per 100,000 persons, with • C. perfringens
a case fatality rate of around 24%. • Bacteroides fragilis TREATMENT
• Vibrio vulnificus
PHYSICAL FINDINGS & CLINICAL • Aggressive surgical debridement of involved
• Methicillin-resistant S. aureus (MRSA), espe-
PRESENTATION necrotic tissues is essential as soon as pos­
cially community-acquired MRSA
CLINICAL TYPES OF NECROTIZING FASCIITIS: sible to reduce mortality.
• Type I: Necrotizing fasciitis: At least one • Fasciotomies of extremities may be
anaerobic species is isolated in conjunction DIAGNOSIS necessary.
with one or more facultative anaerobic spe- • Immediate start of empiric antibiotics:
cies, such as streptococci (not group A), and DIFFERENTIAL DIAGNOSIS 1.  Type I: Vancomycin, daptomycin, or
members of the Enterobacteriaceae (Gram • Cellulitis. linezolid plus piperacillin/tazobactam;
negative rods) • Pyomyositis. a carbapenem (such as imipenem,
• Anaerobic bacteria, most commonly Bacte­ • Gas gangrene. meropenem, or doripenem); and third-
roides or Peptostreptococcus spp. • A classification of necrotizing skin, soft- generation cephalosporin + met-
• Enterobacteriaceae: Escherichia coli, tissue, and muscle infections is described in ronidazole or a fluroquinolone plus
Klebsiella spp., Proteus spp., Enterobacter Table 1. metronidazole (ceftriaxone) are reason-
spp. able choices pending cultures. Empiric
• Usually associated with diabetes or periph- clindamycin may also be added to
eral vascular disease suppress toxin production by staphylo-
• Example of type I: Fournier gangrene of the cocci and streptococci. It is important
perineum to always have anaerobic coverage.
• Type II: Necrotizing fasciitis: Group A Use the highest dosages possible for
Streptococcus is isolated alone or in com- age and CrCl.
bination with other bacteria, most likely 2. Type II: For group A Streptococcus, give
Staphylococcus aureus. Also known as intravenous (IV) penicillin G, 4 million U
hemolytic streptococcal gangrene q4h in patients who weigh >60 kg with
1.  Example of type II: Invasive group A clindamycin, 600 to 900 mg IV q8h.
Streptococcus, associated with virulence a. Clindamycin has the added effect of
factors type 1 and type 3 M protein suppressing toxin production. If MRSA
FIG. 1  Necrotizing fasciitis. The so-called flesh-
EXAMPLES OF NECROTIZING FASCIITIS: is suspected, add vancomycin, dapto-
eating bacteria, group A β-hemolytic Streptococcus,
• Fournier gangrene: Aggressive type I infec- mycin, or linezolid.
can cause significant tissue destruction rapidly. This
tion of the perineum usually caused by • Intravenous gammaglobulin (IVIG): 1 g/kg on
32-year-old woman had pain, erythema, and swell-
penetration of the gastrointestinal or urethral day 1 and 0.5 g/kg on days 2 and 3 neutral-
ing of the foot followed by necrotic ulceration over
mucosa by enteric organisms. It can rapidly izes circulating streptococcal toxins and has
a week. There was no history of trauma. (Courtesy
spread to involve the scrotum, penis, and been shown beneficial in severe forms of
Roger Bitar, MD. From White GM, Cox NH [eds]:
abdominal wall or gluteal muscles, causing invasive group A streptococcal infections,
Diseases of the skin, a color atlas and text, ed 2, St
gangrene. although data are not definitive.
Louis, 2006, Mosby.)

Téléchargé pour Mourad BENNANI (bennani.orthopedics@gmail.com) à Hospital Military Instruction Mohamed V à partir de ClinicalKey.fr par Elsevier sur décembre 17, 2019.
Pour un usage personnel seulement. Aucune autre utilisation n´est autorisée. Copyright ©2019. Elsevier Inc. Tous droits réservés.
954 Necrotizing Fasciitis

TABLE 1  Classification of Necrotizing Skin, Soft-Tissue, and Muscle Infections

Disease Bacteriology Comments

Necrotizing Cellulitis
Clostridial cellulitis Clostridium perfringens Local trauma, recent surgery; fascial/deep muscle spared
Nonclostridial cellulitis Mixed: Escherichia coli, Enterobacter, Peptostreptococ­ Diabetes mellitus predisposes; produces foul odor
cus spp., Bacteroides fragilis
Meleney synergistic gangrene Staphylococcus aureus, microaerophilic streptococci Rare infection; postoperative; slowly expanding, indolent, ulceration in
superficial fascia
Synergistic necrotizing cellulitis Mixed aerobic and anaerobic, including B. fragilis, Pep­ Diabetes mellitus predisposes; variant of necrotizing fasciitis type I;
tostreptococcus spp. involves skin, muscle, fat, and fascia
Necrotizing Fasciitis
Type I Mixed aerobic and anaerobic; staphylococci, B. fragilis, Usually requires a breach in the mucous membrane layer either through
E. coli, group A streptococci, Peptostreptococcus surgery or penetrating injuries or from chronic medical conditions
spp., Prevotella, Porphyromonas spp., Clostridium such as diabetes, peripheral vascular disease, malignancy, and anal
spp. fissures
Type II Group A streptococci Increasing in frequency and severity since 1985; very high mortality;
often begins at site of nonpenetrating minor trauma such as a bruise
or muscle strain but often no identified precursor
Predisposing factors: Blunt/penetrating trauma, varicella (chickenpox),
|intravenous drug abuse, surgical procedures, childbirth, nonsteroidal
antiinflammatory drug use
Myonecrosis
Clostridial myonecrosis Clostridium spp. Predisposing factors: Deep/penetrating injury, bowel and biliary tract
surgery, improperly performed abortion and retained placenta, pro-
longed rupture of the membranes, and intrauterine fetal demise or
missed abortion in postpartum patients. Recurrent gas gangrene
occurs at sites of previous gas gangrene.
Streptococcal myonecrosis Streptococci
Special Type of Necrotizing Soft-Tissue Infection
Fournier gangrene Polymicrobial, with E. coli the predominant aerobe and Necrosis of the scrotum or perineum that starts with scrotal pain and
Bacteroides the predominant anaerobe. Other micro- erythema and rapidly spreads onto anterior abdominal wall and glu-
flora: Proteus, Staphylococcus, Enterococcus, aerobic teal muscle. It is more often seen in diabetics and can be associated
and anaerobic Streptococcus, Pseudomonas, Klebsi­ with trauma.
ella, and Clostridium

From Vincent JL, et al.: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders.

Gas in soft tissues

of muscle planes
Gas in soft tissues
A B C of muscle planes

FIG. 2  Necrotizing fasciitis. This 71-year-old man with aplastic anemia presented with fevers to 38.9° C
(102.02º F), leg weakness, and extreme leg pain. Initially, the patient was thought to have neuropathic pain and
weakness, possibly indicating spinal disease such as epidural abscess. He rapidly developed crepitus of his legs.
Radiographs of the patient’s legs were obtained, followed by noncontrast CT. A, Anterior-posterior (AP) tibia and fibu-
la. B, AP femur. C, AP hip. Air is seen dissecting in muscle planes of the legs. On radiograph, air appears black. Given
the wide distribution of air, a focal abscess is unlikely, and necrotizing fasciitis with gas-producing organisms should
be suspected. (From Broder JS: Diagnostic imaging for the emergency physician, Philadelphia, 2011, Saunders.)

• For Vibrio vulnificus use doxycycline plus SUGGESTED READINGS

ceftazidime; for Aeromonas hydrophila use Available at ExpertConsult.com
doxycycline plus ciprofloxacin.
• Hyperbaric oxygen evaluation as an adjunct AUTHOR: GLENN G. FORT, M.D., M.P.H.
to surgery and IV antibiotics.
Téléchargé pour Mourad BENNANI (bennani.orthopedics@gmail.com) à Hospital Military Instruction Mohamed V à partir de ClinicalKey.fr par Elsevier sur décembre 17, 2019.
Pour un usage personnel seulement. Aucune autre utilisation n´est autorisée. Copyright ©2019. Elsevier Inc. Tous droits réservés.
Necrotizing Fasciitis 954.e1

SUGGESTED READINGS
Bonne SL, Kadri SS: Evaluation and management of necrotizing soft tissue infec-
tions, Infect Dis Clinics North Am 31:497–511, 2017.
Hakkarainen TW, et al.: Necrotizing soft tissue infections: review and current
concepts in treatment, systems of care, and outcomes, Curr Probl Surg
51:344–362, 2014.
Stevens DL, Bisno AL, et al.: Practice guidelines for the diagnosis and manage-
ment of skin and soft tissue infections: 2014 update by the Infectious Diseases
Society of America, Clin Inf Dis 59(2):e10–e52, 2014.
Stevens DL, Bryant AE: Necrotizing soft-tissue infections, N Eng J Med 377:2253–
2265, 2017.
Weaver LK: Hyperbaric oxygen in the critically ill, Crit Care Med 39(7):1784–1791,
2011.

Téléchargé pour Mourad BENNANI (bennani.orthopedics@gmail.com) à Hospital Military Instruction Mohamed V à partir de ClinicalKey.fr par Elsevier sur décembre 17, 2019.
Pour un usage personnel seulement. Aucune autre utilisation n´est autorisée. Copyright ©2019. Elsevier Inc. Tous droits réservés.