Type of Infection Most Common Cause(s) Uncommon Causes

Gangrenous Cellulitis
Clostridial anaerobic cellulitis C. perfringens C. novyi, C. sordellii, C. septicum
Non-clostridial crepitant cellulitis Bacteroides sp., Peptostreptococci E. coli, other enterobacteriaceae
Gangrenous cellulitis in the
immunosuppressed individual
P. aeruginosa (ecthyma gangrenosum) Mucor,
Rhizopus, Aspergillus
Bacillus sp., other bacterial and
fungal sp.
Necrotizing Fasciitis
Type I
Polymicrobial infection with mix of
anaerobes and facultative species
Anaerobes:
Peptostreptococcus or Bacteroides sp.
Facultative species:
non–group A streptococci, Enterobacteriaceae
Groups B, C, and G streptococcus
Type II Group A streptococcus
Necrotizing Fasciitis Variants that Involve
Extra-Fascial Cutaneous Structures
Synergistic Necrotizing Cellulitis:
Polymicrobial with facultative
and anaerobic organisms that
originate in the intestine:
Facultative coliform organisms:
E. coli, Proteus, Klebsiella
Anaerobic organisms:
Bacteroides sp., or
Peptostreptococcus
Progressive Bacterial Synergistic
Gangrene (Meleney Gangrene)
S. aureus and Peptostreptococcus sp.
Infectious myositis
Pyomyositis S. aureus
-hemolytic streptococcus
S. pneumonia
H. influenzae
Enterobactereciae
Mycobacteria
Fungi
Anaerobic myonecrosis (Gas gangrene) C. perfringens C. septicum

Table 179-2
Findings in Necrotizing Skin and Soft-Tissue Infections
Feature
Progressive
Bacterial
Synergistic
Gangrene
Synergistic
Necrotizing
Cellulitis
Streptococcal
Gangrene
Clostridial
Myonecrosis
(gas
gangrene)
Necrotizing
Infections in
Immunosuppression
Microbiology Streptococci,
Staphylococcus
aureus
Mixture of
organisms:
Bacteroides,
peptostreptococci,
or Escherichia coli
Group A
streptococci
Clostridium
perfringens
Rhizopus, Mucor, Absidia,
Pseudomonas aeruginosa
Predisposing
conditions
Surgery or draining
sinus
Diabetes Diabetes or
abdominal surgery
Trauma Diabetes, corticosteroid
use, immunosuppression,
burns
Fever Minimal Moderate High Moderate to high Low in fungal, high in
pseudomonal
Pain Prominent Prominent Prominent Prominent Mild
Anesthesia Absent Absent May occur Absent May occur
Crepitus Absent May occur Absent Present Absent
Course Slow Rapid Very rapid Extremely rapid Rapid

Box 179-1 Differential Diagnosis of Infectious Necrotizing Bacterial

Skin and Soft -Tissue Infections
Noninfectious Infectious
Arteriolar occlusion with cutaneous necrosis (retiform
purpura with necrosis)
Leukocytoclastic vasculitis
Calciphylaxis, oxalosis
Warfarin necrosis
Disseminated intravascular coagulation
Hemolytic uremic syndrome
Thrombotic thrombocytopenic purpura
Hypercoagulable state
Emboli (cholesterol, fat, amniotic fluid, etc.)
Panniculitides with liquefaction necrosis
Pancreatic panniculitis
-1-antitrypsin deficiency
Follicular occlusion syndromes
Acne conglobata
Dissecting cellulitis
Hidradenitis suppurativa
Neutrophilic dermatoses
Pyoderma gangrenosum
Sweet syndrome
Iatrogenic
Fixed drug eruption
Radiation dermatitis
Miscellaneous causes
Insect bites/stings (esp. brown recluse bite)
Irritant contact dermatitis with necrosis
Sterile spontaneous diabetic myonecrosis
Trauma with hematoma formation
Metastatic Crohn’s disease

Infectious
Non-necrotizing bacterial SSTI
Cellulitis
Erysipelas
Abscess, furuncle
Septic emboli/ septic vasculitis
Endocarditis
Internal organ abscess
Meningitis (Neisseria meningitides)
Bacteremia/Sepsis
Herpes zoster and herpes simplex
Deep Fungal infection
Atypical mycobacterial infection
Bursitis, arthritis, osteomyelitis

Box 179-2 Antimicrobial Treatment of Necrotizing Infection of Skin ,

Fascia , and Muscle
Organism Drug of First Choice Alternative Drugs
Mixed infection Ampicillin/sulbactam
Imipenem/cilastatin, meropenem
Ticarcillin/clavulanate
Vancomycin (if suspicion for MRSA)
Cefoxitin, clindamycin, or metronidazole
an aminoglycoside
Streptococcus (A, C, G, B) Penicillin G (clindamycin for toxic
shock syndrome or necrotizing fasciitis)
Ceftriaxone clindamycin
Vancomycin
Linezolid
Enterococcus (systemic Infection) Penicillin G or ampicillin aminoglycoside
Vancomycin aminoglycoside
Linezolid
Quinupristin/dalfopristin
Daptomycin
Staphylococcus aureus Nafcillin (or oxacillin) Cefazolin
Amoxicillin/clavulanate
Vancomycin (for methicillin-resistant
strains)
Clindamycin
Quinupristin/dalfopristin
Linezolid
Daptomycin
Clostridium perfringens Penicillin G clindamycin Metronidazole carbapenem
Ceftriaxone
Chloramphenicol