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Clinical Review

Necrotizing fasciitis
Rukshini Puvanendran MMed FCFP MB BS Jason Chan Meng Huey MB BS Shanker Pasupathy FRCS MB BS

N
ecrotizing fasciitis (NF) is a rare but
potentially fatal infection involv-
Abstract
OBJECTIVE To describe the defining characteristics and treatment of necrotizing
ing the subcutaneous tissue and fas- fasciitis (NF), emphasizng early diagnostic indications.
cia. It is commonly known as flesh-eating QUALITY OF EVIDENCE PubMed was searched using the terms necrotizing fasciitis
disease. Deaths from NF can be sudden and and necrotizing soft tissue infections, paired with early diagnosis. Results were lim-
sensational and often make headline news. ited to human studies in English. Additional articles were obtained from references
within articles. Evidence is levels II and III.
Necrotizing fasciitis is prevalent enough that
MAIN MESSAGE Necrotizing fasciitis is classified according to its microbiology
most primary care physicians will be involved (polymicrobial or monomicrobial), anatomy, and depth of infection. Polymicrobial
with managing at least 1 case during their NF mostly occurs in immunocompromised individuals. Monomicrobial NF is less
time in practice, but infrequent enough for common and affects healthy individuals who often have a history of trauma (usu-
most to be unfamiliar with the disease. ally minor). Patients with NF can present with symptoms of sepsis, systemic toxicity,
or evidence of skin inflammation, with pain that is disproportional to the degree of
At onset, NF can be difficult to differen-
inflammation. However, these are also present in less serious conditions. Hyperacute
tiate from cellulitis and other superficial cases present with sepsis and quickly progress to multiorgan failure, while subacute
infections of the skin. In fact, studies have cases remain indolent, with festering soft-tissue infection. Because the condition is
shown that only 15% to 34% of patients with rare with minimal specific signs, it is often misdiagnosed. If NF is suspected, histol-
NF have an accurate admitting diagnosis.1,2 ogy of tissue specimens is necessary. Laboratory and radiologic tests can be useful
in deciding which patients require surgical consultation. Once NF is diagnosed, next
Only early diagnosis and aggressive surgi-
steps include early wound debridement, excision of nonviable tissue, and wide
cal treatment can reduce mortality and mor- spectrum cover with intravenous antibiotics.
bidity.3 Family physicians are often the first CONCLUSION Necrotizing fasciitis is an uncommon disease that results in gross
point of contact for these patients, and a morbidity and mortality if not treated in its early stages. At onset, however, it is
high index of suspicion is needed, as there difficult to differentiate from other superficial skin conditions such as cellulitis.
Family physicians must have a high level of suspicion and low threshold for surgical
is a paucity of initial signs. This article aims
referral when confronted with cases of pain, fever, and erythema.
to review NF, especially with regard to early
diagnostic clues. We also describe a case
that illustrates the difficulty of diagnosing
Résumé
OBJECTIF Décrire les caractéristiques et le traitement de la fasciite nécrosante (FN),
the disease in its early stages. We chose a en insistant sur l’importance du diagnostic précoce.
case of subacute NF to illustrate how its QUALITÉ DES PREUVES On a consulté PubMed à l’aide des rubriques necrotizing
signs can be subtle—we feel that family phy- fasciitis et necrotizing soft tissue infections, en combinaison avec early diagnosis. Les
sicians should be aware of this entity. résultats se limitaient aux études humaines de langue anglaise. D’autres articles prove-
naient de la bibliographie des articles retenus. Les preuves sont de niveaux II et III.
PRINCIPAL MESSAGE On classe la fasciite nécrosante selon sa microbiologie (poly-
Case description microbienne ou monomicrobienne), son anatomie et la profondeur de l’infection. La
A 62-year-old woman of Chinese descent FN polymicrobienne touche surtout des sujets immunodéprimés. La FN monomicro-
was admitted to hospital with a 3-day his- bienne est plus rare et touche des sujets sains qui ont souvent une histoire de trau-
tory of fever, shortness of breath, and bio- matisme (généralement mineur). La FN peut se manifester par des symptômes de
septicité, de toxicité systémique ou des signes d’inflammation de la peau, avec une
chemical evidence of septicemia (raised
douleur disproportionnée par rapport au degré d’inflammation. Ces signes se ren-
total white blood cell count and C-reactive contrent aussi dans les affections moins graves. Les cas hyper-aigus sont d’emblée
protein levels). No obvious source of sepsis en septicité et évoluent rapidement vers une insuffisance touchant plusieurs
could be identified at the time of admission, organes, alors que les cas subaigus demeurent indolores, avec une suppuration des
except for complaints of left lower leg pain. tissus mous. Puisqu’il s’agit d’une affection rare ayant peu de signes spécifiques, le
diagnostic est souvent erroné. Si ont soupçonne une FN, il faut faire l’histologie
There was no evidence of inflammation of
d’un échantillon de tissu. Des examens de laboratoire et de radiologie peuvent aider
the leg at that time. à décider si un patient requiert une consultation en chirurgie. Une fois le diagnostic
She had a history of left knee osteoar- de FN établi, les étapes suivantes comprennent le débridement précoce de la plaie,
thritis, for which she had been undergo- l’excision du tissu non viable et un traitement avec un antibiotique à large spectre
ing a course of acupuncture for the past par voie intraveineuse.
CONCLUSION La fasciite nécrosante est une maladie rare qui entraîne des taux
6 weeks. Otherwise, her medical history
élevés de morbidité et de mortalité si elle n’est pas traitée précocement. Au début,
was unremarkable. toutefois, elle est difficile à distinguer des autres affections cutanées superfici-
elles comme les cellulites. Le médecin de famille devrait avoir un haut niveau de
This article has been peer reviewed. suspicion et recourir rapidement à une consultation en chirurgie devant un cas de
Cet article a fait l’objet d’une révision par des pairs. douleur, de fièvre et d’érythème.
Can Fam Physician 2009;55:981-7

VOL 55: OCTOBER • OCTOBRE 2009 Canadian Family Physician • Le Médecin de famille canadien 981

10 982 Canadian Family Physician • Le Médecin de famille canadien VOL 55: OCTOBER • OCTOBRE 2009 . synergistic necrotizing cellulitis. Necrotizing fasciitis formed at time of admission.8 mg/L ized controlled trials or meta-analyses were available. Historically. in 1871. systemic toxicity. both also paired with early diagnosis. shortness of breath.0 g/dL our search to articles in English and human studies.9 mmol/L Urea 6. NF has been classified as morbidity.9-11. streptococcal myo- group A necrosis. Type 1 and type 2 infections refer to classifica- initial diagnosis of cellulitis was made.9 For the purposes of this article. Total white blood cell Additional articles were identified from key references 10. By the fourth day of admission she and sometimes patients are treated for simple cellulitis had become apprehensive when examined and fear. Potassium 3. are examples. as surgical exploration. She developed and subcutaneous tissue with relative sparing of the an area of erythema over her left shin. Table 1. Blood cultures grew Necrotizing skin infections were first described by Jones group A β-hemolytic streptococci (Streptococcus pyo. and clinda. and necrotizing adipositis refer to classification by depth of An orthopedic consultation was obtained and an infection. Laboratory results of a woman presenting with a 3-day history of fever. if She complained of leg pain. however. Urine cultures No bacterial NA microbial cause. which was relieved with not treated aggressively. One recently proposed recom- Histology results were reported as consistent with mendation suggested that the term necrotizing soft tis- NF. myonecrosis.Clinical Review Necrotizing fasciitis Table 1 presents some of the investigations per. Terms like necrotizing fasciitis. was used. NA—not applicable.5–4. Different terms and classifications have Creatinine 102 µmol/L 40-85 µmol/L been used to describe necrotizing infections of the skin Glucose 11. This variety of classifications streptococcus and terminology has been based on affected anatomy. and gas gangrene. on day 8 of admission. On day 11 of admission. We limited Hemoglobin 12.7. necrotizing fever did not subside.2–8. angina (involving submandibular and sublingual spaces) sion for surgical exploration was made to exclude NF. The patient was treated with intravenous Wilson in the 1950s to describe necrosis of the fascia clindamycin and crystalline penicillin. debridement was performed. Sodium 131 mmol/L 130-145 mmol/L As such. Initially attributed to the underlying ity.0 mmol/L and subcutaneous tissue. Awareness of growth this helps to reduce confusion. treatment is the same: early surgery and broad spectrum roscopic evidence of early NF. Her erythema Fournier gangrene (involving the perineum) and Ludwig and bullae worsened. She was discharged soon after with minimal Microbiology. which this time suggested mac.7 mmol/L Main message Classification. Google Scholar was used to search for historic texts by Wilson and Jones. and depth of infection. These include necrotizing fas- Blood cultures Positive for NA ciitis.2-7.2 × 109/L 4. datory. An extensive wound antibiotics. A sample of tissue was sent Although these descriptive terms are useful. it is often difficult to diagnose NF. despite the administration of infections were classified according to anatomical sites. and. underlying muscle. although at the time the term hospital gangrene genes) susceptible to penicillin.4. These infections were named after the Intraoperative visual inspection did not reveal any physicians who first described them.5 Necrotizing fasciitis is characterized gressed over the next few days and started to blister.0–16. either type 1 (polymicrobial) or type 2 (monomicrobial). ampicillin. she underwent further sue infections should be used to describe them all.2 mmol/L 2. a deci. they for histologic assessment. and early surgical exploration and debridement is critical to ensuring a good outcome.8 obvious necrotic tissue. necrotizing fasciitis and necrotizing soft tissue infec- INVESTIGATION RESULTS NORMAL VALUES tions. cause much confusion. the pain progressed to reduces risk.6 Antibiotic therapy is man- ful of moving her leg.0-10.0 × 109/L count within articles. She continued to be febrile. gross morbidity and mortal- acetaminophen. until they rapidly deteriorate.4 g/dL 12. However. Early diagnosis and aggressive surgical treatment osteoarthritis of her left knee. however. involve her shin.2 mmol/L 3. by rapid destruction of tissue. which pro. and left Quality of evidence lower leg pain: Later histologic tests were consistent A PubMed search was conducted using the key words with necrotizing fasciitis. and laboratory parameters subsequently normal- ized. the evidence presented here is level II and III.5 Platelets 200 × 109/L 140-400 × 109/L Necrotizing fasciitis is uncommon and no random- C-reactive protein 333 mg/L 0. her tion based on microbial cause.2 mmol/L 3. appropriate intravenous antibiotics. Microbiologically.4 The term necrotizing fasciitis was coined by mycin. and her temperature the more familiar term necrotizing fasciitis will be used.

Most cases commence with trauma to the dia. Bacteroides or Clostridium species. joint Burns some predisposition to infection. Bacteria rapidly multiply within viable tissue. that suppression of symptoms and signs of inflammation Monomicrobial infections are less common than the leads to later diagnosis. For example.13 Clinical features. As in the case we described. common sites tive organisms spread through the tissue along the deep of infection included the lower extremities (28%). likely to neglect or forget to mention it. showed MRSA isolated in one-third of cases. such as Escherichia coli and Nonsteroidal anti-inflammatory drug use has been Pseudomonas species. with evidence of skin inflammation.15 This type of ism found adjacent to the site of infection. Therefore. Risk factors for necrotizing fasciitis feet. with seeding of bacteria.18. the injury can be quite trivial. peripheral vascular disease. Gram-negative aerobes. such as implicated in severe necrotizing streptococcal infections. can lead to widespread infection • Diabetes and tissue destruction.1 Most patients have a history of VOL 55: OCTOBER • OCTOBRE 2009 Canadian Family Physician • Le Médecin de famille canadien 983 .16 However. Gas.17 and afflict healthy patients with no implicative comorbidi.12. These typically occur in the limbs early with nonspecific symptoms. The spread • Immunosuppressive drugs (eg. cocci. and which are often sensationalized. and the although fibrous attachments between subcutaneous tissues and fasciae limit spread to areas like the hands. aspirations. it could also be diabetes mellitus or chronic renal failure. tachycar- Pathology. These are the cases that get has increasingly been described in NF. directly questions the patient. specific history (further examples of which are summa- in NF of the perineum. and scalp. malnutrition and skin infections such as varicella. The isolates reflect normal skin commensal. especially in patients presenting polymicrobial variety. patients presenting with NF have Minor invasive procedures (eg. perineum (21%).13 Type 1 NF occurs in It is postulated that nonsteroidal anti-inflammatory drugs immunocompromised individuals. patients are such as Staphylococcus aureus. trating injury. Calif. Risk factors for NF in the pediatric population include ties. rized in Table 2) is often only obtained if the physician The etiologic isolates consist of Gram-positive organisms. missed. Patients with NF can present with constitutional symptoms of sepsis (eg. Often. • Peripheral vascular disease producing organisms such as Clostridium species can • Renal failure • Underlying malignancy give rise to subcutaneous gas. leading to edema. The clinical disease is expressed when infec. for NF in 3 tertiary hospitals in Canada. altered mental state. Lack of fibrous attachments in the trunk and limbs.11 These infections typically occur in the perineum insect bites or scratches. A recent retrospec. with cul. or there might be a history of surgery or pene- tures yielding a mixture of aerobic and anaerobic organ. otherwise. insect and animal bites) had diabetes mellitus. isms. anaerobic bacteria are isolated. Infection starts in the deep Limbs are among the most common sites of infection. Necrotizing fasciitis Clinical Review Polymicrobial infections are more common. • Intravenous drug misuse infection of the muscle leading to myositis occurs. tissue planes. 70. diabetic ketoacidosis) alone or skin surface (eg. and obesity Intravenous drug use Childbirth are some predisposing factors. However. extremities (27%). NF and trunk. however.3% of patients with NF Penetrating injuries (eg. tive review of cases from 2000 to 2006 in Los Angeles. In addition. infections with toxin-producing bacteria (S aureus and S pyogenes) can lead to a toxic shock–like Table 2. and anaerobic organisms. and entero. prednisolone) of bacteria results in thrombosis of blood vessels in • Malnutrition dermal papilla. trauma. TRAUMATIC NONTRAUMATIC Surgery Soft tissue infection Risk factors. trunk (18%). upper fascia. In a Singapore study. from which stems the • Obesity descriptive term gas gangrene. eg. which makes diag- puncture needles. nosis a little more straightforward. Infection also spreads to venous • Chronic disease and lymphatic channels. type It is important to emphasize that physicians should 2 NF might be associated with toxic shock syndrome.14 If the fascia is breached. Immunocompromise. as was the case with our patient). seemingly limited infection can fasciitis result in septic shock and multiorgan failure. S pyogenes. such as patients with impair lymphocyte function. fever. has even been reported after acupuncture. There is often a history of trauma. resulting in ischemia and gangrene of • Age > 60 years subcutaneous fat and dermis. and the epidermis might not be initially According to a retrospective review of patients treated affected. Box 1. acupuncture advanced age. from a penetrative injury or even acu. Precipitating events causing necrotizing syndrome. Box 1 lists known risk factors. frequently trivial.9 not rule out NF in normal healthy patients with minor Community-acquired methicillin–resistant S aureus (MRSA) dermatologic trauma.19 As S pyogenes and S aureus are the usual pathogens.

sitive.23 progression of disease despite use of antimicrobial medi- The pain patients experience with cellulitis can be assuaged cations. patient with a hyperacute course presents with sepsis cle being compromised.22-26 lists clinical features indicative of NF. is often severe. apparent site of Presentation with degree of skin inflammation. one can expect erythema with Crepitus lymphangitis and minimal blistering. The physi- cal examination should include all parts of the body to Erythema with ill. they are not sen.28 experienced with NF. also sometimes described in NF. The patient might complain of pain systemic disturbance. As the disease is a In summary. is the cornerstone of treatment in these cases. and Subacute NF can present a diagnostic dilemma. sudden deterioration is an 63% of cases and an absence of blistering in 76% to 95% of important clinical feature. gradual tissue necrosis with pro- out of proportion to the degree of dermal involvement or gressive cutaneous changes over the affected site.Clinical Review Necrotizing fasciitis head and neck (5%). and possibly even an tissue infections SKIN PAIN GENERAL altered mental state or diabetic ketoacidosis. ketotic acidosis. necrosis. as these Lack of physical findings are also present in less serious conditions such as ery. Wong et al describe this entity of subacute deep-seated infection.22 Headley. gression of NF or systemic features of sepsis. betic neuropathy with loss of sensation. on the other hand. The signs.22 Progression of Dufel and Martino. by Wang et al6 and with festering soft tissue infection. Primary care physicians have to use likely in concealed sites of infection. as the likely first point of examined. The pain surgery.26 NF is marked with the development of tense edema. Clinical features suggestive of necrotizing soft 38°C). DKA—diabetic ketoacidosis. Two retrospective case series. As mentioned earlier. skin edema.14. such as the perineum or clinical judgment to decide which patients who pres- oral cavity.24 Crepitus is a later sign. tachycardia. with the likelihood of underlying fascia and mus. Pain that extends Fever with toxic search for skin inflammation. taneous fascia and soft tissue. lymphangitis or Tachypnea due to sipelas and cellulitis. histologic features are consistent with NF.23 Hsiao et al. the epidermis is minimally involved NF as having a slow indolent course with an absence of at initial presentation. After the infection Elliot et al. However.20 As NF first starts in the deep tissue A patch of anesthesia over the site of erythema is planes. the degree of pain relative to the lymphadenopathy Decreased pain or acidosis skin condition might provide the physician with clues— anesthesia at NF typically presents with pain out of proportion to the Vesicles or bullae. can experience min- imal pain.14. pain. a grayish-brown discharge. ent with evidence of skin inflammation should be 984 Canadian Family Physician • Le Médecin de famille canadien VOL 55: OCTOBER • OCTOBRE 2009 .26 Patients with NF are usually systemically toxic. and a delay in diag- infections.22 nosis can lead to greater soft tissue loss and mortality. vesicles. should be aware of this. defined margins past margin of appearance sary for patients who present with sepsis of which the apparent infection Tense edema with Altered mental source is not obvious. Data from Seal.14 Green et al. and Disease progression. Although crepitus and blistering are the most specific Several authors have described a subacute variation signs of necrotizing soft tissue infection. ini- tially presenting with fever (temperature greater than Table 3. notably those with dia.12 of sepsis is obvious.21 discharge appears Most patients present with signs of skin inflammation disproportionate to Tachycardia (ie. hemorrhagic bullae infection DKA or HHNK Erysipelas. Aggressive surgical debridement cases upon initial presentation. At the time of along with careful positioning of the affected area. and pain that extends past the apparent margin of infection. has well-defined borders and might blister pro- foundly. and erythema). and these patients are hospitalized.25 reported an absence of crepitus in 62% to reaches a certain threshold. due to infarction of cutaneous nerves in necrotic subcu- tiate from non-necrotizing skin infections and cellulitis. followed by a sudden deterioration with rapid pro- with acetaminophen with codeine or a similar analgesic.24 Elliot et al.25 and out a defined margin or lymphangitis.27-29 Localized pain is another clue to NF. With cellulitis. lym. contact. However. and is found in only about 18% of cases of NF. and rapidly progresses to multiorgan failure. This is thought to be dermal involvement. certain patients. Diagnosis ever. This can make it difficult to differen. HHNK—hyperosmolar hyperglycemic non- Necrotizing fasciitis typically presents with patchy dis. Necrotizing fasciitis can follow crepitus.23 Hemorrhagic bullae and crepitus are sinister a hyperacute or a subacute course of progression. being an infection of the superficial der- Necrosis mis. The perineum and oral cavity are grayish or brown Severe pain that state areas that can be easily missed. of NF. diaphoresis. Table 314. Progression phangitis and lymphadenopathy are absent in necrotizing of disease is invariable in this group. but they remain features of cellulitis. at initial presentation there might be minimal epi. and patients can be exceedingly apprehensive and fearful when the primary care physician. This is especially Hospitalization. how. This is especially neces.27-29 These patients have an indolent disease course. colouration of the skin with pain and swelling. but with. resulting in a missed diagnosis. bullae.

criterion standard for diagnosis of NF is histology of tis. low serum bicar. White blood cell count atinine kinase levels. immunocompromise. or a deep fascia involvement with fluid collection.30 hospital and might yield up to 27. The biopsies rather than delay treatment for imaging studies. ≤5 points indicates a low risk (< 50% probability) of ment and necrosis are indicative of an advanced stage. hypothermia. The cial thickening. MRI might not show early review if symptoms or signs progress.19 an intermediate to Serum glucose > 180 mg/dL (10 mmol/L) 1 point high risk of NF had a positive predictive value of 92% and NF—necrotizing fasciitis. Computed soft tissue infection guidelines indicate that hospitaliza. • 15 000/µL-25 000/µL 1 point ers. Asymmetrical fas- failure of outpatient therapy. cutaneous manifestations ing infections must be considered. thickening. however. probability) of NF. particularly in those with equivocal clinical signs. impaired renal function. but signs and symptoms evolve over et al. are equivocal or diagnosis is in doubt. nance imaging (MRI) might be useful in cases where signs intractable nausea and vomiting. raised cre. This has been disputed.36 In summary. Negative results.6 mg/dL (141 mmol/L) 2 points mediate or high risk) suggests NF. if clinical suspicion is high. acidosis.32).15 Computed tomography and magnetic reso- (including those requiring formal operative intervention). altered Serum C-reactive protein ≥ 150 mg/L 4 points coagulation profile. it is prudent to advise argued that in early cases of NF. However. cases of cellulitis. the LRINEC VOL 55: OCTOBER • OCTOBRE 2009 Canadian Family Physician • Le Médecin de famille canadien 985 .”31 and enhancement after contrast administration. Studies of patients able in the primary care setting. with infection in the early stages and where laboratory betes mellitus. However. severe infection exclude NF.11 compared with the mere 2% pos- infections accompanied by signs and symptoms of sys. Further. elevated creatine phosphokinase level (2-3 thickening with fluid collection. and poor social support. It has not been vali- diagnosis of necrotizing skin and subcutaneous infec. dated in patients for whom the diagnosis of NF is not tion had an admitting diagnosis of NF. marked left shift. itive blood culture yield in patients with cellulitis. Additional bedside tests include needle aspiration sue specimens obtained during surgical exploration. Laboratory risk indicator for NF: A score of integrity indicate a necrotizing infection.3% positive cultures in Hospitalization is indicated for patients with soft tissue necrotizing infections. are all helpful if • > 25 000/µL 2 points viewed within the whole of the clinical context. laboratory and radiologic tests might sometimes be useful. Data from Anaya and Dellinger9 and Wong et al. surgical exploration.33 temic toxicity (fever. fascial involvement. and incision biopsy. tained. this score is not easily ascer- inflammation greater than 70 cm2 are independent pre. some patients with non-necrotizing soft tis.2 apparent in the initial assessment.34 In and/or an elevated creatinine level. Muscle involve. are not readily avail- sue infections will require admission. necrotiz- In the early stages of NF. where patients present with soft tissue infection showed that a history of dia. In a study by Brogan et al. certain tests. and raised inflammatory mark. The patient in our case scored 7.5 g/dL 1 point NF (LRINEC) score are available to help diagnose NF and • < 11 g/dL 2 points differentiate it from other skin and soft tissue infections Serum sodium < 135 mEq/L 2 points (Tables 314. only 15% to 34% of patients with a discharge diagnosed or highly suspected NF. (> 75% probability) of NF.35 the sensitivity of MRI is 100% with a specificity time. tissue integrity and depth of inva- sion can be assessed. at first encounter. A score of 6 and above (inter- Serum creatinine > 1. NF. more than 100 beats/min]). Further. During exclude NF.32 a negative predictive value of 96%. and gas tracking along fas- latest Infectious Diseases Society of America skin and cial planes are important imaging findings. therefore. hand infections. the physician might of 86%. hypotension (systolic blood but this is a specific not a sensitive finding (positive in pressure less than 90 mm Hg or more than 20 mm Hg fewer than 25% of cases) and absence of gas does not below baseline).33 According to Schmid are a continuum. tomography scans are estimated to have a sensitivity of tion should be considered in patients with “hypotension 80% for detecting necrotizing soft tissue infections. C-reactive protein level more than 13 mg/L. pyrexia. 8 points or more indicate a high risk ration.6 Even if. Blood cultures are usually part of the workup in dictors of hospitalization. Necrotizing fasciitis Clinical Review hospitalized or receive further evaluation.0-13. such as C-reactive protein levels.1. and other authors have diagnose uncomplicated cellulitis. cannot which was demonstrated in our case description. an altered mental state.22-26 and 49. such as the C-reactive protein test. Surgical exploration is preferable. and an area of support is limited. surgeons can opt to explore and perform tissue Diagnosis and decision for surgical exploration. Hemoglobin Clinical scores like the laboratory risk indicator for • 11. As mentioned score was based on retrospective studies of patients with earlier. 6-7 points indicate an intermediate risk (50%-75% To help decide which patients require surgical explo. INVESTIGATION SCORE Leukocytosis with neutrophilia. Fascial necrosis and loss of fascial Table 4. fat stranding. tachycardia [heart rate Plain x-ray films can demonstrate subcutaneous gas. when there is times the upper limit of normal). MRI will demonstrate subcutaneous bonate level.

38 Well-controlled randomized con- trolled trials are still lacking. and Gram. Increasingly. wounds associated with devitalizing major trauma. However. gical debridement. excision of all nonviable tissue. doré résistant à la méthicilline d’origine extrahospitalière. and the clinician should draw information from • Necrotizing fasciitis is a rare but potentially fatal disease. necrotic ration chirurgicale est indiquée en présence d’un fort degré de suspicion. peuvent être utiles In particular. it is important to educate them about the partie du corps. Une explo- pected in perineal and abdominal wall wounds. • Management includes fluid resuscitation. awareness of resistance in the patient population being • On tarde souvent à poser le diagnostic vu le peu de signes treated) is started. First. et un faible indice de suspicion. patients are usually immunocompetent with a history of and a positive “finger test” result. mortality of 16. tions. necrotizing infections were first described by Jones. and in heavily contaminated • Le traitement inclut un rééquilibrage liquidien.3% for postprocedural nec- lins might play a therapeutic role. • Necrotizing fasciitis is a clinical diagnosis.4 More recent data indicate a In type 2 NF caused by streptococci resulting in strepto. wide spec. intravenous immunoglobu. lins in streptococcal toxic shock syndrome. • Typiquement. S aureus (including community-acquired MRSA if indi. Its role is still ill-defined. Surgical exploration is advised if clinical sus- tions should be urgently requested with the intention picion is high. but it with streptococcal toxic shock syndrome. morbidity. diabetic foot ulcers. examens sanguins et l’imagerie. (variété monomicrobienne) sont habituellement immuno- trum coverage with intravenous antibiotics (with an compétents avec une histoire de trauma (parfois mineur). magnétique et la tomodensitométrie. (This is also important as tis. si indiqué. notamment la résonance negative aerobes and anaerobes as clinically indicated.39 hyperosmolar hyperglycemic nonketotic acidosis have 986 Canadian Family Physician • Le Médecin de famille canadien VOL 55: OCTOBER • OCTOBRE 2009 . tures. both the patient’s condition and the aggregate of tests. a retrospective Prognosis. Blood tests and imaging. These antibiotics cover S pyogenes. quemment l’agent infectieux identifié est le staphylocoque Some authors have reported a reduction in mortality.) POINTS DE REPÈRE DU RÉDACTEUR Patients are often incredulous at the preoperative brief. mor- baric oxygen therapy. soft tissue infections40 and 36. elle peut survenir dans n’importe quelle skin infection. • La fasciite nécrosante est une maladie rare mais potentiel- ing when told they need an extensive operation for their lement mortelle. mortality approaches 100%. considering medical progress in the last 135 years. immunodéprimés. and need for repeated debridement in up to two-thirds of cases. ceux qui souffrent du type 2 Until blood culture results are available. throm. incluant la cavité buccale et le périnée. patients who develop type 1 (polymicrobial) Macroscopic findings during surgical exploration necrotizing fasciitis are immunocompromised in some include gray necrotic tissue. and early sur- the extent of the disease. Diabetic patients.Clinical Review Necrotizing fasciitis It must be emphasized that diagnosis of NF is clin. according to local resistance patterns). “dishwater” pus. showed 3. ized by lack of resistance to finger dissection in normally • Diagnosis is often delayed because of a paucity of signs adherent tissues. De plus en plus fré- to surgery and antibiotics. Les cated. les patients qui développent une fasciite gravity of their condition and the risk of increased mor- nécrosante de type 1 (polymicrobienne) sont plus ou moins tality if surgical debridement is not performed. it can occur in all parts of the body. if indicated. lack of bleeding. way. mais ne permettent pas de poser le diagnostic. Mortality is higher in patients prematurely stopped because of poor recruitment. methicillin-resistant Staphylococcus aureus is being iden- ics. surgical consulta. with the type 2 (monomicrobial) variety. noncontracting muscle. Mortality due to NF is considerable. Toutefois. • Typically. diagnostic. double-blind. can be helpful but are not must begin on multiple fronts. especially magnetic resonance imaging and Treatment. When with NF was higher in patients who underwent hyper. hospital with intravenous antibiotics and surgical interven- ated the safety and efficacy of intravenous immunoglobu.6-fold higher mortality in the placebo group especially those presenting with diabetic ketoacidosis or compared with the treatment group.37. Once the diagnosis is made. trauma (sometimes minor).4% for community-acquired necrotizing coccal toxic shock syndrome. The trial was mortality is still substantial.20 tality was reported as 46%. which was demonstrated in our patient—her fever tified as the infective agent. des antibiotiques à large spectre par voie intra-veineuse et Hyperbaric oxygen has also been used as an adjunct un débridement chirurgical précoce. Recently. community-acquired sue hypoxia limits the efficacy of intravenous antibiot. low threshold for surgical referral. of early wound debridement for collection of tissue cul. EDITOR’S KEY POINTS ical.9 and a low index of suspicion. and delineation of intravenous broad spectrum antibiotics. Gram-negative organisms would be sus. • Le diagnostic de la fasciite nécrosante est clinique. did not break despite intravenous antibiotics until the wound debridement and fasciotomy were complete. rotizing infections.41 All of these patients were managed in randomized. Without review by Golger et al showed that morbidity associated surgical intervention. Moreover. placebo-controlled trial evalu. including the oral Physicians should have a high index of suspicion and cavity and the perineum. which is character. treatment computed tomography scans. a multicentre. bosed vessels.

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