Necrotizing Fasciitis

Chidiebere Eze, PharmD

March 16, 2018
Objectives
 Define Necrotizing fasciitis

 List the organisms behind necrotizing fasciitis

 Suggest possible empiric antimicrobial treatment for necrotizing fasciitis

 Suggest possible narrowed antimicrobial regimen after culture results

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Insert video
 https://www.youtube.com/watch?v=Vr8ueQ1fQwo

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Introduction 1
 “FLESH-EATING” infection

 Serious bacterial skin infection that spreads quickly and kills the body’s soft tissue

 Can lead to amputation or death in a short period

 Goals of treatment:

 Early recognition

 Accurate diagnosis

 Prompt antibiotic treatment

 Surgical intervention

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Incidence 2-6
 CDC tracks each bacteria– Active Bacterial Core Surveillance (ABCs)

 Classifies by age, state, race/ethnicity, and syndrome

 Most recent 2015

 0.40 adult cases per 100,000 people/year

 0.08 children cases per 100,000 people/year

 64% have diabetes

 Mortality rate is 30-60%

 Limb amputations ~39%

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 Types

Type Other names Bacteria Notes

I Fournier’s gangrene
(perineum/genitalia); Ludwig’s
angina/cervical necrotizing
fasciitis
II Streptococcal gangrene
III Clostridial myonecrosis; gas
gangrene
Bacteroides spp. (>50% cases);
Peptostreptococci (>30% cases);
Strep; Staph; Gram negative rods
Beta-hemolytic streptococci
(majority); Staph (CA-MRSA)
Clostridium spp.
Most common type (~80%); commonly
poly-microbial (4+ organisms)
Associated with toxin production, rapidly
progressing symptoms + necrosis; must
add antitoxin antibiotic
<5% of cases; associated with trauma,
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“skin popping” & devascularization; most
aggressive subtype
Question:
1. Which of the following is the most toxin producing?

a. Type I necrotizing fasciitis – polymicrobial

b. Type II necrotizing fasciitis – monomicrobial

c. Type III necrotizing fasciitis – clostidium

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Question:
1. Which of the following is toxin producing?

a. Type I necrotizing fasciitis – polymicrobial

b. Type II necrotizing fasciitis – monomicrobial

c. Type III necrotizing fasciitis – clostidium

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Goals of treatment
 Early recognition

 Accurate diagnosis

 Prompt antibiotic treatment

 Surgical intervention

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Case
 JF is a 57 YOM with T2DM who presented to the ED complaining of painful, swollen right ankle. He stated
that he tripped and sprained his ankle 3 days ago. The ankle became increasingly painful over the next 3
days to the point where he couldn’t bear weight on it. He stated that a blister developed after the injury,
which he lanced and drained himself.
 PMH: T2DM (A1C: 9.1), hepatitis C, previous ulcerations of lower extremity, liver transplant 15 years ago

 Social history: IVDU, quit smoking 3 years ago

 Family history: Both parents alive. Only child.

 Medications: Tacrolimus, Insulin (non-compliant)

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Early recognition
 Necrotizing fasciitis is present in about half of cases of streptococcal toxic shock–like syndrome

 Primary site of infection generally involves skin and soft tissue

 Affects superficial and sometimes deep fascia

 Acute process but follow sub-acute progressive course

 Commonly occurs:

 After minor trauma (e.g., laceration, abrasion, burn, insect bite)

 In chronic disease and illnesses

 In alcoholics, diabetics, post surgery infections

 In parenteral drug abuse, often following “skin popping” – injection site

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Early recognition - Clinical manifestations
 Involvement based on types:

 In Type I (polymicrobial) infections: abdominal wall, perianal and groin areas, and postoperative wounds

 In Type II (group A streptococcal): Extremity involvement

 70% of patients have tissue findings progressing

 Presentation:

 chills, fever (or hypothermia and shock)

 tachycardia, hypotension, confusion

 vomiting, diarrhea, multi-organ failure

 leukocytosis, thrombocytopenia

 azotemia, increased serum levels of creatinine phosphokinase

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 Surgical
debridement
Development Necrosis of
subcutaneous
Development tissues
of violaceous
Development bullae
of vesicles
Hemolytic
streptococcal
Soft tissue gangrene
findings

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Accurate diagnosis
 Prompt diagnosis is important due to rapid progress. Can enhance survival.

 Physical exam:

 Initial signs (non-distinctive):

 Pain, tenderness, edema, erythema

 Watch for presence of marked systemic toxicity out of proportion to the local findings
 Surgical exploration or biopsy:

 Directly inspect fascia and muscles by small incision over involved area

 Will help differentiate between necrotizing fasciitis and cellulitis

 Helps prevent delay in diagnosis and treatment

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Accurate diagnosis
 Imagine studies:

 CT and MRI:

 Can show subcutaneous fascia edema and tissue gas

 Ultrasonography and CT:

 May help in evaluating Fournier’s gangrene when local scrotal inflammatory findings are present but
cutaneous necrotizing infection or crepitus is not apparent
 Culture

 Blood cultures:

 Positive in: 20% of Type I; 60% of Type II

 Surgical cultures:

 Preferred over aspiration biopsy

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Differential diagnosis

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Case (continued)
 JF is a 57 YOM with T2DM who presented to the ED complaining of painful, swollen right ankle. He stated
that he tripped and sprained his ankle 3 days ago. The ankle became increasingly painful over the next 3
days to the point where he couldn’t bear weight on it. He stated that a blister developed after the injury,
which he lanced and drained himself.
 Initial Examination:

 Temp 100.9oF, WBC 25.5 with left-shift at 93.8% granulocytes, SCr: 4.13, all other labs: WNL

 Right ankle edema and ecchymosis over lateral surface of the leg, tender to palpitation

 Mild cellulitis was present from distal foot to ankle

 JF could move all digits, but hemorrhagic bullae were noted on medial aspect of foot and leg

 Imaging studies:

 X-ray: no evidence of gas

 CT: discrete hypodensities in muscle of the anterolateral and posterior leg compartments 20

 Ultrasound: R/O DVT

 Treatment process 1
 Surgical debridement:

 deep pain with patchy areas of surface

hypoesthesia, crepitation, or bullae and skin
necrosis
 Make extensive incisions through the skin and
subcutaneous tissues, beyond the area of
involvement until normal fascia is found
 Leave wound open

 A “second-look procedure” is common 24 hours later

to ensure adequacy of the initial debridement

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Treatment process – Empiric therapy 1
 Combination therapy:

 Vancomycin + piperacillin-tazobactam +/- clindamycin

 Vancomycin + meropenem +/- clindamycin

 Vancomycin + cefepime + metronidazole +/- clindamycin

 Vancomycin + aztreonam + metronidazole +/- clindamycin

 If intolerant to vancomycin, administer linezolid or daptomycin until assessment of resistant gram-positive

pathogens is completed

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Treatment process – Narrowed therapy 1
 For Polymicrobial:

 Vancomycin + piperacillin-tazobactam

 For Monomicrobial:

 MSSA: Cefazolin/Nafcillin/Oxacillin

 MRSA: Vancomycin

 Streptococcus pyogenes: Penicillin + Clindamycin

 Clostridial species: Penicillin + Clindamycin

 Vibrio vulnificus: Doxycycline + Ceftriaxone/Cefotaxime

 Aeromonas hydrophila: Doxycycline + Ceftriaxone/Ciprofloxacin

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Treatment process
 Treat intravenously initially

 Transition to oral therapy once clinically improved

 cleared bacteremia?

 Evidence of endocarditis? or metastatic abscess?

 Treatment duration:

 Continue until done debriding

 Dependent on what else going on: osteomyelitis? endocarditis?

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Case (continued)
 JF is a 57 YOM with T2DM who presented to the ED complaining of painful, swollen right ankle. He stated
that he tripped and sprained his ankle 3 days ago. The ankle became increasingly painful over the next 3
days to the point where he couldn’t bear weight on it. He stated that a blister developed after the injury,
which he lanced and drained himself.
 Complaints:

 Pain and numbness in foot, pulses were non-palpable

 Treatment:

 IV Vancomycin + piperacillin/Tazobactam + Ciprofloxacin

 Culture:

 Beta-hemolytic streptococcus + Staphylococcus aureus

 Surgery:

 Watery discharge noted in all compartments of fascia; above the knee amputation; hip disarticulation 25
Question
 JF is a 57 YOM with T2DM who presented to the ED complaining of painful, swollen right ankle. He stated
that he tripped and sprained his ankle 3 days ago. The ankle became increasingly painful over the next 3
days to the point where he couldn’t bear weight on it. He stated that a blister developed after the injury,
which he lanced and drained himself.
1. What are 4 predisposing factors for JF?

a. ………………………………….

b. ………………………………….

c. ………………………………….

d. ………………………………….

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Question
 JF is a 57 YOM with T2DM who presented to the ED complaining of painful, swollen right ankle. He stated
that he tripped and sprained his ankle 3 days ago. The ankle became increasingly painful over the next 3
days to the point where he couldn’t bear weight on it. He stated that a blister developed after the injury,
which he lanced and drained himself.
1. What are 4 predisposing factors for JF?

a. IVDU

b. T2DM

c. Hepatitis C

d. Elevated creatinine

e. On immunosuppressive therapy due to transplant

f. Multi-organ failure and sepsis

g. PAD 27
BMH - Cellulitis order set

#1

#2

#3

#4

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BMH - Cellulitis order set

#5

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Other therapies
 IVIG

 Hyperbaric oxygen (HBO)

 Plasma exchange

 Pros vs. Cons

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Necrotizing Fasciitis
Chidiebere Eze, PharmD
March 16, 2018
References
1. IDSA SSTI guidelines. Clinical Infectious Diseases; 2014 ; 59 : 10 -52

2. Beta-hemolytic streptococcus. Survey report findings. CDC. 2015. Available at:

https://www.cdc.gov/abcs/reports-findings/survreports/gas15.html Accessed on: January 17, 2018
3. File Jr TM, Tan JS, DiPersio JR. Group A streptococcal necrotizing fasciitis. Diagnosing and treating the
“flesh-eating bacteria syndrome”. Cleve Clin J Med 1998; 65(5):241-9.
4. Korhan T, Neslihan C, Athan C, et al. Idiopathicnecrotizing fasciitis: Risk factors and strategies for
management. Am Surgeon. April 2005;71:315-320
5. Liu Y, ChiC, Ho M, et al. Microbiology and factors affecting mortality in necrotizing fasciitis. J Microbi
Immunol Infect. July 2005;38:430-435
6. Aragon-Sanchez J, Quintana-Marrero Y, Lazaro-Martinez J, et al. Necrotizing soft tissue infections in the feet
of patients with diabetes: Outcome of surgical treatment and factors associated with limb loss and
mortality. The International Journal of Lower Extremity Wounds 2009;8(3);141-146

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