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Necrotizing fasciitis

Definition
Necrotizing fasciitis is a rapidly progressive and life-threatening infectious disease involving the skin fascia and subcutaneous tissue.
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Pathophysiology
Typical microbiological etiologies include Group A Streptococcus (48%), S. aureus (22%), gram-negative bacteria (21%), Clostridium species (5%), and anerobic organisms (3%). A port of entry for infection may result from a traumatic injury, surgical intervention, or minor skin or mucosal breach (including skin tears, abrasions, lacerations, and insect bites).
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Epidemiology
The estimated incidence of necrotizing fasciitis is 4 cases per 100,000 person-years in the US. Immunosuppression, diabetes mellitus, liver cirrhosis, and malignancy increase the risk of necrotizing fasciitis.
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Disease course
Exotoxins released by pathogens cause local tissue damage resulting in erythema and swelling, which further progresses to eccyhmoses and bullae. Platelet-leucocyte aggregation causes microvascular occlusion, with involvement of deeper tissues and larger venules and arterioles, leading to necrosis, sepsis, shock, multiorgan failure, and death.
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Prognosis and risk of recurrence
In the US, the overall mortality rate for necrotizing fasciitis-related death is 0.48 per 100,000 person-years.
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Key sources
The following summarized guidelines for the evaluation and management of necrotizing fasciitis are prepared by our editorial team based on guidelines from the Surgical Infection Society Europe (SIS-E/WSES 2018), the Eastern Association for the Surgery of Trauma (EAST 2018), and the Infectious Diseases Society of America (IDSA 2014).
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Guidelines

1.Screening and diagnosis

Clinical presentation: suspect necrotizing soft tissue infection in patients with pain out of proportion to clinical findings, edema extending beyond zones of skin erythema, rapid progression of disease, and fever.
B
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2.Classification and risk stratification

Severity assessment: classify patients with necrotizing soft tissue infections according to risk of poor outcome. Scores used for severity assessment of patients with necrotizing infections may be useful in the emergency room or outside the ICU and may identify patients who require early surgical treatment and perioperative intensive care management.
B

3.Diagnostic investigations

Diagnostic imaging: consider obtaining diagnostic imaging to provide useful information when the diagnosis of necrotizing fasciitis is uncertain
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while not delaying surgical consultation and intervention.
B
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4.Medical management

General principles
Ensure a multidisciplinary team approach in the management of patients with necrotizing soft tissue infection.
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Initiate treatment of necrotizing infection early because of the rapid progression of the inflammatory process.
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Initiate early and aggressive supportive treatment to halt the progression of the inflammatory process.
A

More topics in this section

  • Empiric antibiotic therapy

  • Antitoxin therapy

  • Duration of antibiotics

  • IVIG

  • Immunomodulatory agents

5.Therapeutic procedures

Negative pressure wound therapy: consider offering negative pressure wound therapy for wound care after complete removal of necrosis in patients with necrotizing soft tissue infection.
B

6.Surgical interventions

Surgical source control: as per EAST 2018 guidelines, perform early initial debridement within 12 hours of diagnosis in patients with necrotizing soft tissue infection.
B

More topics in this section

  • Surgical re-exploration

7.Specific circumstances

Patients with Fournier's gangrene
Initiate appropriate antibiotic therapy, provide hemodynamic support, and perform early debridement in patients with Fournier's gangrene.
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Consider fecal diversion, either by colostomy or fecal tube system, with or without negative pressure therapy, in patients with Fournier's gangrene in whom fecal contamination is present.
C