Burn center management of necrotizing fasciitis

Necrotizing fasciitis is a rapidly progressive soft-tissue infection associated with significant morbidity and mortality. Necrotizing fasciitis is similar to invasive burn wound infection in that diagnosis requires histologic examination of affected tissue and treatment requires aggressive surgical debridement followed by skin autograft. Transfer to a burn center facilitates the management of necrotizing fasciitis, where requisite surgical and nursing expertise is available. We reviewed the experience of one burn center in the management of necrotizing fasciitis over a 5-year period. Ten patients were transferred to the burn center from other medical facilities for care, arriving a mean of 8.9 days after initial hospital admission. The diagnosis was made by a surgical service or consultation before transfer in all cases; initial admission to a medical rather than a surgical service delayed surgery in five cases. All patients had surgical debridement before transfer but required a mean of 5.1 additional operations at the burn center. Although the mean extent of involvement was 14.8% body surface area, the mean length of burn center stay was 34.9 days. Complications were frequent, including pulmonary failure requiring mechanical ventilation (n = 6), renal insufficiency or failure (n = 5), hypotension requiring pressers (n = 4), deep venous thrombosis (n = 3), and pulmonary emboli (n = 1). Overall mortality was 2 of 10 patients (20%). Both fatalities were associated with delay in initial surgical procedure and in transfer to the burn center. The similarity of necrotizing fasciitis and invasive burn wound infection makes the burn center the ideal setting for the treatment of this disease. We advocate the addition of necrotizing fasciitis to the list of conditions currently recognized by the American Burn Association as appropriate for burn center transfer and care.     

Necrotizing fasciitis in a renal transplant patient

We have described a 28-year-old diabetic woman who had necrotizing fasciitis of the perineum three years after receiving a living related renal transplant. The diagnosis of necrotizing fasciitis was made early and she was referred to a tertiary care center where she received radical perineal debridement and aggressive medical and surgical follow-up. Necrotizing fasciitis in a transplant patient is rare; review of the literature shows few cases and no survivors. Our patient has returned to a normal life despite continuation of all immunosuppressive therapy throughout the entire hospital course. In addition, she had a good cosmetic result despite the large necrotic perineal infection. Her survival can be attributed to early diagnosis and referral, immediate and extensive debridement, and aggressive protein replacement.     

Diagnosis of necrotizing fasciitis in children.

Necrotizing fasciitis is a rare but progressive soft tissue infection. This condition is difficult to recognize in the early phase, when it is often confused with cellulitis. We report the cases of four children with necrotizing fasciitis. The initial presentation in these cases was cellulitis. Fever and soft tissue swelling occurred within 24 h and spreading erythema within 4 to 12 h. Radiologic studies of the lesions showed soft tissue thickening. Ultrasonography of the lesions demonstrated distorted, thickened fascia with fluid accumulation. Well-defined, loculated abscesses were demonstrated in two cases. Although typical dusky skin and purplish patches were not found in our cases, necrotizing fasciitis was strongly suspected on the basis of the clinical course and sonographic findings. Ultrasonography also was used as a guide for aspiration of pus. Gram-stained smears and bacterial cultures yielded the pathogens. The choice of antibiotic therapy was made on the results of smears and culture. All patients survived after immediate surgical debridement, intensive antibiotic therapy, and aggressive wound care. In conclusion, ultrasonography provides a rapid and valuable diagnostic modality for necrotizing fasciitis. The pus obtained through sonographically guided aspiration for bacterial culture can allow identification of the pathogenic organisms.     

Necrotizing fasciitis: pathogenesis and treatment

Necrotizing fasciitis is a rapidly progressive, life-threatening infection and a true infectious disease emergency. Despite much clinical experience, the management of this disease remains suboptimal, with mortality rates remaining approximately 30%. Necrotizing fasciitis rarely presents with obvious signs and symptoms and delays in diagnosis enhance mortality. Therefore, successful patient care depends on the physician's acumen and index of suspicion. Prompt surgical debridement, intravenous antibiotics, fluid and electrolyte management, and analgesia are mainstays of therapy. Adjunctive clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulin are frequently employed in the treatment of necrotizing fasciitis, but their efficacy has not been rigorously established. Improved understanding of the pathogenesis of necrotizing fasciitis has revealed new targets for rationally designed therapies to improve morbidity and mortality.     

Necrotizing fasciitis of cryptoglandular infection treated with multiple incisions and thread-dragging therapy: A case report

BACKGROUNDNecrotizing fasciitis is a fulminant necrotizing soft tissue disease with a high fatality rate. It always starts with impact on the deep fascia rapidly and might result in secondary necrosis of the subcutaneous tissue, fascia, and muscle. Thus, timely and multiple surgical operations are needed for the treatment. Meanwhile, the damage of skin and soft tissue caused by multiple surgical operations may require dermatoplasty and other treatments as a consequence. CASE SUMMARYHere, we report a case of 50-year-old male patient who was admitted to our hospital with symptoms of necrotizing fasciitis caused by cryptoglandular infection in the perianal and perineal region. The symptoms of necrotizing fasciitis, also known as the cardinal features, include hyperpyrexia, excruciatingly painful lesions, demonstration gas in the tissue, an obnoxious foul odor and uroschesis. The results of postoperative pathology met the diagnosis. Based on the premise of complete debridement, multiple incisions combined with thread-dragging therapy (a traditional Chinese medicine therapy) and intensive supportive therapies including comprising antibiotics, nutrition and fluids were given. The outcome of the treatment was satisfactory. The patient recovered quickly and achieved ideal anal function and morphology. CONCLUSIONTimely and effective debridement and multiple incisions combined with thread-dragging therapy are an integrated treatment for necrotizing fasciitis.     

Eyelid Necrotizing Fasciitis: What Were the Early Signs?

Background

Necrotizing fasciitis is a rare, life-threatening subcutaneous soft tissue infection that causes massive tissue destruction.

Objectives

To illustrate the warning signs of this condition by reporting a rare case of eyelid necrotizing fasciitis.

Case Report

A previously healthy 22-year-old man presented with a preseptal eyelid infection that spread rapidly despite prompt treatment with several intravenous antibiotics. He developed the characteristic clinical and radiologic features of necrotizing fasciitis, and required surgical debridement to cure the infection. Histology confirmed the diagnosis.

Conclusion

In this article, we suggest the indicators that may enable physicians to think of the development of necrotizing fasciitis in patients with infections of the skin and subcutis.     

Rapidly progressive septic shock,associated with necrotizing fasciitis

A case is presented of a 59-year-old male with rapidly progressive septic shock and necrotizing fasciitis. The patient was admitted in shock with an extensive skin lesion on the anterior chest wall. The history was relatively short and there was only a questionable history of preceding trauma. Necrotizing fasciitis was suspected from the appearance of the lesion. Antibiotics and anti-shock therapy were given but despite this, his condition deteriorated and he died from septic shock. At autopsy, the diagnosis of necrotizing fasciitis was confirmed. The importance of rapid diagnosis and primary surgical therapy is emphasized.     

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections

OBJECTIVE: Early operative debridement is a major determinant of outcome in necrotizing fasciitis. However, early recognition is difficult clinically. We aimed to develop a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections: the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score. DESIGN: Retrospective observational study of patients divided into a developmental cohort (n = 314) and validation cohort (n = 140) SETTING: Two teaching tertiary care hospitals. PATIENTS: One hundred forty-five patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to the participating hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis. Control patients (n = 225) were randomly selected from patients admitted with severe cellulitis or abscesses during the same period. Hematologic and biochemical results done on admission were converted into categorical variables for analysis. Univariate and multivariate logistic regression was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p =.910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively. CONCLUSIONS: The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of > or = 6 should be carefully evaluated for the presence of necrotizing fasciitis.     

Community-acquired necrotizing fasciitis caused by Acinetobacter calcoaceticus: A case report and literature review

A 61-year-old man presented with pain in the abdomen and right lower limb. He had a history of hepatitis B virus-induced liver cirrhosis, but had not been visiting the outpatient clinic and did not receive any medication. Cutaneous necrosis and bulla were observed on his abdomen and right lower limb. The necrotic skin was incised, and he was diagnosed with necrotizing fasciitis. A nonfermentative Gram-negative bacillus infection was confirmed from aspirated fluid and blood cultures. Therefore, meropenem and immunoglobulins were administered. Because necrosis was widespread, surgical debridement was performed. Thereafter, Acinetobacter calcoaceticus infection was confirmed by semi-quantitative PCR using the bullous fluid and blood cultures. Meropenem was administered for 3 weeks, followed by levofloxacin alone for 1 week. The patient's condition improved; therefore, skin grafting was performed as planned and yielded a favorable response. After rehabilitation, the patient could walk without support and infection did not recur. However, he had severe liver cirrhosis and large esophageal varices, and he eventually died from sudden varix rupture.Necrotizing fasciitis is an uncommon soft tissue infection, associated with high morbidity and mortality, and early recognition and treatment are crucial for survival. Acinetobacter is rarely associated with necrotizing fasciitis. Although this is a very rare case of the occurrence of necrotizing fasciitis due to A. calcoaceticus infection, we believe that this organism can be pathogenic in immunocompromised patients such as those with liver cirrhosis by reporting this case.     

Early diagnosis of retroperitoneal necrotizing fasciitis

OBJECTIVE: To report survival of retroperitoneal necrotizing fasciitis in an inmunocompromised patient and to demonstrate early clinical signs that may help in the prompt diagnosis and treatment of this severe infection. DESIGN: Case report and literature review. SETTING: An adult, 18-bed intensive care unit within a university hospital. PATIENT: A 38-yr-old man who had undergone an uncomplicated closed hemorrhoidectomy was readmitted to the hospital on postoperative day 5 for erythema around the hemorrhoidectomy and a dirty brown discharge from the wound. INTERVENTIONS: Early diagnosis of retroperitoneal necrotizing fasciitis, wide and repeated debridement, broad-spectrum antibiotics, and eventual abdominal wall reconstruction. MEASUREMENTS AND MAIN RESULTS: This patient manifested periumbilical and bilateral flank erythema, reminiscent of the pattern of ecchymosis seen in cases of retroperitoneal hemorrhage. The findings demonstrate a variation of Cullen's and Grey Turner's sign, most often found in patients with hemorrhagic pancreatitis. An abdominal radiograph revealed a ground glass appearance with radiolucency outlining the bladder, consistent with retroperitoneal air. The chest radiograph showed mediastinal air extending into the neck. Sharp debridement of the retroperitoneal fat, the right anterior rectus sheath, and the right anterior thigh fascia was required to gain control of the infection. Operative cultures grew a mixed flora with Eschericha coli, beta-hemolytic streptococcus, and Bacteroides fragilis predominating. The hospital course was complicated by hemodynamic instability, renal failure, pneumonia, and a pelvic abscess. The patient ultimately survived and underwent abdominal wall reconstruction with mesh. CONCLUSION: Retroperitoneal necrotizing fasciitis is an uncommon soft tissue infection that is often fatal. Early diagnosis in this case was facilitated by the unique clinical findings of a modified Cullen's and Grey Turner's sign. A review of the limited available literature suggests that survival of retroperitoneal fasciitis is possible with prompt debridement and antibiotic therapy.     

Necrotizing fasciitis: a challenging diagnosis.

The objective of the study was to evaluate our recent experience in diagnosis and management of necrotizing fasciitis. Records of patients who were diagnosed as having necrotizing fasciitis at Al-Ain Hospital in the period between March 2003 and August 2005 were studied retrospectively with regard to clinical features, risk factors, diagnosis, causative organisms, treatment, and outcome. Eleven patients, eight of whom were men of low socio-economic status, were studied. The median age (range) was 46 (8-65) years. The main risk factor was diabetes mellitus in seven patients (64%). The provisional clinical diagnosis was incorrect in seven patients (64%). Pure beta-hemolytic streptococcus group A or B was the causative organism in five patients (46%). Most of our patients underwent multiple surgical debridements with a median range of two (1-11) operations. Two patients died (overall mortality rate 18%). High clinical suspicion is essential for the diagnosis of necrotizing fasciitis. Accurate early diagnosis, aggressive resuscitation, using proper antibiotics, and extensive surgical debridement are essential for a favorable outcome.     

Necrotizing fasciitis: early sonographic diagnosis

Necrotizing fasciitis is a rare, but potentially fatal bacterial infection of the soft tissues. Establishing the diagnosis at the early stages of the disease remains the greatest challenge. We report a case of necrotizing fasciitis involving the upper extremity. Sonography revealed subcutaneous emphysema spreading along the deep fascia, swelling, and increased echogenicity of the overlying fatty tissue with interlacing fluid collections. The patient responded well to early surgical debridement and parenteral antibiotics.     

Necrotizing fasciitis due to appendicitis.

Necrotizing fasciitis, although rare, is one of the more serious, life-threatening complications of missed acute appendicitis. Patients who are predisposed to developing necrotizing fasciitis, regardless of the cause, are typically immunocompromised. We present a case of a 49-year-old immunocompetent female whose diagnosis of acute appendicitis was missed and who subsequently developed necrotizing fasciitis of the abdominal wall and flank. She recovered 1 month after admission due to aggressive surgical and medical therapy.     

A fatal case of necrotizing Aeromonas schubertii fasciitis after penetrating injury

Necrotizing fasciitis is an uncommon but life-threatening condition with a high associated mortality and morbidity. Most infections are polymicrobial, another distinct form of necrotizing fasciitis that occurred by penetrating freshwater trauma, such as fishing or wading in wet fields. Aeromonas species are responsible. The rapidity of the infectious process is similar to that of clostridial infection, but gas production is not a consistent feature. We report a patient who presented with fever, chills, and bullae on left forearm, despite antibiotics and wound debridement; the infection extend to mid humerus with a rapid onset of skin necrosis and progressive sepsis. Aeromonas schubertii fasciitis is particularly virulent. An apparent superficial cellulitis that fails to respond to standard therapy must raise suspicion of a more extensive underlying subcutaneous infection. Aggressive surgical debridement and antibiotic coverage for gram-negative rods are the essential features of treatment. Delay caused by a mistaken diagnosis of cellulitis and subsequent inadequate debridement would likely prove fatal.     

Modern Concepts of the Diagnosis and Treatment of Necrotizing Fasciitis

Background: Necrotizing fasciitis is a potentially fatal infection involving rapidly progressive, widespread necrosis of the superficial fascia. Objectives: The purpose of this collective review is to review modern concepts of the treatment and diagnosis of necrotizing fasciitis. Discussion: Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and the fascia. Although the pathogenesis of necrotizing fasciitis is still open to speculation, the rapid and destructive clinical course of necrotizing fasciitis is thought to be due to multibacterial symbiosis. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is usually polymicrobial, rather than monomicrobial. Although there has been no published well-controlled, clinical trial comparing the efficacies of various diagnostic imaging modalities in the diagnosis of necrotizing infections, magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection. MRI provides unsurpassed soft tissue contrast and spatial resolution, has high sensitivity in detecting soft tissue fluid, and has multiplanar capabilities. Percutaneous needle aspiration followed by prompt Gram's staining and culture for a rapid bacteriologic diagnosis in soft tissue infections is recommended. Surgery complemented by antibiotics is the primary treatment of necrotizing fasciitis. Conclusion: Wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure should be undertaken. Successful use of intravenous immunoglobulin has been reported in the treatment of streptococcal toxic shock syndrome. The use of adjunctive therapies, such as hyperbaric oxygen therapy, for necrotizing fasciitis infection continues to receive much attention.     

Experience with necrotizing fasciitis at a burn care center

Necrotizing fasciitis is a soft tissue infection that causes necrosis of subcutaneous tissue and fascia but usually spares skin and muscle. Management of this condition consists of early diagnosis, broad-spectrum antibiotic coverage, aggressive surgical debridement, wound closure, and intensive supportive care. Mortality estimates reported in the literature have ranged from 20 to 75%. We report the cases of 12 patients treated at the Joseph M. Still Burn Center in Augusta, GA. Because aggressive surgical debridement combined with medical support is required for successful treatment, we recommend that treatment be administered at a burn care center. We performed a retrospective chart review of all patients admitted to our center with a diagnosis of necrotizing fascitis between May 1, 1995, and June 1, 2000. Patients were managed collaboratively by burn surgeons and critical care intensivists in consultation with other appropriate specialists. The mean time from initial diagnosis until transfer to the burn center was 14 days (range, 0-60 d). Complications included pneumonia, heart failure, metabolic abnormalities, anemia, and sepsis. Four (33%) of the 12 patients died, with the primary cause of death being multiorgan failure. Although our sample size is too small to reach statistical significance, the data suggest that early referral to a burn or wound care center improves patient outcome.     

Necrotizing fasciitis

OBJECTIVE

To describe the defining characteristics and treatment of necrotizing fasciitis (NF), emphasizng early diagnostic indications.

QUALITY OF EVIDENCE

PubMed was searched using the terms necrotizing fasciitis and necrotizing soft tissue infections, paired with early diagnosis. Results were limited to human studies in English. Additional articles were obtained from references within articles. Evidence is levels II and III.

MAIN MESSAGE

Necrotizing fasciitis is classified according to its microbiology (polymicrobial or monomicrobial), anatomy, and depth of infection. Polymicrobial NF mostly occurs in immunocompromised individuals. Monomicrobial NF is less common and affects healthy individuals who often have a history of trauma (usually 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 inflammation. However, these are also present in less serious conditions. Hyperacute cases present with sepsis and quickly progress to multiorgan failure, while subacute cases remain indolent, with festering soft-tissue infection. Because the condition is rare with minimal specific signs, it is often misdiagnosed. If NF is suspected, histology of tissue specimens is necessary. Laboratory and radiologic tests can be useful in deciding which patients require surgical consultation. Once NF is diagnosed, next steps include early wound debridement, excision of nonviable tissue, and wide spectrum cover with intravenous antibiotics.

CONCLUSION

Necrotizing fasciitis is an uncommon disease that results in gross morbidity and mortality if not treated in its early stages. At onset, however, it is 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 referral when confronted with cases of pain, fever, and erythema.     

Multiple dimensions of caring for a patient with acute necrotizing fasciitis.

Critical care nurses within acute care settings are responsible for providing healthcare to a wide variety of patients and, consequently, knowledge regarding how to care for a patient with acute necrotizing fasciitis is imperative. A case study is presented to evidence the need for a multidisciplinary approach. Necrotizing fasciitis is defined and treatment options are presented. Caring for this patient is very challenging and demands a multidisciplinary team to coordinate all aspects of care to promote better patient outcomes.     

Hemorrhagic bullae are not only skin deep

Background

Dermatologic complaints are common presentations in the ED. Hemorrhagic bullae are an example of dermatologic manifestation caused by variable etiologies. The life-threatening skin lesion usually is an external sign of a systemic or immune response stimulated by an infection, toxin, medication, or disease process. Although most patient with life-threatening skin lesion, such as hemorrhagic bullae, may appear ill, patients who present in the early course of illness may appear well but deteriorate rapidly. For greater comprehension of hemorrhagic bullae, we prospectively followed 42 patients who presented with hemorrhagic bullae at the ED and analyzed their clinical characteristics and their confirmative diagnoses.

Methods

This is a prospective, observational cohort study conducted at a university-affiliated community hospital. Data were collected from January 2002 to January 2007. Patients presenting to the ED with hemorrhagic bullae were enrolled prospectively.

Results

All of our patients with hemorrhagic bullae had evidence of a serious disease: necrotizing fasciitis (42 case, 100%). The most common comorbidity was diabetes mellitus (18 cases; 42.9%). Vibrio species was the most common organism from blood culture (8/16 cases) and wound culture (17/27 cases). Streptococcal species was found in only 1 patient via blood culture and 4 patients via wound culture. The yield of positive wound culture with Vibrio species was significantly greater than with streptococcal species (P < .05). Fourteen (33.3%) patients came to the ED for help 48 hours later after the onset of hemorrhagic bullae. None of these 14 patients died. In our total of 42 patients, 8 (19%) died.

Conclusion

In our study, the most common causative disease of hemorrhagic bullae was necrotizing fasciitis. Hemorrhagic bullae are a more common clinical feature in Vibrio infection than in streptococcal infection. Hemorrhagic bullae may occur in the early stage of necrotizing fasciitis. Necrotizing fasciitis may be the first sign that emergency physicians come across in patients with hemorrhagic bullae that are not in the oral, genital, anal, ocular area, and high index of suspicion of Vibrio infection should be considered. More aggressive treatment may be needed as hemorrhagic bullae may occur in the early stage of a serious disease. Further multi-institution study may be required to support these findings.