Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis

Thirty patients with necrotizing fasciitis were analyzed. The first 20 patients were reviewed from the patient records of the University of Cincinnati Medical Center (Group A). An additional 10 patients from the University of Cincinnati Medical Center and the Medical University of South Carolina were more recently treated (Group B). The 20 patients in Group A had a mortality rate of 50 percent, whereas no deaths occurred in Group B. The age range and race and sex ratios were essentially identical between the groups. The most common site of infection in both groups was the leg or perirectal-perioneal area. Hemolytic streptococcus, Escherichia coli, and Staphylococcus aureus were the most frequently isolated organisms in Group B patients. The most common organisms isolated from patients in Group A were identical to those found in Group B, with the addition of Bacteriodes. The clinical manifestations in Group A patients were most commonly fever, edema, crepitus, gangrene, cellulitis, and pus in the involved area. In Group B patients clinical signs of fever, crepitus, skin anesthesia, and roentgenographic evidence of gas were the most common clinical manifestations. Ninety percent of patients in Group B were found to have roentgenographic evidence of soft tissue gas. Diabetes and atherosclerotic vascular disease occurred in more than 75 percent of all patients in both groups. Patients in Groups A and B were identical in nutritional status at the time of admission to the hospital. The improvement in the rate of survival in patients in Group B can be attributed to earlier diagnosis and referral, immediate and extensive debridement of all involved tissue, and aggressive protein replacement.     

Post-traumatic necrotizing fasciitis

We are reporting the case of a 39-year-old male, without notable previous history except for an important alcoholic and tobacco consumption, who suffered a bicycle accident resulting in a minor wound on the left elbow. The neglected wound evolved extremely rapidly towards a necrotizing fasciitis, which underwent further complications consisting of a heat shock and multivisceral failure that necessitated reanimation procedures. The patient benefited a triple antibiotic therapy (amoxicillin-clavulanic acid, ornidazole and levofloxacin) and an extensive surgical debridement. The progression was then slow but favourable. The patient is now in functional reeducation. This observation illustrates the rate of evolution of the lesions caused by necrotizing fasciitis and reminds on the importance of prompt therapy.     

Craniocervical necrotizing fasciitis

Craniocervical necrotizing fasciitis (CCNF) is a severe, progressive bacterial infection of the cervical fascia. The most significant manifestations of this disease are extensive fascial necrosis with widespread undermining of the surrounding tissues and extreme systemic toxicity. We are adding three cases to the 29 previously reported cases of CCNF. We will discuss the regional anatomy, focusing on the relationship of the cervical fascial planes to vital structures. Available data suggest that CCNF is a synergistic infection produced in most instances by a combination of facultative anaerobic and obligate anaerobic organisms. Although antimicrobial therapy should provide broad-spectrum activity against mixed flora, treatment also includes aggressive excision and debridement of involved fascia, subcutaneous tissue, and necrotic skin.     

Retroperitoneal necrotizing fasciitis.

Necrotizing fasciitis is a mixed infection of the skin and subcutaneous tissues with a characteristic clinical and pathological appearance. Early radical surgical excision of all affected tissue is the treatment of choice. In a series of 19 patients with necrotizing fasciitis, bacteriological assessment in 15 confirmed the mixed nature of the infection, with Bacteroides sp. isolated from ten patients. All 12 patients who underwent radical surgical excision survived. A subgroup of patients was identified in whom the appearance of necrotizing fasciitis in the abdomen or perineum was indicative of more extensive disease in the retroperitoneal tissues. Surgical resection of all affected tissue was not feasible in these cases and the outcome was uniformly fatal, giving an overall mortality rate for the series of 37 per cent.     

Severe necrotizing fasciitis]

The pathophysiology of necrotizing fasciitis remains unclear in patients with no apparent immunologic disorders. Between 1987 and 1990 we treated six patients with necrotizing fascitis and septic-toxic multiple organ failure, three patients survived. The mean age was 38 years (25-62). In all patients the primary bacteriological examination revealed streptococcus. Between the first symptoms and an adequate therapy were 4 days in surviving patients and 7 days in patients who died. Four patients showed spread of the gangrene into the adjacent tissue: muscles (n = 3), bowel (n = 2), mediastinum (n = 1). Adequate débridement was not possible or not performed in patients with spread into the abdominal cavity or the mediastinum. These patients did not survive. The duration of intensive care treatment in surviving patients were 14 to 78 days. We conclude that survival of patients with severe necrotizing fasciitis is influenced by the delay before adequate treatment, the localisation of the gangrene and intensive care facilities.     

Odontogenic cervical necrotizing fasciitis

Two cases of cervical necrotizing fasciitis, secondary to dental infection, are presented. It is a potentially life-threatening severe mixed infection with rapidly progressive inflammation and necrosis of the fascia, muscle and fat. Laboratory and CT features are described. CT scan was also useful for progress monitoring during the treatment. Both cases were complicated by mediastinitis with pleural effusions. A successful non-fatal outcome was achieved following multiple surgical interventions, aggressive culture based antimicrobial therapy, multi-specialty approach and intensive supportive care of the patients.     

坏死性筋膜炎研究现状

坏死性筋膜炎(NF)在全世界的发病率呈上升趋势,易误诊并易造成严重并发症和后遗症,致残率和死亡率较高.预防和控制NF发展,关键是提高临床认识,做到早期诊断、及时彻底引流,并配合有效的抗生素治疗及辅助治疗.该文就NF致病因素、危险因素、临床表现及诊断和治疗等研究现状作一综述.     

坏死性筋膜炎研究进展

坏死性筋膜炎是一个发展迅速,以筋膜和皮下组织坏死为特点的感染性疾病,常伴有严重的全身毒血症,死亡率高(12%~35%)。NF根据致病菌分为三种类型,大多数情况下为多细菌混合感染。其风险因素包括糖尿病、免疫抑制、慢性酒精疾病、慢性肾功能衰竭、肝硬化等。疾病早期出现红斑、肿胀、疼痛,中期因皮肤缺血出现水泡,危重患者可表现感染性休克和多器官功能障碍的症状及体征。临床表现是诊断的重要依据,LRINEC得分、CT、超声或MRI可以有助于诊断,手指实验被认为是NF诊断的最佳方法。感染应早期使用广谱抗生素,早期彻底的清创引流是至关重要的。适当营养支持和手术伤口处理对疾病预后起着重要作用。HBO、VSD已证明有助于疾病愈合。     

Pyoderma gangrenosum following AICD implantation: differential diagnosis to necrotizing fasciitis

Pyoderma gangrenosum is rarely seen in the surgical disciplines. In the described case the patient was initially diagnosed with necrotizing fasciitis and admitted to the intensive care unit suffering from septic shock. The automated implantable cardioverter defibrillator (AICD), the suspected focus for infection, had already been removed. Following weeks of broad spectrum antibiotics and wound debridement without clinical improvement the alternative diagnosis of pyoderma gangrenosum was reached. Consequently the patient was treated with immunosuppressive therapy and his condition improved rapidly such that he was ultimately discharged to rehabilitation.     

急性坏死性筋膜炎的早期诊断与治疗

急性坏死性筋膜炎是一种临床少见的坏死性软组织感染 ,其发病急、进展快、全身反应重 ,如不及时诊断治疗 ,常危及生命。笔者自 1990年以来诊疗 6例 ,总结如下。1　材料与方法1 1　病例资料　本组 6例 ,男 5例 ,女 1例 ,年龄 2 1～ 6 7岁。发病诱因 :皮肤挫裂伤 3例 ,下腹部术后 2例 ,无明显诱因1例。感染部位 :上臂和前臂 1例 ,手和前臂 1例 ,腹部 1例 ,下腹部、髋部、大腿和小腿 1例 ,大腿和小腿 1例 ,小腿和足部 1例。术前外院延误诊治 3例。1 2 　临床表现　均于外伤或术后 3～ 4d发病 ,局部肿胀、发红 ,疼痛不明显 ,起水泡 ,有血性渗液 …     

急性坏死性筋膜炎的综合治疗

目的：探讨急性坏死性筋膜炎的综合治疗。方法：回顾2003年7月～2013年7月我院收治的7例急性坏死性筋膜炎患者的,临床特点及综合治疗临床资料进行分析。结果：7例患者均治愈,经过1月～3年的随访,患者愈合后功能恢复良好,生活均能自理,部分患者恢复劳动能力。结论：明确诊断及时切开减压,扩大清创引流,必要时反复清创,延期修复创面并结合全身支持的综合治疗是治疗急性坏死性筋膜炎的关键。     

Anesthetic implications of cervicofacial necrotizing fasciitis

Cervicofacial necrotizing fasciitis is a necrotizing soft tissue infection of face and neck spreading at the level of fascia. It has been described as a putrid ulcer, phagedaena, and hospital gangrene. It has a high mortality rate, and presents a challenge to anesthesiologists who must secure an airway to deliver anesthesia safely. We report a case of cervicofacial necrotizing fasciitis in which the patient underwent repeated radical surgical debridement of face and neck, including a mandibulectomy. These critically ill patients often present with sepsis and multiple system organ failure. Extensive preoperative evaluation, invasive monitoring, and possibly the use of vasopressors and inotropes are essential in treating these patients. The tracheas of these patients should remain intubated after initial debridement. Tracheostomy should be performed early. Antibiotic therapy, nutritional support, early debridement, and hyperbaric oxygen therapy all help to decrease mortality in these patients.