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Necrotizing Fasciitis
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Necrotizing FascitiisDefinitionRisk
factorsEtiologyPathophysiologyEpidemiologyClinical
FeaturesInvestigationsManagement
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Difficult to diagnoseExtremely toxicSpread rapidlyMay lead to
limb amputation
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Classification @ Colistridial :
# Necrotizing cellulitis # Myositis
@ Non-colistridial :
# NECROTIZING FASCIITIS # Streptococcal gangrene
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Necrotizing Fasciitis
It is a progressive, rapidly spreading, inflammatory infection
located in the deep fascia with 2ry necrosis of the subcutaneous
tissue.
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Risk FactorsImmunocompression illnesses e.g.: DM, Cancer,
alcoholism, vascular insufficiency, organ transplant, HIV or
neutropenia.
Trauma or foreign bodies in surgical wound.
Idiopathic as scrotal or penile necrotizing fasciitis.
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Causative AgentsIt is a mixed microbial flora: # microaerophilic
streptococci. # staphylococci. # aerobic gram ve # anaerobes (
peptostreptococi bacteroids)
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Pathophysiology
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Mortality & MorbidityThe overall morbidity & mortality
is 70 80%
Fourniers gangrene has a reported mortality as high as 75%
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Sex: Male : Female 3:1
Age: * the mean age is 38 to 44 years. * pediatric cases are
rare but reported from countries where poor hygiene in.
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Clinical FeaturesSymptoms: *sudden onset of pain and swelling at
the site of trauma or recent surgery. *in some cases, the symptoms
may begin at the site distant from the initial traumatic insult.
*Fournier's gangrene begin with pain and itching of the scrotal
skin.
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Clinical Features (cont.)Sings: * pt. appears moderately to
severely toxic (but sometimes might looks well) * typically,
erythema that quickly spread over a course of hours to days. * the
redness quickly spread & the margin of infection move out into
normal skin without being raised nor sharply demarcated. *
anesthesia
# Note: *I.M. injections & I.V. infusions may lead to
necrotizing fasciitis. *minors insect bites may set the stage for
necrotizing infections.
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Investigations
Lab: CBC, U&E, Glu, Creatinine, Blood & tissue cultures,
Urine analysis, & ABG.
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Investigations (cont.) Imaging Studies:
# X-ray gas in the subcutaneous fascia planes. ?? D.D. of
subcutaneous gas in a radiograph.
# C.T. demonstrating necrosis with asymmetric fascial thickening
& gas in the tissues.
# MRI.
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Investigations (cont.) Microbiology:
Gram stain & wound culture
Procedures: Biopsy is the best method to use to obtain proper
cultures for micro-organisms.
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ManagementIf streptococci are the identified major pathogens,
the D.O.C is Penicillin-G with clindamycin as an alternative.
To ensure adequate treatment, we have to cover aerobic &
anaerobic bacteria.
The anaerobic coverage can be provided by Metronidazole or 3rd
generation cephalosporin's.
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Management (cont.)Gentamicine combined with clindamycine or
chloramphenicol has been reported as a standard coverage.
Ampicilline may be added to the basic regimen to treat
enterococci if suspected by gram stain.
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Further In-Patient Care
Surgical debridment.
Fasciotomy.
H.B.O.
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Complications
Renal Failure.
Septic Shock with cardiovascular collapse.
Scarring with cosmetic deformity.
