Necrotizing fasciitis: A comprehensive review.

Necrotizing soft-tissue infections (NSTIs) are rare but rapidly progressive, life-threatening bacterial infections with high morbidity and mortality. NSTIs include necrotizing forms of fasciitis, myositis, and cellulitis. This article focuses on necrotizing fasciitis (NF) and discusses NF classifications, clinical features, diagnostic approaches, evidence-based treatments, and nursing interventions.

The Potential Prognostic Significance of the Laboratory Risk Indicator for the Necrotizing Fasciitis (LRINEC) Score in Necrotizing Fasciitis.

Background: We discuss the role of Laboratory Risk Indicator for the Necrotizing Fasciitis (LRINEC) on the prognosis of this disease. Necrotizing Fasciitis (NF) is characterised by rapid spreading of infection and necrosis of the soft tissues and fascia. Methods: Thirty patients (17 male, 13 female, mean age 57.5 years) were treated between 2011- 2016 (in our center); they were analysed retrospectively regarding age, sex, isolated microbiological agents, modalities of treatment and mortality rate. Results: The majority of the infections were detected in the perineum (14 patients). Other sites of infection were: the presacral region (3 patients), as well as abdominal region after elective (10 patients) and emergency surgery (2 patients), respectively. 53.3% of patients had at least one predisposing comorbid factor such as diabetes mellitus, hypertension, cardiomyopathy and congestive heart failure. The tissue cultures were positive in 12 patients. Mean LRINEC score on admission was 8.5 +-2.85. There was a strong correlation between LRINEC score and patient age (p=0.018, R=0.43). LRINEC score was affected by neither gender nor the presence of any comorbidities. The patients were classified according to Wang and Wong staging system, as follows: one patient in stage 1, 15 patients in stage 2 and 14 patients in stage 3. Patients with higher Wang and Wong stages had significantly higher LRINEC scores. The mortality rate was 16.7%. The mean LRINEC score of deceased patients compared to patients who were successfully treated was 9.2Â+-2.2 and 8.36Â+-2.9. Conclusion: Even though LRINEC score and Wang and Wong stage were significatly related with ICU stay, their direct effect on mortality wasn't significant in our study.

High Mortality of Non-Fournier Necrotizing Fasciitis With Enterobacteriales: Time to Rethink Classification?

This cohort study describes mortality predictors of necrotizing fasciitis (NF). Higher age, chronic kidney disease, and higher Charlson score increased the mortality rate. Mortality was >3 times higher in monomicrobial gram-negative NF than in type I or type II NF. Highest mortality was found with Enterobacteriales in non-Fournier NF.

Clinical classification of cervical necrotizing fasciitis.

PURPOSE: Necrotizing fasciitis of the craniofacial region is a rare and potentially life-threatening bacterial infectious disease. Odontogenic infections primarily spread along facial fascia and subcutaneous tissues, resulting in upper chest skin or thoracic necrosis. The purpose of this clinical classification was to demonstrate clinically important guidelines for early diagnosis and prompt management of CNF. METHODS: Although the incidence of cervical necrotizing fasciitis (CNF) is very rare in many developed countries, prompt management with appropriate initial diagnosis is essential, especially in tropical low-economic rural regions of African countries. Over the last 12 years, our charitable team in West Africa made clinical classifications of CNF according to onset time and spreading pattern to thoracic extension. RESULTS: CNF patients could be divided into two primary types, limited to neck type and extended to upper chest type. We also further categorized from each type into three different groups according to the CNF onset and clinical characteristics, including acute type with hematogenous spread within 2 weeks, subacute type with suppuration over 2 to 4 weeks, chronic type without suppuration over 4 weeks, multiple type with partial skin necrosis, island type with necrotic skin coverage, and broad type with whole skin necrosis. CONCLUSIONS: These classifications will help decrease the mortality rate in severely infected patients.

Necrotizing Fasciitis and The Diabetic Foot.

Necrotizing fasciitis (NF) represents a rapidly progressive, life-threatening infection involving skin, soft tissue, and deep fascia. An early diagnosis is crucial to treat NF effectively. The disease is generally due to an external trauma that occurs in predisposed patients: the most important risk factor is represented by diabetes mellitus. NF is classified into 3 different subtypes according to bacterial strains responsible: type 1 associated to polymicrobial infection, type 2 NF, generally associated to Streptococcus species, often associated to Staphylococcus aureus and, eventually, Type 3, due to Gram-negative strains, such as Clostridium difficile or Vibrio. NF is usually characterized by the presence of the classic triad of symptoms: local pain, swelling, and erythema. In daily clinical practice immune-compromised or neuropathic diabetic patients present with atypical symptomatology. This explains the high percentage of misdiagnosed cases in the emergency department and, consequently, the worse outcome presented by these patients. Prompt aggressive surgical debridement and antibiotic systemic therapy are the cornerstone of its treatment. These must be associated with an accurate systemic management, consisting in nutritional support, glycemic compensation, and hemodynamic stabilization. Innovative methods, such as negative pressure therapy, once the acute conditions have resolved, can help fasten the surgical wound closure. Prompt management can improve prognosis of patients affected from NF reducing limb loss and saving lives.

[Plastic-surgical treatment options in necrotising fasciitis]. / Plastisch-chirurgische Therapieoptionen bei der nekrotisierenden Fasziitis.

Necrotising fasciitis (NF) is considered a rare and possibly life-threatening infection of the subcutaneous tissue and of the fascia. A specific characteristic is the rapid progress of the disease associated with considerable local pain. Since laboratory parameters as well as imaging are only unspecific, diagnosis is set up clinically. Even in the case of a serious suspicion, an immediate and radical debridement has to be initiated, accompanied by intensive care and adequate antibiotic treatment. Only after stabilisation of the general physical condition and local - sometimes extensive - wound debridement, can coverage and reconstruction of soft tissue defects be appropriately performed by the measures and procedures of plastic surgery.

Necrotizing cervical fasciitis: Prognosis based on a new grading system.

We conducted a 10-year retrospective study to determine the prognosis of necrotizing cervical fasciitis (NCF). Our study population included 38 patients-32 males and 6 females, aged 10 months to 70 years (mean: 55 yr)-who had presented for management of NCF at our tertiary care hospital between Jan. 1, 2000, and Dec. 31, 2009. We classified each case into four categories based on the duration of disease prior to presentation, the severity of disease, and other factors that influence outcomes. We found that the most important factor in determining prognosis was the time interval between the onset of NCF and subsequent presentation for specialist or surgical intervention. Patients with a higher grade of NCF had longer hospital stays. Although aggressive surgical and medical intervention is the gold standard for the management of NCF, many of our patients presented with a relatively healthy appearing wound, which could mislead the evaluating clinician and delay prompt management. We believe that our new grading system will help obviate this problem and make clinicians more vigilant when faced with a new case of necrotizing fasciitis.

[Pathogenesis, classification and diagnosis of necrotizing soft tissue infections]. / Pathogenese, Klassifikation und Diagnose der nekrotisierenden Weichteilinfektionen.

Necrotizing soft tissue infections are caused by a variety of pathogens and may affect different types of soft tissue. Even today mortality and lethality are very high. The primary symptoms of necrotizing soft tissue infections are local pain out of proportion, swelling, erythema and crepitation in cases of subcutaneous gas. A systemic inflammatory response syndrome (SIRS) is often associated. During the last decades early recognition and initiation of an adequate therapy were able to reduce lethality to an average of 20%. The physical examination remains the diagnostic gold standard and may be supported by typical findings of imaging technologies, e.g. subcutaneous gas on x-rays and laboratory tests. After diagnosis an adequate antibiotic and surgical therapy should be performed immediately.

Necrotizing fasciitis: classification, diagnosis, and management.

Necrotizing fasciitis (NF), a life-threatening rare infection of the soft tissues, is a medical and surgical emergency. It is characterized by subtle, rapid onset of spreading inflammation and necrosis starting from the fascia, muscles, and subcutaneous fat, with subsequent necrosis of the overlying skin. Once suspected, immediate and extensive radical debridement of necrotic tissues is mandatory. Appropriate antibiotics and intensive general support avoid massive systemic diffusion of the infective process and are the key for successful treatment. However, early diagnosis is missed or delayed in 85% to 100% of cases in large published series: because of the lack of specific clinical features in the initial stage of the disease, it is often underestimated or confused with cellulitis or abscess. Mortality rates are still high and have shown no tendency to decrease in the last 100 years. Unfortunately, the prevalence of the disease is such that physicians rarely become sufficiently confident with NF to be able to proceed with rapid diagnosis and management. This review covers the literature published in MEDLINE in the period 1970 to December 31, 2010. Particular attention is given to the clinical and laboratory elements to be considered for diagnosis. A wide variety of diagnostic tools have been described to facilitate and hasten the diagnosis of NF, but the most important tool for early diagnosis still remains a high index of clinical suspicion.

Skin and soft-tissue infections: classifying and treating a spectrum.

Skin and soft-tissue infections (SSTIs) are a common presenting problem in both inpatients and outpatients. SSTIs have been broadly classified as complicated or uncomplicated, but specific disease processes and patient characteristics are important in guiding clinical management. Early recognition of the extent of infection, close follow-up, and familiarity with local antibiotic susceptibility data are critical to successful treatment.

Diagnosis and management of necrotising fasciitis: a multiparametric approach.

Necrotising fasciitis (NF) is situated with myositis and myonecrosis at the severe end of a spectrum of skin and soft tissue infections but is far removed from erisepelas, impetigo and cellulitis. Inexperienced clinicians are easily misled by the protean manifestations of infection, especially exotoxin or superantigen mediated consequences from streptococcal NF. Early clinical suspicion and surgery are key to improving survival, and patients with NF need integrated multidisciplinary management, adjusted to the infecting organism(s), the site of infection, and the effects from any toxins produced. A multiparametric approach, incorporating various clinical and laboratory parameters, can aid aggressive management. This review describes the diagnosis and management of the major types of NF, emphasising important aetiological clues from the history and the appropriate usage of diagnostic investigations. The potential benefits of controversial therapeutic approaches, including hyperbaric oxygen and intravenous immunoglobulin, are discussed.

Necrotizing fasciitis of the head and neck: report of 5 cases and review of the literature.

BACKGROUND: Necrotizing fasciitis (NF) is a severe, rapidly spreading soft tissue infection of polymicrobial origin. This condition most frequently affects thorax, abdominal wall, extremities, perineum and groin, but according to recent literature the head and neck area is also involved with increasing frequency. PATIENTS AND METHODS: Five cases of head and neck NF were detected among patients who were admitted at the Department of Otorhinolaryngology-Head and Neck Surgery of the University Hospital of Patras, Patras, Greece, over a 5-years period. Various parameters including patients' health status, co-morbidity, etiology, microbiology, affected area, antibiotic therapy, hospital stay, surgical treatment and complications were considered. CONCLUSIONS: The management of NF should comprise of hemodynamic and respiratory evaluation and monitoring, broad-spectrum i.v. antimicrobial therapy, surgical debridement and nutritional support. Close postoperative management of NF patients remains of paramount importance.

Five cases of necrotizing fasciitis: lack of skin inflammatory signs as a clinical clue for the fulminant type.

Herein, we describe five patients with necrotizing fasciitis (NF) who had variable outcomes and clinical manifestations. At the onset, all patients exhibited purpura with or without blister and ulceration accompanied by severe pain and tenderness in the affected skin. Out of five patients, three lacked inflammatory signs such as redness and heat, and two of the three patients showed fulminant progression and died despite intensive treatments including surgical debridement, antimicrobial therapy, close monitoring and physiological support. Tissue specimens from the patients without skin inflammatory signs showed mild neutrophil infiltration in addition to necrosis from the epidermis to subcutaneous fat, and variable amounts of thrombi. Furthermore, numerous bacteria were detected by Gram stain. By contrast, the remaining two patients with skin inflammatory signs revealed slower progression, and tissue specimens from both patients showed heavy neutrophil infiltration, but bacteria were hardly detected. Therefore, these cases suggest the possibility that the paucity of skin inflammatory signs, such as redness and heat, in NF may be a clinical clue to predict the fulminant type.

What is subacute necrotizing fasciitis? A proposed clinical diagnostic criteria.

OBJECTIVE: Subacute necrotizing fasciitis is a poorly defined clinical entity. Its very existence has been the subject of much controversy. While rarely reported, subacute forms of necrotizing fasciitis have been documented in the literature by many authors. This paper highlights some recently reported cases in the literature that clearly shows that subacute forms of necrotizing fasciitis indeed exist and may in fact be under-reported because of the lack of awareness and a consistent diagnostic criteria. METHODS: A Medline search was performed with the following keyword; necrotizing fasciitis, subacute, variant and indolent. RESULTS: Majority of reported cases did not give sufficient information to satisfy the reviewer that these cases were indeed subacute forms of necrotizing fasciitis. We identified three cases of subacute necrotizing fasciitis that clearly are subacute cases and analysed their clinical presentation. A diagnostic criterion for defining subacute necrotizing fasciitis was proposed based on these cases and the authors' clinical experiences. CONCLUSION: This proposed diagnostic criterion serves to facilitate future reporting and documentation of this condition. The clinical significance and implication of this are discussed.

Necrotising fasciitis: a new management algorithm based on clinical classification.

Necrotising fasciitis is a rare infection of the subcutaneous tissues. If untreated, it is invariably fatal, and thus a high index of suspicion for the diagnosis is required. The disease's manifestation can range from a fulminant presentation to a subtle and insidious development. The priority in every case is to proceed to radical surgical debridement. On review of the literature and based on our clinical experience, we propose a new classification based on clinical presentation and suggest an algorithm to facilitate the management of this devastating condition. Increasing awareness should be given to the management of the large wounds resulting from the surgical debridement of necrotising fasciitis.

[Necrotizing soft tissue infections: nomenclature and classification]. / Infecciones necrosantes de partes blandas: nomenclatura y clasificación.

Terminology used to refer to necrotizing infections is extensive because of the absence of clear definitions and the use of classification systems based on a variety of criteria, including etiologic, microbiologic, anatomic, and clinical aspects. This situation has led to some confusion. In the attempt to unify terminology, it might be more appropriate to use only the terms necrotizing fasciitis and myonecrosis, in which differentiation is mainly anatomical. Another option would be to use only the expression necrotizing soft tissue infections, a non-specific term, since these constitute a group of clinical processes having similar pathophysiologic characteristics and therapeutic principles.

[Necrotizing dermatitis, infections of soft tissue and deep fascia: classification and treatment]. / Martwicze zapalenie skóry, tkanki podskórnej, powiezi glebokiej oraz miesni: klasyfikacja i leczenie.

Nectrotizing fasciitis is a mixed infection of skin and subcutaneous tissue with a characteristic clinical and pathological appearance. Necrotizing soft tissue infections, caused by aerobic, anaerobic and mixed bacterial flora are an increasing problem in medical and surgical practice. The apparently wide variety of these infections is systematized. Etiology and bacteriology are discussed, as the role of surgery, antibiotics and hyperbaric chamber in the treatment of the infections. Early and radical surgical excision of all affected tissue is the treatment of choice. Adjuvant hyperbaric oxygen appears to be important in refractory progressive bacterial gangrene. A combination of hyperbaric oxygen, surgical treatment and antibiotics gives the lowest mortality and morbidity in gas gangrene compared with other treatment modifications. Extensive clinical experience shows the efficacy of these treatment protocols.

Cervical necrotizing fasciitis: a distinct clinicopathological entity?

Necrotizing fasciitis of the head and neck has previously been classified as a homogeneous group. We present two cases of necrotizing fasciitis confined to the neck and demonstrate with a review of the literature that cervical necrotizing fasciitis and craniofacial necrotizing fasciitis are two distinct clinicopathological conditions.