Necrotizing fasciitis

Last Updated: 2019-08-27

Author(s): -

Wilson 1952.

Erysipelas gangraenosum, necrotizing fasciitis, necrotizing fasciitis, streptococcal gangrene.

Severe, very rare, deep, necrotizing infection of the tissue (the skin, subcutaneous tissue, fascia, partly also the musculature) with high lethality.

Pathogen

  • Mostly Streptococcus group A (Streptococcus pyogenes), in 10% common occurrence with Staphylococcus aureus or S. epidermidis.
  • Rare mixed infections (e.g. Bacteroides, Peptostreptococcus spp., Non-A-Streptococcus and Enterococcus, E. coli, Enterobacter, Klebsiella, Proteus, Acinobacter baumannii).
  • Necrotizing myositis is rare. Only 21 cases were documented between 1900 and 1985.
  • Predisposing factors: diabetes mellitus, steroid-containing exteriors, alcoholism, drug abuse, liver cirrhosis, neoplasia, childhood (even without underlying disease, but often after a VZV infection), possibly NSAID.

This can be caused by injuries, surgical wounds, needle bites, bruises, burns and sometimes even insect bites.

  • In the initial stage (first 3-7 days), severe pain (often unjustifiable with local findings) is characteristic. In some cases even no skin changes are visible. In the course of the disease, there is an extensive, oedematous, partly hard redness with plaques and sometimes subcutaneous nodules.
  • Hemorrhagic infarction causes the skin, subcutis and fascia to die. Since nerves also die, clinical painlessness occurs. However, systemic signs of infection often appear at this stage.
  • Clinic.
  • Differential-Bood Count (leukocytosis), CRP, CK, kidney parameters, electrolytes, blood cultures, blood gas analysis and several bacterial smears with antibiogram.
  • Sonography of muscles.
  • CT, MRT.
  • Neck or extremities (lower leg), abdomen and genital area (gangraena acuta genitalium).
  • Joint involvement 
  • coagulopathy of consumption 
  • Toxic Shock Syndrome

In 50% of cases a lethal outcome (sepsis) occurs despite optimal therapy.

  • Always combination of 
  • Extensive surgical debridement (as soon as possible), open wound treatment, in some cases a new necrectomy is necessary in the course of the procedure.

 

  • High-dose antibiotic therapy 
  • After Antibiogram

 

  • Ex juvantibus:
  • Carbapenem (Meropenem) intravenously  20mg/kg bw 3x daily 

 

  • Beta-lactam antibiotic (PenicillinG) intravenously 4 million IU 6x daily.
  • With 
  • Clindamyin (Dalacin C®) p.o. 600 mg 3x daily 
  • With 
  • Vancomycin intravenously 1 g 2x daily (infusion duration 1 hour)

 

  • or 

 

  • Linezolid i.v. 600 mg 2x daily 
  • IVIG: up to 2 g/kg  
  • For streptococcal and clostridial infections: 
  • Hyperbaric oxygenation in the pressure chamber 
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