Necrotizing Fasciitis
Published on Nov 18, 2015
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PRESENTATION OUTLINE
NECROTIZING FASCIITIS
TYSON BARBER, LAUREN CAMP, MELVA ADAMS, USHA IYER, CHRISTINA
NECROTIZING FASCIITIS IS AlSO KNOWN AS
- Necrotizing Soft Tissue Infection
- Necrotizing fasciitis of the scrotum or vulva
- Necrotizing fasciitis of the submandibular space
- Flesh-eating skin disease
WHAT IS NECROTIZING FASCIITIS?
- It is an uncommon but life-threatening infection.
- It is defined as necrotizing infection involving the dermis, subcutaneous tissue, fascia, or muscle
VARIOUS BACTERIA INVOLVED
- Type I - polymicrobial infection with aerobic and anaerobic bacteria; usually in patient's with immunocompromise or chronic infection.
- Type II - Group A Streptococcus (GAS) occurs in any age group and in otherwise healthy people; occasionally accompanied by a staphylococcal infection.
- Type III - Gram Negative monomicrobial infection including Vibrio support. and Aeromonas hydrophila, which can occur following seawater contamination of wounds, injuries involving fish fins or stings, and raw seafood consumption.
- Type IV - Fungal Infections such as Zygomycetes after traumatic wounds or burns or candidal infection in immunocompromised patients.
We determined that our patient's NF was caused by Type II beta-hemolytic streptococcus also known as Group A Streptococcus. Bacteria spreads through the skin, subcutaneous tissue, and fascia aided by the release of hyaluronidase, collagenase, streptokinase, and lipase. If these toxins and enzymes are not stopped tissue necrosis and thrombosis will result.
EPIDEMOLOGY
- According to the CDC, 10,000 - 15,000 cases of invasive Group A Streptococcus cases are reported annually in the United States.
- The incidence in the UK is estimated at 500 new cases each year.
- In a 1994, approximately 15 people in Britain had developed the disease and 11 of them died. In the US, a handful of NF cases were reported in California, Colorado, Connecticut, Florida, Michigan, New York, and Georgia.
- In 1924, 20 cases were described in China.
RISK FACTORS
- Skin injury, including insect bite, trauma, or surgical wounds.
- Underlying conditions including alcohol abuse, IV drug use, chronic liver or renal disease, diabetes, malignancy, immunosuppression, and possibly TB.
- In children, it may follow varicella zoster infection.
SIGNS AND SYMPTOMS
- Days 1-2: local pain, swelling, and erythema (redness). Severe, constant pain, out of proportion to the physical signs, no response to antibiotics, poorly defined margins of infection, fever, dehydration, malaise, tachycardia.
- Days 2-4: discolored pain, tense edema, pain sensation may progress from intense tenderness to feeling of nothing due to destroyed nerves.
- Day 4-5: hypotension and septic shock, confusion, and apathy.
DIAGNOSIS
- The diagnosis is clinical; exploratory surgery is required regardless of the test results.
LABORATORY RISK INDICATOR for NECROTIZING FASCIITIS
This slide here is the Laboratory Risk Indicatior for Necrotizing Fasciitis. It indicates a robust score capable of detecting even clinically early cases of NF. The variables used are routine measures to assess severe soft tissue infections. Patients with a LRINEC = or > 6 should be carefully evaluated for the presence of NF.
OTHER TEST
- Microbiology: blood cultures, wound swab, Gram stain and culture if the affected tissue, fungal culture if the patient is immunocompromised or a trauma patient.
- Radiology: MRI scan may show tissue involvement but may not accurate, x-ray or CT scan may show soft tissue gas, ultrasound has also been used to show subcutaneous gas.
- Near-Infrared spectroscopy is used to show tissue oxygen saturation; done by the bedside.
MEDICAL CARE
- IV Immunoglobulins
- IV Fluids and Strong Narcotics
- Surgery
- Antibiotics
- Nutritional Support
The patient will be placed in the ICU so that they can receive a strict routine of medical care. This care will involve Lactated Ringer IV fluid, Oxygen Therapy, (maybe even Hyperbaric Oxygen Therapy), cardiac monitoring, aggressive wound care, and adequate nutritional support. Patients suffering from NF are in a catabolic state and require increased caloric intake to fight infection. The calories can be given orally, via Nasogastric tube, Percutaneous endoscopic gastrostomy tube, or IV hyperalimentary.
Photo by quinn.anya
Surgery
- Surgical debridement is the key in treatment and improved survival of NF.
- Debridement occurs daily and is quite extensive.the patient is monitored very closely.
- When the infection is under control the dressing changes require the patient to be under sedation.
- Wound closure is done by secondary suturing, possibly with the addition of skin grafts.
- Vacuum- assisted wound closing devices have been used to assist with healing.
ANTIBIOTICS
- An Aminoglycoside such as Penicillin G and Gentamycin, which damages the cell walls of the bacteria.
- A 4th Generation Cephalosporin such as Imipenem, which
- A Lincosamide such as Clindamycin, if the patient has a penicillin allergy, which works by slowing or stopping the growth of bacteria
- A Nitroimidazole such as Metronidazole, which is effective again anerobic bacteria.
A combination of broad-sprectrum antibiotcs will be started immediately via IV, at large doses. The antibiotics should cover streptococci, staphylococci, Gram-negative bacilli, and anaerobes. *You may need to change your course of ABT once you receive your Gram stain results. Also, be sure to carefully monitor renal function test.
Photo by MTSOfan
COMPLICATIONS
- Death
- Tissue Loss Requiring Skin Graft
- Amputation
- Nerve and Muscle Damage
- Organ Failure
PROGNOSIS
- If detected and treated rapidly, prevents limb loss as well as loss of life.
- Increased mortality rates are associated with diabetics, delayed diagnosis, and poor surgical technique.
Untitled Slide
KNOWN CASES
- Aimee Copeland from Snellville,Georgia May 1, 2013 zipline accident injuring her left calf lead to NF.
- Crystal Spencer from Detroit, Michigan July 2012 leg abscess lead to NF in abdomen.
- Debbie Grosch-Squance from Plymouth, UK 2006 chest infection lead to NF in leg
- Eric Allin Cornell from Boulder, Colorado October 2004 unknown reason for developing NF in left arm and shoulder.
Aimee Copeland of Snellville, Georgia was 24 years old at the time of her accident. She was ziplining with some friends on May1, 2012, when her zipline snapped causing her to fall into Little Tallapoosa River. The river was infected with Aeromonas hydrophilia, which falls under Gram-negative monomicrobial infection, causing her left calf to become infected with the bacteria. She ended up with multiple organ failure, having her left leg,, left foot, and both hands amputated.
Crystal Spencer of Detroit, Michigan was 33 years old at the time of her infection. In July of 2012, she had a leg abscess drained which lead to her dieing from NF of the abdomen. She was also a diabetic.
Debbie Grosch-Squance of Plymouth, UK was a 47 years old at the time of her infection. She lost her right leg after a chest infection lead to NF.
Eric A. Cornell from Boulder, Colorado was 43 years old at the time of his infection. He lost his left arm and shoulder due to NF. He had no wounds.
Crystal Spencer of Detroit, Michigan was 33 years old at the time of her infection. In July of 2012, she had a leg abscess drained which lead to her dieing from NF of the abdomen. She was also a diabetic.
Debbie Grosch-Squance of Plymouth, UK was a 47 years old at the time of her infection. She lost her right leg after a chest infection lead to NF.
Eric A. Cornell from Boulder, Colorado was 43 years old at the time of his infection. He lost his left arm and shoulder due to NF. He had no wounds.
RECAP & QUESTIONS
A patient undergoing a dressing change and wound measuring.
Necrotizing Fasciitis is a fatal, rapidly progressive condion. It is often times misdiagnosed as cellulitis. Causes of NF range from Type I polymicrobial infection, Type II Group A Streptococcal infection, Type III Gram-negative monomicrobial infection, or Type IV fungal infection. Mortality rates for NF range from 30%-76%. The prognosis depends on the delay of diagnosis, broad spectrum antibiotics, and surgical excision of all necrotic tissue.
