Necrotizing Fasciitis

BY
Hosam Mohammad Hamza, Msc

GENERAL SURGEON & ENDOSCOPIST

MINIA FACULTY OF MEDICINE
MINIA- EGYPT
Outline
• Definition
• Causes.
• Pathophysiology.
• Clinical features.
• Diagnosis
• D.D.
• Complications.
• Treatment
 Definition
A progressive life-threatening soft-
tissue infection (with liquifactive
necrosis of subcutaneous fat and
fascia) ± skin .
Cheng NC, Su YM, Kuo YS, Tai HC, Tang
YB. Factors affecting the mortality of necrotizin
g fasciitis involving the upper extremities. Surg
Today. 2008;38(12):1108-13.
Early reports date back to the 5th century
B.C. , when Hippocrates described a
complication of erysipelas.
The term “ necrotizing fasciitis” was first
used on 1952
Causes
• Surgery may induce local tissue injury and
bacterial invasion (e.g. intraperitoneal or perianal
abscesses)

• Trauma.

• IM injections.

• Local hypoxia with systemic illness

(immunosuppression or DM  compromise of the fascial
blood supply) Schwartz’s principles of surgery, 9th ed.

• A possible relationship between the use of NSAIDs

(as ibuprofen) and development of necrotizing
fasciitis during varicella infections has been
shown.
Zerr DM, Alexander ER, Duchin JS, et al. A case-
control study of necrotizing fasciitis during
primary varicella. Pediatrics. Apr 1999;103(4
Pt 1):783-90.
Idiopathic necrotizing fasciitis
• No obvious portal of entry.
• typically involves genetalia
(Fourniere Gangrene) or lower
extremities.
• caused by single organism (e.g.
Strep. pyogenes)
• May be due to unrecognized
breaks in skin or hematogenous
spread
 Pathophysiology
• 1ry site of pathology is the superficial
fascia.

• Surgery / Trauma  tissue hypoxia  PMNL

dysfunction  good environment for facultative
aerobes more ↓ oxidation  proliferation of anae
robic bacteria angiothrombotic microbial
invasion  liquefactive necrosis

• Microbiology:
- Group A haemolytic streptococci.
- Staph. Aureus.
- Others : Bacteroides, Clostridium, and (Vibrio
vulnificus often in chronic liver D.)
- Fungi (Rare and less aggressive forms)SCH
• Aerobic metabolism Co2 + H2O.
• Anaerobic metabol.  H, N, H2S.
Type I
- Polymicrobial (aerobic and anaerobic)
- Common with DM and PVD, after surgical
procedures
Type II
- Monomicrobial (primarily by GAS,
occasionally caused by community-
associated MRSA).
Clinical features
 ♂ : ♀ ratio = 2-3 : 1, adult or elderly.
 History of recent trauma or surgery.
 sudden onset of pain and swelling.

hours to days

anaesthesia.
 Early Diagnosis can be challenging as
physical findings may be out of proportion
with degree of patient discomfort (high
degree of suspicion is mandatory).
 Physical findings

• Toxaemia (esp. late)

• area of erythema quickly spreads into
normal skin without
sharp demarcation

dusky or purplish skin multiple identical patches of

gangrenous skin
- large area of skin gangrene.
- Bullae with putrid
- Fever. discharge.
- Shock. - Local crepitus (infrequent)
- MOF - Fascial necrosis.
- Without ttt  myonecrosis.
Important distinguishing features:
(SABISTON’S TEXTBOOK OF SURGERY)
- wooden hard feel of subcutaneous Tissue.
while yeilding in cellulitis and erysipelas.
- If an open wound  probing allows easy
dissection of superficial fascial planes
beyound wound margins with little pain.
CLINICAL STAGES OF NECROTISING FASCIITIS
A. This patient developed pain on
moving the rt hip with cellulitis 2
weeks after total colectomy.
B. Cellulitis didn’t respond to medical
ttt, and surgery was done
showing dishwater oedema of sc
tissue.
C. Muscles were viable.
Source: Brunicardi FC, Andersen
DK, Billiar TR, Dunn DL:
Schwatrz’s Principles of
Surgery. 9th ed. All rights
reserved
Can affect any part of body
- Scalp/Periorbital: trauma, eyelid
infections.
- Face/Neck: progressive dental
infections, peritonsillar abscess,
salivary gland infections, cervical - Trauma
adenitis, otologic sources - drug abuse
- insect bites (r
post-op complication of abd surgery
Complication of percutaneous catheter
placement: chest tube or percutaneous drain of
abd. abscess

• Perineum:
- neglected ischiorectal/perineal abscess.
• Vulva:
- Bartholin’s gland duct abscess
- vulvar abscess
- post-op wound infection from C-section or
episiotomy.
• Fourniere gangrene:
- GU infection or surgery.
- traumatic instrumentation
 Diagnosis
It is mainly a Clinical Diagnosis.
LAB: LRINEC
Lab Risk Indicator for NECrotizing fascii.
PARAMETER POINTS
CRP > 150 mg/L 4

Leucocytosis 15 – 25 X 103 1
> 25 X 103 2
Hb 11 – 13 g% 1
< 11 g% 2
Serum Na < 135 Meq / L 2

Serum Glucose > 180 mg % 1

> 6 should raise suspicion of NF
> 8 is highly predictive of NF Imaging
PLAIN X RAY of an established
case of necrotizing fasciitis of
lower limb (stage 3) showing:
1- Soft tissue thickening
2- Subcutaneous gas
 • Imaging techniques ( such as MRI )
and frozen section biopsies, have been
reported to be of value in early recogni
tion of necrotizing fasciitis.
Curr Opin Infect Dis 18:101–106. # 2005 Lippincott
Williams & Wilkins.

-acute inflammatory cells in

the necrotic tissue.
- Bacteria are located in the
haziness of their cytoplasm.
- Obliterative thrombosis of
a,v
 D.D
Clinical Type 1 Type 2 Gas Pyomyo Myositis
Findings Gangren sitis viral/
e parasitic

Fever ++ ++++ +++ ++ ++

Diffuse + + + + ++++
Pain
Local ++ ++++ ++++ ++ ++
Pain
Systemi ++ ++++ ++++ + +
c
Toxicity
Gas in ++ - ++++ - -
tissue
Obvious ++++ + ++++ - -
portal of
entry
DM ++++ + - - -
 Complications:
- Overall mortality is up to 30% from:
• MOF
• Septic shock.
• Toxic shock syndrome (TSS)
- Contributing factors:
* Old age. * DM. * Missed early diagnosis.
* Trunkal invol. * Anorectal invol.
* Late pres. * Failure after 1st op.
File TM, Tan JS. Group A strept. necrotizing
fasciitis. Compr Ther. 2000;26(2):73-8.
Treatment
• Delay in diagnosis and treatment of
necrotizing fasciitis increases mortality
McHenry CR, Piotrowski JJ, Petrinic D,
Malangoni MA. Determinants of mortality i
n necrotizing soft tissue infections. Ann Sur
g 1995; 221:558–563.

• Aggressive ttt is needed even for

suspected cases to reduce mortality.
 • ABC.
• Antibiotics as soon as possible (aerobic and
anaerobic bacteria)
• Surgery:
- Aggressive resuscitation followed by aggressive
debridement of all necrotic tissue.
- may need to be repeated (careful daily postop inspection).
- fasciotomies in extremities.
- Amputation for myonecrosis in limbs
• Postop use of unprocessed honey
- Stimulates epithelialization.
- Debrides
- Deodourizes wound
- Dehydrates
Akram Rajiput, Waseem Abul Samad, Mortality in
necrotizing fasciitis. J Ayub Med Coll Abbottabad
2008; 20(2)
• IV IG (UNDER STUDY)
• Hyperbaric oxygen therapy
(HBO)
- Def. = use of 100 % O2 at +++
pressure (3 AP).
- ↑ normal O2 saturation in infected
wounds by a thousand fold:
 bacteriocidal effect.

 ↑ PMN function
 ↓ clostridial α toxin
production.

 enhanced wound healing.

Mulla ZD. Hyperbaric oxygen in
necrotizing fasciitis. Plast
Reconstr Surg. Dec 2008;122 (6):
1984-5.
 Hyperbaric oxygen therapy

Indications Contraindications

-Air embolism - Untreated pneumothorax

-CO poisoning - Asthma
-Necrotizing soft tissue - COPD
infections - Eustachian tube dysfunction
-Gas gangrene - Pregnancy
-Crush injury - Claustrophobia
-Decompression sickness
-Enhancement of healing in
selected wounds
-Osteomyelitis (refractory)
-Compromized skin grafts
 HBO cannot replace surgery. The best
outcome is obtained using a combined
approach of antibiotics, surgery, and HBO,
when readily available.