Necrotizing Fasciitis

Necrotizing Fascitiis

Definition
Risk factors
Etiology
Pathophysiology
Epidemiology
Clinical Features
Investigations
Management

Difficult to diagnose
Extremely toxic
Spread rapidly
May lead to limb amputation

Classification
@ Colistridial :
# Necrotizing cellulitis
# Myositis
@ Non-colistridial :
# NECROTIZING FASCIITIS
# Streptococcal gangrene

Necrotizing Fasciitis
It is a progressive, rapidly spreading,
inflammatory infection located in the
deep fascia with 2ry necrosis of the
subcutaneous tissue.

Risk Factors
Immunocompression 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.

Causative Agents
It is a mixed microbial flora:
#
#
#
#

microaerophilic streptococci.
staphylococci.
aerobic gram ve
anaerobes ( peptostreptococi

bacteroids)

Pathophysiology

Mortality & Morbidity

The overall morbidity & mortality is 70
80%
Fourniers gangrene has a reported
mortality as high as 75%

Sex:

Male : Female

3:1

Age:
years.

* the mean age is 38 to 44

* pediatric cases are rare but
reported from countries where
poor hygiene in.

Clinical Features
Symptoms:
*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.

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.

Investigations
Lab: CBC, U&E, Glu, Creatinine, Blood
&
tissue cultures, Urine analysis,
&
ABG.

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.

Investigations (cont.)
Microbiology:
Gram stain & wound culture

Procedures:
Biopsy is the best method to use to obtain
proper cultures for micro-organisms.

Management
If 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.

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.

Further In-Patient Care

1. Surgical debridment.
2. Fasciotomy.
3. H.B.O.

Complications
Renal Failure.
Septic Shock with cardiovascular
collapse.
Scarring with cosmetic deformity.