A life-threatening subcutaneous soft-tissue infection that requires a high index of suspicion for diagnosis.
Infection may be polymicrobial in aetiology (type I) due to mixed anaerobic/facultative anaerobic organisms, or due to a single organism,
Streptococcus pyogenes
, also called group A streptococcus (type II).
Necrotising fasciitis should be suspected in any patient with a soft-tissue infection accompanied by prominent pain and/or anaesthesia over the infected area, or signs and symptoms of systemic toxicity such as fever or hypothermia, tachycardia, tachypnoea, and/or hypotension.
Diagnosis should be aggressively pursued by surgical consultation. Treatment should not be delayed while awaiting microbiological and imaging investigations.
Indications for hospital admission for patients with soft-tissue infection may include the presence of SIRS (systemic inflammatory response syndrome). Hospital admission is essential for patients presenting with suspected necrotising fasciitis. Signs that raise suspicion for necrotising fasciitis include the presence of hypotension and/or elevated creatinine, elevated CK, elevated C-reactive protein (>124 nanomol/L [13 mg/L]), elevated WBC count with marked left shift, and/or low serum bicarbonate.
Definitive treatment is surgical debridement, repeated as necessary. Adjunctive antibiotic therapy is a crucial aspect of management, and should provide coverage for the major bacterial aetiological agents, as well as consideration of streptococcal toxic shock that can often accompany type II necrotising fasciitis.
Necrotising fasciitis is a life-threatening subcutaneous soft-tissue infection that may extend to the deep fascia, but not into the underlying muscle. The causal organisms may be aerobic, anaerobic, or mixed flora. Two main clinical forms exist. Type I necrotising fasciitis is a polymicrobial infection with an anaerobe such as
Bacteroides
or
Peptostreptococcus
and a facultative anaerobe such as an Enterobacteriaceae or non-group A streptococcus.
[1]
Hoadley DJ, Mark EJ. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 28-2002. A 35-year-old long-term traveler with a rapidly progressive soft-tissue infection. N Engl J Med. 2002;347:831-837.
http://www.ncbi.nlm.nih.gov/pubmed/12226155?tool=bestpractice.com
[2]
Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68:109-116.
http://www.ncbi.nlm.nih.gov/pubmed/11842952?tool=bestpractice.com
[3]
Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005;330:830-833. [Erratum in: BMJ. 2005;330:1143.]
http://www.ncbi.nlm.nih.gov/pubmed/15817551?tool=bestpractice.com
[4]
Swartz MN, Pasternack MS. Cellulitis and subcutaneous tissue infections. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 6th ed. Philadelphia, PA: Elsevier; 2005:1172-1194.
[5]
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10-e52.
http://cid.oxfordjournals.org/content/59/2/e10.full
http://www.ncbi.nlm.nih.gov/pubmed/24973422?tool=bestpractice.com
Type II necrotising fasciitis is most commonly a monomicrobial infection with
Streptococcus pyogenes
(group A streptococci).
[1]
Hoadley DJ, Mark EJ. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 28-2002. A 35-year-old long-term traveler with a rapidly progressive soft-tissue infection. N Engl J Med. 2002;347:831-837.
http://www.ncbi.nlm.nih.gov/pubmed/12226155?tool=bestpractice.com
[2]
Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68:109-116.
http://www.ncbi.nlm.nih.gov/pubmed/11842952?tool=bestpractice.com
[3]
Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005;330:830-833. [Erratum in: BMJ. 2005;330:1143.]
http://www.ncbi.nlm.nih.gov/pubmed/15817551?tool=bestpractice.com
[4]
Swartz MN, Pasternack MS. Cellulitis and subcutaneous tissue infections. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 6th ed. Philadelphia, PA: Elsevier; 2005:1172-1194.
[5]
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10-e52.
http://cid.oxfordjournals.org/content/59/2/e10.full
http://www.ncbi.nlm.nih.gov/pubmed/24973422?tool=bestpractice.com
[6]
Centers for Disease Control and Prevention. Active bacterial core surveillance (ABCs) report, Emerging Infections Program Network, group A streptococcus, 2006. January 2008. http://www.cdc.gov/ (last accessed 4 July 2016).
http://www.cdc.gov/abcs/reports-findings/survreports/gbs06.pdf
[7]
Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. 1996;334:240-245.
http://www.ncbi.nlm.nih.gov/pubmed/8532002?tool=bestpractice.com
