坏死性筋膜炎

坏死性筋膜炎是一种危及生命的皮下软组织感染，需要有高度警惕性才能诊断。

病因学上，感染可能为混合厌氧/兼性厌氧菌所致的多种微生物感染（I 型），或者是由于单一病原体（II 型）所致，最常见的是化脓性链球菌（也称为 A 族链球菌）。

对于出现软组织感染伴感染部位上方显著疼痛和/或感觉麻木，或者出现全身毒性体征或症状的患者，均应怀疑坏死性筋膜炎。

可疑罹患坏死性筋膜炎的体征包括：出现低血压和/或肌酐升高、肌酸激酶 (CK) 升高、C 反应蛋白升高 (＞124 nmol/L [13 mg/L])、白细胞计数 (WBC) 升高伴有显著核左移和/或低碳酸氢根血清浓度。

没有实验室检查或影像学检查（单独使用或联合使用）对确诊或排除坏死性筋膜炎有足够的敏感性和特异性。

一旦怀疑该诊断，应尽快进行外科急会诊。在等待微生物培养及影像学检查结果时，不能延误治疗。

外科清创是确定性治疗，必要时可反复清创。抗生素治疗至关重要，但被认为是外科手术的辅助治疗。经验性使用抗生素应覆盖主要的细菌性病原体以及 A 族链球菌（II 型坏死性筋膜炎可伴有 A 族链球菌产生毒素）。

坏死性筋膜炎是一种危及生命的皮下软组织感染，可累及深筋膜，但不累及肌肉层。致病菌可能为需氧菌、厌氧菌或混合菌。有两种主要的临床类型。I 型坏死性筋膜炎由多重微生物感染所致，包括厌氧菌（例如拟杆菌属或消化链球菌属）以及兼性厌氧菌（例如肠杆菌科或非 A 族链球菌）。[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 Sep 12;347(11):831-7. 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 Feb;68(2):109-16. http://www.ncbi.nlm.nih.gov/pubmed/11842952?tool=bestpractice.com [3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.] http://www.ncbi.nlm.nih.gov/pubmed/15817551?tool=bestpractice.com [4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[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 Jul 15;59(2):e10-52. https://academic.oup.com/cid/article/59/2/e10/2895845 http://www.ncbi.nlm.nih.gov/pubmed/24973422?tool=bestpractice.com II 型坏死性筋膜炎多由单一微生物感染所致，致病菌为化脓性链球菌（A 族链球菌）。[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 Sep 12;347(11):831-7. 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 Feb;68(2):109-16. http://www.ncbi.nlm.nih.gov/pubmed/11842952?tool=bestpractice.com [3]Hasham S, Matteucci P, Stanley PR, et al. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3. [Erratum in: BMJ. 2005 May 14;330(7500):1143.] http://www.ncbi.nlm.nih.gov/pubmed/15817551?tool=bestpractice.com [4]Pasternack MS, Swartz MN. Cellulitis, necrotizing fasciitis, and subcutaneous tissue infections. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier; 2015:1194-215.[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 Jul 15;59(2):e10-52. https://academic.oup.com/cid/article/59/2/e10/2895845 http://www.ncbi.nlm.nih.gov/pubmed/24973422?tool=bestpractice.com [6]Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. 1996 Jan 25;334(4):240-5. http://www.ncbi.nlm.nih.gov/pubmed/8532002?tool=bestpractice.com 其他感染性病因很少引起可能与特定暴露或危险因素（例如：与嗜水气单胞菌相关的淡水暴露、盐水暴露或与创伤弧菌相关的进食生牡蛎）相关的单一微生物坏死性感染。