Running head: Necrotizing Fasciitis

Necrotizing Fasciitis
Pablo Pereira
Southern Technical College
May 13, 2016
Esla Barclay-Henry

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Abstract

Necrotizing fasciitis is a rapidly progressive, life-threatening infection, and is very

terrifying. It was most likely discovered in the 1950s after war world two, and was found due to
medical advances in science.

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Necrotizing fasciitis is a rapidly progressive, life-threatening infection involving the skin,

soft tissue and deep fascia (The journal of emergency medicine, 1996). During the 1990s, the
media described necrotizing fasciitis as flesh-eating bacteria, these infections are typically
caused by group A streptococcus, Clostridium perfringens, or a mixture of aerobic and anaerobic
organisms, typically including Group A streptococcus, the Enterobacteriaceae, anaerobes, and
Staphylococcus aureus (The journal of emergency medicine, 1996). Usually infections from
group A strep bacteria are generally mild and are easily treated, but in cased of necrotizing
fasciitis, bacteria spread rapidly once they enter the body (Davis, 2013) They infect flat layers of
a membrane known as the fascia, where the infection damages the tissues next to the fascia
(Davis, 2013). Sometimes toxins made by these bacteria destroy the tissue they infect, causing it
to die (Davis, 2013).When this happens, the infection is very serious and can result in loss of
limbs or death. S. aureus is one of the most common causes of severe community-associated
(community-acquired) infections of skin and soft tissue (The journal of emergency medicine,
1996). Historically, necrotizing fasciitis was described during the United States Civil War by
Confederate Army surgeon Joseph Jones (Medscape, 2015). In 1883, Jean Alfred Fournier
documented necrotizing fasciitis in the perineal and genital area, with Frank Meleney later
reporting on 20 patients that he encountered in China in whom necrotizing fasciitis was caused
by hemolytic streptococcus (Medscape, 2015).
Theoretically, anyone with an infection has a small risk of getting necrotizing fasciitis.
The risk begins to increase if the infection occurs in immunosuppressed individuals (for
example, diabetics, elderly, infants, those with liver disease, or those taking immunosuppressive
drugs such as chemotherapy for cancer) (Centers for disease control and prevention, 2015).

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Visible infections (skin, hair follicles, fingernails, visible trauma sites) are more likely to be
noticed and treated than some deep infections (Centers for disease control and prevention, 2015).
Patients who have any deep infections (muscle, bone, joint, gastrointestinal) are at somewhat
higher risk for the disease because the initial infection and subsequent spread is usually not as
noticeable as more visible infections (Centers for disease control and prevention, 2015).
Although pregnant women rarely develop the disease, the risk increases in the postpartum
period, especially if the mother has diabetes and has procedures such as cesarean delivery (CSection) or episiotomy (Centers for disease control and prevention, 2015). Necrotizing
enterocolitis occurs mainly in premature or sick infants and may be another variant of
necrotizing fasciitis, but there is still controversy about the cause of this disease (Centers for
disease control and prevention, 2015). Necrotizing fasciitis has interesting demographics; more
males than females affected (almost 3-1) (Centers for disease control and prevention, 2015). The
symptoms often start within hours after an injury and may seem like any other illness or injury.
Some people infected with necrotizing fasciitis may complain of pain or soreness, similar to that
of a pulled muscle (Davis, 2013). The skin may be warm with red or purplish areas of swelling
that spread rapidly (Davis, 2013). There may be ulcers, blisters or black spots on the skin (Davis,
2013). Patients often describe their pain as severe and way out of proportion to how the painful
area looks when examined by a doctor (Davis, 2013). Fever, chills, fatigue (tiredness) or
vomiting may follow the initial wound or soreness (Davis, 2013). These confusing symptoms
may delay a person from seeking medical attention (Davis, 2013). Noteworthy, most cases of
necrotizing fasciitis occur randomly and are not linked to similar infections in others. The most
common way of getting necrotizing fasciitis is when bacteria enter the body through a break in
the skin, like a cut, scrape, burn, insect bite, or puncture wound.

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Diagnosis of necrotizing fasciitis can be difficult and requires a high degree of suspicion.
In many cases of necrotizing fasciitis, antecedent trauma or surgery can be identified.
Surprisingly, the initial lesion is often trivial, such as an insect bite, minor abrasion, boil, or
injection site (Medscape, 2015). Laboratory tests, along with appropriate imaging studies, may
facilitate the diagnosis of necrotizing fasciitis. Laboratory evaluation should include the
following: complete blood count with differential, serum chemistry studies, arterial blood gas
measurement, urinalysis, blood and tissue cultures (Medscape, 2015). Skin and superficial tissue
cultures may be inaccurate because samples may not contain infected tissue (Medscape, 2015).
Deep tissue samples, obtained at the time of surgical debridement, are needed to obtain proper
cultures of microorganisms (Medscape, 2015). New techniques include rapid streptococcal
diagnostic kits and a polymerase chain reaction assay for tissue specimens that tests for the genes
of streptococcal pyrogenic exotoxin produced by group A streptococci (Medscape, 2015) Bmode and possibly color Doppler ultrasonography, contrast-enhanced computer tomography
scanning, or magnetic resonance imaging can promote early diagnosis of necrotizing fasciitis. In
addition, these studies permit visualization of the location of the rapidly spreading infection.
More importantly, MRI or CT scan delineation of the extent of necrotizing fasciitis may be
useful in direction rapid surgical debridement (Medscape, 2015). Although the laboratory results
may vary in a clinical setting, the following may be associated with necrotizing fasciitis: elevated
white blood cell count, elevated blood urea nitrogen and reduced serum sodium level (Medscape,
2015). However, when the patient is seriously ill, necrotizing fasciitis is a surgical emergency
with high mortality, therefore, laboratory tests and imaging studies should not delay surgical
intervention.

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Common sense and good wound care are the best ways to prevent a bacterial skin
infection. Keep draining or open wounds covered with clean, dry bandages until they heal, not
delaying first aid of even minor, non-infected wounds like blisters, scrapes or any break in the
skin, avoiding hot tubs, swimming pools and other high bacteria areas while having an open
wound and most importantly by washing hands often with soap and water, or using an alcoholbased hand rub if soap and water or not available.
Once the diagnosis of necrotizing fasciitis is confirmed, initiate treatment without delay
because necrotizing fasciitis is a surgical emergency. The patient should be admitted immediately
to a surgical intensive care unit in a setting such as a regional burn center or trauma center, where
the surgical staff is skill in performing extensive debridement and reconstructive surgery. Such
regional burn centers are ideal for the care of these patients because they also have hyperbaric
oxygen facilities (Medscape, 2015). A regimen of surgical debridement is continued until tissue
necrosis ceases and growth of fresh viable tissue is observed (Medscape, 2015). Unfortunately, if
a limb or organ is involved, amputation may be necessary because of irreversible necrosis and
gangrene or because of overwhelming toxicity, which usually occurs. Prompt surgery ensures a
higher likelihood of survival. Antibiotic therapy is a key consideration; with possible regimens
include a combination of penicillin G and an aminoglycoside, as well as clindamycin (Medscape,
2015).
Untreated necrotizing fasciitis has a poor prognosis; death or severe morbidity (i.e. Limb
loss) is the frequent outcome. Even with appropriate treatment, the death rate can be as high as
25% (Centers for disease control and prevention, 2015). Infection with MRSA and other
antibiotic-resistant organisms tends to have higher morbidity and mortality rates (Davis, 2013).
Combined mortality and morbidity for all cases of necrotizing fasciitis has been reported as 70-

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80% (Centers for disease control and prevention, 2015). The worst complication of this disease is
rapid advancement that results in death with other complications including tissue loss requiring
surgical removal and amputation to limit disease, as well as sepsis, kidney failure, and extensive
scarring.
In conclusion, necrotizing fasciitis is a rapidly progressive, life-threatening infection
involving the skin, soft tissue and deep fascia, where in the early 90s was declared as flesheating bacteria (The journal of emergency medicine, 1996). Were a patient be admitted to a
facility with necrotizing fasciitis, immediate lab and imaging studies would be ordered, and
surgical consultation should take place as soon as humanly possible. Surgical debridement where
biopsies will be taken for lab work will be done, and the patient will be taken to a Critical Care
Unit for close observation. The patient and his or her family members will be informed of the
risks of necrotizing fasciitis, lab tests that will be done, imaging tests that will most likely be
ordered, the surgical procedures that will need to be attempted, and that there is a possibility that
the patient may lose a limb or worse, die.

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Left upper extremity shows necrotizing fasciitis in an individual who used illicit drugs. Cultures grew Streptococcus milleri
and anaerobes (Prevotella species). Patient would grease, or lick, the needle before injection.

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Photomicrograph of Fournier gangrene (necrotizing fasciitis), oil immersion at 1000X magnification. Note the acute
inflammatory cells in the necrotic tissue. Bacteria are located in the haziness of their cytoplasm. Courtesy of Billie Fife, MD,
and Thomas A. Santora, MD.

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Left lower extremity in a 56-year-old patient with alcoholism who was found comatose after binge drinking. Surgical drainage
was performed to treat the pyomyositis-related, large, nonfoul-smelling (sweetish) bullae. Gram staining showed the
presence of gram-positive rods.

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References
Centers for Disease Control and Prevention. (2015, April 17). Necrotizing Fasciitis: A Rare
Disease, Especially for the Healthy| Features | CDC. Retrieved from
http://www.cdc.gov/features/necrotizingfasciitis/
Davis, C. P. (2013, November 13). Necrotizing Fasciitis Symptoms, Causes, Treatment - Who is
at risk to get necrotizing fasciitis? - MedicineNet. Retrieved from
http://www.medicinenet.com/necrotizing_fasciitis/page8.htm
The Journal of Emergency Medicine. (1996, December). Retrieved from www.jemjournal.com/article/S0736-4679(96)00197-7/abstract
Medscape. (2015, July 9). Necrotizing Fasciitis Medication: Antibiotics. Retrieved from
http://emedicine.medscape.com/article/2051157-medication
The New England Journal of Medicine. (2005, April 7). Necrotizing Fasciitis Caused by
Community-Associated Methicillin-Resistant Staphylococcus aureus in Los Angeles
NEJM. Retrieved from
http://www.nejm.org/doi/full/10.1056/NEJMoa042683#t=articleTop

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