RECENT ADVANCES

NECROTISING FASCITIS
RECENT ADVANCES IN SURGERY 39TH
EDITION
BY
DR.PRAVEEN KUMAR C.P
S III UNIT
FINAL YEAR POSTGRADUATE
DEPARTMENT OF GENERAL SURGERY
GVMCH
 Nectrotising fascitis , term to describe NECROTISING SOFT TISSUE
INFECTIONS (NSTI)
 Includes , cellulitis , fasciitis and myositis depends of depth of tissues involved
 Refer as flesh eating bacteria ,
 Necrosis of the fascia is a significant feature of the disease
 Fourniers gangrene - involves genito urinary tract
 Ludwig angina – when involves submandibular and sublingual spaces
Meleney’s ulcer –abdominal wall
necrotizing fascitis
EPIDEMOLOGY

 INCIDENCE – 0.4 TO 1 PER 1,00,000 PER YEAR

 Mortality rate – 25%
 Affects male and female equally
RISK FACTORS

 IMMUNO SUPPRESSION – AIDS,medications

diabetes -70 % of cases
 Chronic diseases – cirrhosis liver ,chronic kidney disease,and peripheral vascular
disease
 Trauma-contaminated wounds and burns
 Age more than 60 years
 Malignancy ,
 Iv drug abuse
PATHOPHYSIOLOGY

 Necrotising fascitis results from action of one or more bacteria that proliferate in
the subcutaneous tissues .
 Microbial invasion of local blood vessels with toxins cause severe sepsis ,
multiorgan failure , and death
 Rapid spread facilitated by Enzymes – Hyaluronidase that degrade the
polysaccharides responsible for tissue adhesions and
Excretion of exotoxins occurs

Production of cytokines damages endothelial lining cause leaking of fluid into

extravascular space

Reduced intravascular
blood flow results in vessel
occlusion by microthrombi

Tissue becomes ischemic

results in pain and skin
necrosis
 Fascia becomes
necrosis , liquefied ,
progression to
Gases accumulate deeper fascia ,
and produce intermuscular
Anaerobic bacteria produce crepitus , gas on septum and
carbon di oxide ,hydrogen , imaging myonecrosis
nitrogen , methane ,
hydrogen sulphide
Hypoxia enables
proliferation of
anaerobic bacteria
accelerating
disease process
Classification of necrotizing fascitis
Polymicrobial- 90 % cases, MC ,
• Gram positive cocci , Staph aureus , E.coli, Pseudomonas ,
• Anaerobes bacteria Clostridia species

Monomicrobial
• Group A beta hemolytic Streptococci ,Staph pyogenes ,Staphylococcus aureus
• MRSA

Marine organisms
• Vibrio vulnificus

Fungal infection –zygomycetes

candida
Polymicrobial

 Most common – 90% cases

 Synergestically – aerobic bacteria causing tissue destruction and hypoxia enables
anaerobic bacteria to grow
 Infect older and immunocompromissed patients
 In trauma – clostridium welchii- gas gangrene by toxins – cause neutrophil
dysfunction and platelet adherence causing impaired phagocyte function and
hemolysis
Type II – monomicrobial

 Less common
 0ccurs in healthy patients mostly after trivial trauma
 Group A Beta hemolytic Streptococci can evade body’s immune system by
expressing M proteins
Picture showing lower limb necrotizing fascitis in 25 year old male
following trauma
 Type III- Contaminated with Gram negative marine organisms typically vibrio
species.
 Type IV – fungal infections
traumatic wounds , burns – zygomycetes
immunocompromised – candida infections
Rapidly progressive
Sites of infections

SITE FREQUENCY
LOWER LIMBS 28%
UPPER LIMBS 27%
PERINEUM 21%
TRUNK 18%
HEAD AND NECK 5%
CLINICAL FEATURES

 Early features – pain , erythema and edema

 Late features such as – pyrexial , tachycardia , hypotension , tachypnea , and
altered mental status
Local symptoms

 Pain – localized to overlying skin and muscle , beyond apparent site of infection ,
out of proportion inflammation
 Pain reduced in diabetic neuropathy
 Skin changes- erythema , edema
 Skin vesicles , bullae containing serous fluids are specific signs
 Lymphangitis , lymphadenopathy are absent
 Late signs – skin necrosis and patch of anaesthesia over erythema due to
infarction of cutaneous nerves
Necrotizing fascitis with blebs and skin
discolouration
Systemic symptoms

 FEVER – temperature more than 38 degree celcius ,

 Tachycardia
 Hypotension
 Tachypnea- secondary to acidosis
 In diabetis patients – DKA
 On inspection, the tissue will appear necrotic – grayish necrotic fascia with dead
muscle, thrombosed vessels,
 Presence of foul smelling purulent discharge -classic “dishwater” fluid,
 positive finger sweep test, in which the tissue layers can be easily passed between
fascial planes
 Absence of bleeding during tissue dissection
Investigations

 Complete blood count

 Serum glucose
 Serum electrolytes
 Liver enzymes
 Serum urea , creatinine
 CRP
 Blood grouping and typing
 BLOOD CULTURE , PUS CULTURE AND SENSITIVITY
Risk predictors in necrotizing fascitis
The Laboratory Risk Indicator for
Necrotizing Fasciitis (LRINEC) score
variable value points
C REACTIVE PROTEIN <150 0
>150 4
WBC (per mm^3) <15 0
15-25 1
>25 2
HAEMOGLOBIN g/dl >13.5 0
11-13.5 1
<11 2
Serum Sodium mmol/L >135 0
<135 2
Serum <141 0
creatinine(micromol/L) >141 2
Serum glucose (mmol/L) <10 0
>10 1
Risk of Necrotising Fascitis

Group Score Risk of Necrotising fascitis

Low <5 <50%
Moderate 6-7 50-75%
high >8 75%
 Raised lactate on an arterial blood gas and metabolic acidosis are indicators of
critical illness
IMAGING

 XRAY PLAIN FILM

 CT SCAN
 ULTRASOUND
 MRI
 Xray Plain film findings may reveal extensive soft tissue gas
 CT examination can reveal asymmetric thickening of deep fascia in association
with gas, and associated abscesses may also be present
 Ultrasound – determine abscess , subcutaneous gas and edema along fascial plains
 MR imaging can also assist in the diagnosis of NSTIs.MR imaging has been
documented to effectively differentiate between necrotizing and nonnecrotizing
infections of the lower extremity and other areas of the body,
MANAGEMENT

 Three principles form the foundation of the management

of NSTIs:
(a) source control with wide surgical debridement,
(b) broad-spectrum intravenous antibiotics, and
(c) supportive care and resuscitation
Medical management

 Empirical treatment – intravenous meropenam and clindamycin

clindamycin and metronidazole
 In case of pencillin allergy – ciprofloxacin
 The Infectious Diseases Society of America recommends initiating therapy with
intravenous vancomycin and piperacillin/tazobactam,
 unless a monomicrobial agent is identified, in which case more directed therapy
would be appropriate.
 Antibiotic therapy should continue until
the patient requires no further debridement,
is clinically improving, and
has been afebrile for 48 to 72 hours.
SURGERY

 Radical surgical debridement is mainstay of treatment

 Time delay and inadequate debridement increases mortality
 All infected and necrotic tissues should be excised , necrotic fascia extends
beyond area of overlying skin
 Extent of infected tissue can be large but excision should continue back to healthy
bleeding tissue at all margins
 Haemostasis , sterile wound dressing
 Within 24 to 48 hrs – second look , again excise non viable tissue , this process
continue until wound healthy and patients condition improves
Reconstruction
 Patients condition stable , wounds look clean and healthy
 Small wounds – delay primary closure or allow wound heal by secondary
intention
 Larger wound – skin grafting / local flaps of tissue for reconstruction and wound
closure
ADJUNCTIVE TREATMENTS

Hyperbaric oxygen
-may inhibit Wound closure and
infection by creating reconstructive
IVIG -may modulate
an oxidative burst, surgeries are
the immune
with anecdotally performed once
response to
fewer debridements bacteriologic,
streptococcal
required and metabolic, and
superantigens .
improved nutritional balances
survival, but limited are obtained.
availability
PROGNOSIS

 Mortality is high without surgery

 Depends on many factors such as underlying medical problems , causative
organisms and speed ,extent of surgical debridement
 Mortality – 6 % to 76%
Take home message

 Necrotising fascitis is a clinical diagnosis and a surgical emergency

 The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score- risk
predictor in necrotizing fascitis
 Radical surgical debridement is mainstay of treatment
 Multi disciplinary working with microbiology and intensive care can improve
patient outcome
REFERRENCES

 RECENT ADVANCES IN SURGERY 39TH EDITION IRVING TAYLOR

 Schwartz’s Principles of Surgery 11TH EDITION
 Greenfield’s SURGERY Scientific Principles & Practice SIXTH EDITION
 https://radiopaedia.org/articles/necrotising-fasciitis
 https://radiopaedia.org/cases/necrotising-faciitis-in-a-diabetic-foot
THANK YOU