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OUTLINE
Definition
Risk factors
Classification
Pathophysiology
Symptoms
Investigations
Treatment

WHAT IS NECROTIZING FASCIITIS?

It is a progressive, rapidly spreading, inflammatory

infection located in the deep fascia with secondary
necrosis of the subcutaneous tissue..
infection rapidly destroy the skin and soft tissue
beneath it
Also known as: flesh-eating bacteria.
Other names: -hemolytic streptococcal gangrene,
Meleney ulcer, acute dermal gangrene, hospital
gangrene, and necrotizing cellulitis.
3 types of NF.
Type I : a polymicrobial flora.
Type II Group A -Streptococcus bacteria (most common
case)
Type III : marine vibrio gram-negative rods.

TYPE I NECROTIZING FASCIITIS

Mixed aerobic and anaerobic infection
Bacteria almost always isolated
S. aureus, Streptococci, Enterococci, E.
coli, Peptostreptococcus spp,
Prevotella, Porphyromonas, B. fragilis,
and Clostridium spp.
More common in diabetics, post op pt,
and pt with peripheral vascular disease.

 Cervical necrotizing fasciitis

Ludwigs angina (Ludwig's angina is an infection of the
floor of the mouth under the tongue. It is due to
bacteria)
Fourniers gangrene
Caused by penetration of the GI or urethral mucosa by
enteric organisms
fournier's gangrene:A horrendous infection of the genitalia
that causes severe pain in the genital area (in the penis
and scrotum or perineum) and progresses from erythema
(redness) to necrosis (death) of tissue.Gangrene can occur
within hours. The mortality (death) rates are up to 50%

TYPE II NECROTIZING FASCIITIS

Monomicrobial
Group A Strep
MRSA ( methicillin resistant staphylococcus aureus )
Can occur in any age group and in healthy patients
Risk factors
H/o blunt trauma or laceration
Varicella
Injection drug use
Post op
Post partum
Burns

TYPE II (CONTD)

Can result from hematogenous

translocation from GAS in
throat
NSAIDs thought to inhibit
neutrophil function or mask
symptoms and delay diagnosis

TYPE III
Type 3 - Gram-negative monomicrobial infection:
This includes marine organisms such as Vibrio
spp. and Aeromonas hydrophila, which can
occur following seawater contamination of
wounds, injuries involving fish fins or stings,
and raw seafood consumption - particularly in
patients with chronic liver disease.
These marine infections are particularly virulent
and can be fatal within 48 hours.

RISK FACTOR
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.

PATHOPHYSIOLOGY
Bacteria eat away at tissue between skin and
muscle
Increase in sensitivity or anaesthetic feel to the
skin itself
Inflammatory response by immune system
Bacterial toxins released exotoxin A
Cytokines impede function of phagocytic cells
Anaerobes thrive speeding up necrotic process
Endothelial cells become damaged;
Increased permeability of the lining of vessels in the
body
Poor blood supply inhibit:
Inflammatory response process
Ability for the immune system to properly work
Ability to transfer antibiotics to the affected fascial layer
Vasoconstriction and thrombosis edema

SYMPTOMS
Comparing the uninfected skin to the early and advanced
forms of the disease:

Normal skin

Early stage

Advanced stage

WHAT ARE THE EARLY SYMPTOMS

AND SIGNS OF NF?
Flu like symptoms that include
fever, chills, nausea, weakness,
dizziness, aches and a heat rate
of more than 100 beats per
minute.
Skin becomes tender, warm, red in
color, and will start to swell.
Patients may experience pain
greater than expected from the
appearance of the wound.
Subcutaneous tissue may also
have a hard feel on palpation
that goes past the visibly
infected area.
Clinically indistinguishable from
other possible soft tissue
infections with only the
presentation of pain,
tenderness, and warm skin.

ADVANCED SYMPTOMS
The advanced symptoms appear
as the disease progresses
The area of the body
experiencing pain begins to
swell excessively.
Multiple discolored patches
develop to produce a large
area of gangrenous skin.
Initial necrosis appears as a
massive destruction of the skin
and subcutaneous layer.
The normal skin and
subcutaneous tissue are
loosened.
Large, dark marks that become
blisters filled with a yellowgreen necrotic fluid appear.

CRITICAL SYMPTOMS
The critical symptoms form in the
last stages of NF.
30% of patients develop
hemorrhagic bullae which may
cause them to become anemic.
Vasculature of the skin becomes
inflamed and thrombosed.
Resulting in necrotic eschars
that look like deep thermal
burns.
Without treatment, secondary
involvement of deeper muscle
layers may occur.
Patients may become numb
because of nerve damage and
progressing gangrene in the
infected area.
Unconsciousness will occur as the
body becomes too weak to
fight off the infection along
with a severe decrease in the
patients blood pressure.
As toxins are being released, the

EXAMS AND LABORATORY TESTING

In order to get a definitive diagnosis of NF,
physicians look for abnormalities in the test
results that are characteristics of the disease.
Some of these tests include:
1. Blood samples
2. Testing for elevated or lowered creatinine,
glucose, CPK, bicarbonate, albumin, and calcium
levels.
3. X-ray
4. CT, and MRI scanning
5. And most importantly antibiotic culture and
sensitivity tests

INVESTIGATIONS
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 scans may help to show the extent of tissue involvement
but may not be accurate and should not delay surgery.
Ultrasound has also been used to show subcutaneous gas. [14]

INVESTIGATION
Computed
tomography
demonstrates
soft tissue gas
collection from an
invasive Group A
Streptococci
Bacteria.

Gas
Gas
vesicles
vesicles

DIFFERENTIAL DIAGNOSES
Acute Epididymitis
Cellulitis
Emergent Treatment of Gas Gangrene
Orchitis
Testicular Torsion in Emergency Medicine
Toxic Shock Syndrome

TREATMENT
Early and aggressive surgical exploration and
debridement
Reexploration should be performed w/in 24 hrs
Antibiotic therapy
Type I: ampicillin or unasyn with clindamycin or flagyl
If recent hospitalization, use zosyn or timentin instead of unasyn.

Type II: PCN G and clindamycin; vancomycin

Hemodynamic support
Intravenous immunoglobulin (currently under
investigation, but not recommended)
Hyperbaric oxygen therapy

ANTIBIOTIC THERAPY IS A KEY CONSIDERATION. POSSIBLE REGIMENS INCLUDE A COMBINATION

OF PENICILLIN G AND AN AMINOGLYCOSIDE (IF RENAL FUNCTION PERMITS), AS WELL AS
CLINDAMYCIN (TO COVER STREPTOCOCCI, STAPHYLOCOCCI, GRAM-NEGATIVE BACILLI, AND
ANAEROBES).

Penicillin G (Pfizerpen)
Penicillin G interferes with synthesis of cell wall
mucopeptide during active multiplication, resulting in
bactericidal activity against susceptible microorganisms.
Clindamycin (Cleocin)
Clindamycin is a lincosamide for treatment of serious skin
and soft tissue staphylococcal infections. It is also effective
against aerobic and anaerobic streptococci (except
enterococci). This agent inhibits bacterial growth, possibly
by blocking dissociation of peptidyl transfer RNA (t-RNA)
from ribosomes causing RNA-dependent protein synthesis to
arrest. It is used as an alternative to penicillin G.
Metronidazole (Flagyl)
Metronidazole is an imidazole ringbased antibiotic active
against various anaerobic bacteria and protozoa. It is used
in combination with other antimicrobial agents (except for
Clostridium difficile enterocolitis).
Metronidazole appears to be absorbed into cells of
microorganisms containing nitroreductase. Unstable
intermediate compounds that bind DNA and inhibit synthesis
are formed, causing cell death.

Ceftriaxone (Rocephin)
Ceftriaxone is the drug of choice in initial treatment. It is a
third-generation cephalosporin with broad-spectrum, gramnegative activity. It has lower efficacy against gram-positive
organisms and higher efficacy against resistant organisms. It
arrests bacterial growth by binding to one or more penicillinbinding proteins.
Gentamicin
Gentamicin is an aminoglycoside antibiotic for gram-negative
coverage. It is used in combination with both an agent against
gram-positive organisms and one that covers anaerobes. It is
not the drug of choice, but should be considered if penicillins
or other less toxic drugs are contraindicated, when clinically
indicated, and in mixed infections caused by susceptible
staphylococci and gram-negative organisms.
Adjust the dose based on creatinine clearance (CrCl) and
changes in volume of distribution. Follow each regimen by at
least a trough level drawn on the third or fourth dose (0.5 h
before dosing). Peak level may be drawn 0.5 h after a 30-min
infusion

Chloramphenicol
Chloramphenicol binds to 50 S bacterial-ribosomal
subunits and inhibits bacterial growth by inhibiting
protein synthesis. It is effective against gram-negative
and gram-positive bacteria.
Ampicillin
Ampicillin has bactericidal activity against susceptible
organisms. It is an alternative to amoxicillin when the
patient is unable to take medication orally. It may be
added to the initial regimen if the Gram stain suggests
that enterococci are present.
Imipenem and cilastatin (Primaxin)
This combination is used for treatment of infections
due to multiple organisms in which other agents do
not have wide-spectrum coverage or are
contraindicated because of potential for toxicity.

Ampicillin and sulbactam (Unasyn)

This combination of ampicillin and a betalactamase inhibitor covers skin, enteric flora,
and anaerobes. It is not ideal for treatment of
nosocomial pathogens.
Vancomycin (Vancocin)
Vancomycin is an antibiotic directed against
gram-positive organisms and active against
Enterococcus species. It is useful in the
treatment of septicemia and skin-structure
infections. Vancomycin is indicated for
patients who cannot take or whose conditions
fail to respond to penicillins and
cephalosporins or those with infections with
resistant staphylococci.
To prevent toxicity, the current

HYPERBARIC OXYGEN THERAPY (HBOT) IS A MEDICAL

TREATMENT WHICH ENHANCES THE BODY'S NATURAL
HEALING PROCESS BY INHALATION OF 100% OXYGEN IN
A TOTAL BODY CHAMBER, WHERE ATMOSPHERIC
PRESSURE IS INCREASED AND CONTROLLED. IT IS USED
FOR A WIDE VARIETY OF TREATMENTS USUALLY AS A
PART OF AN OVERALL MEDICAL CARE PLAN

PREVENTION!!!
Most people are in good
health before they become
infected.
Degrees to lessen your
chances
basic hygienic practices (washing
hands),
keep all wounds clean,
watch for signs of infection (increase
pain, swelling, pus, heat or fever),
seek immediate medical attention if
have symptoms of flesh-eating
disease, and
have precaution if in close contact
with someone with the bacteria.

PICTURES