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Necrotizing Fasciitis

Definition. Characterized by fulminant destruction of tissue, systemic signs of toxicity, and a high mortality rate.Pathologic features include extensive tissue destruction, thrombosis of blood vessels, abundant bacterial spread along fascial planes, and unimpressive infiltration of acute inflammat

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Necrotizing Fasciitis

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    1. Necrotizing Fasciitis Morning Report November 21, 2007 Sally Ravanos, MD

    2. Definition Characterized by fulminant destruction of tissue, systemic signs of toxicity, and a high mortality rate. Pathologic features include extensive tissue destruction, thrombosis of blood vessels, abundant bacterial spread along fascial planes, and unimpressive infiltration of acute inflammatory cells.

    3. Risk Factors Drug use Diabetes mellitus Obesity Immunosuppression Renal failure

    4. Types of Necrotizing Infection Necrotizing cellulitis Clostridial cellulitis Nonclostridial anaerobic cellulitis Meleney’s synergistic gangrene Synergistic necrotizing cellulitis Necrotizing fasciitis Type I Type II

    5. 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.

    6. Type I (cont’d) Cervical necrotizing fasciitis Ludwig’s angina Fournier’s gangrene Caused by penetration of the GI or urethral mucosa by enteric organisms

    7. Type II Necrotizing Fasciitis Monomicrobial Group A Strep ORSA 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 Exposure to a case ?NSAIDs

    8. Type II (cont’d) Can result from hematogenous translocation from GAS in throat NSAIDs thought to inhibit neutrophil function or mask symptoms and delay diagnosis

    9. Clinical Manifestations

    10. Risk Score Serum CRP >/= 150mg/L (4 pt) WBC 15K-25K (1 pt) or >25K (2 pt) Hgb 11-13.5 (1 pt) or </= 11 (2 pt) Na < 135 (2 pt) Cr >1.6 (2 pt) Glucose >180 (1 pt) Score >/= 6 should raise suspicion for NF >/= 8 highly predictive of NF

    11. Diagnosis Imaging Soft tissue X-rays, CT, MRI Can reveal gas in the tissues, but not as good as direct surgical exploration Cultures Blood Cx positive in 60% with type II, 20% with type I Surgical wound cultures almost always positive

    12. Pictures

    13. 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

    14. Mortality Rate Overall mortality 17% Type I 21% Type II 14-34% Type I cervical NF 22% Type I Fournier’s gangrene 22-40% Predictors of mortality WBC >30K Cr >2.0 Clostridial infection Presence of heart disease at admission

    15. NF and ORSA Houston 74 pts w/NF over 5 years 39% ORSA, 15% mortality Los Angeles 843 pts w/ORSA positive wound Cx 1.7% w/NF, 0% mortality Taiwan 53 pts w/NF over 5 years 37.7% Staph aureus (40% OSSA, 60% ORSA) 0% mortality with ORSA

    16. References Up to Date 2007. Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med. 2005; 352: 1445. Lee TC, Carrick MM, et al. Incidence and clinical characteristics of methicillin-resistant Staphylococcus aureus necrotizing fasciitis in a large urban hospital. Am J Surg. 1007 Dec; 194 (6): 809-813. Lee YT, Lin JC, Wang NC, et al. Necrotizing fasciitis in a medical center in Northern Taiwan: emergence of methicillin-resistant Staphyloccus aureus in the community. J Microbiol Immunol Infect. 2007; 40: 335-341.

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