Necrotizing FasciitisNecrotizing Fasciitis

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Dr.Hana’a TashkandiDr.Hana’a Tashkandi

Necrotizing FascitiisNecrotizing Fascitiis

•DefinitionDefinition•Risk factorsRisk factors

•EtiologyEtiology•PathophysiologyPathophysiology

•EpidemiologyEpidemiology•Clinical FeaturesClinical Features

•InvestigationsInvestigations•ManagementManagement

Diffuse Necrotizing InfectionDiffuse Necrotizing Infection(flesh-eating)(flesh-eating)

•Dangerous………………WhyDangerous………………Why??

•Difficult to diagnoseDifficult to diagnose

•Extremely toxicExtremely toxic

•Spread rapidlySpread rapidly

•May lead to limb amputationMay lead to limb amputation

ClassificationClassification

@ @ ColistridialColistridial: :

# # Necrotizing cellulitisNecrotizing cellulitis # # MyositisMyositis

@ @ Non-colistridialNon-colistridial: :

# # NECROTIZING FASCIITISNECROTIZING FASCIITIS # # Streptococcal gangreneStreptococcal gangrene

Necrotizing FasciitisNecrotizing Fasciitis

It is a progressive, rapidly spreading, It is a progressive, rapidly spreading, inflammatory infection located in the inflammatory infection located in the deep fascia with 2ry necrosis of the deep fascia with 2ry necrosis of the subcutaneous tissuesubcutaneous tissue..

Risk FactorsRisk Factors

•Immunocompression illnessesImmunocompression illnesses

e.g.: DM, Cancer, alcoholism, vascular e.g.: DM, Cancer, alcoholism, vascular insufficiency, organ transplant, HIV or insufficiency, organ transplant, HIV or neutropenianeutropenia..

• Trauma or foreign bodies in surgical woundTrauma or foreign bodies in surgical wound..

•Idiopathic as scrotal or penile necrotizing Idiopathic as scrotal or penile necrotizing fasciitisfasciitis..

Causative AgentsCausative Agents

It is a mixed microbial floraIt is a mixed microbial flora::

# # microaerophilic streptococcimicroaerophilic streptococci..

# # staphylococcistaphylococci..

# # aerobic gram –veaerobic gram –ve

# # anaerobes ( peptostreptococianaerobes ( peptostreptococi – –

bacteroidsbacteroids))

PathophysiologyPathophysiology

Mortality & MorbidityMortality & Morbidity

The overall morbidity & mortality is 70 The overall morbidity & mortality is 70 – 80%– 80%

Fournier’s gangrene has a reported Fournier’s gangrene has a reported mortality as high as 75%mortality as high as 75%

Sex: Male : Female 3:1Sex: Male : Female 3:1

AgeAge : : * * the mean age is 38 to 44 yearsthe mean age is 38 to 44 years..

* * pediatric cases are rare butpediatric cases are rare but reported from countries wherereported from countries where

poor hygiene inpoor hygiene in . .

Clinical FeaturesClinical Features

SymptomsSymptoms::

* * sudden onset of pain and swelling sudden onset of pain and swelling at the site of trauma or recent surgeryat the site of trauma or recent surgery..

* * in some cases, the symptoms may in some cases, the symptoms may begin at the site distant from the initial begin at the site distant from the initial traumatic insulttraumatic insult..

* * Fournier's gangrene begin with Fournier's gangrene begin with pain and itching of the scrotal skinpain and itching of the scrotal skin..

Clinical Features (cont.)Clinical Features (cont.)

SingsSings:: * * pt. appears moderately to severely toxic (but pt. appears moderately to severely toxic (but

sometimes might looks well)sometimes might looks well) * * typically, erythema that quickly spread over a course typically, erythema that quickly spread over a course

of hours to daysof hours to days.. * * the redness quickly spread & the margin of infection the redness quickly spread & the margin of infection

move out into normal skin without being raised nor sharply move out into normal skin without being raised nor sharply demarcateddemarcated..

* * anesthesiaanesthesia

# #NoteNote : :* * I.M. injections & I.V. infusions may lead to necrotizing I.M. injections & I.V. infusions may lead to necrotizing

fasciitisfasciitis..* * minors insect bites may set the stage for necrotizing minors insect bites may set the stage for necrotizing

infectionsinfections..

InvestigationsInvestigations

Lab: CBC, U&E, Glu, Creatinine, BloodLab: CBC, U&E, Glu, Creatinine, Blood & &

tissue cultures, Urine analysistissue cultures, Urine analysis & , & ,

ABGABG..

Investigations (cont.)Investigations (cont.)

Imaging StudiesImaging Studies::

# # X-ray X-ray gas in the subcutaneous gas in the subcutaneous fascia planesfascia planes..

?? ?? D.D. of subcutaneous gas in aD.D. of subcutaneous gas in a radiographradiograph..

# # C.T. C.T. demonstrating necrosis with demonstrating necrosis with asymmetric fascial thickeningasymmetric fascial thickening

& & gas in the tissuesgas in the tissues..

# # MRIMRI..

Investigations (cont.)Investigations (cont.)

MicrobiologyMicrobiology::

Gram stain & wound cultureGram stain & wound culture

ProceduresProcedures::

Biopsy is the best method to use to obtainBiopsy is the best method to use to obtain proper cultures for micro-organismsproper cultures for micro-organisms..

Emergency Department Emergency Department carecare

•AA

•BB

•CC

•DD

ManagementManagement

If streptococci are the identified major pathogens, If streptococci are the identified major pathogens, the D.O.C is Penicillin-G with clindamycin as an the D.O.C is Penicillin-G with clindamycin as an alternativealternative..

To ensure adequate treatment, we have to cover To ensure adequate treatment, we have to cover aerobic & anaerobic bacteriaaerobic & anaerobic bacteria..

The anaerobic coverage can be provided by The anaerobic coverage can be provided by Metronidazole or 3Metronidazole or 3rdrd generation cephalosporin's generation cephalosporin's..

Management (cont.)Management (cont.)

Gentamicine combined with Gentamicine combined with clindamycine or chloramphenicol has clindamycine or chloramphenicol has been reported as a standard been reported as a standard coveragecoverage..

Ampicilline may be added to the basic Ampicilline may be added to the basic regimen to treat enterococci if regimen to treat enterococci if suspected by gram stainsuspected by gram stain..

Further In-Patient CareFurther In-Patient Care

•Surgical debridmentSurgical debridment..

•FasciotomyFasciotomy..

•H.B.OH.B.O..

ComplicationsComplications

•Renal FailureRenal Failure..

•Septic Shock with cardiovascular Septic Shock with cardiovascular collapsecollapse..

•Scarring with cosmetic deformityScarring with cosmetic deformity..

Medico-legal PitfallsMedico-legal Pitfalls

Early in the course of the disease, Early in the course of the disease, necrotizing fasciitis may appear quiet necrotizing fasciitis may appear quiet benignbenign..

Be wary of the patient with pain out of Be wary of the patient with pain out of the proportion to physical findingthe proportion to physical finding . .

THANK YOUTHANK YOU

Hana’a TashkandiHana’a Tashkandi