Synergistic Necrotizing Cellulitis

H. HARLAN STONE, M.D., J. D. MARTIN, JR., M.D.

From the Joseph B. Whitehead Department of Surgery, Emory UniversitySchool of Medicine, Atlanta, Georgia 30303

UNEQUIVOCAL infection due to a synergismbetween aerobic and anaerobic bacteria wasfirst clearly documented in 1926.1 In thisinitial report, Brewer and Meleney pre-sented clinical and bacteriologic evidenceof symbiotic growth and augmented in-vasiveness of an anaerobic Streptococcus incombination with hemolytic Staphylococcusaureus. A similar case lacking adequate cul-ture data had been described by Cullen 2years previously.3 Many additional caseshave since been reported,2 6 with all in-vestigators stressing the fact that this infec-tion is caused by a synergism between thetwo distinct bacterial species with greatlydifferent oxygen requirements, that the clin-ical course is relentless and progressive, andthat skin and subcutaneous tissues are pri-marily and often exclusively involved. Gan-grene of muscle and fascia develop sec-ondarily and occur only after overlying skinand subcutaneous tissue have either beendestroyed by infection or removed throughdebridement.

In addition to cases of so-called Meleney'scellulitis as mentioned above,1 3, 6 8 pureStreptococcal gangrene,5 and classical gasgangrene due to one of the Clostridia,4 ex-tensive tissue necrosis has also been notedto follow symbiotic infection due to anaero-bic Streptococci with one or more of thevarious gram-negative rods as an aerobicpartner.4' Although many of the latter in-

Presented at the Southern Surgical AssociationMeeting held at Hot Springs, Virginia, December6-8, 1971.

fections may be associated with the pres-ence of Bacteroides, the exact role of thisthird microbial component is uncertain. Incontrast to other infections caused at leastin part by Streptococci, synergistic necrotiz-ing cellulitis is more similar to gas gan-grene; for there is widespread involvementof the deeper tissues.4' Necrosis of muscleand fascia is the rule, while gangrenouschanges in skin and subcutaneous fat arethe direct consequence of a more extensiveinfectious process beneath.

Case MaterialDuring the 13-year period from January

1, 1958 through December 31, 1970, 63 pa-tients with synergistic necrotizing infectionsof deep fascial planes and enveloped mus-cles were treated on the surgical service atGrady Memorial Hospital. The race dis-tribution was similar to the general patientpopulation (15 white, 48 negro). Therewere 26 men and 37 women; while agesranged from 16 to 90 years, the averagebeing 54.

Clinical Presentation

Most of the patients were first referredto the surgical service because of small skinulcers that drained thin, reddish-brown,foul-smelling fluid (Fig. 1). Such a dis-charge was usually referred to as "dish-water" pus. Surrounding these drainingwounds were variable amounts of skin ne-crosis, though rarely was superficial gan-grene very extensive. Almost a fourth of the

702

SYNERGISTIC NECROTIZING CELLULITIS

patients had gaseous emphysema of ad-jacent tissues. Exquisite local tenderness inthe absence of any obviously serious infec-tion was characteristic. Bounding arterialpulses distal to the site of infection tendedto eliminate the possibility of occlusive vas-cular disease as the cause of such gan-grenous changes.

All patients exhibited a generalized toxic-ity, despite the fact that not all were febrile.Oral temperatures on admission to the hos-pital were usually in the range of 100 to1020 F. Other than a septic appearance andthe obvious local infection, additional phys-ical findings were primarily related to asso-ciated disease processes.The majority of the infections were lo-

cated within the immediate vicinity of theperineum (Fig. 2). Perirectal abscess wasthe initial presentation in 24 patients, whilefive others were found to have deep infec-tions involving the gluteal musculature. Twopatients had a periurethral abscess, and an-other two presented with extensive pelviccellulitis. The lower extremity was the nextmost frequently involved site. Infection usu-ally arose in the adductor compartment ofthe thigh, although dissection from thepelvis above or an amputation stump belowwas often considered to be a possibility.Several infections developed in the foot andleg following conservative amputations fordiabetic gangrene. Other areas of involve-ment included the proximal arm and deepfascial planes of the neck.Symptoms and findings had been present

in many of the patients for as long as 2weeks; a few had even been treated as out-patients with antibiotic agents and drainageof the area in question. All too often thetrue reason for eventual hospital admissionwas a failure to control derangements inassociated disease states.

Associated Conditions

Approximately three fourths of the pa-tients, that is 47 of the 63, had diabetes

SYNERGISTIC NECROTIZING CELLULITISCLINICAL FINDINGS

-,' A, ST7 T. 7 7N0\\\

s Emphysema (16)

_I _ _ _ _ _

10 20 30 40 50 60 70 80INCIDENCE (%)

90 100

FIG. 1. Clinical features at initial presentation.

mellitus (Fig. 3). In eight, the diagnosis ofdiabetes had not been previously consid-ered, while more than half of the remainingdiabetic patients had been managed on dietalone prior to the onset of infection. Onlysix patients had required insulin. Neverthe-less, most of the diabetics were in keto-acidosis on admission to the hospital.

Slightly more than half of the patientshad some combination of cardiovascularand/or renal disease. Such appeared to bemore a reflection of their age and diabetesrather than any specific predispositiontoward the development of a synergistic in-fection. However, a significant impairmentin renal function, particularly as noted in

SYNERGISTIC NECROTIZING CELLULITISSit. of Original Infection

NUMBER /NC/DENCE(%)

NECK

i. -- ARM

PERIRECTAL) GWTEALPERIURETHRALPELVIC

___________THIGH

LEG

FOOT

2 3

2 3

24 385 82 32 3

/5 24

8 /3

3 5

FTG. 2. Origin of infection.

703

STONE AND MARTIN Ann. Surg. - May 1972Vol. 175 * No. 5

SYNERGISTIC NECROTIZING CELLULITISASSOCIATED CONDITIONS

(33)

I I II I

10 20 30 40 50 60 70 80INCIDENCE (%)

90

FIG. 3. Common associated diseases.

diabetics with Kimmelstiel-Wilson syn-drome, made the infection less likely torespond to any form of treatment.

TABLE 1. Synergistic Necrotizing CellulitisLaboratory Data

IncidenceNo. (%)

Hematocrit-mm.

More than 40 13 2130to40 24 38Less than 30 25 40Unknown 1 2

Leukocytosis-/mm.3Less than 15,000 22 3515,000 to 25,000 15 24More than 25,000 21 33Unknown 5 8

Uremia (BUN)-mg./100 ml.Less than 30 14 2230to 50 4 651 to 100 28 44More than 100 16 25Unknown 1 2

Blood sugar-mg./100 ml.

Less than 100 3 5100 to 150 24 38151 to 300 16 25More than 300 16 25Unknown 4 6

Acidosis (CO,)-mEq./l.More than 20 21 3310to 20 22 35Less than 20 16 25Unknown 4 6

Another important consideration was thepatient's nutritional state. Marked obesitywas noted in 41, while 13 patients demon-strated a significant amount of wasting.Other associated diseases included prioramputation for occlusive vascular disease,alcoholism, previous episodes of perirectalabscess, and urethral stricture. Clinical tet-anus, treated by extremity amputation, pre-ceded the development of synergistic cel-lulitis in two patients.

Laboratory DataA mild anemia was often present (Table

1). The white blood cell count was elevatedin almost all patients, although counts wereless than 15,OO/mm3. in more than a thirdof cases.

Routine blood chemistries were of con-siderable help in assessing and managingthe associated impairments in renal func-tion and the frequently accompanying dia-betic keto-acidosis. Uremia was present inthe majority of cases, and any significantreduction in renal function proved to havean adverse effect on the eventual survival.

Diabetes mellitus was noted in almosttwo thirds of the patients, and keto-acidosisdeveloped in all of them. More fulminantinfections evoked a severe acidosis and oc-curred principally in patients with diabeteshaving large insulin requirements.

TABLE 2. Synergistic Necrotizing CellulitisAerobic Cultures of Wound

IncidenceNo. (%)

Klebsiella-aerobacter 27 43Proteus 26 41E. coli 21 33Pseudomonas 10 16Other gram-negative 14 22

No gram-negative 1 2Mixed gram-negatives 39 62Enterococcus 15 19

No culture 6 10

704

SYNERGISTIC NECROTIZING CELLULITIS

Bacteriology

Aerobic cultures of the wound consist-ently grew various gram-negative species,

particularly Klebsiella-Aerobacter, Proteus,and Escherichia coli (Table 2). In only one

case was there a failure to isolate one of thegram-negative rods. A mixture of such mi-crobes was obtained from more than halfof the infections. Unfortunately, either theculture was lost or no culture was takenfrom the wound of six of the patients.An anaerobic culture of the wound pro-

duced growths of Streptococcus in 32 pa-

tients and Bacteroides in 15 (Table 3). Fourpatients had wounds containing both ofthese anaerobes. Because of a failure tosuspect the presence of anaerobes, appro-

priate cultures were not even obtained insix others. Nevertheless, these 12 patientshave been included in the review, for ex-

amination of the fluid draining from theirwounds confirmed a definite mixture ofgram-positive cocci and gram-negative rods.In addition, the clinical course of each ofthe patients was sufficiently typical to war-

rant their inclusion in a retrospective study.Blood cultures were positive for one of

the gram-negative rods in more than a thirdof the cases (Table 4). An anaerobe couldbe isolated from the blood in 19%, repre-

senting four patients with Streptococcusand eight others with Bacteroides. Mixedgrowths of bacteria were obtained from theblood in six patients, and in each instance a

Bacteroides was one of the species isolated.

TABLE 3. Synergistic Necrotizing CellulitisAnaerobic Cultures of Wound

IncidenceNo. (C0)

Streptococcus 32 51Bacteroides 15 24Both anaerobes 4 6

No growth 6 10No culture 6 10

TABLE 4. Synergistic Necrotizing CellulitisBlood Cultures

IncidenceNo. (%10)

Gram-negative 23 37

Anaerobic streptococcus 4 6Bacteroides 8 13

Mixed 6 10No growth 32 51

No culture 8 13

Treatment

Forty-one patients had undergone inci-sion with drainage as outpatients, and 34had been given antibiotics. Nine patientsreceived a broad-spectrum antibiotic alone,while one other had merely been directedto apply warm compresses. It was specifi-cally because such measures gave no im-provement that these patients returned tothe emergency clinic or were re-evaluatedby the surgical service.

Survival of the patient was determined inpart by the type of definitive treatmentgiven (Fig. 4). No patient lived after mereincision and drainage, with or without anti-biotic treatment. Antibiotic agents alonelikewise met with failure. Conservative de-

SYNERGISTIC NECROTIZING CELLULITISDEFINITIVE TREATMENT

\ a y ~~~~~~Antibiotics.(24)

10 20 30 40 50 60 70 80 90 00MORTALITY (%)

FIG. 4. Methods of definitive treatment.

705

STONE AND MARTIN Ann. Surg. * May 1972Vol. 175 * No. 5

dressing changes than any definite improve-inent could justify.

NECK

ARM

PERIRECTALGWTEALIPERIURETHRALlPELVIC

THIGH

-LEG

FOOT

FIG. 5. Survival accordingoriginal in

bridement of the wounof systemic antibioticqof only four patients oJ

However, antibiotics vment, that is, excisionobviously infected tissialmost half of the patiAmputation, whene'

the easiest and mostdebridement. Such waby disarticulation at t]proximal to the infecteSince necrosis often e

muscular compartmenof all infected tissue cc

only when infection v

extremity. If both thewere involved, howevpossible to gain a co:cordingly, these patientvisits to the operatingand often daily sessiunder general anesthezThe topical applicat

of considerable help inwound flora. Bubbliicatheters into the wousome benefit, though irgen peroxide seemed tdiscomfort and dem

2

2

2 /00 Results50

The overall mortality rate was 76%o; as24 22 92

5 3 60 only 15 of the 63 patients eventually sur-2 2 /00Fi

2 2 /00 vived (Fig. 4). An early death, that is/5 9 60 within the first week following admission to

the hospital, occurred in 30 instances. Eigh-8 4 50 teen other patients subsequently died be-

cause of complications related to associated3 3 /00 diseases or because of recurrence of the

synergistic infection in more proximal as-site of origin of the pects of their wound. All survivors had con-

siderable residual morbidity and generallya prolonged hospital course.

id and massive doses The high mortality rate appeared to bes permitted survival based on several factors. Patients with se-

f the 18 thus treated. vere renal disease almost never survived,vith radical debride- and diabetes mellitus significantly worsenedof all necrotic and the prognosis. The mortality for the diabetic

ue, was successful in was 85%, as compared to 44% for the non-

ients so managed. diabetic. The presence of other associatedver feasible, offered conditions played less important roles in de-complete method of termining the eventual outcome in the indi-is best accomplished vidual case.

he joint immediately Probably the most decisive influence on

d extremity segment. survival was the area of involvement (Fig.xtended beyond the 5). Whenever the infection developedt of origin, removal within an extremity, radical debridement)uld be accomplished by either amputation or disarticulation was

vas confined to that usually practical. Accordingly, the mortalityperineum and pelvis rate was significantly lower in such cases

or, it was almost im- than it was for those patients with more

mplete excision. Ac- centrally located infections. For example,ts required additional all patients with deep infections of theX room for repeated pelvis and neck died. There were only twoons at debridement survivors of the 24 patients with extensionsia. from a perirectal origin; yet gangrenous in--ion of antibiotic was fections just outside the pelvis, i.e., the but-controlling the local tock, were conducive to more complete de-ng oxygen through bridement and therefore had a lower mor-

nd appeared to be of tality rate.^rigations with hydro- Other major considerations were the ex-

.o cause more patient tent and duration of the necrotizing process.and more frequent Whenever infection was confined primarily

706SYNERGISTIC NECROTIZING CELLULITIS

Site of Infection and Mortality Rate

h NUMBER DIED MORTAL/TY(%

SYNERGISTIC NECROTIZING CELLULITIS

to a single muscle compartment, chancesfor survival were significantly improved.However, if the infection had been presentfor more than a week, spread both aboveand below usually precluded any hope ofcomplete debridement. As expected, essen-tially all such patients died.

Discussion

Synergistic necrotizing cellulitis is causedby a symbiosis between one or more speciesof gram-negative, aerobic bacteria (Kleb-siella-Aerobacter, Proteus mirablis, or Esche-richia coli) and an absolute, or at least afacultative, anaerobe (anaerobic Streptococ-cus and/or Bacteroides). If only one anaero-bic microbe can be isolated from the in-fected wound or draining fluid, it is usuallythe microaerophilic Streptococcus. Whetherthe anaerobic Streptococcus and a speciesof Bacteroides need both be present for thedevelopment of this fulminant infection isuncertain, as anaerobic cultures have notalways been taken and, when obtained, fre-quently have not been expeditiously or care-fully processed. In any event, for such ex-tensive and rapid muscle necrosis to occurin the absence of comparable cutaneouschanges or major vascular embarrassment,the combination of these two bacterial com-ponents-an aerobe and an anaerobe-ap-pears to be essential.The frequency of the various gram-nega-

tive rods that have been isolated from thesewounds is evenly distributed between Kleb-siella-Aerobacter, Proteus mirablis, andEscherichia coli. Nevertheless, a mixture ofthese in the aerobic flora is common. Gase-ous emphysema of the wound and its sur-rounding tissues favors the presence ofKlebsiella-Aerobacter. Infection with Pseu-domonas aeruginosa is usually associatedwith more obvious and wide-spread necro-sis of skin and subcutaneous fat than wouldbe the case otherwise.

Differentiation from Gas GangreneSuch a necrotizing synergism must be

differentiated from infection due to Clos-tridium welchii or one of its related gram-positive rods. Gas gangrene has a dramaticand sudden onset, is more rapid in progres-sion, and has an easily recognizable portalof entry. There is also extensive skin andsubcutaneous involvement, as demonstratedby bluish-purple discoloration of the skin,hemorrhagic blebs elevating the epidermisand in the subdermal fat, the diffuse gaseousemphysema. Pain in the area of infection isintense, and there is a characteristic odorto the patient's wound as well as to his im-mediate environment. Finally, no predilec-tion exists for the middle-aged or elderlyindividual with diabetes, severe renal im-pairment, obesity, or malnutrition.

Differentiation from Streptococcal Gan-greneStreptococcal gangrene is almost as ful-

minant as is gas gangrene. High fever,jaundice, and irrational behavior likewisemimic infection due to one of the Clos-tridio. In addition to hemorrhagic blebs inthe skin and marked edema, however, thereis obvious erythema with heat and no gase-ous crepitation. Both skin and deeper tis-sues seem to be equally involved by theinfection, and any draining fluid tends tobe purulent.

Differentiation from Meleney's CellulitisAlthough Meleney's cellulitis is also

caused by a bacterial synergism, in this casethe responsible microbes are an anaerobicStreptococcus and hemolytic Staphylococ-cus aureus. In contrast to symbiotic infec-tions with one of the gram-negative rods asa partner, this gram-positive synergism is amuch more indolent process. It primarily in-volves the skin and subcutaneous tissues,with subsequent necrosis of the deep en-veloping fascia only as a late development.Rarely is there destruction of the muscle

707

708 STONE AND MARTIN

beneath. As a general rule, Meleney's cel-lulitis readily responds to more conservativedebridement and the systemic administra-tion of specific antibiotics.

Differentiation from Necrotizing Fasciitis

Necrotizing fasciitis is somewhat of amisnomer in that there is extensive involve-ment of the skin and subcutaneous fat, withonly secondary destruction of the deep en-veloping fascia.) 4, 8 Rarely are muscle com-partments invaded. The process is not asrapidly progressive as is the case with gasgangrene, Streptococcal cellulitis, or truenecrotizing cellulitis. As a general rule,aerobic bacteria in various combinationsform the principal wound flora; anaerobesdo not appear to have an important func-tion in this type of infection.

Bacteriologic Diagnosis

Once the presence of synergistic necrotiz-ing cellulitis is suspected, bacteriologic con-firmation of the diagnosis must be soughtenergetically. Initially this consists of micro-scopic examination of the characteristicfluid draining from the wound. In additionto leukocytes and necrotic debris, almostall smears will contain easily recognizablegram-positive cocci and gram-negative rods.If only gram-positive cocci are noted, thenMeleney's cellulitis is more likely the case.However, the presence of gram-positiverods indicates that gas gangrene is a realpossibility, often in combination with amixed bacterial flora.The diagnosis can be made with absolute

certainty only through culture of the woundand its draining fluid by both aerobic andanaerobic methods. Cultures of the bloodshould also be drawn. It is of utmost im-portance that the specimen for anaerobicgrowth be streaked on a culture plate aswell as inoculated into an appropriate brothwithout delay and then placed almost im-mediately in an oxygen-free environment. It

Ann. Surg. * May 1972Vol. 175 * No. 5

cannot be over stressed that bacteriologicconfirmation is absolutely dependent uponthe expeditious and careful handling of theinfected sample to be studied.

Treatment

Once the clinical diagnosis of synergisticnecrotizing cellulitis has been supported bya positive smear of the draining fluid, onlyenergetic measures will offer any hope ofpatient survival. Initial treatment must in-clude the rapid repletion of fluid, electro-lyte, and red cell mass deficits. Continuousmeasurements of the central venous pres-sure are extremely valuable in monitoringthe patient's response to the infusion oflarge volumes of fluid during a brief periodof time in an often elderly individual withmajor associated diseases. The establish-ment of an adequate urine output, the cor-rection of acidosis as indicated by bloodgas and pH determinations, and the reversalof diabetic ketosis and hyperglycemia aremandatory and are achieved by the addi-tion of appropriate amounts of sodium bi-carbonate and regular insulin to the intra-venous solutions used for fluid resuscitation.Whenever these derangements have beenat least temporarily corrected, radical sur-gical debridement must be carried out; thepatient at no subsequent time will ever bein any better condition to tolerate the majoroperation required. Further delay merelyworsens the risk of operation.

Local treatment of the infection must in-clude as complete an excision of all infectedtissue as is possible. The only valid contra-indications to more extensive debridementare the limitations imposed by interveningvital organs or body cavities to be main-tained inviolate. Actual entry into the peri-toneal cavity is warranted only for the per-formance of a diverting colostomy in caseswith wide-spread pelvic involvement. Ade-quate debridement of the pelvis and thighmay even demand a hemipelvectomy, al-

SYNERGISTIC NECROTIZING CELLULITIS

though hip disarticulation is the more fre-quently selected procedure. Needless to say,

all necrotic, infected muscle and the fascialplanes enveloping its anatomical compart-ment must be removed. Accordingly, dis-articulation is usually chosen in an effortto shorten the operative time, to lessen themagnitude of the resultant wound, and toeliminate problems with a then ischemicand functionless distal extremity.The wound is always dressed open. Oxy-

gen catheters are placed in its depths, andthen antibiotic cream (Neosporin or Gara-mycin) is spread in generous amounts over

the fresh raw surfaces. Loose dry dressingsare placed on top so as to provide both bulkand gentle pressure. Strict isolation pro-

cedures are always practiced. When thepatient has returned to his room, the in-stalled catheters are connected to a source

of humidified oxygen running at to 2 litersper minute. It is most important that theoxygen be bubbled through sterile water,for otherwise the wound will become se-

verely dehydrated because of the extractionof tissue water by the constant flow of a

dry gas.

Since debridement is seldom as completeas would be desired and since small foci ofpersisting infection often lead to localizedareas from which further progression can

ensue, the dressing should be changed atdaily or every other day intervals in theoperating room with the patient undereither deep sedation or general anesthesia.Additional amounts of tissue are excised as

necessary, and the wound is then redressedas before. After two consecutive dressingchanges without evidence of recurrent in-vasion of the infective process, the dress-ing can then be changed on the ward withsedation alone.

Antibiotics are second in importance onlyto radical debridement. As mentionedabove, topical antibacterials are appliedwith each dressing change. However, sys-

temic antibiotics are always necessary. The

bacterial spectrum must extend from thegram-negative rods, including Pseudomonasaeruginosa, through the anaerobic Strepto-cocci and Bacteroides. In addition, an error

in the clinical diagnosis may have obscuredthe presence of true gas gangrene. No singleantibiotic will give the necessary bacterialcoverage. Personal preference has been forthe combination of a cephalosporine (Keflinfor the Streptococci at 8 to 12 Gm. per day),chloramphenicol for the Bacteroides (at 2to 4 Gm. per day), and gentamycin sulfate(Garamycin at 3 mg./Kg./day) to combatthe gram-negative bacteria. These agentsare begun preoperatively by placing themin the intravenous fluids and are continueduntil all evidence of systemic sepsis has beeneradicated and the threat of local recur-

rence is no longer a problem.

Summary

Synergistic necrotizing cellulitis has beena heretofore seldom-recognized virulent in-fection that is caused by the symbiotic ac-

tion of an aerobic gram-negative rod incombination with an anaerobic Strepto-coccus. One of the Bacteroides group ofanaerobes is often present as well, especiallyonce septicemia has developed.The infection carries a high mortality and

must be differentiated from gas gangreneand true Meleney's cellulitis. There is a pred-ilection for middle-aged and elderly indi-viduals who have diabetes, renal disease,and either obesity or malnutrition. Charac-teristically, the infectious process causes ex-

tensive necrosis of entire muscle compart-ments with little damage to the overlyingskin and subcutaneous tissues. Microscopicexamination of the dishwater-appearing lo-cal exudate is diagnostic when both gram-positive cocci and gram-negative rods can

be identified.Treatment must be energetic. After cor-

rection of fluid and electrolyte deficits andreversal of the diabetic keto-acidosis, radicaldebridement must be performed. The ad-

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710 STONE AND MARTIN Ann. Surg. May 1972Vol. 175 No. 5

ministration of topical and systemic anti-biotics is equally important.During a 13-year period, 63 such infec-

tions were encountered on the SurgicalService at Grady Memorial Hospital. The48 resultant deaths produced a 76% mor-tality rate.

References1. Brewer, G. E. and Meleney, F. L.: Progressive

Gangrenous Infection of the Skin and Subcu-taneous Tissues Following Operation for AcutePerforative Appendicitis. A Study in Symbio-sis. Ann. Surg., 84:438, 1926.

2. Crosthwait, R. W. and Jordan, G. L.: Necrotiz-ing Fasciitis. J. Trauma, 4:148, 1964.

3. Cullen, T. S.: A Progressively Enlarging Ulcerof the Abdominal Wall Involving the Skin andFat Following Drainage of a Abdominal Ab-scess Apparently of Appendiceal Origin. Surg.Gynecol. Obstet., 38:579, 1924.

4. Meade, J. W. and Mueller, C. B.: NecrotizingInfections of Subcutaneous Tissue and Fascia.Ann. Surg., 168:274, 1968.

5. Meleney, F. L.: Hemolytic Streptococcus Gan-grene. Arch. Surg., 9:317, 1924.

6. Sandusky, W. R., Pulaski, E. J., Johnson, B. A.and Meleney, F. L.: The Anaerobic Non-hemolytic Streptococci in Surgical Infectionson a General Surgical Service. Surg. Gynecol.Obstet., 75:145, 1942.

7. Stone, H. H., Morrison, C. W. and Martin, J.D., Jr.: Ischemic Necrotizing Cellulitis. Med.Sci., 15:58, 1964.

8. Wilson, B.: Necrotizing Fasciitis. Amer. Surg.,18:416, 1952.

DISCUSSIONDR. ROBERT M. MILES (Memphis): These

necrotizing infections pose serious problems, whichdemand an acute, proper decision for therapy.Most of the time this decision must be based onthe clinical appearance and characteristics, sincethere is no time to wait for culture reports, andmany times smears are unrewarding, possibly be-cause of previous antibiotic agents.

Synergistic necrotizing cellulitis is a killer withan extremely high mortality rate, and only radicaldebridement coupled with wide sprectrum anti-biotic coverage and general supportive treatmentwill salvage these patients.We would like to mention two illustrative cases

that bear this out. The first was a 62-year-oldwoman, who was referred to us 4 days after thenailing of a trochanteric fracture. Temperaturewas 1040 and she was in renal failure. There wasa gray discoloration of the skin about the wound,and a mottled, similar discoloration in the posteriorthigh and calf. Gas was crepitant in the wound. Atypical dishwater exudate, as Dr. Stone de-scribed, was present. A culture revealed onlyanaerobic strep, but she had received broad spec-truc antibiotic therapy for 4 days.A radical debridement was done, in which

several pounds of necrotic muscle, skin, and sub-cutaneous tissue were removed such as Dr. Stoneshowed us. Neither amputation nor quarterectomywould have sufficed, because of the extent of theprocess into the gluteir and lumbar muscles.

She improved, but then developed more necrosiswhich required resection of several more pounds ofnecrotic muscle.

However, because of renal failure marked azo-temia and hyperkalemia developed. Peritoneal dial-ysis decreased the BUN and potassium levels, andabout the time she appeared to be recovering, amassive hemorrhage from the small intestine oc-curred and she died.

Autopsy showed the hemorrage was due tomucosal necrosis of the small intestine, probablysecondary to the azotemia.We do better with Meleney's, however. About

2 weeks ago, a friend from Mississippi called abouta patient with Meleney's of the abdominal wallfollowing a hysterectomy they had been workingwith for several days.

[Slide] I do not know whether you can seeit as well as I, but this is a typical Meleney's bac-terial synergistic gangrene, with necrosis in thecenter, a blue zone of ecchymosis and undermin-ing, with gangrene in this area, and then a haloof erythema about this.

The patient's temperature was 1040, pulse160, she was extremely toxic. She had been treatedwith penicillin, Vibramycin and Chloromycetin.At the previous hospital and subsequently at ourscultures of the pus, tissue and blood were negative,as were smears.We thought it was a Meleney's, though, and did

an immediate debridement. Massive penicillintherapy coupled with Garamycin was instituted.The problem was, though: How much to debride?

Meleney in 1933 said that one should debridebeyond the area of erythema. We were reluctantto go out quite that far. We excised the necrotic