Skip to main content
SpringerLink
Log in

Necrotizing Soft-Tissue Infections: Clinical Features and Diagnostic Aspects

  • Chapter
  • First Online:
Necrotizing Soft Tissue Infections

Part of the book series: Advances in Experimental Medicine and Biology ((AEMB,volume 1294))

Abstract

The term necrotizing soft-tissue infection (NSTI) encompasses a heterogenous group of patients with necrotizing infections, involving any body part. NSTI is diagnosed by surgical exploration, where necrosis of the subcutaneous tissue and/or muscle tissue, undermining of the skin, thrombosis of the superficial veins, and deliquescent tissue can be seen. Patients can present with vague symptoms, and approximately half of patients experience severe pain. The clinical presentation and microbiological etiology vary according to affected body site, with NSTI located to the extremities being dominated by monomicrobial group A streptococcal infections, and NSTI located to the anogenital area dominated by polymicrobial infections. No set of diagnostic criteria exists, and suspicion of the diagnosis should come from careful clinical examination and signs of local or systemic severity. Laboratory blood values show no distinct pattern but resemble those of sepsis. Imaging can aid the diagnostic process but must not delay surgical intervention.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 119.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 159.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  • Ali SZ, Srinivasan S, Peh WCG (2014) MRI in necrotizing fasciitis of the extremities. Br J Radiol 87:20130560

    Article  CAS  PubMed  Google Scholar 

  • Al-Qurayshi Z, Nichols RL, Killackey MT, Kandil E (2020) Mortality risk in necrotizing fasciitis: national prevalence, trend, and burden. Surg Infect 21:sur.2019.277

    Article  Google Scholar 

  • Anaya DA, Dellinger EP (2007) Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis 44:705–710

    Article  CAS  PubMed  Google Scholar 

  • Anaya DA, McMahon K, Nathens AB et al (2005) Predictors of mortality and limb loss in necrotizing soft tissue infections. Arch Surg 140:151–157

    Article  PubMed  Google Scholar 

  • Arif N, Yousfi S, Vinnard C (2016) Deaths from necrotizing fasciitis in the United States, 2003-2013. Epidemiol Infect 144:1338–1344

    Article  CAS  PubMed  Google Scholar 

  • ARISE Investigators, ANZICS Clinical Trials Group, Peake SL et al (2014) Goal-directed resuscitation for patients with early septic shock. N Engl J Med 371:1496–1506

    Article  CAS  Google Scholar 

  • Bakleh M, Wold LE, Mandrekar JN et al (2005) Correlation of histopathologic findings with clinical outcome in necrotizing fasciitis. Clin Infect Dis 40:410–414

    Article  PubMed  Google Scholar 

  • Barbic D, Chenkin J, Cho DD et al (2017) In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open 7:e013688

    Article  PubMed  PubMed Central  Google Scholar 

  • Barker FG, Leppard BJ, Seal DV (1987) Streptococcal necrotising fasciitis: comparison between histological and clinical features. J Clin Pathol 40:335–341

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Beck MK, Jensen AB, Nielsen AB et al (2016) Diagnosis trajectories of prior multi-morbidity predict sepsis mortality. Sci Rep 6:36624

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Bisno AL, Cockerill FR, Bermudez CT (2000) The initial outpatient-physician encounter in group A streptococcal necrotizing fasciitis. Clin Infect Dis 31:607–608

    Article  CAS  PubMed  Google Scholar 

  • Borschitz T, Schlicht S, Siegel E et al (2015) Improvement of a clinical score for necrotizing fasciitis: “pain out of proportion” and high CRP levels aid the diagnosis. PLoS One 10:e0132775

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  • Boyer A, Vargas F, Coste F et al (2009) Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med 35:847–853

    Article  PubMed  Google Scholar 

  • Bucca K, Spencer R, Orford N et al (2013) Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study. ANZ J Surg 83:365–370

    Article  PubMed  Google Scholar 

  • Carbonetti F, Cremona A, Carusi V et al (2016) The role of contrast enhanced computed tomography in the diagnosis of necrotizing fasciitis and comparison with the laboratory risk indicator for necrotizing fasciitis (LRINEC). Radiol Med 121:106–121

    Article  PubMed  Google Scholar 

  • Carey IM, Critchley JA, Dewilde S et al (2018) Risk of infection in type 1 and type 2 diabetes compared with the general population: a matched cohort study. Diabetes Care 41:513–521

    Article  PubMed  Google Scholar 

  • Chuang PY, Yang TY, Huang TW et al (2019) Hepatic disease and the risk of mortality of Vibrio vulnificus necrotizing skin and soft tissue infections: a systematic review and meta-analysis. PLoS One 14:e0223513

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Cribb BI, Wang MTM, Kulasegaran S et al (2019) The SIARI score: a novel decision support tool outperforms LRINEC score in necrotizing fasciitis. World J Surg 43:2393–2400

    Article  PubMed  Google Scholar 

  • Deganello A, Gallo O, Gitti G, De Campora E (2009) Necrotizing fasciitis of the neck associated with Lemierre syndrome. Acta Otorhinolaryngol Ital 29:160–163

    CAS  PubMed  PubMed Central  Google Scholar 

  • Erichsen Andersson A, Egerod I, Knudsen VE, Fagerdahl AM (2018) Signs, symptoms and diagnosis of necrotizing fasciitis experienced by survivors and family: a qualitative Nordic multi-center study. BMC Infect Dis 18:1–9

    Article  Google Scholar 

  • Esper AM, Moss M, Martin GS (2009) The effect of diabetes mellitus on organ dysfunction with sepsis: an epidemiological study. Crit Care 13:R18

    Article  PubMed  PubMed Central  Google Scholar 

  • Fernando SM, Tran A, Cheng W et al (2019) Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging, and LRINEC score: a systematic review and meta-analysis. Ann Surg 269:58–65

    Article  PubMed  Google Scholar 

  • Flavahan PW, Cauchi P, Gregory ME et al (2014) Incidence of periorbital necrotising fasciitis in the UK population: a BOSU study. Br J Ophthalmol 98:1177–1180

    Article  CAS  PubMed  Google Scholar 

  • Goh T, Goh LG, Ang CH, Wong CH (2014) Early diagnosis of necrotizing fasciitis. Br J Surg 101:e119–e125

    Article  CAS  PubMed  Google Scholar 

  • Gunaratne DA, Tseros EA, Hasan Z et al (2018) Cervical necrotizing fasciitis: systematic review and analysis of 1235 reported cases from the literature. Head Neck 40:2094–2102

    Article  PubMed  Google Scholar 

  • Hadeed GJ, Smith J, O’Keeffe T et al (2016) Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: a single academic center experience. J Emerg Trauma Shock 9:22–27

    Article  PubMed  PubMed Central  Google Scholar 

  • Hakkarainen TW, Burkette Ikebata N, Bulger E, Evans HL (2014) Moving beyond survival as a measure of success: understanding the patient experience of necrotizing soft-tissue infections. J Surg Res 192:143–149

    Article  PubMed  PubMed Central  Google Scholar 

  • Hansen MB, Rasmussen LS, Garred P et al (2016) Pentraxin-3 as a marker of disease severity and risk of death in patients with necrotizing soft tissue infections: a nationwide, prospective, observational study. Crit Care 20:40

    Article  PubMed  PubMed Central  Google Scholar 

  • Hayeri MR, Ziai P, Shehata ML et al (2016) Soft-tissue infections and their imaging mimics: from cellulitis to necrotizing fasciitis. Radiographics 36:1888–1910

    Article  PubMed  Google Scholar 

  • Horn DL, Shen J, Roberts E et al (2020) Predictors of mortality, limb loss, and discharge disposition at admission amongst patients with necrotizing skin and soft tissue infections. J Trauma Acute Care Surg 89(1):186–191

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Howell EC, Keeley JA, Kaji AH et al (2019) Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection. Trauma Surg Acute Care Open 4:e000264

    Article  PubMed  PubMed Central  Google Scholar 

  • Hsiao CT, Chang CP, Huang TY et al (2020) Prospective validation of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for necrotizing fasciitis of the extremities. PLoS One 15:e0227748

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Hua C, Sbidian E, Hemery F et al (2015) Prognostic factors in necrotizing soft-tissue infections (NSTI): a cohort study. J Am Acad Dermatol 73:1006–12.e8

    Article  PubMed  Google Scholar 

  • Huang K-F, Hung M-H, Lin Y-S et al (2011) Independent predictors of mortality for necrotizing fasciitis: a retrospective analysis in a single institution. J Trauma 71:467–473; discussion 473

    Article  PubMed  Google Scholar 

  • Investigators TP (2014) A randomized trial of protocol-based care for early septic shock. N Engl J Med 370(18):1683–1693

    Article  CAS  Google Scholar 

  • Jones WHS (1923) Hippocrates, vol 1: Airs, waters and places. Epidemics 1 and 3. Harvard University Press, Cambridge

    Google Scholar 

  • Khamnuan P, Chongruksut W, Jearwattanakanok K et al (2015a) Necrotizing fasciitis: epidemiology and clinical predictors for amputation. Int J Gen Med 8:195–202

    CAS  PubMed  PubMed Central  Google Scholar 

  • Khamnuan P, Chongruksut W, Jearwattanakanok K et al (2015b) Necrotizing fasciitis: risk factors of mortality. Risk Manag Healthc Policy 8:1

    PubMed  PubMed Central  Google Scholar 

  • Kim K-T, Kim YJ, Won Lee J et al (2011) Can necrotizing infectious fasciitis be differentiated from nonnecrotizing infectious fasciitis with MR imaging? Radiology 259:816–824

    Article  PubMed  Google Scholar 

  • Leichtle SW, Tung L, Khan M et al (2016) The role of radiologic evaluation in necrotizing soft tissue infections. J Trauma Acute Care Surg 81:921–924

    Article  CAS  PubMed  Google Scholar 

  • Lille ST, Sato TT, Engrav LH et al (1996) Necrotizing soft tissue infections: obstacles in diagnosis. J Am Coll Surg 182:7–11

    CAS  PubMed  Google Scholar 

  • Loudon I (1994) Necrotising fasciitis, hospital gangrene, and phagedena. Lancet (Lond) 344:1416–1419

    Article  CAS  Google Scholar 

  • Madsen MB, Skrede S, Perner A et al (2019) Patient’s characteristics and outcomes in necrotising soft-tissue infections: results from a Scandinavian, multicentre, prospective cohort study. Intensive Care Med 45:1241–1251

    Article  CAS  PubMed  Google Scholar 

  • McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA (1995) Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 221:558–563; discussion 563–565

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Meleney FL (1924) Hemolytic streptococcus gangrene. Arch Surg 9:317–364

    Article  Google Scholar 

  • Moore SA, Levy BH, Prematilake C, Dissanaike S (2015) The prediction predicament: rethinking necrotizing soft tissue infections mortality. Surg Infect 16:813–821

    Article  Google Scholar 

  • Polzik P, Grøndal O, Tavenier J et al (2019) SuPAR correlates with mortality and clinical severity in patients with necrotizing soft-tissue infections: results from a prospective, observational cohort study. Sci Rep 9:5098

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  • PRISM Investigators (2017) Early, goal-directed therapy for septic shock - a patient-level meta-analysis. N Engl J Med 376(23):2223–2234

    Article  Google Scholar 

  • Rahmouni A, Chosidow O, Mathieu D et al (1994) MR imaging in acute infectious cellulitis. Radiology 192:493–496

    Article  CAS  PubMed  Google Scholar 

  • Rodriguez C, Jary A, Hua C et al (2020) Pathogen identification by shotgun metagenomics of patients with necrotizing soft-tissue infections. Br J Dermatol 183(1):105–113

    Article  CAS  PubMed  Google Scholar 

  • Rudkjøbing VB, Thomsen TR, Xu Y et al (2016) Comparing culture and molecular methods for the identification of microorganisms involved in necrotizing soft tissue infections. BMC Infect Dis 16:652

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  • Sarin SK, Kumar M, Eslam M et al (2020) Liver diseases in the Asia-Pacific region: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 5:167–228

    Article  PubMed  Google Scholar 

  • Sartelli M, Guirao X, Hardcastle TC et al (2018) 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg 13:58

    Article  PubMed  PubMed Central  Google Scholar 

  • Simonart T, Simonart J-M, Derdelinckx I et al (2001) Value of standard laboratory tests for the early recognition of group A -hemolytic streptococcal necrotizing fasciitis. Clin Infect Dis 32:e9–e12

    Article  CAS  PubMed  Google Scholar 

  • Singh A, Ahmed K, Aydin A et al (2016) Fournier’s gangrene. A clinical review. Arch Ital Urol Androl 88:157–164

    Article  PubMed  Google Scholar 

  • Skitarelic N, Mladina R, Morovic M et al (2003) Cervical necrotizing fasciitis: sources and outcomes. Infection 31:39–44

    Article  CAS  PubMed  Google Scholar 

  • Sorensen MD, Krieger JN, Rivara FP et al (2009) Fournier’s Gangrene: population based epidemiology and outcomes. J Urol 181:2120–2126

    Article  PubMed  PubMed Central  Google Scholar 

  • Stamenkovic I, Lew PD (1984) Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med 310:1689–1693

    Article  CAS  PubMed  Google Scholar 

  • Stevens DL, Bryant AE (2017) Necrotizing soft-tissue infections. N Engl J Med 377:2253–2265

    Article  PubMed  Google Scholar 

  • Stevens DL, Bisno AL, Chambers HF et al (2014) Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis 59:147–159

    Article  PubMed  Google Scholar 

  • Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC (1987) Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg 206:661–665

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Thänert R, Itzek A, Hoßmann J et al (2019) Molecular profiling of tissue biopsies reveals unique signatures associated with streptococcal necrotizing soft tissue infections. Nat Commun 10:3846

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  • Tso DK, Singh AK (2018) Necrotizing fasciitis of the lower extremity: imaging pearls and pitfalls. Br J Radiol 91:20180093

    Article  PubMed  PubMed Central  Google Scholar 

  • Umbert IJ, Winkelmann RK, Oliver GF, Peters MS (1989) Necrotizing fasciitis: a clinical, microbiologic, and histopathologic study of 14 patients. J Am Acad Dermatol 20:774–781

    Article  CAS  PubMed  Google Scholar 

  • Urbina T, Madsen MB, de Prost N (2020) Understanding necrotizing soft tissue infections in the intensive care unit. Intensive Care Med 38. https://doi.org/10.1007/s00134-020-06071-w

  • Whitson MR, Mayo PH (2016) Ultrasonography in the emergency department. Crit Care 20:227

    Article  PubMed  PubMed Central  Google Scholar 

  • WHO (2017) International classification of diseases. http://www.who.int/classifications/icd/en/. Accessed 1 Feb 2018

  • Wilson B (1952) Necrotizing fasciitis. Am Surg 18:416–431

    CAS  PubMed  Google Scholar 

  • Wolf H, Rusan M, Lambertsen K, Ovesen T (2010) Necrotizing fasciitis of the head and neck. Head Neck 32:1592–1596

    Article  PubMed  Google Scholar 

  • Wong C-H, Chang H-C, Pasupathy S et al (2003) Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am 85-A:1454–1460

    Article  Google Scholar 

  • Wong C-H, Khin L-W, Heng K-S et al (2004) The LRINEC (laboratory risk Indicator for necrotizing fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 32:1535–1541

    Article  PubMed  Google Scholar 

  • Würtz NS, Mikkelsen LH, Jørgensen JS et al (2020) Periocular necrotizing soft tissue infection in Greater Copenhagen. Acta Ophthalmol 98(2):207–212

    Article  PubMed  CAS  Google Scholar 

  • Wysoki MG, Santora TA, Shah RM, Friedman AC (1997) Necrotizing fasciitis: CT characteristics. Radiology 203:859–863

    Article  CAS  PubMed  Google Scholar 

  • Yen Z-S, Wang H-P, Ma H-M et al (2002) Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med 9:1448–1451

    Article  PubMed  Google Scholar 

  • Yilmazlar T, Gulcu B, Isik O, Ozturk E (2017) Microbiological aspects of Fournier’s gangrene. Int J Surg 40:135–138

    Article  PubMed  Google Scholar 

Download references

Acknowledgement

Financial support: The work was supported by the European Union Seventh Framework Programme: (FP7/2007-2013) under the grant agreement 305340 (INFECT project).

Author information

Authors and Affiliations

  1. Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark

    Martin Bruun Madsen

  2. Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden

    Per Arnell

  3. Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark

    Ole Hyldegaard

Authors
  1. Martin Bruun Madsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Per Arnell
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ole Hyldegaard
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Martin Bruun Madsen .

Editor information

Editors and Affiliations

  1. Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Huddinge, Sweden

    Anna Norrby-Teglund

  2. Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Huddinge, Sweden

    Mattias Svensson

  3. Department of Clinical Science, University of Bergen, Bergen, Norway

    Steinar Skrede

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Madsen, M.B., Arnell, P., Hyldegaard, O. (2020). Necrotizing Soft-Tissue Infections: Clinical Features and Diagnostic Aspects. In: Norrby-Teglund, A., Svensson, M., Skrede, S. (eds) Necrotizing Soft Tissue Infections. Advances in Experimental Medicine and Biology, vol 1294. Springer, Cham. https://doi.org/10.1007/978-3-030-57616-5_4

Download citation

Publish with us

Policies and ethics

Search

Navigation