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Necrotizing fasciitis: treatment concepts and clinical results

  • M. Leiblein
  • I. Marzi
  • A. L. Sander
  • J. H. Barker
  • F. Ebert
  • J. Frank
Original Article

Abstract

Background

Necrotizing fasciitis is a life-threatening soft tissue infection characterized by a rapid spreading infection of the subcutaneous tissue and in particular the fascia. The management of infected tissues requires a rapid diagnosis, immediate aggressive surgical management and an extended debridement. In some cases early amputations of the affected tissues and maximum intensive care treatment, in case of sepsis, are required. Due to a rising number of cases we aimed to evaluate our patients in a retrospective review.

Method

All patients diagnosed with necrotizing fasciitis from 2014 to 2016 (21 months) in our level one trauma center were identified. Their charts were reviewed and data were analyzed in terms of demographic and social information, microbiological results, therapeutic course, socio-economic outcome and mortality.

Results

We found 15 patients with necrotizing fasciitis. None of these died in the observation period. The mean number of surgical interventions was seven. Two patients underwent limb amputation; diabetes mellitus was assigned with a significant higher risk for amputation. The mean hospitalization was 32 days, including 8 days on intensive care unit. Of the discovered bacteria 93% were sensitive to the initial antibiotic treatment with Ampicillin, Clindamycin and Clont.

Conclusion

Surgical therapy is indicated if necrotizing fasciitis is suspected. Diabetes mellitus was a clinical predictor of limb amputation in patients with necrotizing fasciitis in our cohort. Aminopenicillin ± sulbactam in combination with clindamycin and/or metronidazole is recommended as initial calculated antibiotic treatment.

Keywords

Necrotizing fasciitis Soft tissue infection Hemolytic streptococcal gangrene Necrotizing cellulites 

Notes

Compliance with ethical standards

Funding

There has been no source of support/funding, either pharmaceutical or industry support. No funding from any organization has been received.

Ethical approval

This retrospective study was approved by the ethic committee of the Johann Wolfgang Goethe-University Frankfurt (352/16).

Conflict of interest

Maximilian Leiblein, Ingo Marzi, Anna Lena Sander, John H. Barker, Federico Ebert and Johannes Frank declare that they have no conflict of interest.

References

  1. 1.
    Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014;51(8):344–62.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Pfanner W. Zur Kenntnis und Behandlung des nekrotisierenden Erysipels. Deutsche Zeitschrift für Chirurgie. 1918;144(1–2):108.CrossRefGoogle Scholar
  3. 3.
    Wilson B. Necrotizing fasciitis. Am Surg. 1952;18(4):416–31.PubMedGoogle Scholar
  4. 4.
    Frank J, Barker JH, Marzi I. Necrotizing fasciitis of the extremities. Eur J Trauma Emerg Surg. 2008;34(3):229.CrossRefPubMedGoogle Scholar
  5. 5.
    Herr M, Grabein B, Palm HG. Nekrotisierende Fasziitis. Der Unfallchirurg. 2011;114(3):197–216.CrossRefPubMedGoogle Scholar
  6. 6.
    Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014;1:36.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Lamagni TL, Darenberg J, Luca-Harari B, et al. Epidemiology of severe Streptococcus pyogenes disease in Europe. J Clin Microbiol. 2008;46(7):2359–67.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Davies HD, McGeer A, Schwartz B, et al. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med. 1996;335(8):547–54.CrossRefPubMedGoogle Scholar
  9. 9.
    Ryssel H, Germann G, Kloeters O, et al. Necrotizing fasciitis of the extremities: 34 cases at a single centre over the past 5 years. Arch Orthop Trauma Surg. 2010;130(12):1515–22.CrossRefPubMedGoogle Scholar
  10. 10.
    Lacy MD, Horn K. Nosocomial transmission of invasive group a streptococcus from patient to health care worker. Clin Infect Dis. 2009;49:354–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Johansson L, Thulin P, Low DE, et al. Getting under the skin: the immunopathogenesis of Streptococcus pyogenes deep tissue infections. Clin Infect Dis. 2010;51(1):58–65.CrossRefPubMedGoogle Scholar
  12. 12.
    Zhu L, Olsen RJ, Nasser W, et al. A molecular trigger for intercontinental epidemics of group A Streptococcus. J Clin Investig. 2015;125(9):3545–59.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    O’Seaghdha M, Wessels MR. Streptolysin O and its co-toxin NAD-glycohydrolase protect group A Streptococcus from xenophagic killing. PLoS Pathog. 2013;9(6):e1003394.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Sarani B, Strong M, Pascual J, et al. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009;208(2):279–88.CrossRefPubMedGoogle Scholar
  15. 15.
    Machado N. Necrotizing fasciitis: the importance of early diagnosis, prompt surgical debridement and adjuvant therapy. North Am J Med Sci. 2011;3(3):107.CrossRefGoogle Scholar
  16. 16.
    Chen JL, Fullerton KE, Flynn NM. Necrotizing fasciitis associated with injection drug use. Clin Infect Dis. 2001;33(1):6–15.CrossRefPubMedGoogle Scholar
  17. 17.
    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;352:1445–53.CrossRefPubMedGoogle Scholar
  18. 18.
    Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535–41.CrossRefPubMedGoogle Scholar
  19. 19.
    Goh T, Goh LG, Ang CH, et al. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):e119–25.CrossRefPubMedGoogle Scholar
  20. 20.
    Wang YS, Wong CH, Tay YK. Staging of necrotizing fasciitis based on the evolving cutaneous features. Int J Dermatol. 2007;46(10):1036–41.CrossRefPubMedGoogle Scholar
  21. 21.
    Wall DB, Virgilio C, Black S, et al. Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection. Am J Surg. 2000;179:17–21.CrossRefPubMedGoogle Scholar
  22. 22.
    Narashiman V, Ooi G, Weidlich S, et al. Laboratory risk indicator for necrotizing fasciitis score for early diagnosis of necrotizing fasciitis in Darwin. ANZ J Surg. 2017. (Epub ahead of print).Google Scholar
  23. 23.
    El-Menyar A, Asim M, Mudali IN, et al. The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic value. Scand J Trauma Resusc Emerg Med. 2017;25(1):28.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Burner E, Henderson SO, Burke G, et al. Inadequate sensitivity of laboratory risk indicator to rule out necrotizing fasciitis in the emergency department. West J Emerg Med. 2016;17(3):333–6.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Tan JH, Koh BT, Hong CC, et al. A comparison of necrotising fasciitis in diabetics and non- diabetics: a review of 127 patients. Bone Joint J. 2016;98-B(11):1563–1568.Google Scholar
  26. 26.
    Carbonetti F, Cremona A, Carusi V, et al. 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. 2015; [Epub ahead of print].Google Scholar
  27. 27.
    Sun X, Xie T. Management of necrotizing fasciitis and its surgical aspects. Int J Low Extrem Wounds. 2015;14(4):328–34.CrossRefPubMedGoogle Scholar
  28. 28.
    Bilton BD, Zibari GB, McMillan RW, et al. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg. 1998;64(5):397–400.PubMedGoogle Scholar
  29. 29.
    Wong CH, Yam AK, Tan AB, et al. Approach to debridement in necrotizing fasciitis. Am J Surg. 2008;196(3):e19–24.Google Scholar
  30. 30.
    Hietbrink F, Bode LG, Riddez L, et al. Triple diagnosis for early detection of ambivalent necrotizing fasciitis. World J Emerg Surg. 2016;11:51.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Misiakos EP, Bagias G, Papadopoulos I, et al. Early diagnosis and surgical treatment for necrotizing fasciitis: a multicenter study. Front Surg. 2017;4:5.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Wall DB, Klein SR, Black S, et al. A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. J Am Coll Sure. 2000;191(3):227–31.CrossRefGoogle Scholar
  33. 33.
    Burnham JP, Kirby JP, Kolleg MH. Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review. Intensive Care Med. 2016;42:1899–911.CrossRefPubMedGoogle Scholar
  34. 34.
    Chester DL, Waters R. Adverse alteration of wound flora with topical negative-pressure therapy: a case report. Br J Plast Surg. 2002;55:510–1.CrossRefPubMedGoogle Scholar
  35. 35.
    Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. S2-Leitlinie HNO: Antibiotikatherapie der Infektionen an Kopf und Hals, 2008.Google Scholar
  36. 36.
    Khamnuan P, Chongruksut W, Jearwarttanakanok K, et al. Necrotizing fasciitis: epidemiology and clinical predictors for amputation. Int J Gen Med. 2015;8:195–202.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Cheng NC, Tai HC, Chang SC, et al. Necrotizing fasciitis in patients with diabetes mellitus: clinical characteristics and risk factors for mortality. BMC Infect Dis. 2015;15:417.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Elliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg. 1996;224(5):672–83.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Frazee BW, Fee C, Lynn J, et al. Community-acquired necrotizing soft tissue infections: a review of 122 cases presenting to a single emergency department over 12 years. J Emer Med. 2008;34(2):139–46.CrossRefGoogle Scholar
  40. 40.
    Dworkin M, Westercamp M, Park L, et al. The epidemiology of necrotising fasciitis including factors associated with death and amputation. Epidemiol Infect. 2009;137:1609–14.CrossRefPubMedGoogle Scholar
  41. 41.
    Nisbet M, Ansell G, Lang S, Dzendrowskyj P, Holland D, et al. Necrotising fasciitis: review of 82 cases in South Auckland. Intern Med J. 2011;47:543–8.CrossRefGoogle Scholar
  42. 42.
    Wong CH, Chang HC, Pasupathy S, et al. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003;85(8):1454–60.CrossRefPubMedGoogle Scholar
  43. 43.
    Singh G, Sinha S, Adhikary S, et al. Necrotising infections of soft tissues—a clinical profile. Eur J Surg. 2002;168:366–71.CrossRefPubMedGoogle Scholar
  44. 44.
    Hsiao CT, Weng HH, Yuan YD, et al. Predictors of mortality in patients with necrotizing fasciitis. Am J Emerg Med. 2008;26(2):170–5.CrossRefPubMedGoogle Scholar
  45. 45.
    Huang KF, Hung MH, Lin YS, et al. Independent predictors of mortality for necrotising fasciitis: a retrospective analysis in a single institution. J Trauma. 2011;71:467–73.CrossRefPubMedGoogle Scholar
  46. 46.
    Park KH, Jung SI, Jung YS, et al. Marine bacteria as a leading cause of necrotizing fasciitis in coastal areas of South Korea. Am J Trop Med Hyg. 2009;80(4):646–50.PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • M. Leiblein
    • 1
  • I. Marzi
    • 1
  • A. L. Sander
    • 1
  • J. H. Barker
    • 2
  • F. Ebert
    • 1
  • J. Frank
    • 1
  1. 1.Department of Trauma, Hand, and Reconstructive SurgeryJohann Wolfgang Goethe-UniversityFrankfurt am MainGermany
  2. 2.Experimental Trauma and Orthopedic Surgery, Frankfurt Initiative for Regenerative MedicineGoethe-Universität, Friedrichsheim gGmbHFrankfurt/MainGermany

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