Necrotizing infection of
        the skin and fascia
        Department of Obstetrics and Gynaecology
        INTRODUCTION
        Necrotizing infections of the skin and fascia include necrotizing forms of cellulitis and fasciitis types I and II. These infections are characterized clinically by fulminant destruction of tissue, systemic signs of toxicity, and a high rate of mortality.

        NECROTIZING CELLULITIS
        There are several different types of necrotizing cellulitis including clostridial and nonclostridial anaerobic infections.

        Clostridial cellulitis - Clostridial cellulitis, most often due to Clostridium perfringens, is usually preceded by local trauma or recent surgery. Gas is invariably found in the skin, but the fascia and deep muscle are spared. Magnetic resonance imaging (MRI) or CT scanning and measurement of the serum creatine kinase (CK) concentration can help to determine if muscle tissue is involved.

        Nonclostridial anaerobic cellulitis - Is due to infection with mixed anaerobic and aerobic organisms that produce gas in tissues. Unlike clostridial cellulitis, this infection is usually associated with diabetes mellitus and often produces a foul odor. It must be distinguished from myonecrosis and necrotizing fasciitis by surgical exploration

        NECROTIZING FASCIITIS
        Necrotizing fasciitis is a deep-seated infection of the subcutaneous tissue that results in progressive destruction of fascia and fat, but may spare the skin. Two clinical types exist.
        • Type I necrotizing fasciitis is a mixed infection caused by aerobic and anaerobic bacteria and occurs most commonly after surgical procedures and in patients with diabetes and peripheral vascular disease.
        • Type II the bacteria that causes these infections was originally identified as haemolytic group A streptococcus (GAS, Streptococcus pyogenes) and 50% have no obvious portal of entry, but subsequent observation have implicated nummerous other aerobic and anaerobic which often acts synergestical i.e Staphylococcus aureus (meticillin-resistent), clostridium perfringens and sardellii . Almost one-half had streptococcal toxic shock syndrome.
        In contrast to type I necrotizing fasciitis, type II can occur in any age group and among patients who do not have complicated medical illnesses.

        Fournier's gangrene - In the perineal area, penetration of the gastrointestinal or urethral mucosa by enteric organisms can cause Fournier's gangrene, which is an aggressive infection. These infections begin abruptly with severe pain and may spread rapidly onto the anterior abdominal wall, and into the gluteal muscles. These infections are induced by a mixture of aerobic and anaerobic organisms and are therefore classified as type I infections.

        Clinical manifestations - Early recognition of necrotizing fasciitis is important since there may be a remarkably rapid progression from an inapparent process to one associated with extensive destruction of tissue, systemic toxicity and loss of limb or death.
        Unexplained pain, which increases rapidly over time, may be the first manifestation of necrotizing fasciitis. Whenever postoperative/posttraumatic pain is increasing in severity, the patient should be examined expeditiously to verify that a serious wound complication, such as necrotizing fasciitis, is not the source of the increasing pain. Thus the triad of incordinate pelvic pain, oedema (unilateral) and any sign af septicemia in the post partum period create a high suspision on necrotizing fasciitis and mandate imediately surgical intervention.
        Erythema may be present diffusely or locally. Within 24 to 48 hours, erythema may develop or darken to a reddish-purple color, frequently with associated blisters and bullae; bullae can also develop in normal appearing skin. Once the bullous stage is reached, there is already extensive deep soft tissue destruction such as necrotizing fasciitis or myonecrosis. Crepitus is present in about 10 percent of patients. GAS production does not play a significant role in the early diagnosis. GAS is seen by X-ray, CT-scan or magnetic Imagining (MR) and should be obtain if the diagnosis is in doubt.

        Awaiting results of blood cultures or skin aspirates should not be done. Surgical exploration should proceed rapidly if this diagnosis is suspected. The patient can develop bakteriaemia -sepsis - sepsis shock and multiple organ dysfunction syndrome (MODS).

        Recommendations
        • When necrotizing fasciitis is suspected, surgical exploration is the only way to be certain whether this is the correct diagnosis (fever, toxic symptoms , soft tissue involment and pain out of proportion with skin findings and elevated CRP with or without radiological findings.
        • Aggressiv volumensubstitution
        • Prompt surgical exploration both facilitates early debridement and obtaining material for appropriate cultures.

        Clindamycin may be more effective because it is not affected by inoculum size or the stage of growth, it suppresses toxin production, it facilitates phagocytosis of S. pyogenes by inhibiting M-protein synthesis, it suppresses production of regulatory elements controlling cell wall synthesis and it has a long postantibiotic effect. Recently, a retrospective analysis of cases demonstrated a greater efficacy for clindamycin compared to beta-lactam antibiotics in patients with invasive infections.

        Some recommend the administration of penicillin G (4 million units intravenously every four hours in adults >60 kg in weight and with normal renal function) in combination with clindamycin (600 to 900 mg intravenously every eight hours). RH in Denmark Menonem 2 g IV and then 1 g x 3 Cepoxin 400 mg x 2, Dalacin 600 mg x 3 and Gammaglobolin 25 g daily for 3 days.

        Antibiotic therapy should be narrowed based upon operative culture results and susceptibility for at least 10 days

        References:
        (1) Nekrotiserende Fascit: Guidelines from Rigshospitalet, Copenhagen

        (2) www.uptodate.com 2007 UptoDate 2006. version 14.3

        Se also

        Piper JM, West P. Necrotizing fasciitis following postpartum tubal ligation. A case report and review of the literature. Arch Gynecol Obstet. 1995;256(1):35-8.

        Ozalay M, et all Necrotizing soft-tissue infection of a limb: clinical presentation and factors related to mortality. 2006

        Schroeder JL, Steinke EE. Necrotizing fasciitis--the importance of early diagnosis and debridement. 2005

        Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. 2005

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