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maintained in this group 2 the first symptom of nf the center is clearly getting darker red purple early symptoms of necrotizing fasciitis the darker red center is going black necrotizing fasciitis type iii caused by vibrio vulnificus causes edit risk factors edit vulnerable populations are typically older with medical comorbidities such as diabetes mellitus obesity and immunodeficiency 4 other documented risk factors include any trauma or lacerations injection drug use recent surgery injury of mucous membranes including hemorrhoids rectal fissures peripheral artery disease cancer alcohol use disorder pregnancy or recent childbirth 9 for unclear reasons it can also infect healthy individuals without medical history or injury 9 11 nsaids may increase the rates of necrotizing infections by impairing the body s immune response nsaids inhibit the production of prostaglandins responsible for fever inflammation and pain in theory it also prevents white blood cells from migrating to infected areas thus increasing the risk of soft tissue infections 2 9 skin infections such as abscesses and ulcers can also complicate nf a small percentage of people can also get nf when bacteria from streptococcal pharyngitis spreads through the blood 12 for infection of the perineum and genitals fournier gangrene urinary tract infection renal stones and bartholin gland abscess may also be implicated 2 prevention edit good wound care and handwashing reduce the risk of developing necrotizing fasciitis 3 it is unclear if people with a weakened immune system would benefit from taking antibiotics after being exposed to a necrotizing infection generally such a regimen entails 250 mg of penicillin four times daily for 10 days 9 bacteria edit necrotizing fasciitis is classified into four groups based on the type of bacteria causing the infection this classification system was first described by giuliano and his colleagues in 1977 4 2 type i infection this is the most common type of infection and accounts for 70 80 of cases it is caused by a mixture of bacterial types usually in the abdominal or groin areas 4 these bacterial species include gram positive cocci staphylococcus aureus streptococcus pyogenes and enterococci 3 gram negative rods escherichia coli pseudomonas aeruginosa klebsiella species bacteroides species prevotella species 3 clostridium species clostridium perfringens clostridium septicum and clostridium sordellii 4 in polymicrobial mixed infections group a streptococcus s pyogenes is the most commonly found bacterium followed by s aureus 12 however when the infection is caused solely by s pyogenes and or s aureus it is classified as a type ii infection gram negative bacteria and anaerobes such as clostridia are more often implicated in fournier gangrene this is a subtype of type i infections affecting the groin and perianal areas 12 clostridia account for 10 of overall type i infections and typically cause a specific kind of necrotizing fasciitis known as gas gangrene or myonecrosis type ii infection this infection accounts for 20 30 of cases mainly involving the extremities 4 13 this involves streptococcus pyogenes alone or in combination with staphylococcal infections methicillin resistant staphylococcus aureus mrsa is involved in up to a third of type ii infections 4 infection by either type of bacteria can progress rapidly and manifest as shock type ii infection more commonly affects young healthy adults with a history of injury 2 type iii infection vibrio vulnificus is a bacterium found in saltwater it occasionally causes nf after entering the body through a break in the skin 14 one in three patients with a v vulnificus infection develop necrotizing fasciitis 14 disease progression is similar to type ii but sometimes with few visible skin changes 2 type iv infection this type of nf accounts for less than 1 of cases it is mostly caused by the candida albicans fungus risk factors include age and immunodeficiency 4 15 diagnosis edit micrograph of necrotizing fasciitis showing necrosis center of image of the dense connective tissue i e fascia interposed between fat lobules top right and bottom left of image h e stain early diagnosis is difficult as the disease often first appears like a simple superficial skin infection 4 while several labs and imaging can raise the suspicion for necrotizing fasciitis none can rule it out 16 the gold standard for diagnosis is a surgical exploration and subsequent tissue biopsy when in doubt a 2 cm incision can be made into the affected tissue under local anesthesia 2 17 if a finger easily separates the tissue along the fascia then the finger test is positive this confirms the diagnosis and an extensive debridement should be performed 2 17 medical imaging edit ct scan of right thigh showing inflammatory stranding and low attenuation in vastus lateralis muscle arrow necrotizing fasciitis is ideally a clinical diagnosis based on symptoms due to the need for rapid surgical treatment the time delay in performing imaging is a major concern 17 hence imaging may not be needed if signs of a necrotizing infection are clear however due to the vague symptoms associated with the earlier stages of this disease imaging is often useful in clarifying or confirming the diagnosis 17 both ct and mri scans are used to diagnose nf but neither is sensitive enough to rule out necrotizing changes completely 2 computed tomography ct edit necrotizing fasciitis producing gas in the soft tissues as seen on ct scan if available computed tomography ct is the most convenient tool in diagnosing nf due to its speed and resolution detects about 80 of nf cases 18 ct scan may show fascial thickening edema or abscess formation 2 17 ct can pick up on gas within tissues better than mri but it is not unusual for nf to present without gas on imaging 17 in addition ct helps evaluate complications due to nf and find possible sources of infections 17 its use may be limited in pregnant patients and patients with kidney issues 17 magnetic resonance imaging mri edit axial t2 weighted mri a and contrast enhanced mri b of left wrist showing necrotizing fasciitis there is diffuse hyperintensity with irregular enhancement of the deep fascia asterisks the arrows indicate a lobulating abscess and the triangle a skin bulla magnetic resonance imaging mri is considered superior to computed tomography ct to visualize soft tissues and can detect about 93 of nf cases 17 it is especially useful in finding fluid in the deep fascia which can distinguish between nf and cellulitis 17 when fluid collects in the deep fascia or thickening or enhancement with contrast necrotizing fasciitis should be strongly suspected however mri is much slower than ct and not as widely available 17 there may also be limitations on its use in patients with kidney problems 17 point of care ultrasonography pocus edit necrotizing fasciitis as seen on ultrasound 19 necrotizing fasciitis with soft tissue gas seen on b plain radiography and c ultrasound point of care ultrasound pocus may be useful in the diagnosis of nf when mri and ct are unavailable 20 it can also help rule out diagnoses that mimic earlier stages of nf including deep vein thrombosis dvt superficial abscesses and venous stasis 20 linear probes are generally preferred for the assessment especially in the extremities 20 findings characteristic of nf include abnormal thickening air or fluid in the subcutaneous tissue 20 this can be summarized as the mnemonic staff subcutaneous irregularity or thickening air and fascial fluid 20 the official diagnosis of nf using ultrasound requires the presence of both diffuse subcutaneous thickening and fascial fluid more than 2 mm 20 gas in the subcutaneous tissue may show dirty acoustic shadowing 17 however similar to other imaging modalities the absence of subcutaneous free air does not definitively rule out a diagnosis of nf because this is a finding that often emerges later in the disease process 20 of note the quality and accuracy of pocus are highly user dependent it may also be difficult to visualize nf over larger areas or if there are many intervening layers of fat or muscle it is still unclear whether pocus improves the speed of diagnosis of nf or if it reduces the time to surgical intervention as a whole 20 plain radiography x ray edit it is difficult to distinguish nf from cellulitis in earlier stages of the disease using plain radiography 17 x rays can detect subcutaneous emphysema gas in the subcutaneous tissue which is strongly suggestive of necrotizing changes however air is often a late stage finding and not all necrotizing skin infections create subcutaneous emphysema hence radiography is not recommended for the initial diagnosis of nf 17 however it may be able to identify the source of infection such as foreign bodies or fractures and thus aid in subsequent treatment 17 scoring system edit correlated with clinical findings a white blood cell count greater than 15 000 cells mm 3 and serum sodium level less than 135 mmol l are predictive of necrotizing fasciitis in 90 of cases 3 if lab values do not meet those values there is a 99 chance that the patient does not have nf there are various scoring systems to determine the likelihood of getting necrotizing fasciitis the laboratory risk indicator for necrotizing fasciitis lrinec scoring system developed by wong and their colleagues in 2004 is the most common it evaluates people with severe cellulitis or abscesses to determine the likelihood of necrotizing fasciitis lrinec uses six laboratory values c reactive protein total white blood cell count hemoglobin sodium creatinine and blood glucose 2 a score of 6 or more indicates that there is a 50 75 probability of necrotizing fasciitis a score of 8 or more represents over 75 likelihood of nf 17 21 22 patients with a lrinec score 6 may have a higher rate of both death and amputation as well 23 the scoring criteria are 21 24 lrinec scoring system lab value criteria points crp 15 mg dl 150 mg l 4 wbc count 10 3 15 25 mm 3 1 25 mm 3 2 hemoglobin 11 13 5 g dl 1 11 g dl 2 sodium 135 meq l 2 creatinine 1 6 mg dl 141 μmol l 2 glucose 180 mg dl 10 mmol l 1 if the lab value does not meet the listed criteria it is assigned 0 points however this scoring system is yet to be validated 3 a lrinec score 6 is only able to detect 70 of nf cases and a lrinec score 8 has shown even poorer sensitivity 22 moreover these lab values may be falsely positive if any other inflammatory conditions are present therefore this scoring system should be interpreted with caution 2 treatment edit necrotizing fasciitis is treated with surgical debridement cutting away affected tissue 3 however antibiotics should be started as soon as this condition is suspected appropriate antibiotic coverage may change based on tissue cultures additional support should be initiated for those with unstable vital signs and low urine output 2 surgery edit aggressive wound debridement should be performed as soon as the diagnosis is made the affected area may need to be debrided several times usually once every 12 36 hours 3 large sections of tissue and muscle may need to be removed to prevent the infection from spreading amputation may be needed if the infection is too severe 3 en bloc debridement ebd is most commonly employed in treating nstis 25 this involves cutting away the skin overlying all diseased areas at the cost of increased scar formation and potential decreased quality of life post operatively 25 more recently skin sparing debridement ssd has gained traction as it resects the underlying tissue and sources of infection while preserving skin that is not overtly necrotic 25 however more studies are needed to examine whether ssd actually accelerates the healing process after surgery 25 fournier gangrene and subsequent vsd after the wound debridement adequate dressings should be applied to promote wound healing 2 wounds are generally packed with wet to dry dressings and left open to heal 3 in certain cases vacuum sealing drainage vsd may help the wound heal especially in fournier gangrene for necrotizing infection of the perineal area fournier s gangrene wound debridement and care in this area can be difficult because of the excretory products that often render the area dirty and negatively affect wound healing therefore regular dressing changes with a fecal management system can help to keep the wound in the perineal area clean sometimes colostomy may be necessary to divert the excretory products to keep the wound in the perineal area clean 2 wound after aggressive acute debridement of nf necrotic tissue from the left leg surgically removed postsurgical debridement and skin grafting after knee disarticulation amputation antibiotics edit empiric antibiotics are usually initiated as soon as the diagnosis of nsti has been made they are then changed to culture guided antibiotic therapy in the case of nstis empiric antibiotics are broad spectrum covering gram positive including mrsa gram negative and anaerobic bacteria 26 often a combination of clindamycin daptomycin iv vancomycin and gentamicin is used 2 gram negative coverage may entail the use of fluoroquinolones piperacillin tazobactam or carbapenems 3 despite multiple studies there is no consensus on how long antibiotics should be given 26 generally antibiotics are administered until surgeons decide that no further debridement is needed and the patient no longer shows any systemic signs of infection from a clinical and laboratory standpoint 3 evidence regarding the efficacy of treatment and adverse effects is also unclear add on therapy edit hyperbaric oxygen hbo in theory hbo decreases local inflammation in the wound and bolsters the body s immune response however the impact of hbo on patients with nstis remains unclear 26 intravenous immunoglobulin ivig ivig is intended to combat the exotoxins released by s pyogenes toxic shock syndrome tss 27 however studies have failed to find any effect on patient mortality 27 there may also be serious adverse effects with ivig use 26 ab103 reltecimod aka ab103 is a new drug that binds to the cd28 t cell receptor and thus mitigates the effects of bacterial toxins studies show that it may decrease the severity of organ failure in nf patients 27 however other studies found no difference in mortality with this therapy 26 supportive therapy intravenous hydration wound care anticoagulants to prevent thromboembolic events pain control vasopressors etc should always be provided to patients when appropriate 9 epidemiology edit prevalence edit necrotizing fasciitis occurs in about 4 people per million per year in the u s and about 1 per 100 000 in western europe 4 about 1 000 cases of necrotizing fasciitis occur per year in the united states but the rates have been increasing this could be due to increasing awareness of this condition and increased reporting or increasing antibiotic resistance 2 both sexes are affected equally 2 it is more com...
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