AUTHOR INFORMATION

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Authored by Michael Maynor, MD, Clinical Assistant Professor, Department of Hyperbaric/Emergency Medicine, Louisiana State University School of Medicine

Michael Maynor, MD, is a member of the following medical societies: Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Edited by Eric Kardon, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Athens Regional Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School

Author's Email:	Michael Maynor, MD
Editor's Email:	Eric Kardon, MD, FACEP

eMedicine Journal, December 11 2006, VOLUME 7, Number 12

INTRODUCTION

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Background: For more than a century, many authors have described soft tissue infections. Their occurrence has been on the rise because of an increase in immunocompromised patients with diabetes mellitus, cancer, alcoholism, vascular insufficiencies, organ transplants, HIV, or neutropenia.

Necrotizing fasciitis can occur after trauma or around foreign bodies in surgical wounds, or it can be idiopathic, as in scrotal or penile necrotizing fasciitis.

Necrotizing fasciitis has also been referred to as hemolytic streptococcal gangrene, Meleney ulcer, acute dermal gangrene, hospital gangrene, suppurative fascitis, and synergistic necrotizing cellulitis. Fournier gangrene is a form of necrotizing fasciitis that is localized to the scrotum and perineal area.

Necrotizing fasciitis is a progressive, rapidly spreading, inflammatory infection located in the deep fascia, with secondary necrosis of the subcutaneous tissues. Because of the presence of gas-forming organisms, subcutaneous air is classically described in necrotizing fasciitis. This may be seen only on radiographs or not at all. The speed of spread is directly proportional to the thickness of the subcutaneous layer. Necrotizing fasciitis moves along the deep fascial plane.

These infections can be difficult to recognize in their early stages, but they rapidly progress. They require aggressive treatment to combat the associated high morbidity and mortality.

The causative bacteria may be aerobic, anaerobic, or mixed flora, and the expected clinical course varies from patient to patient.

Pathophysiology: Most necrotizing soft tissue infections have anaerobic bacteria present, usually in combination with aerobic gram-negative organisms. They proliferate in an environment of local tissue hypoxia in those patients with trauma, recent surgery, or medical compromise.

Facultative aerobic organisms grow since polymorphonuclear (PMN) leukocytes exhibit decreased function under hypoxic wound conditions. This growth further lowers the oxidation/reduction potential, enabling more anaerobic proliferation and, thus, accelerating the disease process.

Carbon dioxide and water are the end products of aerobic metabolism. Hydrogen, nitrogen, hydrogen sulfide, and methane are produced from the combination of aerobic and anaerobic bacteria in a soft tissue infection. These gases, except carbon dioxide, accumulate in tissues because of reduced water solubility.

In necrotizing fasciitis, group A hemolytic streptococci and Staphylococcus aureus, alone or in synergism, are frequently the initiating infecting bacteria. However, other aerobic and anaerobic pathogens may be present, including Bacteroides, Clostridium, Peptostreptococcus, Enterobacteriaceae, coliforms, Proteus, Pseudomonas, and Klebsiella.

Bacteroides fragilis is usually noted as part of a mixed flora in combination with Escherichia coli. B fragilis does not directly cause these infections, but it does play a part in reducing interferon production and the phagocytic capacity of macrophages and PMNs.

A variant synergistic necrotizing cellulitis is considered to be a form of necrotizing fasciitis, but some authorities feel that it is actually a nonclostridial myonecrosis. This condition begins in the same manner as necrotizing fasciitis, but it progresses rapidly to involve wide areas of deeper tissue and muscle at an earlier stage than might be expected. Severe systemic toxicity occurs.

Anaerobic streptococci, occasionally seen in drug addicts, cause many forms of nonclostridial myonecrosis. Some cases of necrotizing fasciitis can be caused by Vibrio vulnificus. This organism is seen more often in patients with chronic liver dysfunction, and it often follows the consumption of raw seafood. V vulnificus may cause subcutaneous bleeding.

Frequency:

• In the US: Since 1883, more than 500 cases have been reported in the literature.

• Internationally: There may be an increased incidence in African and Asian countries; however, because of the lack of recorded cases, the true incidence is not known.

Mortality/Morbidity: The overall morbidity and mortality is 70-80%.

• Fournier gangrene has a reported mortality as high as 75%.

• The mean age of survivors is 35 years.

• The mean age of nonsurvivors is 49 years.

Sex: The male-to-female ratio is 2-3:1.

Age:

• The mean age of a patient with necrotizing fasciitis is 38-44 years.

• This disease rarely occurs in children. Pediatric cases have been reported from countries where poor hygiene is prevalent.

CLINICAL

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History:

• A history of trauma or a recent surgery to the involved area is often present. Idiopathic cases are not uncommon.

• Typically, there is a sudden onset of pain and swelling at the site of trauma or recent surgery. In some cases, the symptoms may begin at a site distant from the initial traumatic insult.

• Over the next several hours to days, the local pain progresses to anesthesia.

• Fournier gangrene begins with pain and itching of the scrotal skin.

• A history of comorbid factors, including diabetes mellitus, should be sought in all cases of suspected necrotizing fasciitis.

Physical:

• The patient usually appears moderately to severely toxic, but early on, the patient may look deceptively well.

• Typically, the infection begins with an area of erythema that quickly spreads over a course of hours to days.

• The redness quickly spreads, and the margins of infection move out into normal skin without being raised or sharply demarcated.

• As it progresses, the infection gives way to dusky or purplish skin discoloration near the site of insult.

• Multiple identical patches develop to produce a large area of gangrenous skin, as the erythema continues to spread.

• The initial necrosis appears as a massive undermining of the skin and subcutaneous layer.

• If the skin is open, gloved fingers can pass easily between the 2 layers and may reveal yellowish-green necrotic fascia. If the skin is unbroken, a scalpel incision will reveal it.

• The normal skin and subcutaneous tissue are loosened from the rapidly spreading deeper necrotic fascia that is a great distance from the initiating wound.

• Fascial necrosis is typically more advanced than the appearance suggests.

• Anesthesia in the involved region may be detected, and it usually is caused by thrombosis of the subcutaneous blood vessels, leading to necrosis of nerve fibers.

• Without treatment, secondary involvement of deeper muscle layers may occur, resulting in myositis or myonecrosis. Normally, however, the muscular layer remains healthy red with normal bleeding muscle under the yellowish-green fascia.

• Usually, the most important signs are tissue necrosis, putrid discharge, bullae, severe pain, gas production, rapid burrowing through fascial planes, and lack of classical tissue inflammatory signs.

• Usually, some degree of intravascular volume loss is detectable on clinical examination.

• General signs, such as fever and severe systemic reactions, may be present.

• Fournier gangrene begins with local tenderness, edema, and erythema of the scrotal skin.

• This progresses to necrosis of the scrotal fascia. The scrotum enlarges to several times its normal diameter.

• There can be local crepitation in more than one half of patients.

• If the process continues beyond the penile-scrotal region to the abdomen or the upper legs, the normal picture of necrotizing fasciitis can be seen.

• In males, the scrotal subcutaneous layer is so thin that most of the patients present after the skin is already exhibiting signs of necrosis.

• In 2-7 days, the skin becomes necrotic, and a characteristic black spot can be seen.

• Early on, this infection may resemble acute orchitis, epididymitis, torsion, or even a strangulated hernia.

• In women, Fournier gangrene acts more like necrotizing fasciitis because of the thicker subcutaneous layers involving the labia majora and the perineum.

Causes:

• Surgical procedures may cause local tissue injury and bacterial invasion, resulting in necrotizing fasciitis. These procedures include surgery for intraperitoneal infections and drainage of ischiorectal and perianal abscesses.

• IM injections and IV infusions may lead to necrotizing fasciitis.

• Minor insect bites may set the stage for necrotizing infections. Streptococci can be introduced into the wounds, but the bacteriologic pattern changes from hypoxia-induced proliferation of anaerobes.

• Local ischemia and hypoxia can occur in patients with systemic illnesses (eg, diabetes).

• Host defenses can be compromised by underlying systemic diseases favoring the development of these infections. Illnesses such as diabetes or cancer have been described in over 90% of cases of progressive bacterial gangrene.

• The number of diabetic patients has been reported to be 20-40%. As many as 80% of Fournier gangrene cases occur in people with diabetes.

• In some series, as many as 35% of patients were alcoholics.

• Recent studies have shown a possible relationship between the use of nonsteroidal anti-inflammatory agents (NSAIDs), such as ibuprofen, and the development of necrotizing fasciitis during varicella infections. Additional studies are needed to establish whether ibuprofen use has a causal role in the development of necrotizing fasciitis and its complications during varicella infections. This has not previously been described.

DIFFERENTIALS

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Cellulitis
Epididymitis
Gas Gangrene
Hernias
Orchitis
Testicular Torsion
Toxic Shock Syndrome

WORKUP

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Lab Studies:

• CBC with differential

• Electrolytes, glucose, BUN, and creatinine

• Blood and tissue cultures

• Urinalysis

• Arterial blood gas

Imaging Studies:

• Local radiographs can reveal the presence of gas in subcutaneous fascial planes.

• The presence of subcutaneous gas in a radiograph does not necessarily indicate a clostridial infection, as E coli, Peptostreptococcus species, and Bacteroides species may produce gas under appropriate conditions.

• Misleading subcutaneous gas can also result from the undermining of tissue planes during surgical debridement.

• Perforations of the esophagus, the respiratory tract, and the GI tract related to endoscopy or chest tube insertion can result in the radiographic appearance of gas.

• CT scanning can pinpoint the anatomic site of involvement by demonstrating necrosis with asymmetric fascial thickening and the presence of gas in the tissues.

• Magnetic resonance imaging and computerized tomography have been utilized recently in the diagnosis of necrotizing fasciitis. Absence of gadolinium contrast enhancement in T1 images reliably detects fascial necrosis in those requiring operative debridement. Combined with clinical assessment, MRI can determine the presence of necrosis and the need for surgical debridement.

Other Tests:

• The Gram stain usually shows a polymicrobial flora with aerobic gram-negative rods and positive cocci.

Procedures:

• Biopsy

• Tissue biopsies are the best method to use when diagnosing necrotizing fasciitis. They can be performed from the spreading periphery of the necrotizing infection or the deeper tissues, reached only in surgical debridement, to obtain proper cultures for microorganisms.

• Avoid doing this procedure from the actual necrosis or granulating center, as many bacteria that neither cause nor add to the infection would be detected.

TREATMENT

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Emergency Department Care:

• Aggressively treat the patient with suspected necrotizing fasciitis to reduce morbidity and mortality.

• Perform endotracheal intubation in patients who are unable to maintain their airway.

• Provide supplemental oxygen.

• Obtain IV access. Be careful to not use an infected extremity.

• Place patient on continuous cardiac monitoring.

• Begin fluid resuscitation with normal saline or lactated Ringer solution.

• In patients with suspected hypovolemia, Foley catheterization may be needed to monitor urine output. This procedure should probably be avoided in patients with Fournier gangrene.

• Begin antibiotics as soon as possible.

Consultations:

• Obtain early surgical consultation for aggressive debridement.

• Consider surgical subspecialty consultation for necrotizing fasciitis involving specific anatomic areas, as needed.

• Obtain urological consultation in cases of Fournier gangrene.

• Consult with a hyperbaric specialist.

• A consultation with an infectious disease specialist may be useful to guide initial empiric antibiotic therapy.

MEDICATION

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It is common to see misdirected treatment that is aimed at coexisting flora instead of the causative organism. If streptococci are the identified major pathogens, the DOC is penicillin G, with clindamycin as the alternative. To ensure adequate treatment, there must be coverage for aerobic and anaerobic bacteria. The anaerobic coverage can be provided by metronidazole or third-generation cephalosporins. Gentamicin, combined with clindamycin or chloramphenicol, has been proposed as a standard coverage. Ampicillin may be added to the basic regimen to treat enterococci if suspected by Gram stain.

Drug Category: Antibiotics -- Therapy must cover all likely pathogens in the context of the clinical setting.

Drug Name	Penicillin G (Pfizerpen) -- Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult Dose	8-10 million U/d IV divided q4-6h
Pediatric Dose	500,000-800,000 U/kg/d IV divided q4-6h
Contraindications	Documented hypersensitivity
Interactions	Probenecid can increase effects; coadministration of tetracyclines decreases effects
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in impaired renal function and elevated potassium levels

Drug Name	Clindamycin (Cleocin) -- Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. To be used as an alternative to penicillin G.
Adult Dose	600 mg IV q6h
Pediatric Dose	5 mg/kg IV q6h
Contraindications	Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, and antibiotic-associated colitis
Interactions	Use with erythromycin or chloramphenicol may decrease effects of clindamycin; increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; antidiarrheals may delay absorption
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Drug Name	Metronidazole (Flagyl) -- Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis). Appears to be absorbed into cells of microorganisms containing nitroreductase. Unstable intermediate compounds that bind DNA and inhibit synthesis are formed, causing cell death.
Adult Dose	Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h Maintenance dose: 6 h following loading dose; infuse 7.5 mg/kg or 500 mg IV for 70-kg adult over 1 h q6-8h; not to exceed 4 g/d
Pediatric Dose	15-30 mg/kg/d IV divided bid/tid; not to exceed 2 g/d
Contraindications	Documented hypersensitivity
Interactions	Cimetidine may increase toxicity; may increase effects of anticoagulants (monitor PT); may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol; phenobarbital, phenytoin, and other hepatic enzyme-inducing drugs decrease metronidazole levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Drug Name	Ceftriaxone (Rocephin) -- DOC in initial treatment. Third-generation cephalosporin with broad-spectrum, gram-negative activity. Lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult Dose	1-2 g IV qd or divided bid
Pediatric Dose	75 mg/kg/d IV divided bid
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin

Drug Name	Gentamicin (Garamycin) -- Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Not the DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Adjust dose based on CrCl and changes in volume of distribution. Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing). Peak level may be drawn 0.5 h after 30-min infusion.
Adult Dose	3 mg/kg/d IV divided q8h
Pediatric Dose	2 mg/kg/d IV divided q8h
Contraindications	Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Interactions	Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Drug Name	Chloramphenicol (Chloromycetin) -- Binds to 50 S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult Dose	50-100 mg/kg/d IV divided q6h; not to exceed 4 g/d
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Concomitant use with clindamycin may cause a decrease in the effects of clindamycin; Concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants (monitor PT); may increase serum hydantoin levels, possibly resulting in toxicity
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Use only for indicated infections, or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)

Drug Name	Ampicillin (Omnipen) -- Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally. May be added to initial regimen if Gram stain suggests enterococci.
Adult Dose	8-14 g/d IV divided q6h
Pediatric Dose	100-200 mg/kg/d IV divided q6h
Contraindications	Documented hypersensitivity
Interactions	Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

FOLLOW-UP

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Further Inpatient Care:

• Aggressive surgical debridement of all necrotic tissue is necessary. This is best accomplished by early and extensive incision of skin and subcutaneous tissue wide into healthy tissue, followed by excision of all necrotic fascia and nonviable skin and subcutaneous tissue. Meticulous hemostasis is critical.

• This process may need to be repeated multiple times. Within the first 24 hours, inspection of the entire infected area, under general anesthesia, is mandatory, with further excision of any newly discovered necrotic tissue. Delayed closure is recommended.

• Perform fasciotomies in extremities with compromised viability.

• Hyperbaric oxygen therapy (HBO) involves the use of oxygen at increased pressure in a monoplace or a multiplace chamber.

• HBO increases the normal oxygen saturation in the infected wounds by a thousand fold, leading to a bacteriocidal effect, improved PMN function, and enhanced wound healing. Some authors have noted a higher oxygen saturation (PO₂) in infected necrotic tissue secondary to HBO-induced vasodilation.

• No large controlled randomized studies have been published to support the complete effectiveness of HBO in necrotizing fasciitis. It has been shown that HBO improves the tissue defense against infection and prevents the necrosis from spreading.

• Early and recent retrospective studies with necrotizing infections showed high mortality rates of 30-50% when using only surgery, antibiotics, or both. This was related to delayed surgical intervention, advanced age, or concurrent diabetes mellitus.

• The mortality of patients treated with surgery, antibiotics, and HBO has been reduced to as low as 9-20% in many recent retrospective studies. These authors feel that HBO should be used routinely in the treatment of necrotizing fasciitis, as it significantly reduces mortality and wound morbidity.

• HBO cannot replace surgery. The best outcome is obtained using a combined approach of antibiotics, surgery, and HBO, when readily available.

• A typical treatment protocol involves HBO, given aggressively after the first surgical debridement. Three treatment sessions, in a multiplace chamber at 3 atmosphere absolute (ATA), 100% oxygen for 90 minutes each, can be given in the first 24 hours. Appropriate air breaks are given, as necessary.

• In a monoplace chamber, 2.5-2.8 ATA, 100% oxygen for 90 minutes per session, can be given. On the second day, twice daily treatments can ensue until granulation is obtained to a total of 10-15 treatments.

Transfer:

• If the current facility is not capable of handling the aggressive care, monitoring, and serial surgical debridement that these patients require, then arrangements for transfer should be made.

• Transfer to a hyperbaric center may be necessary after initial debridement.

• Patients should not be considered for transfer until they remain hemodynamically stable.

Complications:

• Renal failure

• Septic shock with cardiovascular collapse

• Scarring with cosmetic deformity

Prognosis:

• The overall morbidity and mortality is 70-80%.

• Some authors have reported mortality in Fournier gangrene as high as 75%.

MISCELLANEOUS

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Medical/Legal Pitfalls:

• Early in the course of the disease, necrotizing fasciitis may appear quite benign. Be wary of the patient with pain out of proportion to physical findings.

TEST QUESTIONS

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CME Question 1: Which of the following is not a possible benefit of hyperbaric oxygen in necrotizing fasciitis?

A: Improved polymorphonuclear (PMN) function
B: Increasing the tissue oxygen saturation
C: Bacteriocidal effect
D: Compression of gas gangrene-induced bubbles
E: Enhanced wound healing

The correct answer is D: It has been shown that hyperbaric oxygen will increase the normal oxygen saturation by a thousand fold, which leads to a bacteriocidal effect. Enhanced wound healing and PMN function also are benefits.

CME Question 2: Which statement typifies necrotizing fasciitis?

A: It usually has a slow indolent course.
B: Treatment usually is limited to observation and antibiotics.
C: A traumatic injury always begins the pathological process.
D: Antibiotics should be withheld until culture and sensitivities are available.
E: None of the above.

The correct answer is E: Necrotizing fasciitis is a disease that may idiopathically occur. It often has a rapid and fulminant course. Treatment consists of aggressive surgical debridement and antibiotics. Antibiotics should be started as soon as possible.

Pearl Question 1 (T/F): The rationale for using hyperbaric oxygen (HBO) therapy in necrotizing fasciitis is so that more aggressive amputations can be performed.

The correct answer is False: Hyperbaric treatment regimens should result in more limb salvage, not less.

Pearl Question 2 (T/F): Surgical procedures may result in necrotizing fasciitis as a complication.

The correct answer is True: Surgical procedures may cause local tissue injury and bacterial invasion, resulting in necrotizing fasciitis. These procedures include surgery for intraperitoneal infections and drainage of ischiorectal and perianal abscesses.

Pearl Question 3 (T/F): Fournier gangrene is a form of necrotizing fasciitis.

The correct answer is True: Hemolytic streptococcal gangrene, Meleney ulcer, or Fournier gangrene are all forms of necrotizing fasciitis.

Pearl Question 4 (T/F): On an initial Gram stain from a patient with necrotizing fasciitis, one would most likely see a single pathogen.

The correct answer is False: One would see a wide variety of organisms, including group A Streptococcus, Staphylococcus aureus, Bacteroides, Clostridium, Peptostreptococcus, Enterobacteriaceae, coliforms, Pseudomonas, and Klebsiella. There is a wide mixture of aerobes and anaerobes to confuse the picture.

BIBLIOGRAPHY

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• Baker DJ: Selected aerobic and anaerobic soft tissue infections - diagnosis and the use of hyperbaric oxygen. Hyperbaric Medicine Practice 1994; 395-418.
• Baracco GJ, Bisno AL: Therapeutic Approaches to Streptococcal Toxic Shock Syndrome. Curr Infect Dis Rep 1999 Aug; 1(3): 230-237[Medline].
• Brothers TE, Tagge DU, Stutley JE, et al: Magnetic resonance imaging differentiates between necrotizing and non-necrotizing fasciitis of the lower extremity. J Am Coll Surg 1998 Oct; 187(4): 416-21[Medline].
• Cullen TS: A progressively enlarging ulcer of abdominal wall involving the skin and fat, following drainage of an abdominal abscess apparently of appendiceal origin. Surg Gynecol Obstet.
• Demello FJ, Haglin JJ, Hitchcock CR: Comparative study of experimental Clostridium perfringens infection in dogs treated with antibiotics, surgery, and hyperbaric oxygen. Surgery 1973 Jun; 73(6): 936-41[Medline].
• Eke N: Fournier's gangrene: a review of 1726 cases. Br J Surg 2000 Jun; 87(6): 718-28[Medline].
• File TM, Tan JS: Group A streptococcus necrotizing fasciitis. Compr Ther 2000; 26(2): 73-81[Medline].
• Fink S, Chaudhuri TK, Davis HH: Necrotizing fasciitis and malpractice claims. South Med J 1999 Aug; 92(8): 770-4[Medline].
• Fournier JA: Jean-Alfred Fournier 1832-1914. Gangrene foudroyante de la verge (overwhelming gangrene). Sem Med 1883. Dis Colon Rectum 1988 Dec; 31(12): 984-8[Medline].
• Fujisawa N, Yamada H, Kohda H, et al: Necrotizing fasciitis caused by Vibrio vulnificus differs from that caused by streptococcal infection. J Infect 1998 May; 36(3): 313-6[Medline].
• Hart GB, Lamb RC, Strauss MB: Gas gangrene. J Trauma 1983 Nov; 23(11): 991-1000[Medline].
• Hirn M, Niinikoski J, Lehtonen OP: Effect of hyperbaric oxygen and surgery on experimental gas gangrene. Eur Surg Res 1992; 24(6): 356-62[Medline].
• Holmstrom B, Grimsley EW: Necrotizing fasciitis and toxic shock-like syndrome caused by group B streptococcus. South Med J 2000 Nov; 93(11): 1096-8[Medline].
• Hsiao GH, Chang CH, Hsiao CW, et al: Necrotizing soft tissue infections. Surgical or conservative treatment?. Dermatol Surg 1998 Feb; 24(2): 243-7; discussion 247-8[Medline].
• Jones RB, Hirschmann JV, Brown GS, Tremann JA: Fournier's syndrome: necrotizing subcutaneous infection of the male genitalia. J Urol 1979 Sep; 122(3): 279-82[Medline].
• Kaul R, McGeer A, Low DE, et al: Population-based surveillance for group A streptococcal necrotizing fasciitis: Clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med 1997 Jul; 103(1): 18-24[Medline].
• Korhonen K, Kuttila K, Niinikoski J: Tissue gas tensions in patients with necrotising fasciitis and healthy controls during treatment with hyperbaric oxygen: a clinical study. Eur J Surg 2000 Jul; 166(7): 530-4[Medline].
• Lamerton AJ: Fournier's gangrene: non-clostridial gas gangrene of the perineum and diabetes mellitus. J R Soc Med 1986 Apr; 79(4): 212-5[Medline].
• Larsson A, Elmqvist, Stenberg A: Cervical necrotizing fasciitis - 11 cases treated according to a multidisciplinary protocol. Undersea Hyperb Med 2002; 29(2): 105.
• Mader JT: Mixed anaerobic and aerobic soft tissue infection. In: Problem Wounds: The Role of Oxygen. 1988: 173-186.
• McGeehan DF, Asmal AB, Angorn IB: Fournier's gangrene. S Afr Med J 1984 Nov 10; 66(19): 734-7[Medline].
• Meleney FL: Hemolytic streptococcus gangrene. Arch Surg 1924; 9: 317-364.
• Mohammedi I, Ceruse P, Duperret S, et al: Cervical necrotizing fasciitis: 10 years' experience at a single institution. Intensive Care Med 1999 Aug; 25(8): 829-34[Medline].
• Niinikoski J, Aho A: Combination of hyperbaric oxygen, surgery and antibiotics in the treatment of clostridial gas gangrene. Infect Surg 1983; 2: 23-27.
• Nomikos IN: Necrotizing perineal infections (Fournier's disease): old remedies for an old disease. Int J Colorectal Dis 1998; 13(1): 48-51[Medline].
• Reyzelman AM, Armstrong DG, Vayser DJ, et al: Emergence of non-group A streptococcal necrotizing diabetic foot infections. J Am Podiatr Med Assoc 1998 Jun; 88(6): 305-7[Medline].
• Riseman JA, Zamboni WA, Curtis A, et al: Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 1990 Nov; 108(5): 847-50[Medline].
• Somers WJ, Lowe FC: Localized gangrene of the scrotum and penis: a complication of heroin injection into the femoral vessels. J Urol 1986 Jul; 136(1): 111-3[Medline].
• Sriskandan S, Kemball-Cook G, Moyes D, et al: Contact activation in shock caused by invasive group A Streptococcus pyogenes. Crit Care Med 2000 Nov; 28(11): 3684-91[Medline].
• Stephenson H, Dotters DJ, Katz V, Droegemueller W: Necrotizing fasciitis of the vulva. Am J Obstet Gynecol 1992 May; 166(5): 1324-7[Medline].
• Stevens DL, Bryant AE, Adams K, Mader JT: Evaluation of therapy with hyperbaric oxygen for experimental infection with Clostridium perfringens. Clin Infect Dis 1993 Aug; 17(2): 231-7[Medline].
• Wilkinson D, Doolette D: Hyperbaric oxygen treatment and survival from necrotizing soft tissue infection. Arch Surg 2004 Dec; 139(12): 1339-45[Medline].
• Wysoki MG, Santora TA, Shah RM, Friedman AC: Necrotizing fasciitis: CT characteristics. Radiology 1997 Jun; 203(3): 859-63[Medline].
• Zamboni WA, Mazolewski PJ, Erdmann D, et al: Evaluation of penicillin and hyperbaric oxygen in the treatment of streptococcal myositis. Ann Plast Surg 1997 Aug; 39(2): 131-6[Medline].
• Zerr DM, Alexander ER, Duchin JS, et al: A case-control study of necrotizing fasciitis during primary varicella. Pediatrics 1999 Apr; 103(4 Pt 1): 783-90[Medline].
• Zerr DM, Rubens CE: NSAIDS and necrotizing fasciitis. Pediatr Infect Dis J 1999 Aug; 18(8): 724-5[Medline].
• Zurawski CA, Bardsley M, Beall B, et al: Invasive group A streptococcal disease in metropolitan Atlanta: a population-based assessment. Clin Infect Dis 1998 Jul; 27(1): 150-7[Medline].

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