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The microbiological and clinical characteristics of 83 patients with necrotizing fasciitis (NF) treated over a period of 17 years are presented. Bacterial growth was noted in 81 of 83 (98%) of specimens from patients with NF. Aerobic or facultative bacteria only were recovered in 8 (10%) specimens, anaerobic bacteria only were recovered in 18 (22%) specimens, and mixed-aerobic-anaerobic floras were recovered in 55 (68%) specimens. In total, there were 375 isolates, 105 aerobic or facultative bacteria and 270 anaerobic bacteria, for an average of 4.6 isolates per specimen. The recovery of certain bacteria from different anatomical locations correlated with their distribution in the normal flora adjacent to the infected site. Anaerobic bacteria outnumbered aerobic bacteria at all body sites, but the highest recovery rate of anaerobes was in the buttocks, trunk, neck, external genitalia, and inguinal areas. The predominant aerobes were Staphylococcus aureus (n = 14 isolates), Escherichia coli (n = 12), and group A streptococci (n = 8). The predominant anaerobes were Peptostreptococcus spp. (n = 101), Prevotella and Porphyromonas spp. (n = 40), Bacteroides fragilis group (n = 36), and Clostridium spp. (n = 23). Certain clinical findings correlated with some bacteria: edema with B. fragilis group, Clostridium spp., S. aureus, Prevotella spp. and group A streptococci; gas and crepitation in tissues with members of the family Enterobacteriaceae and Clostridium spp.; and foul odor with Bacteroides spp. Certain predisposing conditions correlated with some organisms: trauma with Clostridium spp.; diabetes with Bacteroides spp., members of the family Enterobacteriaceae, and S. aureus; and immunosuppression and malignancy with Pseudomonas spp. and members of the family Enterobacteriaceae. These data highlight the polymicrobial nature of NF.
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PMID:Clinical and microbiological features of necrotizing fasciitis. 749 32

Forty-five cases of cervical necrotizing fasciitis are reported, and their clinical, bacteriologic, and therapeutic implications are considered. Fasciitis was of dental origin in 78% of cases, pharyngeal in 16%, and surgical or posttraumatic in 6%. The condition extended to the face in 22% of cases, to the lower part of the neck in 56%, and to the mediastinum in 40%. Soft-tissue cultures were positive in 78% of cases. Anaerobes were isolated along with aerobes in 49% of cases (mean, 2.2 isolates per patient) and in pure culture in 22%. Treatment included surgical debridement and drainage and the administration of antibiotics active against both anaerobic and gram-negative aerobic bacteria. Hyperbaric oxygen was used for adjunctive treatment. The bacteria involved did not affect clinical manifestations, extension, or mortality. The survival rate among our patients was 78%. Mortality was significantly higher among cases with mediastinal extension (44% vs. 7%; P < .01); thus the prompt recognition and drainage of sites of mediastinal extension are of critical importance. Other risk factors for death were an age of > 70 years, underlying diabetes, the development of septic shock within 24 hours after admission, and prolonged prothrombin time.
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PMID:Cervical necrotizing fasciitis: clinical manifestations and management. 757 59

In this article, we report on two cases of gas-forming necrotising fasciitis of the neck admitted to our university hospital. In both patients, large gas-forming abscesses were detected by CT scan. Microbiologic smears revealed a mixed flora of aerobic and anaerobic bacteria, predominantly anaerobic streptococci. Emergency surgery with debridement and drainage, appropriate antibiotic therapy, and intensive care were performed. One 58-year-old patient with no concommittent disease recovered well after fourteen days. The other 71-year-old patient with diabetes mellitus and renal insufficiency died despite adequate therapy as a result of metabolic disturbances.
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PMID:[Gas producing anaerobic infection of the neck]. 760 74

Cervical necrotizing fasciitis is a devastating polymicrobial soft tissue infection characterized by gas formation and extensive necrosis of subcutaneous fat and fascia with extension to skin and muscle. Involvement of the head and neck is rare and is typically dental in origin. Despite broad-spectrum antibiotics, mortality rates for this disease remain high. We report a successfully treated case of necrotizing fasciitis arising from a peritonsillar abscess. Review of the literature reveals only 6 other cases, with 3 successful outcomes. Early diagnosis, broad-spectrum antibiotics, and aggressive surgical debridement are the cornerstones of therapy. The pathophysiology is typically a mixed aerobic and anaerobic infection. Supportive treatment options such as hyperbaric oxygen therapy and high-calorie supplemental nutrition may be of benefit. A comprehensive literature review of craniocervical necrotizing fasciitis is presented. Factors associated with poor outcomes include diabetes mellitus, mediastinitis, cardiovascular disease, and peritonsillar abscess.
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PMID:Peritonsillar abscess: an unlikely cause of necrotizing fasciitis. 785 15

Early recognition and treatment of necrotizing fasciitis (NF) is essential for survival. The diagnosis of primary or idiopathic NF may be particularly challenging because it occurs in the absence of a known causative factor or portal of entry for bacteria. Patients with NF treated between 1989 and 1993 were reviewed to determine the incidence, clinical features, bacteriology, and results of treatment in patients with idiopathic NF. Idiopathic NF occurred in nine (18%) of 51 patients, five men and four women, ranging in age from 21 to 67 years. Associated conditions included diabetes mellitus (4), alcoholism (3), remote infection (3), and pregnancy (2). NF affected the lower extremity in eight and the perineum in one patient. Pain and tenderness occurred in all patients, soft tissue gas was recognized in two, and the presence of erythema and edema was variable. Idiopathic NF was monomicrobial in seven (78%) patients, compared to 21 per cent of patients with secondary NF (P = 0.003). S. pyogenes was the causative organism in five of seven monomicrobial infections. Time from admission to operation was significantly longer (62.3 +/- 54.8 hours) in patients with idiopathic NF compared to patients with secondary NF (17.0 +/- 16.6 hours) (P = 0.001). Treatment included operative debridement (means = 3.3) and limb amputation (n = 1) to control infection. Three patients (33%) with idiopathic NF died. Primary or idiopathic NF is principally a monomicrobial infection usually caused by S. pyogenes that most commonly occurs in the extremities. Mortality is high but is comparable to secondary NF. It is important to recognize that NF may occur spontaneously, and it should be suspected in patients with unexplained soft tissue pain and tenderness.
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PMID:Idiopathic necrotizing fasciitis: recognition, incidence, and outcome of therapy. 801 May 62

The term "necrotizing soft tissue infections" describes a group of limb and life-threatening infections. Depending on the tissue level, microbiology and clinical course the necrotizing soft-tissue infections are classified in primary located infections to the subcutaneous level and fascia--like hemolytic streptococcus gangrene, necrotizing fasciitis, gram-negative synergistic necrotizing cellulitis, clostridium-cellulitis, anaerobic non-clostridium-cellulitis and in primary located infections to the muscle--like clostridium myonecrosis and streptococcal myositis. Between 1989 and 1992, 17 patients with necrotizing soft-tissue infections were treated at the Department of Surgery, University Hospital of Zurich. These infections originated from small traumatic injuries or operative wounds ("neglected wounds"). 11 patients suffered from debilitating diseases like diabetes mellitus, drug or alcohol abuse or were compromised by tumors. The average age was 42 years (21-84 years). Following bacteria were found: Staphylococcus aureus, hemolytic Streptococcus, Enterococcus, E. coli, Streptococcus milleri. 2 patients had a mixed infection with more than 3 different bacteria, 6 patients with 2, and 9 patients had a monoinfection. In 14 patients the infection was on the subcutaneous and fascia level, 3 patients showed a myositis or myonecrosis. No patient died, amputation of the limb was necessary in 4 cases. The average hospitalisation was 41 days (13-137 days) whereas 10 patients required between 4 and 53 days intensive care (average 18.3 days). Necrotizing soft-tissue infections are severe illnesses which are underestimated in the primary phase due to atypical or minor primary signs. The infections can be caused by a variety of bacteria and are spreading rapidly.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Necrotizing soft tissue infection of the extremities]. 803 28

Necrotizing fasciitis (NF) is a rapidly progressive disease characterized by extensive necrosis of the skin, fascia, and subcutaneous tissue, with sparing of the underlying muscle. Diabetes mellitus, Bartholin's gland abscess, and recent surgical procedures (including episiotomy) are factors often found in obstetric and gynecologic patients. Mortality in this group of patients is higher than in the general surgical population. Death is usually due to overwhelming sepsis, renal and respiratory failure, and multiple organ failure. The infections are usually polymicrobial, with alpha-hemolytic streptococci, gram-negative coliforms, and anaerobic bacteria. Lower survival has been reported in large series when the groin is involved or when the general nutritional state is poor. From October 1988 to August 1990, we treated five patients with necrotizing fasciitis. Certain important characteristics of such patients have not been discussed in the obstetric and gynecologic literature. Nutritional status, with special emphasis on total protein, albumin, and the effects of alcoholism, has a significant impact on mortality. Nutritional support of these patients may improve survival. To limit the impact of secondary infections, surgical approaches should be modified by the anatomic location of the initial lesions. More frequent debriding in the operating room and early fecal diversion are recommended.
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PMID:Necrotizing surgical infection and necrotizing fasciitis in obstetric and gynecologic patients. 827 12

Diabetic peripheral neuropathy is one of the most common complications of diabetes. We present a case of necrotizing fasciitis in a 38 year old man with insulin dependent diabetes, who had been treated by an alternative therapist with a vacuum boot. The treatment resulted in ulcerations and later infection of the foot and ankle, which had to be treated by acute amputation. The story illustrates the risk of consulting alternative treatment when suffering from diabetic neuropathy or circulatory disturbances. We can therefore not recommend that patients of this kind receive treatment from any person without medical experience.
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PMID:[Purulent myofasciitis in a patient with diabetes treated with a vacuum boot by a zone therapist]. 832 69

We report a 31-year-old diabetic woman who underwent carpal tunnel release for median nerve compression followed by a laparoscopic tubal ligation. The procedure was complicated by a severe postoperative necrotizing fasciitis infection of the carpal tunnel release incision. This has not been previously reported. The wound was poorly responsive to antibiotic therapy and serial wound debridements. Control of the woman's infection required total excision of the palmar skin and fascia. Complicating factors in this case included the woman's long history of insulin-dependent diabetes and a concomitant clean-contaminated procedure.
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PMID:Carpal tunnel release complicated by necrotizing fasciitis. 836 84

Morbidity from wound healing was retrospectively analyzed in a series of 202 consecutive patients with tumors of the soft tissue of the extremities, torso and head and neck region who were treated with preoperative irradiation and conservative operation at the Massachusetts General Hospital between January 1971 and June 1989. A radiation boost dose was given to 143 patients (71 percent) postoperatively. The overall wound complication rate was 37 percent. One patient died because of necrotizing fasciitis. In 33 instances (16.5 percent), secondary operation was necessary, including six patients (3 percent) who required amputation. The wounds in the remaining 40 patients (20 percent) were treated without operation. Multivariate analyses of the data showed the factors that were significantly associated with wound morbidity: tumor in the lower extremity (p < 0.001), increasing age (p = 0.004) and postoperative boost with interstitial implant (p = 0.016). Accelerated fractionation (BID, two fractions per day) reached borderline statistical significance (p = 0.074). Two other factors showed association with wound morbidity by univariate analysis, but not in multivariate model: high pathologic grade (p = 0.02) and estimated volume of resected specimen > or = 200 milliliters (p = 0.065). Patient gender, intercurrent disease (diabetes or hypertension), obesity, maximal tumor size, primary versus recurrent tumor, duration of bed rest postoperatively, dose of postoperative boost radiation, the use of postoperative boost, the use of adjuvant chemotherapy and year of treatment did not show significant importance for wound morbidity. When the severe wound complications (defined as requiring secondary operation and including the patient who died because of necrotizing fasciitis) were considered, among all analyzed variables, only localization of tumor in the lower extremity as a single factor was significant (p < 0.001). Techniques for managing the wound are considered which are judged likely to contribute to a decrease of the incidence of wound healing delays.
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PMID:Wound healing after preoperative radiation for sarcoma of soft tissues. 842 99


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