Necrotizing fasciitis (NF) is an infection that affects the fascia and leads to rapidly spreading tissue death and rapidly spreading to include adjacent soft tissue. It is also called meat-eating disease (bacteria). Several different types of meat-eating bacteria can cause life-threatening conditions that affect both healthy and individuals with underlying medical problems. Although rare, there has been an increase in the incidence of necrotizing fasciitis in the last decade. Although probably not adequately reported, the annual incidence of necrotizing fasciitis is estimated to be approximately 500-1,000 cases per year with a prevalence of 0.40 cases per 100,000 populations per year. Early diagnosis and emergency treatment of necrotizing fasciitis is critical to managing the potentially devastating consequences of this medical emergency.
What is the history of necrotizing fasciitis?
One of the first definitions of necrotizing fasciitis was the diagnosis of erysipelas. It came from Hippocrates in the 5th century. Although necrotizing fasciitis has existed for centuries, more detailed explanations of this condition have been reported in the early 19th and early 20th centuries. In 1952, B. Wilson first used the term necrotizing fasciitis to describe this condition, and it remained the term most commonly used in modern medicine. Other terms used to describe this same condition include meat-eating bacterial syndrome, necrotizing soft tissue infection, suppurative fasciitis, dermal gangrene, streptococcal gangrene, hospital gangrene, necrotizing cellulitis, Melener’s ulcer and Melener’s gangrene. When necrotizing fasciitis affects the genital area, it is often referred to as Fournier’s gangrene.
What Causes and Risk Factors of Necrotizing Fasciitis?
Most cases of necrotizing fasciitis are caused by bacteria, but fungi can rarely cause it. Most cases of necrotizing fasciitis originate from group A beta-hemolytic streptococci, but many bacteria may be isolated and associated with other bacterial pathogens. Group A is the same bacterium responsible for streptococci, strep throat, impetigo (skin infection) and rheumatic fever. In recent years, there has been an increase in intravenous drug addicts in cases of necrotizing fasciitis caused by community-acquired methicillin-resistant Staphylococcus aureus (MRSA). Most cases of necrotizing fasciitis are polymicrobial and include both aerobic and anaerobic bacteria. Additional bacterial organisms that may be isolated in cases of necrotizing fasciitis include Escherichia coli, Klebsiella, Pseudomonas, Proteus, Vibrio,
Most cases of necrotizing fasciitis have a previous history of trauma, such as cuts, abrasions, insect bites, burns or needle sores. These lesions may initially appear insignificant or small. Surgical incision sites and various surgical procedures may also serve as a source of infection. In most cases, however, there is no obvious source of infection or entry portal to explain the cause.
Once the bacterial pathogen has gained entry, the infection can spread from subcutaneous tissues to involve deeper facial planes. Infection spreads progressively rapidly, sometimes involving adjacent soft tissues, including muscle, fat and skin. Various bacterial enzymes and toxins cause vascular obstruction, resulting in tissue hypoxia and tissue necrosis. In most cases, these tissue conditions allow the proliferation of anaerobic bacteria, allowing the progressive spread of infection and the continued destruction of tissue.
There is also a risk of developing necrotizing fasciitis in people with underlying medical problems and a weak immune system. Various medical conditions such as diabetes, renal failure, liver disease, cancer, peripheral vascular disease and HIV infection are frequently present in patients who develop necrotizing fasciitis, such as those receiving chemotherapy. In addition, patients undergoing organ transplants and receiving corticosteroids for various reasons, alcoholics and drug addicts are at risk. However, most cases of necrotizing fasciitis occur in a healthy individual and in healthy cases without predisposing factors.
For classification purposes, necrotizing fasciitis is divided into three groups, primarily based on the microbiology of the underlying infection. Type 1 NF is caused by multiple bacterial species (polymicrobial), type 2 NF is caused by a single bacterial species (monomicrobial), typically Streptococcus pyogenes; type 3 NF (gas gangrene) is caused by Clostridium spp, type 4 NF is caused by fungal infections, particularly Candida spp. And infection caused by Zygomycetes Vibrio spp. (Often Vibrio vulnificus) is a variable form that is frequently seen in people with liver disease. It usually occurs after eating seafood or exposing skin wounds to sea water contaminated by this organism.
Is Necrotizing Fasciitis Infectious?
Necrotizing fasciitis is not considered an infectious disease. However, it is theoretically possible that an individual is infected with the same organism, for example an MRSA infection, which causes necrotizing fasciitis in a person in direct contact with them. Although it is possible for the exposed individual to continue to develop necrotizing fasciitis, it is very rare and unlikely.
What are the symptoms?
Symptoms of necrotizing fasciitis vary according to the degree and progression of the disease. Necrotizing fasciitis usually affects the extremity or genital area, although it is in any part of the body. During the course of the disease, patients with necrotizing fasciitis may initially look deceptively good and may not show any superficial signs of an underlying infection. Some people may complain of pain similar to the muscle initially taken. However, as the infection spreads rapidly, symptoms of serious illness become apparent.
Necrotizing fasciitis usually appears as a localized area of redness, warmth, swelling and pain that resembles a superficial skin infection. Often, patients’ pain and tenderness are not commensurate with visible signs of the skin. There may be fever and chills. The skin’s redness spreads rapidly over hours and the skin can be dark, purplish or dark. Overlapping blisters, necrotic siblings (black shells), skin hardening, skin deterioration and wound drainage may develop. Sometimes a subtle crackling sensation can be felt in the tissues under the skin. Severe pain and tenderness may be reduced due to subsequent nerve damage and may lead to localized anesthesia of the affected area. If left untreated, infection continues to spread and generalized physical detention, it can often lead to sepsis and often death. Other symptoms associated with necrotizing fasciitis may include malaise, nausea, vomiting, weakness, dizziness, and confusion.
When to seek medical help?
Immediate identification and treatment of necrotizing fasciitis is critical to increase the likelihood of a positive outcome. Due to the rapid progression of this condition, detailed screening and early diagnosis are required to initiate immediate treatment immediately. Individuals with underlying medical problems or a weak immune system should be particularly vigilant. If any of the following symptoms occur, a healthcare professional should be consulted:
• An unexplained skin rash, temperature, tenderness or swelling area with or without a history of skin trauma •
Changes in skin color or skin texture
• Drain from an open wound
• Fever or chills
• Intense pain or discomfort of the body area that has previously been traumatized or not traumatized
If a person has previously been evaluated by a healthcare professional and the above symptoms have progressed or the person cannot recover, an antibiotic treatment at home should be re-evaluated immediately. If necrotizing fasciitis is suspected, an accelerated surgical consultation is needed.
Tests and Inspection
Diagnosis of necrotizing fasciitis is usually predicted initially based on the patient’s history and physical examination findings. Although there are several laboratory tests and imaging studies that can help make the diagnosis, immediate results may not be immediately available. Therefore, in any patient with signs or symptoms suggestive of necrotizing fasciitis, a high index of suspicion should be promptly discussed with a surgeon to accelerate management. The tests are as follows:
• Laboratory tests: include various blood tests, such as a complete blood count, which may reveal an elevated number of white blood cells. Electrolyte panels, blood cultures and other blood tests are also generally obtained. However, the results of these blood tests cannot be used solely for an immediate diagnosis.
• Imaging studies such as CT scan, MRI and ultrasound: These imaging studies have been used successfully to identify cases of necrotizing fasciitis. It can be used when symptoms are equivalent or when the diagnosis is suspicious. These methods can help determine the degree of infection, as well as identify fluid areas, inflammation, and gas fields within the soft tissue. Although occasional plain radiographs may show gas in soft tissue, they are considered less useful and less valuable. Imaging studies in cases suggesting necrotizing fasciitis should not delay the definitive treatment.
• Tissue culture, tissue biopsy and gram staining results: It can help to accurately identify the organisms responsible for infection, and this can help guide appropriate antibiotic therapy.
Are There Home Remedies for Necrotizing Fasciitis?
• Necrotizing fasciitis is an emergency that cannot be managed at home.
• Patients with necrotizing fasciitis require hospital admission, appropriate IV antibiotics, surgical debridement, and close observation in the intensive care unit.
What are Necrotizing Fasciitis Treatments?
• When the diagnosis of necrotizing fasciitis is suspected or confirmed, urgent measures should be taken to promptly intervene treatment to reduce Necrotizing analytes. Medical treatment of necrotizing fasciitis mainly involves the use of much less used antibiotics, hyperbaric oxygen therapy and intravenous immunoglobulin. Definitive treatment for necrotizing fasciitis ultimately requires surgical intervention.
• Initial treatment includes patient stabilization, including additional oxygen, cardiac monitoring, and intravenous fluid delivery.
• Some patients with sepsis may require the administration of intravenous medications to increase blood pressure and require a breathing tube in case of serious illness or respiratory failure.
• Intensive care requires close monitoring and supportive care.
Antibiotics of Necrotizing Fasciitis
• Broad-spectrum antibiotics should be started immediately. Since responsible organisms are not initially known, antibiotics should cover a wide variety of organisms including aerobic gram-positive and gram-negative bacteria, as well as anaerobes. Consideration of infection caused by MRSA should also be considered.
• There are various antibiotic regimens that may include monotherapy or multidrug regimens. Commonly recommended antibiotics include penicillin, ampicillin-sulbactam, clindamycin, aminoglycosides, metronidazole, carbapenems, vancomycin and linezolid. Most clinicians treat multiple IV antibiotics because bacteria that cause necrotizing fasciitis are usually resistant to more than one antibiotic and some infections are caused by more than one bacterial species.
• Antibiotic coverage can be adjusted when culture results, causative organisms, organisms are identified and antibiotic susceptibility results are found. Antibiotic susceptibility testing is required to properly treat MRSA and new NDM-1 antibiotic-resistant bacteria species.
Hyperbaric Oxygen Therapy (HBO)
This therapy gives patients in a special room a high concentration of oxygen, thereby increasing tissue oxygenation. This inhibits anaerobic bacteria and promotes tissue healing. Some researchers believe that HBO reduces mortality in some patients when combined with an aggressive treatment regimen including surgery and antibiotics. HBO is not commonly available, so consultation with a hyperbaric specialist may be necessary. However, this should not delay definitive surgical treatment.
Intravenous Immunoglobulin (IVIG)
Some investigators believe that IVIG may be a useful adjunctive treatment in some cases of streptococcal necrotizing fasciitis, as it has been shown to successfully neutralize streptococcal ecotoxins in Streptococcal toxic shock syndrome. However, its use in necrotizing fasciitis is controversial and is therefore not considered a standard of care.
Rapid surgical debridement of infected tissue is the cornerstone of treatment in cases of necrotizing fasciitis. Early diagnosis and emergency surgery have been shown to reduce morbidity and mortality, which emphasize the importance of early surgical involvement and consultation. Comprehensive surgical debridement is required in all necrotic tissues. Infected all tissues, fascia, muscle, skin and so on. Large and deep incisions may be required to excise until healthy, viable tissue appears. Repeated surgical debridement is required between the following hours and days after the first surgical intervention, because the progression of the disease may not be sudden, severe and stubborn. Sepsis may lead to other sites of infection, and surgical intervention may be required in these areas, which may also require some patients to require amputation. In some cases, despite repeated surgical debridement,
Follow-up After Treatment
Patients recovering from necrotizing fasciitis usually require follow-up with various specialists depending on the complications encountered during hospital stay and subsequent outcomes. Many patients require physical therapy and rehabilitation with skin graft and reconstructive surgery. Sometimes psychological intervention is required for some patients who may experience depression, anxiety, or other psychological repercussions.
Preventive measures may be taken to reduce the likelihood of necrotizing fasciitis, however, not all cases may be completely preventable, as the underlying cause is usually not identified. Since many cases start after some kind of skin trauma, proper wound care and treatment are important. All wounds should be kept clean and any signs of infection should be observed. Early detection and treatment of infection may be the best measure to prevent necrotizing of this disease. If any signs of infection occur, seek medical attention immediately.
Patients with underlying medical problems, such as diabetes, should pay attention to any signs of infection, and people with weakened immune systems should take precautions to avoid exposure to potential infections. For people with liver disease it is recommended to avoid seafood and direct contact with hot sea water potentially contaminated with Vibrio species. People with active skin infections or open wounds should be avoided in jacuzzis, swimming pools and natural water sources.
Good personal hygiene and frequent handwashing can prevent infection and control the spread of infection. Compliance with the appropriate sterile surgical technical rules and gloves, gowns, masks, etc. in hospitals. strict barrier measures should be observed. And the implementation of isolation measures may also prevent health personnel from preventing the development and spread of infection.
What is the Prognosis of Necrotizing Fasciitis?
Prognosis for patients with necrotizing fasciitis depends on many factors such as patient age, underlying medical problems, causal organisms, the extent of infection, and the duration of diagnosis and onset of treatment. Early diagnosis and aggressive surgery and medical treatment are the most important factors in determining the outcome. Necrotizing fasciitis is a life and limb threatening condition with poor prognosis if left untreated. Complications and potential outcomes may include limb loss, scarring, deformity and disability, while many patients continue to develop sepsis, multiple system organ failure and death. Disease rates are as follows:
• Combined morbidity and mortality rates have been reported to range from 70% to 80%.
• Mortality rates in the scientific literature range from 8.7% to 76%.
• The mortality rate for untreated necrotizing fasciitis approaches approximately 100%.