How is necrotizing fasciitis diagnosis

Clinical features that helped early diagnosis were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics; presence of bullae in the skin; and gas in the soft tissue on plain X-ray although this occurred in only Conclusion: A high index of suspicion of necrotizing fasciitis is needed in a patient presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or liver disease.

The presence of bullae, or gas on plain X-ray can be diagnostic. Therefore, doctors may not wait for test results if they think a patient might have necrotizing fasciitis. Necrotizing fasciitis can lead to sepsis , shock, and organ failure. It can also result in life-long complications from loss of limbs or severe scarring due to surgically removing infected tissue. Even with treatment, up to 1 in 3 people with necrotizing fasciitis die from the infection.

Six out of every 10 people who get both necrotizing fasciitis and streptococcal toxic shock syndrome at the same time die from their infections. Streptococcal toxic shock syndrome is another very serious illness caused by group A strep. It causes the body to go into shock and involves low blood pressure and multiple organ failure. While anyone can get necrotizing fasciitis, it is rare. Most cases of necrotizing fasciitis occur randomly. It is very rare for someone with necrotizing fasciitis to spread the infection to other people.

For this reason, doctors usually do not give preventive antibiotics to close contacts of someone with necrotizing fasciitis. Since , approximately to cases occur each year in the United States. This is likely an underestimate. According to ABCs data, the number of annual group A strep necrotizing fasciitis infections reported to ABCs does not appear to be rising.

The pain will become worse, and the affected area will grow quickly. There may be oozing from the infected area, or it may become discolored as it decays. Blisters, bumps, black dots, or other skin lesions might appear. In the early stages of the infection, the pain will be much worse than it looks. To get necrotizing fasciitis, you need to have the bacteria in your body.

This typically occurs when the skin is broken. For example, the bacteria can enter your body through a cut, scrape, or surgical wound. Even a needle puncture can be enough. Several types of bacteria cause necrotizing fasciitis.

The most common and well-known type is group A Streptococcus. Other bacteria that can cause necrotizing fasciitis include:. People who already have health issues that weaken the immune system, such as cancer or diabetes, are at greater risk of developing infections caused by group A Streptococcus.

In addition to looking at your skin, your doctor may perform several tests to diagnose this condition. They may take a biopsy , which is a small sample of the affected skin tissue for examination.

Blood tests can show if your muscles have been damaged. Treatment begins with strong antibiotics. These are delivered directly into your veins. The majority of patients were initially treated with aggressive fluid resuscitation and empirical antibiotic treatment consisted of ampicillin—sulbactam and metronidazole.

In 11 cases Antibiotic treatment was started in almost all patients intraoperatively, and it was continued proportionally to infection parameters. The mean duration of antibiotic treatment was The average time from admission to operation was We performed aggressive surgical debridement in all patients, and we performed repeated debridement in almost all of them.

The median number of repetitive debridement needed for every patient was 5 1—9. In eight cases with infection of the abdominal wall, the underlying peritoneum was infected, and part of the underlying large intestine was not viable; therefore, a colectomy was required Furthermore, in 16 cases Thirty-two patients were transferred immediately after operation to the intensive care unit ICU The mean length of ICU hospitalization was 2. In four patients, we used a vacuum-assisted device to accelerate wound healing.

Necrotizing fasciitis is a rare clinical entity, with an annual incidence of 1, cases annually, and global prevalence of 0. There is no age predilection for NF; however, middle-aged and elderly patients over 50 years of age are more likely to be infected 2. Indeed, the median age of our patients is comparable to other clinical series The advanced age of patients with NF seems to be a crucial risk factor for higher mortality.

We noted a statistically significant correlation between advanced age and mortality, and this is in accordance with large clinical studies that have shown that advanced age is a strong, independent predictor of mortality However, other studies have maintained that although advanced age is a risk factor for mortality, it must be accompanied by a more aggressive clinical course as well Unlike age, sex as a risk factor for mortality is still a topic of debate.

In our series, there was a correlation between female sex and mortality, with a considerable level of significance. Moreover, in a study from Czymek et al. As far as the site of infection is concerned, in a large clinical study from Anaya et al. Nevertheless, it is widely agreed that NF of the upper limbs is significantly rare compared to that of the lower limbs Patients with NF, mainly due to their advanced age, usually have at least one comorbidity.

The most frequent comorbidity is diabetes mellitus. Goh et al. In our series, there was no statistically significant correlation between diabetes and mortality. Chronic renal failure is also a frequent comorbidity in patients with NF, which seems to be a decisive risk factor for mortality.

Elevated serum creatinine, along with elevated blood urea, is strongly associated with high mortality rates The clinical onset of patients with NF is not always evident, leading usually to misdiagnosis.

The most common symptoms are local pain, swelling, and erythema; however, the simultaneous presence of these three symptoms is not a common phenomenon Local skin changes consist of tenderness, crepitus, skin necrosis, and hemorrhagic bullas. The presence of crepitus suggests infection from anaerobic bacteria, which is useful for treatment strategy. This strong correlation between septic shock and mortality has been repeatedly reported in the literature 22 — As the clinical presentation of patients with NF is not characteristic, the laboratory tests can provide not only useful information regarding the diagnosis of NF but may also indicate its severity.

In our series, 46 patients had LRINEC score under 8 26 of them under 6 , which indicates that the two-thirds of study population had a moderate form of NF. This can indirectly explain many of the results of our treatment, like relatively low hospital rate, and foremost our low mortality rate. However, in most of our cases, the diagnosis was equivocal; therefore, we used CT more frequently than in other series to set the diagnosis Apart from CT and plain radiography, which we widely used, magnetic resonance imaging MRI or ultrasonography can also be used.

Plain radiography is useful only in cases of gas gangrene, where gas formation is present. Despite its low sensitivity, it is generally widely used due to its low cost A CT scan can demonstrate the extent of tissue infection, fascial swelling, inflammation, and gas formation. An MRI scan may provide additional information but is rarely used. Ultrasonography is also a feasible option, mainly in cases of gas gangrene.

Bedside tests such as finger test and frozen section biopsy are occasionally used for confirmation of diagnosis, and when the diagnosis remains unclear, surgical exploration can set the diagnosis Actually, the combination of surgical exploration and microbiological and histopathological analysis of 1 cm 3 of soft tissue is considered the gold standard for confirming diagnosis, when the latter is ambivalent; however, because of the acute nature of the disease this combination is rarely used by the clinicians.

Undoubtedly, the time from admission to surgery is the most decisive factor for survival. Emergency surgical debridement should be performed in all patients within 12—15 h after admission, since a delay in treatment beyond 12 h especially in the fulminant forms of NF can prove fatal At any case a delay over 24 h is unacceptable, as the mortality rate can be nine times greater when primary surgery is performed 24 h after the onset of symptoms 4.

We managed to maintain a mean time of Nonetheless, before surgery and during diagnostic procedures, patients should be resuscitated with crystalloids, and broad-spectrum antibiotics should be given. Although blood culture results are not always available in an emergency basis, the empirical usage of antibiotics is based on the suspected microbiological type of NF. Medical history and imaging tests can also be indicative for the microbiological type.

When a polymicrobial infection is suspected, ampicillin or ampicillin—sulbactam combined with metronidazole or clindamycin are used Alternatively, carbapenems can be administered. In cases of previously hospitalized patients, piperacillin—tazobactam, ticarcillin—clavulanate acid, third- or fourth-generation cephalosporins, or carbapenems are used, but at a higher dosage. Monomicrobial infection by beta-hemolytic streptococcus A is treated with first- or second-generation cephalosporins, except of cases with suspected MRSA coinfection, in which vancomycin, or daptomycin and linezolid are used Gas gangrene is usually a result of Clostridium species infection and is treated with clindamycin and penicillin.

Finally, NF caused by fungi can be treated with amphotericin B or fluoconazole, with disappointing results