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  • • Usually caused by multiple bacterial pathogens

    • Infection usually mixed flora, including streptococci, staphylococci, anaerobes, gram-negative aerobes

    • Typically begins in localized area (puncture wound, incision)

    • Spreads along fascial planes

    • Results in thrombosis of penetrating vessels and tissue necrosis

    • Area of fascial necrosis usually more extensive than skin appearance indicates

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Epidemiology

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  • • More common in patients who are immunosuppressed or debilitated and in those who have diabetes or cancer

    • 1000 cases reported in United States per year

    • May also develop more frequently in obese patients, following penetrating trauma, postpartum women, injection drug abusers

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Symptoms and Signs

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  • • Hemorrhagic bullae

    • Crepitus may be present

    • Skin may be anesthetic, edematous

    • Fever, pain

    • Tachycardia

    • Undermining and dissection of the subcutaneous tissue, liquefaction of fat, preservation of overlying skin

    • "Dishwater" exudate from wound

    • Skin necrosis/gangrene seen in advanced disease

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Laboratory Findings

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  • • Elevated WBC count

    • Positive wound culture, Gram stain

    • Biopsy of infected tissue reveals:

    • -Necrosis

      -Polymorphonuclear leukocyte (PMN) infiltration

      -Thrombi of arteries and veins passing through fascia

      -Angiitis

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Imaging Findings

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  • • Plain x-ray may reveal subcutaneous air

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  • • Superficial cellulitis

    • Abscess

    • Fistula

    • Have high index of suspicion; delay in treatment augments morbidity and mortality significantly

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  • • High index of suspicion required for diagnosis

    • Obtain tissue biopsy/wound aspirate and culture may help direct antimicrobial therapy

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When to Admit

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  • • Patients require aggressive resuscitation and surgical treatment

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  • • Wide surgical debridement is mainstay of therapy

    • Aggressive resuscitation

    • Broad-spectrum IV antibiotics

    • Multiple debridements may be required

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Surgery

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Indications

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  • • Surgical emergency

    • High index of suspicion required

    • Aggressive debridement of devitalized soft tissue

    • Fascial compartments should be decompressed

    • Amputation may be required if evidence of diffuse myositis, complete loss of blood supply, and if debridement would clearly leave a useless limb

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Contraindications

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  • • Patients should be as aggressively resuscitated as possible prior to operation

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Medications

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  • • IV broad-spectrum antibiotics: penicillin+aminoglycoside+clindamycin or imipenem-cilastatin

    • Intravenous immunoglobulin (IVIG) may be useful for streptococcal toxic shock syndrome

    • Aggressive resuscitation required for potential large volume deficits

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Treatment Monitoring

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  • • Wounds may require further debridement either at bedside or in operating room

    • Wound cultures likely to be polymicrobial

    • May need to change antibiotic regimen based on wound cultures and sensitivities

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Complications

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  • • Sepsis

    • Devitalization of entire limb/limb loss

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Prognosis

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  • • Potentially lethal

    • -20% with necrotizing fasciitis die

      -> 50% mortality with streptococcal toxic shock syndrome

    • Deaths occur when treatment delayed or in ...

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