• 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
• 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
• Hemorrhagic bullae
• Crepitus may be present
• Skin may be anesthetic, edematous
• Fever, pain
• 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
• Wide surgical debridement is mainstay of therapy
• Aggressive resuscitation
• Broad-spectrum IV antibiotics
• Multiple debridements may be required
• 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
• 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
• 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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