Let's learn about the approach to a patient with Necrotizing fasciitis.

1. Approach to a patient with
Necrotizing fasciitis
Presented by
- Manoj Khadka
(Intern, Shree Birendra Hospital)
- Manita Khadka
(Intern, Shree Birendra Hospital)

2. Outline of the presentation
● Applied anatomy
● Necrotizing fasciitis
○ Introduction
○ Historical background
○ Risk factors, Etiology, Clinical features
○ Pathophysiology
○ Diagnosis
○ Management (incl Recent advances)
○ Prevention, Complication, Prognosis
● Take home message

4. Historical background
5th century BC- Necrotizing soft tissue infection earliest recognized
1871- 1st clearly described by an army surgeon, Joseph Jones during the Civil War (termed hospital gangrene)
1884- Fournier described a gangrenous infection of perineum & male genitalia
1918- Bacterial infection identified as the etiology of necrotizing fasciitis
1952- Term ‘Necrotizing fasciitis’ coined by Wilson
Necrosis of the fascia & subcutaneous tissue with relative sparing of underlying muscle
19th & 20th centuries- only sporadic cases, usually restricted to military hospitals during wartime
Mid-1980s to early 1990s- rates of Necrotizing fasciitis increased worldwide
Epidemiology- incidence- 0.3 to 15 cases per 100,000 population
The incidence among patients admitted with soft tissue infection- 40.38%

5. Case Scenario
61 yrs/F, with type 2 DM & hypothyroidism presented with complains of
- Pain & swelling of right lower limb for 7 days
- Fever for 7 days
History of cut injury by metallic object (tin)
Progression of symptoms with blackish discoloration of skin, bulla formation
Undergone hysterectomy 2 yrs back

6. History
● Age (>60 yrs)
● H/o trauma (insect/animal bite)
● Past h/o
○ Diabetes, renal failure, peripheral vascular disease, malignancy
○ Surgical h/o, minor invasive procedures (joint aspiration)
● Drug h/o (steroids, NSAIDs)

7. Physical Examination
•General appearance
• Malnourished/obese
• Toxic look
• Altered mental status
Vital parameters
• Fever
•Tachycardia
•Tachypnea
•Hypotension

8. Local Examination

12. Pathophysiology
Trauma to the skin surface
Microbial invasion of the subcutaneous tissues (epidermis not affected initially)
Bacterial growth within the superficial fascia
Release of a mixture of enzymes toxins causing spread of infection through fascia
Infection spreading to venous & lymphatic channels (edema)
Thrombosis of small veins & arteries passing through the fascia
Results in poor microcirculation, ischaemia in affected tissues, & ultimately cell necrosis.
Early pathological stages- apparently normal-looking skin despite extensive infection of the underlying fascia.
Late pathological stages– Haemorrhagic bullae, ulceration, and skin necrosis

13. Types
Based on etiology
● Type I (70–80%)- Polymicrobial (aerobic & anaerobic), perineal & trunk areas,
immunocompromised
● Type II (20-30%)- Monomicrobial (GAS, sometimes S. aureus), extremities, healthy,
h/o minor trauma
● Type III- Marine related organism, h/o exposure to warm sea water
● Type IV- fungal (Candida species), immunocompromised

14. Diagnosis
➢ The diagnosis is usually clinical
➢ 35% of cases were initially misdiagnosed as simple
cellulitis, superficial erysipelas, or abscesses
presenting with only pain, tenderness, and warm
skin- so high suspicion required
Gold standard: surgical exploration and tissue biopsy
(fascial necrosis diagnostic)

15. Lab Parameters
CBC- leucocytosis/leucopenia, anemia (dilutional from fluid
resuscitation/hemolysis), coagulopathy, DIC
Increased CRP (d/t infection, inflammation & necrosis)
Biochemistry (hypocalcemia-fat necrosis & calcium deposition in
necrotic tissue; organ dysfunction- abnormal LFT/RFT, acidosis)
Positive Blood culture

16. Role of imaging in diagnosis of NF
X ray- Subcutaneous gas
CT -deep fascial thickening & enhancement,
presence of fluid & gas within soft tissue
planes in & around the superficial fascia
Ultrasound- f/s/o thickening, distortion, and
fluid collections along the deep fascia
MRI- differentiates necrotic and inflamed or
oedematous tissue

17. LRINEC (Laboratory Risk Indicator for Necrotising Fasciitis) scoring system
≤5 = <50% risk (low)
6–7 = intermediate risk
≥8 = >75% risk (high).

19. Necrotizing fasciitis is a Surgical Emergency

20. Management
RESUSCITATION
(fluids & inotropes)
SURGERY
(Debridement of all non
viable tissues incl fascia)
SOFT TISSUE
RECONSTRUCTION
ANTIMICROBIAL
THERAPY

22. Hyperbaric oxygen therapy
- Raise physically dissolved oxygen level in blood
- A pO2 of 80–250 mm Hg stops the production of alpha-toxin and a pO2
of 1,500 mm Hg is bactericide to Clostridia
- reduces systemic toxicity, limits necrosis and enhances demarcation of
gangrene

23. Recent advances
● Vacuum assisted Closure
○ reduction in tissue edema & exudate from wound should also reduce the
bacterial load in addition to stimulating granulation tissue and improving wound
healing[Al-Subhi F, 2010]
● Preparing the graft bed
○ dermal regenerative matrix grafting- layered to allow for fill of the deep defect
and cover the bone and tendon. [Narayanan AS, 2021]
○ a hyaluronic-based extracellular matrix (eHAM)- acts as a scaffold for cellular
colonization (eg, by fibroblasts) and capillary ingrowth [Kapp DL 2018]
● Cadaveric skin allograft [Gupta M, 2020]

24. Prevention
● Management of predisposing conditions
○ Diabetic patients- foot care, screening for diabetic neuropathy, debridement of
calluses
○ Acute traumatic wounds- copious irrigation, debridement. Contaminated
wounds- left for healing by secondary intention
● Post exposure prophylaxis
○ For close contacts with patients of NF with GAS- Penicillin(250 mg orally 4
times daily) for 10 days
○ Educate about signs and symptoms
● Infection control
○ droplet precautions and contact precautions (discontinued after 24 hrs of
antimicrobial therapy)

25. Complications
● Multiorgan failure
● Septic shock
● Loss of extremity
● Severe scarring
● Toxic shock
● Death

26. Prognosis
Depends on patient age, type of organism, the speed of diagnosis and treatment and patient
comorbidity
Without surgical treatment, necrotizing fasciitis has mortality rates of 100%, and overall
mortality rates of about 30%
considerably higher, approximately 80%, when the disease is associated with sepsis and
renal failure [Smuszkiewicz P, 2008]
Polymicrobial (type I) necrotizing fasciitis – 21 percent
Monomicrobial (type II) necrotizing fasciitis – 14 to 34 percent

27. Take Home Message
● A progressive, fulminant bacterial infection of subcutaneous tissue and fascia
● History- trauma, immunocompromised state
● Pain out of proportion
● Surgical emergency
● Resuscitation, serial debridement and IV antibiotics are key in management

29. References
1. Taviloglu K, Yanar H. Necrotizing fasciitis: strategies for diagnosis and management. World J Emerg Surg.
2007 Aug 7;2:19. doi: 10.1186/1749-7922-2-19. https://wjes.biomedcentral.com/articles/10.1186/1749-7922-
2-19
2. Hasham, S., Matteucci, P., W Stanley, P. R., & Hart, N. B. (2005). Necrotising fasciitis. BMJ : British
Medical Journal, 330(7495), 830-833. https://doi.org/10.1136/bmj.330.7495.830
3. Puvanendran, R., Meng Huey, J. C., & Pasupathy, S. (2009). Necrotizing fasciitis. Canadian Family
Physician, 55(10), 981-987. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762295/
4. Sadasivan, J., Maroju, N. K., & Balasubramaniam, A. (2013). Necrotizing Fasciitis. Indian Journal of Plastic
Surgery : Official Publication of the Association of Plastic Surgeons of India, 46(3), 472-478.
https://doi.org/10.4103/0970-0358.121978
5. Wang YS, Wong CH, Tay YK. Staging of necrotizing fasciitis based on the evolving cutaneous features. Int J
Dermatol. 2007 Oct;46(10):1036-41. https://pubmed.ncbi.nlm.nih.gov/17910710/
6. Gupta Y, Chhetry M, Pathak KR, Jha RK, Ghimire N, Mishra BN, Karn NK, Singh GK, Bhagabati JN. Risk
Factors For Necrotizing Fasciitis And Its Outcome At A Tertiary Care Centre. J Ayub Med Coll Abbottabad.
2016 Oct-Dec;28(4):680-682. https://pubmed.ncbi.nlm.nih.gov/28586594/
7. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the
literature. J Am Coll Surg. 2009 Feb;208(2):279-88. https://pubmed.ncbi.nlm.nih.gov/19228540/
8. UpToDate

30. THANK YOU !
Acknowledgment
We are grateful to Dr Sunil Basukala sir for reviewing the presentation.
We owe our special thanks to the Department of Surgery, SBH for this learning
opportunity.