Infecciones necrotizantes tejidos blandos

INFECCIÓN NECROTIZANTE DE
TEJIDOS BLANDOS
Dr Oscar David Rubio - Cirujano general
Clínica de Marly - Abril 2016

HISTORIA
➤ Hipócrates describió hace unos 2000 años, frente a
un cuadro de erisipela complicada: “…sea la causa un
accidente trivial o una herida muy pequeña…la
erisipela rápidamente se disemina en todas
direcciones. Músculos, tendones, y huesos caen en
grandes cantidades...La ﬁebre no siempre está
presente. Ocurren muchas muertes”
Descamps V, Aitken J, Lee MG: Hippocrates on
necrotising fasciitis. Lancet 1994; 344:556
➤ Joseph Jones, Cirujano Confederado en 1871
describió 2642 casos de “gangrena de hospital” con
mortalidad del 46%
Necrotizing Skin and Soft Tissue
Infections
Haytham M.A. Kaafarani, MD, MPH*, David R. King, MD
KEYWORDS
Necrotizing skin and soft tissue infection (NSSTI) Necrotizing fasciitis
Gas gangrene Fournier’s gangrene Wide local debridement
KEY POINTS
INTRODUCTION
Necrotizing skin and soft tissue infections (NSSTIs) are
life-threatening soft tissue destruction and necrosi
secreting bacteria. Extensive, rapid, and widespread
and necrosis along soft tissue planes is the essential c
Epidemiology
The epidemiology of NSSTIs is not very well established
are largely absent from medical literature, and mo
Division of Trauma, Emergency Surgery and Surgical Critical C
pital, Harvard Medical School, 165 Cambridge Street, Suite 8
* Corresponding author.
E-mail address: hkaafarani@partners.org
Immunosuppressed individuals are especially susceptible
Systemic signs of infection are ubiquitous, with patient
showing signs of multiorgan dysfunction syndrome.
The Laboratory Risk Indicator for Necrotizing Fasciitis ha
predictive value for NSSTIs.
Computed tomography might be helpful in diagnosing NSS
rule it out.
Prompt wide surgical debridement and broad spectrum a
needed for successful management and prevention of th
associated with NSSTIs.
Surg Clin N Am 94 (2014) 155–163
http://dx.doi.org/10.1016/j.suc.2013.10.011
0039-6109/14/$ – see front matter Ó 2014 Elsevier Inc. All righ
Infections
KEYWORDS

HISTORIA
➤ A principios y mediados del siglo 20,
esta entidad fue popularizado por la
expresión “bacteria come carne”
➤ NSSTI fue descrita en la literatura como
Gangrena Gaseosa, Infección
necrotizante de la piel y tejidos, Fascitis
Necrotizante
Gangrena de Fournier (cuando afecta el
escroto, órganos genitales y periné)
Angina de Ludwig (cuando afecta el piso
de la lengua y el área submandibular,
asociado a infecciones dentales severas)
Dr.Wilhem Friedric von Ludwig 1836

EPIDEMIOLOGIA
➤ La incidencia en de Infección Necrotizante de Tejidos
Blandos o NSSTI (Siglas en ingles) es de 500 a 1500 casos
por año solo en Estados Unidos.
➤ 3.5 casos por cada 100.000 personas, especialmente de
Estreptococo Grupo A en USA
➤ Mortalidad 13.7% (cifras entre 7% y 30%)
➤ Factores de riesgo DM 44%, obesidad 33%, abuso de
alcohol 31%, desnutrición (albúmina menor a 3 g/dl) 31%.
Infections
KEYWORDS
KEY POINTS
INTRODUCTION
Necrotizing skin and soft tissue infections (NSSTIs) are severe infections resulting in
life-threatening soft tissue destruction and necrosis and resulting from toxin-
secreting bacteria. Extensive, rapid, and widespread progression of the infection
and necrosis along soft tissue planes is the essential characteristics of the disease.
Epidemiology
The epidemiology of NSSTIs is not very well established; reliable data on its incidence
are largely absent from medical literature, and most published studies reflect
Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hos-
pital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA 02114, USA
Computed tomography might be helpful in diagnosing NSSTIs, but is often not sufficient to
rule it out.
Prompt wide surgical debridement and broad spectrum antibiotics are the key elements
needed for successful management and prevention of the high morbidity and mortality
Surg Clin N Am 94 (2014) 155–163
http://dx.doi.org/10.1016/j.suc.2013.10.011 surgical.theclinics.com
0039-6109/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
Infections
KEYWORDS

MICROBIOLOGIA
➤ TIPO I - MONOMICROBIALES
Bacterias anaerobias como Clostridia, Streptococci o Bacteroides
➤ TIPO II - POLIMICROBIAL
Clostridium perﬁngers, el cual secreta exotoxinas (ej hemolisina,
colagenasas, lecitinasas y proteasas) que producen una rápida evolución en
profundidad y extensión hacia la fascia y los límites musculares.
Infections
KEYWORDS
KEY POINTS
INTRODUCTION
Necrotizing skin and soft tissue infections (NSSTIs
life-threatening soft tissue destruction and ne
secreting bacteria. Extensive, rapid, and widesp
and necrosis along soft tissue planes is the essen
Epidemiology
The epidemiology of NSSTIs is not very well establ
are largely absent from medical literature, and
Division of Trauma, Emergency Surgery and Surgical Cri
pital, Harvard Medical School, 165 Cambridge Street, Su
The Laboratory Risk Indicator for Necrotizing Fasciit
Computed tomography might be helpful in diagnosing
rule it out.
Prompt wide surgical debridement and broad spectr
needed for successful management and prevention
Surg Clin N Am 94 (2014) 155–163
0039-6109/14/$ – see front matter Ó 2014 Elsevier Inc. A
Necrotizing Skin and Soft Tiss
Infections
KEYWORDS

FISIOPATOLOGIA
➤ Posterior a la producción de exotoxinas descritas y de la
progresión rápida hay una Trombosis de vasos pequeños (capilares y
perforantes) resultando en falta de perfusión titular y necrosis
celular, produciendo la característica descarga de “agua sucia”.
➤ Sistémicamente, hay incremento en la producción de
citoquinas, proliferación de células-T, interleuquinas (IL) y
secreción de linfocitos (IL-1, IL-2, IL-6, factor de necrosis
tumoral α y β) produciendo Shock séptico y disfunción
multisistémica.
Infections
KEYWORDS
INTRODUCTION
Necrotizing skin and soft tissue infections (NSSTIs) are severe infections resulting in
life-threatening soft tissue destruction and necrosis and resulting from toxin-
secreting bacteria. Extensive, rapid, and widespread progression of the infection
and necrosis along soft tissue planes is the essential characteristics of the disease.
Epidemiology
The epidemiology of NSSTIs is not very well established; reliable data on its incidence
are largely absent from medical literature, and most published studies reflect
Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hos-
pital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA 02114, USA
NSSTIs may be caused by single agents such as clostridia or streptococci (type I), but are
often polymicrobial (type II).
Immunosuppressed individuals are especially susceptible to NSSTIs.
Systemic signs of infection are ubiquitous, with patients often becoming septic and
The Laboratory Risk Indicator for Necrotizing Fasciitis has a high positive and negative
Computed tomography might be helpful in diagnosing NSSTIs, but is often not sufficient to
rule it out.
Prompt wide surgical debridement and broad spectrum antibiotics are the key elements
needed for successful management and prevention of the high morbidity and mortality
Surg Clin N Am 94 (2014) 155–163
http://dx.doi.org/10.1016/j.suc.2013.10.011 surgical.theclinics.com
0039-6109/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
Infections
KEYWORDS

in 10–30% of all patients. Typically, these infections occur after
small incisions, and appear to be highly correlated with the use
of NSAIDs (37). Specifically observed in patients without serious
co-morbidities, the infection is most often found in the limbs. The
risk of toxic shock syndrome is increased in such cases, and the
outcome is unfavorable.
Type III includes monomicrobial infections involving the
Clostridium species or Gram-negative bacteria. Clostridium
species are anaerobic bacteria that can be produced by external
injuries (deep wound or crush injury causing local devasculariza-
tion) or surgical wounds (intestinal and obstetric). Clostridium
infections are currently more frequent among drug addicts (38),
and advanced symptoms (43). The most common early signs are
erythema, local warmth, skin sclerosis, and edema. However, in
the fulminant form of disease, the patient is critically ill with signs
and symptoms of severe septic shock and multiple organ dys-
function syndrome, along with extensive necrosis of soft tissue.
In this case, the clinical picture deteriorates rapidly within a few
hours; pain is severe and usually manifests before the cutaneous
signs.Remarkably,painseemstobedisproportionatetotheclinical
findings.
In contrast, the subacute form of the disease has a relatively
slow clinical course, which may endure for days or weeks. The
early clinical status of the subacute form is the result of an existing
Table 1 | Classification of responsible pathogens according to type of infection.
Microbiological type Pathogens Site of infection Co-morbidities
Type I (polymicrobial) Obligate and facultative anaerobes Trunk and perineum Diabetes mellitus
Type II (monomicrobial) Beta-hemolytic streptococcus A Limbs
Type III Clostridium species Limbs, trunk, and perineum Trauma
Gram-negative bacteria Seafood consumption (for Aeromonas)
Vibrios spp.
Aeromonas hydrophila
Type IV Candida spp. Limbs, trunk, perineum Immunosuppression
Zygomycetes
www.frontiersin.org September 2014 | Volume 1 | Article 36 | 3
REVIEW ARTICLE
published: 29 September 2014
doi: 10.3389/fsurg.2014.00036
Current concepts in the management of necrotizing
fasciitis
Evangelos P. Misiakos*, George Bagias, Paul Patapis, Dimitrios Sotiropoulos, Prodromos Kanavidis and
Anastasios Machairas
3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
Edited by:
Hubert Scheuerlein,
Universitätsklinikum Jena, Germany
Reviewed by:
Carolina Isabella Alexandra
Pape-Köhler, University of
Witten/Herdecke, Germany
Markus Philipp Hussein Ghadimi,
Universitätsklinik Düsseldorf,
Germany
*Correspondence:
Evangelos P. Misiakos, 3rd
Department of Surgery, Attikon
University Hospital, University of
Athens School of Medicine, 76 Aigeou
Pelagous Street, Agia Paraskevi,
Athens 15 341, Greece
e-mail: misiakos@med.uoa.gr,
emisiakos@yahoo.com
Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that devel-
ops in the scrotum and perineum, the abdominal wall, or the extremities. The infection
progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median
mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as
diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and
liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most
cases are polymicrobial, classed as type I. The clinical status of the patient varies from
erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and
bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with
signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical
condition is the most important clue for diagnosis. However, in equivocal cases, the diag-
nosis and severity of the infection can be secured with laboratory-based scoring systems,
such as the laboratory risk indicator for necrotizing fasciitis score or Fournier’s gangrene
severity index score, especially in regard to Fournier’s gangrene. Computed tomography or
ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery
at the infected sites. Management of the infection begins with broad-spectrum antibiotics,
but early and aggressive drainage and meticulous debridement constitute the mainstay
of treatment. Postoperative management of the surgical wound is also important for the
patient’s survival, along with proper nutrition. The vacuum-assisted closure system has
proved to be helpful in wound management, with its combined benefits of continuous
cleansing of the wound and the formation of granulation tissue.
Keywords: necrotizing fasciitis, Fournier’s gangrene, gas gangrene, surgical debridement
INTRODUCTION
The term necrotizing fasciitis (NF) describes a group of relatively
uncommon, but life-threatening infections of the skin, soft tis-
described a condition in 1783 that was very similar to modern
descriptions of NF (5). The first description of “modern” NF was
made by Joseph Jones, a military surgeon of the army of the Con-

Tipo 1 : Infección sinérgica polimicrobiana (excepto
Estreptococo B-hemolitico grupo A) - Pacientes
inmunocomprometidos
Tipo 2 : Estreptococo B-hemolitico grupo A solo o con
Estafilococo - Pacientes inmunocompetentes/drogas IV
Tipo 3 : Infecciones por Vibrio y especies de Aeromonas -
Exposición al agua de mar
Necrotizing fasciitis: The need for urgent surgical
intervention and the impact of intravenous drug
use
Carmel Waldron a
, Jacqueline Gemma Solon a
, Joanne O’Gorman b,c
,
Hilary Humphreys b,c
, John Patrick Burke a
, Deborah Ann McNamara a,
*
a
Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
b
Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin 2, Ireland
c
Department of Microbiology, Beaumont Hospital, Dublin 9, Ireland
a r t i c l e i n f o
Article history:
Received 31 July 2013
Received in revised form
22 December 2013
Accepted 1 January 2014
Available online 30 March 2014
Keywords:
Outcomes
Necrotizing fasciitis
Intravenous drug users
a b s t r a c t
Background: Necrotizing fasciitis (NF) is a relatively rare infection of soft tissues. This study
reviewed the epidemiology and pathophysiology of admissions to a tertiary referral hos-
pital over a twelve year period comparing outcomes and findings with international norms
and to identify potential areas of change to optimise outcomes.
Study design: A retrospective review of patients diagnosed with NF from Jan 1st 1999 to Dec
31st 2011 was performed. Patient demographics, risk factors, operative procedures,
microbiology results and outcomes were recorded. Comparative analysis was performed.
Results: 37 patients were admitted with NF, comprising 30 males and 7 females with a
median age of 55 years. The most common site of infection was the perineum (51%). The
overall mortality rate was 29% and was significantly associated with age greater than 60
years (p ¼ 0.0018) and the presence of one or more risk factor (p ¼ 0.0046). The number of
surgical procedures ranged from one to fifteen with a median length of stay of 35.5 days.
There was a significant increase in the number of admissions in 2009e2010 (p 0.001),
coinciding with the emergence of NF in intravenous drug users (IVDU). 43% of patients
(n ¼ 16/37) required skin grafting, which was significantly higher in the IVDU group (n ¼ 5/6,
p ¼ 0.0232).
Conclusions: Necrotizing fasciitis remains a significant life-threatening event. The diversity
of causative pathogens emphasises the need for prompt microbiology/infectious diseases
consultation. The increased occurrence within the IVDU cohort in this study highlights the
need for a heightened level of clinical suspicion in these patients to prompt early surgical
intervention.
ª 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and
Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
www.thesurgeon.net
Necrotizing fasciitis: The need for urgent surgical
intervention and the impact of intravenous drug
use
Carmel Waldron a
, Jacqueline Gemma Solon a
, Joanne O’Gorman b,c
,
Hilary Humphreys b,c
, John Patrick Burke a
, Deborah Ann McNamara a,
*
a
Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
b
Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin 2, Ireland
c
Department of Microbiology, Beaumont Hospital, Dublin 9, Ireland
a r t i c l e i n f o
Article history:
Received 31 July 2013
Received in revised form
22 December 2013
Accepted 1 January 2014
Available online 30 March 2014
Keywords:
Outcomes
Necrotizing fasciitis
Intravenous drug users
a b s t r a c t
Background: Necrotizing fasciitis (NF) is a relatively rare infection of soft tissues. This study
reviewed the epidemiology and pathophysiology of admissions to a tertiary referral hos-
pital over a twelve year period comparing outcomes and findings with international norms
and to identify potential areas of change to optimise outcomes.
Study design: A retrospective review of patients diagnosed with NF from Jan 1st 1999 to Dec
31st 2011 was performed. Patient demographics, risk factors, operative procedures,
microbiology results and outcomes were recorded. Comparative analysis was performed.
Results: 37 patients were admitted with NF, comprising 30 males and 7 females with a
median age of 55 years. The most common site of infection was the perineum (51%). The
overall mortality rate was 29% and was significantly associated with age greater than 60
years (p ¼ 0.0018) and the presence of one or more risk factor (p ¼ 0.0046). The number of
surgical procedures ranged from one to fifteen with a median length of stay of 35.5 days.
There was a significant increase in the number of admissions in 2009e2010 (p 0.001),
coinciding with the emergence of NF in intravenous drug users (IVDU). 43% of patients
(n ¼ 16/37) required skin grafting, which was significantly higher in the IVDU group (n ¼ 5/6,
p ¼ 0.0232).
Conclusions: Necrotizing fasciitis remains a significant life-threatening event. The diversity
of causative pathogens emphasises the need for prompt microbiology/infectious diseases
consultation. The increased occurrence within the IVDU cohort in this study highlights the
need for a heightened level of clinical suspicion in these patients to prompt early surgical
intervention.
ª 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and
Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ353 1 8093092.
drug user (IVDU) n ¼ 6/37, malignancy n ¼ 4/37, end-stage
dialysis dependent renal failure n ¼ 3/37. The presence of
one or more risk factors was significantly associated with
mortality (n ¼ 9/11, p ¼ 0.0046). However, there wasn’t a sig-
nificant increase in mortality associated with increased
numbers of risk factors (p ¼ 0.0983). This is probably a type two
statistical error however due to the limited number of patients
in the study with higher numbers needed to accurately
determine whether an association exists.
The median length of stay was 34 days (range: 2e140) with
the majority of patients requiring up to five surgical de-
bridements (p 0.0001) (Fig. 1). The patient with a length of
stay of two days died from multi-organ failure related to their
NF. The most common site of infection was the perineum, in
2010. There wasn’t a
number of IVDU adm
(Fig. 3). The median a
(range 31e34 years) w
(range 3e36) and an ov
6). In total 43% of all
grafting, but this was
(n ¼ 5/6, p ¼ 0.0232).
Discussion
The identifying sign
colouration, crepitus
t h e s u r g e o n 1 3 ( 2 0 1 5 ) 1 9 4 e1 9 9196

and DM, as might be expected. The mortality of the IVDU the difference may be partly explained by the more high risk
Table 2 e Micro-organisms isolated.
Classification of micro-organisms Monomicrobial Polymicrobial Total no of cases
Gram negative
Enterobacteriaceae (not identified) 0 5 5
Enterobacter sp. 0 1 1
Enterobacter cloacae 0 2 2
Morganella morganii 0 1 1
Proteus mirabilis 0 3 3
Citrobacter freundii 0 1 1
Klebsiella pneumoniae 0 1 1
Escherichia coli 2 4 6
Gram positive
Enterococcus spp. 0 7 7
Vancomycin-resistant enterococci 0 2 2
Group A Streptococci 2 2 4
Group B Streptococci 0 1 1
Group C Streptococci 1 0 1
Group F Streptococci 1 2 3
MSSA 0 2 2
MRSA 0 3 3
CoNS 0 8 8
Pseudomonas sp. 0 2 2
Cornybacterium sp. 1 0 1
Anaerobes
Bacteroides sp. 0 1 1
Anaerobes (not identified) 0 4 4
Sterile 5
MSSA, methicillin-resistant S. aureus; MRSA, methicillin-resistant S. aureus; CoNS, Coagulase negative staphylococci.
t h e s u r g e o n 1 3 ( 2 0 1 5 ) 1 9 4 e1 9 9 197

MICROBIOLOGY — Necrotizing soft tissue infections are comprised of two distinct bacteriologic entities: type
I (polymicrobial infection) and type II (group A streptococcal [GAS] infection). There are also case reports of
monomicrobial necrotizing soft tissue infections due to other organisms, including Haemophilus influenzae
[1-3].
●
In type I infection, at least one anaerobic species (most commonly Bacteroides, Clostridium, or
Peptostreptococcus) is isolated in combination with one or more facultative anaerobic streptococci (other than
group A) and members of the Enterobacteriaceae (eg, E. coli, Enterobacter, Klebsiella, Proteus) [4-6]. An
obligate aerobe, such as P. aeruginosa, is only rarely a component of such a mixed infection. Necrotizing
fasciitis of the head and neck is usually caused by mouth anaerobes, such as Fusobacteria, anaerobic
streptococci, Bacteroides, and spirochetes. Fournier’s gangrene is caused by facultative organisms (E. coli,
Klebsiella, enterococci), along with anaerobes (Bacteroides, Fusobacterium, Clostridium, anaerobic or
microaerophilic streptococci) [7].
●
In type II, necrotizing fasciitis is generally mono-microbic, most commonly caused by group A Streptococcus
(also known as hemolytic streptococcal gangrene). Aeromonas hydrophila has been associated with traumatic
lesions in fresh water, and Vibrio vulnificus can cause necrotizing fasciitis in association with seawater injuries
(Gulf coast and South Atlantic seaboard) or among patients with cirrhosis who ingest raw oysters [8]. Group A
streptococci or other beta-hemolytic streptococci are isolated alone or in combination with other species, most
commonly S. aureus. In communities with relatively high prevalence of community-acquired methicillin-
resistant Staphylococcus aureus (CA-MRSA) infection, this organism is also a potential cause of
monomicrobial necrotizing infection [9].
Literature review current through: Mar 2016. | This topic last updated: Dec 11, 2014.

SIGNOS Y SINTOMAS
➤ Usualmente dolor fuera de proporción
con el ex físico
➤ Bullas hemorrágicas en la piel
➤ Coloración grisácea o hipoperfusión en la
piel
➤ “Descarga de Agua turbia” (“Dishwasher-
like”)
➤ Crepitos es clásicamente descrito pero
raramente encontrado
➤ Respuesta inﬂamatoria sistémica
importante con estado mental alterado,
hipotensión y taquicardia
C-reactive protein, sodium, glucose, and creatinine levels) (T
validation study, an LRINEC score 6 had a positive predictiv
negative predictive of 96% for NSSTI.3
Subsequent attempts
have failed to show reliable sensitivity.4,5
Fig. 1. Clinical presentation of necrotizing skin and soft tissue infe
Infections
KEYWORDS
INTRODUCTION
Necrotizing skin and soft tissue infections
life-threatening soft tissue destruction
secreting bacteria. Extensive, rapid, and
and necrosis along soft tissue planes is th
Epidemiology
The epidemiology of NSSTIs is not very we
are largely absent from medical literatu
Division of Trauma, Emergency Surgery and Su
pital, Harvard Medical School, 165 Cambridge
Immunosuppressed individuals are especia
Systemic signs of infection are ubiquitous
showing signs of multiorgan dysfunction syn
The Laboratory Risk Indicator for Necrotizin
Computed tomography might be helpful in di
rule it out.
Prompt wide surgical debridement and broa
needed for successful management and pr
Surg Clin N Am 94 (2014) 155–163
0039-6109/14/$ – see front matter Ó 2014 Elsev
Necrotizing Skin and Soft
Infections
KEYWORDS
Necrotizing skin and soft tissue infection (NSSTI) Necrotizing
Gas gangrene Fournier’s gangrene Wide local debridemen

LABORATORIOS - LRINEC
➤ En validación original del estudio, un LRINEC Score ≥6 tenia
VPP del 92% y VPN 96% para NSSTI. Posteriormente las
validaciones han mostrados que esta sensibilidad no es tan
buena.
Radiography
Table 1
The LRINEC
Variable Points
WBC count (Â106
/mm3
)
15 0
15–25 1
25 2
Hemoglobin (g/dL)
13.5 0
11–13.5 1
11 2
C-reactive protein 150 mg/L 4
Sodium (mmol/L) 135 2
Creatinine 141 umol/L 2
Glucose 10 mmol/L 1
Kaafarani King158

DIAGNOSTICO - “LRINEC”
➤ Menor o igual a 5:
menos de 50%
➤ Entre 6-7 : riesgo 50%-75%
➤ Igual o mayor a 8: más de
75% riesgo asociado a FN con
valor predictivo positivo tan
alto como 93%
Review article http://dx.doi.org/10.1016/j.joad.2015.11.003
Laboratory risk indicators for acute necrotizing fasciitis in the emergency setting
Syed Shayan Ali1
, Fatimah Lateef2*
1
The Aga Khan University, Karachi, Pakistan
2
Department of Emergency Medicine, Singapore General Hospital, Singapore
ARTICLE INFO
Article history:
Received 5 Oct 2015
Received in revised form 20 Oct, 2nd
revised form 23 Oct 2015
Accepted 22 Nov 2015
Available online 8 Jan 2016
Keywords:
Laboratory risk indicator for
necrotizing fasciitis
Acute necrotizing fasciitis
Soft tissue infection
Early diagnosis
Urgent care
A B S T R A C T
Necrotizing fasciitis is a rare bacterial skin condition which forms a major diagnostic
challenge and is associated with poor prognosis unless promptly treated. Initial clinical
presentation is often misleading with characteristic features developing only late in the
course of the disease. In this review, we discuss the applicability and usefulness of
laboratory risk indicator for necrotizing fasciitis score in facilitating rapid diagnosis of
necrotizing fasciitis in emergency department by differentiating it from other skin in-
fections like cellulitis and abscesses. A high index of suspicion resulting from the lab-
oratory risk indicator for necrotizing fasciitis score can facilitate early diagnosis enabling
prompt antibiotic administration and timely referral to surgery for wound debridement,
ultimately reducing both the morbidity and mortality.
1. Introduction
Necrotizing fasciitis (NF) is a type of bacterial infection of
the soft tissues associated with a high rapid mortality. It is
characterized by inﬂammation and necrosis arising from the
NF has been classiﬁed into two major categories based on
microbiology and localization of the infection. Type 1 is poly-
microbial involving at least one anaerobe with or without a
facultative anaerobe localized mainly on trunk, abdomen and
perineum. Type 2 is monomicrobial caused mainly by group A
HOSTED BY
Contents lists available at ScienceDirect
Journal of Acute Disease
journal homepage: www.jadweb.org
of C-reactive protein, white blood cell, hemoglobin, Na, serum
creatinine and serum glucose measured at the time of
admission, enabled categorization of patients into low-,
intermediate-, and high risk groups (Table 1). A score of less
than or equal to 5 meant a probability of less than 50% for
developing NF. A score of 6–7 meant 50%–75% risk of NF
whereas any score more than 8 is a high indicator to more than
75% risk being associated with NF with a positive predictive
value of as high as 93%[6]
. All the parameters needed for the
calculation of the score are readily available in emergency
department at the ‘bedside’[7]
.
Wong et al. argued that biochemical and hematologic
Table 1
Variables included in the laboratory risk indicator for acute NF scoring
system.
Variables Value LRINEC score point
C-reactive protein (mg/L) 150 0
150 4
White blood cell (cells/mm3
) 15 0
15–25 1
25 2
Hemoglobin (g/dL) 13.5 0
11.0–13.5 1
11.0 2
Sodium (mmol/L) 135 0
135 2
Creatinine (mg/dL) 1.6 0
1.6 2
Glucose (mg/dL) 180 0
180 1
Journal of Acute Disease 2016; 5(2): 114–116

AYUDAS IMAGENOLOGICAS
➤ Radiograﬁas simples raramente ayudan al Dx dado que el aire
en tejidos blandos tiene una sensibilidad extremadamente
baja para NSSTIs.
➤ TAC puede revelar edema y alteración de la grasa en fascia
profunda y ocasionalmente muestra gas entre los tejidos. El
gas presente tiene una muy alta especiﬁcidad pero muy baja
sensibilidad.
➤ RMN puede tener “sobresensibilidad” y no servir para el
diagnostico de NSSTIs.
Infections
KEYWORDS
INTRODUCTION
Epidemiology
rule it out.
Surg Clin N Am 94 (2014) 155–163
Infections
KEYWORDS

PATOLOGIA
Destrucción extensa de tejidos
Trombosis de los vasos sanguíneos
Bacterias abundantes a lo largo de los planos fasciales
Infiltración de células inflamatorias agudas .
**Las concentraciones relativas de las bacterias y neutrófilos
observados en el examen histopatológico del tejido resecado pueden
tener importancia pronóstica.
Los hallazgos histopatológicos característicos de miositis
necrotizante incluyen degeneración y necrosis de fibras musculares
esqueléticas, la infiltración de granulocitos, y numerosas bacterias en
áreas de necrosis muscular

FG INDICE DE SEVERIDAD
In our multicentre study, we have found that older age, DM, anaemia, sepsis, delay in initial
treatment and FGSI core ≥9 are the important predicting severity factors.

TRATAMIENTO
➤ Desbridamiento y resección quirúrgica
agresiva con manejo simultáneo de los
siguientes objetivos.
1. Soporte hemodinámico y resucitación con
líquidos
2. Resección quirúrgica agresiva
3. Manejo antibiotico de amplio espectro
Puede servir también Oxigeno Hiperbárico
y administración de inmunoglobulinas
intravenosas.
No se debe demorar el tratamiento
quirúrgico por una conﬁrmación radiológica.
central or mixed venous oxygen saturation greater than 65% to 70%
were elevated, normalization of lactate levels with resuscitation should
sopressors should be used early, as needed.
Wide Surgical Debridement
All necrotic tissue needs to be aggressively debrided until all rem
healthy, clearly viable, and bleeds briskly (Figs. 2 and 3). The overlyin
Fig. 2. Wide surgical debridement of necrotizing skin and soft tissue infe
Infections
KEYWORDS
INTRODUCTION
Epidemiology
rule it out.
Surg Clin N Am 94 (2014) 155–163
Infections
KEYWORDS

Fig. 3. Necrotizing skin and soft tissue infection of the lower extremity requiring serial wi
debridement.

TRATAMIENTO ANTIBIOTICO

empiric regimen. Clindamycin has additional antitoxin activity in addition to its anti-
bacterial effects. Antibiotic coverage should be narrowed down as soon as Gram stain
and culture results are available. The Infectious Diseases Society of America guide-
lines for NSSTIs are reported in Table 2.8
Hyperbaric Oxygen
The utility of hyperbaric oxygen in the treatment of NSSTI is controversial. There is
hardly any level 1 data supporting its use, although multiple small retrospective
studies reported decreased mortality with hyperbaric therapy.9,10
In the authors’
opinion, the logistic difficulties associated with transferring a critically ill patient to a
hyperbaric chamber and providing nursing care to that patient in a hyperbaric cham-
ber might outweigh the potential benefit the patient gets from the hyperbaric oxygen
treatment.
Immunoglobulins
Intravenous immunoglobulins can neutralize the exotoxins secreted by clostridia and
might also be effective against streptococcal superantigens. There are limited data
suggesting a survival benefit of intravenous immunoglobulins in critically ill patients
with group A streptococci NSSTIs, but the data are small and nondefinitive.11–13
PROGNOSIS
NSSTIs are associated with an elevated mortality (14%–50%). Factors associated
with higher mortality include age greater than 60 years, heart disease, liver cirrhosis,
leukocytosis greater than 30,000/mL, creatinine greater than 2.0 mg/dL, partial thmo-
boplastin time greater than 60 seconds, bandemia greater than 10%, bacteremia, soft
Infections
KEYWORDS
INTRODUCTION
Necrotizing skin and soft tissue infections (NSS
life-threatening soft tissue destruction and
secreting bacteria. Extensive, rapid, and wide
and necrosis along soft tissue planes is the ess
Epidemiology
The epidemiology of NSSTIs is not very well esta
are largely absent from medical literature, a
Division of Trauma, Emergency Surgery and Surgical
pital, Harvard Medical School, 165 Cambridge Street
Immunosuppressed individuals are especially sus
Systemic signs of infection are ubiquitous, with
showing signs of multiorgan dysfunction syndrom
The Laboratory Risk Indicator for Necrotizing Fas
Computed tomography might be helpful in diagnos
rule it out.
Prompt wide surgical debridement and broad spe
needed for successful management and prevent
Surg Clin N Am 94 (2014) 155–163
0039-6109/14/$ – see front matter Ó 2014 Elsevier Inc
Necrotizing Skin and Soft Tis
Infections
KEYWORDS

Infecciones necrotizantes tejidos blandos

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