Flesh-eating bacteria described.

1. NECROTIZING FASCIITIS
Priyansha Srivastava
A121100817005
MSc Genomics

2. DEFINITION
Necrotizing fasciitis is a rapidly progressive
inflammatory infection of the fascia(inner
connective tissue made of fibrous
collagen fibres), with secondary necrosis of
the subcutaneous tissues(hypodermis).

3. IN HISTORY
• Probably, Hippocrates was 1st person to describe the Necrotizing Fasciitis in
circa 500 BC.
• Necrotizing fasciitis was also described by a Confederate Army surgeon,
Joseph Jones, during the US Civil War in 1871.
• It was also described as ‘hospital gangrene’ by British naval surgeon, in 18th
& 19th century.
• In 1883, Fournier documented necrotizing fasciitis in the perineal and genital
region.
• Wilson used the term necrotizing fasciitis without assigning a specific
pathologic bacterium that caused the disease
• Smith et al first classified soft tissue infections as either local or spreading.
• Lewis later further classified soft tissue infections into either necrotizing or
non-necrotizing. He further subdivided these infections into either focal or
diffuse.
• In the 1990s, the media popularized the idea that this infection was caused by
"flesh-eating bacteria.“

4. This is how, the history describes the
“FLESH- EATING BACTERIA”

5. Necrotizing fasciitis has also been referred to as
Hemolytic streptococcal gangrene
Meleney ulcer
 Acute dermal gangrene
Hospital gangrene
Suppurative fasciitis
 Synergistic necrotizing cellulitis
Fournier gangrene is a form of necrotizing fasciitis that
is localized to the scrotum and perineal area.
There is a great deal of confusion surrounding the identification and
definition of necrotizing fasciitis. Therefore , necrotizing fasciitis is
classified on the basis of different term.

6. TREATMENT
MODALITY
by Baxter in 1972
ANATOMIC
CATEGORIES
By Lewis

7. CAUSITIVE ORGANISMS
Group A Hemolytic streptococci (Streptococcus pyogenes) and
Staphylococcus aureus, alone or in synergism, are frequently the initiating
infecting bacteria. However, other aerobic and anaerobic pathogens may be
present, including the following:
 Bacteroides fragilis
 Clostridium perfringens
 Peptostreptococcus
 Enterobacteriaceae
 Coliforms
 Proteus
 Pseudomonas
 Klebsiella
During the last 2 decades, researchers have found that necrotizing fasciitis
is usually polymicrobial rather than monomicrobial.
Anaerobic bacteria are present in most necrotizing soft-tissue infections,
usually in combination with aerobic gram-negative organisms

8. SOME UNUSUAL CAUSITIVE AGENTS
Phycomycetes (fungus)
• In one patient, the fungus Phycomycetes appeared to be
responsible for necrotizing fasciitis.
Streptococcus pneumoniae and Candida
tropicalis
• In one patient, S. pneumoniae serotype 5 was also
isolated.
• In 3 patients, candida tropicalis was isolated.

9. TYPE 1
• Polymicrobial cause
TYPE 2
• Monomicrobial cause
TYPE 3
• Gas Gangrene by clostridial myonecrosis
TYPE 4 (recently placed under of classification)
• Fungal cause

10. PATHOPHYSIOLOGY
• Organisms spread from the subcutaneous tissue
along the superficial and deep fascial planes,
presumably facilitated by bacterial enzymes and
toxins.
• This deep infection causes vascular occlusion,
ischemia, and tissue necrosis. Superficial nerves
are damaged, producing the characteristic localized
anesthesia.
• Important bacterial factors include surface protein
expression and toxin production. M-1 and M-3
surface proteins, which increase the adherence of
the streptococci to the tissues, also protect the
bacteria against phagocytosis by neutrophils.

11. The speed of spread is directly proportional to the
thickness of the subcutaneous layer.
Necrotizing fasciitis moves along the fascial
plane.

12. TYPES OF NECROTIZING FASCIITIS
There are some specific types of necrotizing fasciitis with
characteristic features:
• Necrotizing Cellulitis or hemolytic streptococcal gangrene
– presents shortly after minor trauma
– erythema, warmth, and swelling ,severe pain is common.
– There may be rapid development of gas distal to the wound and blebs
which contain dark serous fluid.
• Streptococcal Myositis
– The hallmarks are severe local pain.
– Wounds have a foul odour, discoloration, and edema.
– Patients might develop blebs and gangrene of the overlying skin.
– disease progression is characteristically slow.
– Underlying muscle is not viable and will require excision.
• Clostridial Cellulitis
– severe pain occurring days after local tissue injury.
– Patients subsequently develop skin blebs that contain a reddish-brown,
foul smelling fluid.
– There is rapid progression of cellulitis over hours.
– Crepitus might be noted, but it is not a universal finding.

13. Contd…….
• Progressive Bacterial Synergistic Gangrene or Meleney’s Gangrene.
– PBSG is a rapidly progressive infection.
– Caused by nonhemolytic streptococci in association with hemolytic
staphylococci or gram-negative bacilli.
– Commonly found following abdominal surgeries with infected wound.
– A wound with a central necrotic area that is surrounded by purple,
erythematous zones of skin.
– In addition, necrotic tracts can extend through the underlying tissue,
resulting in additional ulcerations at sites distant from the primary lesion.
• Fournier’s Gangrene.
– Acute, rapidly progressive, and potentially fatal, infective necrotizing
fasciitis
– Affect the external genitalia, perineal, or perianal regions.
– Sudden pain in the scrotum, prostration, pallor, and pyrexia (at first only
the scrotumis involved, but if unchecked, the cellulitis spreads until the
entire scrotal coverings slough, leaving the testes exposed).
– Strong “repulsive, fetid odour”.
– Patients can present with varying signs and symptoms including fever
greater than 38∘c, scrotal swelling and erythema, purulence or wound
discharge.

14. SYMPTOMS
The symptoms of necrotizing fasciitis infection are much like any
type of infection, but they appear more rapidly and are more
intense:
 Small, red, painful lump or bump on the skin
 Changes to a very painful bruise-like area and grows rapidly, sometimes in less
than an hour
 The center may become black and die
 The skin may break open and ooze fluid
 Severe pain
 Bullae formation (thin walled fluid filled blisters)
Other symptoms may include:
– Fever
– Chills
– Sweating
– Nausea
– Weakness
– Lightheadedness or dizziness

16. RISK FACTORS
This type of infection, although rare, can happen to anyone at any
time. Therefore, it would be important to look at anyone who may
be a higher risk of developing any type of infection. These are
people who:
• Age greater than 50 years
• Burns
• Cancer or other
• Immunocompromised state
• Chronic alcoholism
• Diabetes mellitus
• Malnutrition
• Obesity
• Trauma
• Patients in hospitals or healthcare facilities can contract an infection through various
ways, such as:
– Surgical wounds
– Puncture wound (intravenous, injection, biopsy needle)
– Urinary catheters

17. DIAGNOSIS
Laboratory Testing:
 Abnormal laboratory findings include an elevated white blood cell
(WBC) count, azotemia, abnormal coagulation profiles, and decreased
platelet and fibrinogen levels.
 Other laboratory findings such as elevated lactate and blood glucose
levels, hypocalcemia, hypoalbuminemia, and anemia are also commonly
found.
 The sensitivity of these studies varies, although leukocytosis and
hyponatremia have been found to be predictive of necrotizing infection.
Imaging studies:
Plain radiography, ultrasonography, CT, and MRI have all been used to
help diagnose NSTI.
Macroscopic and microscopic tools:
Examination of a frozen section biopsy specimen from the compromised
site that includes deep fascia and possibly muscle has been recommended
as a means to achieve earlier diagnosis of NSTI in patients

18. Necrotising fasciitis producing gas in
the soft tissues as seen on CT scan
Micrograph of necrotizing fasciitis, showing
necrosis (center of image) of the dense
connective tissue, i.e. fascia, interposed
between fat lobules
Culture showing staphylococcus aureus and
streptococcus pyogenes
Necrotizing fasciitis as seen on
ultrasound

19. TREATMENT
The treatment includes:
• Intravenous antibiotic therapy (antibiotics are injected directly
into the veins) and oral antibiotics sometimes.
– Mono-drug therapy
– Triple-drug therapy
– Protein synthesis inhibitors
• Process of debridement is done for removal of heavily
contaminated tissue and all devitalized tissues by surgery.
Amputations of affected limbs, in some cases.
• Medications to raise blood pressure and stable breathing.
• Hyperbaric oxygen therapy (HBO): Increased oxygen partial
pressure has been associated with the reversal of basic
pathophysiologic mechanisms of necrosis

21. NEW TREATMENT
DISCOVERED
Surgical treatment with regular irrigation of the area with an FDA-
approved wound cleanser called NeutroPhase.
• NeutroPhase contains hypochlorous acid, a common chemical
disinfectant.
• Hypochlorous acid is produced by the body’s white blood cells when it
fights infection. It is one of the common chemicals found to purify
water in swimming pools and is used as a disinfectant in food
preparation.
• Small incisions are made to get the irrigation going.
NeutroPhase seemed to effectively neutralize the toxins produced by the
infection, halting the body’s inflammatory-reaction and allowing the patient to
begin to heal normally.

22. Summary till now…..

23. PREVENTIVE MEASURES
Common sense and good wound care are the best
ways to prevent a bacterial skin infection.
• Keep draining or open wounds covered with
clean, dry bandages until healed.
• Don’t delay first aid of even minor, non-infected
wounds (like blisters, scrapes, or any break in the
skin).
• Avoid spending time in whirlpools, hot tubs,
swimming pools, and natural bodies of water
(e.g., lakes, rivers, oceans) if you have an open
wound or skin infection.
• Wash hands often with soap and water or use an

24. Necrotizing cases studied in INDIA
1) A series of case studies for 4 years (2010-2014) in different patients
coming to R.D. Gardi Medical College, Ujjain, shows that 25.49% of
all cases of necrotizing fasciitis was caused by the bite of Indian Russell
viper (Dubioa russeli), a snake found in asian region. The patients were
mostly males of rural areas. Pus showed similar type of bacteria as in
other cases. Hospital stay and graft rejection was more than other NF
cases, also required aggressive treatment.
2) A total 58 cases of Necrotizing fasciitis was studied in Post-Graduate
Institute of Medical Education and Research, Chandigarh. Out of 58
cases, 18 cases of NF were found to be caused by fungus.
3) Necrotizing fasciitis is very much rare in children, 0.03% out of all
cases. But case study in NRS Medical College and Hospital, Kolkata
shows 3 cases out of all cases of NF in children which is very rare.
4) A prespective study shows the monomicrobial infection (56%) to be
more common than polymicrobial (44.4%) in India.
5) In 2016, a case report prepared, demonstrate that 3 patients shows
Candida tropicalis as a causitive agent.

25. REFERENCES
• Necrotizing Fasciitis: Diagnostic Challenges and Current Practices
by Abhishek Vijayakumar, Rajeev Pullagura and Durganna Thimmappa, Review
Article, 2014
• Necrotizing fasciitis: current concept and review of the literature
by Babak Sarani, Michelle Strong, Jose Pascual and William Schwab, Elsevier Inc.,
2009
• Necrotizing fasciitis: New treatment discovered for deadly flesh-
eating disease By Amanda Woerner, 2013
• Necrotizing Fasciitis by Richard F Edlich, 2017
• Case series of necrotizing fasciitis due to Candida tropicalis and
review of fungal necrotizing fasciitis from India by Bhawna Sharma,
Malini R Capoor, Raj, Pradeep Kumar Verma, 2016
• Necrotizing fasciitis – A rare fatal outcome of road traffic
accidents by Siddhartha Das and Debdatta Basu, 2013
• The study of necrotising fasciitis due to bite of Indian russell
viper by Vishal Dubey, Rajshree Mukhiya, 2014

26. THANK YOU