Necrotizing fasciitis has also been referred to as haemolytic streptococcal gangrene, Meleney ulcer, acute dermal gangrene, hospital gangrene, suppurative fasciitis, and synergistic necrotizing cellulitis. Fournier gangrene is a form of necrotizing fasciitis that is localized to the scrotum and perineal area.

1. NECROTISING FASCITIS
RAMYA PONNUSAMY

2. INTRODUCTION

3. INTRODUCTION
• Necrotizing fasciitis has also been referred to
as haemolytic streptococcal gangrene,
Meleney ulcer, acute dermal gangrene,
hospital gangrene, suppurative fasciitis, and
synergistic necrotizing cellulitis.
• Fournier gangrene is a form of necrotizing
fasciitis that is localized to the scrotum and
perineal area.

4. DEFINITION
• An acute disease in which inflammation of
the fasciae of muscles or other organs
results in rapid destruction of overlying
tissues.

5. INCIDENCE
Rare disease
Incidence: 1000 cases/year, 0.04 cases/1000
person-years
Prevalence: one or two cases/career for
average practitioner.

6. FACTS….
• Necrotising fasciitis is difficult to diagnose in
its initial stages, as it mimics cellulitis.
• Important early clues are pain, tenderness
and systemic illness.
• Bullae and ecchymotic skin lesions also point
to the condition (and are not normally found
with cellulitis).
• A high index of suspicion is necessary and
suspected cases should be referred
immediately. Prompt surgical debridement is
essential.

9. Classification
• Type 1 – poly microbial infection with
aerobic and anaerobic bacteria
• Type 2 - Group A streptococcus (GAS):
• Type 3 - Mono microbial infection:
• Type 4 - fungal infection:

10. CAUSES
• An opening in the skin that allows bacteria to enter the body. This may
occur following minor injury (eg small cut, graze, pinprick, injection), or a
large wound due to trauma or surgery (eg laparoscopy, sclerotherapy,
endoscopic gastrostomy, thoracostomy, caesarean section, hysterectomy).
Sometimes no point of entry can be found.
• Cervicofacial necrotising fasciitis can follow mandibular fracture or dental
infection.
• Direct contact with a person who is carrying the bacteria or the bacteria is
already present elsewhere on the person.

11. CAUSES
• Particularly invasive strains of bacteria, eg
streptococci that evade the immune system
and produce a toxin called cysteine protease ,
which dissolves tissue.
• NF In children may follow varicella zoster
infection.
• Other causes of necrotising fasciitis in children
include omphalitis, necrotising enterocolitis
and urachal anomalies.

12. Risk factors
• Advanced age
• Diabetes
• Immune suppression
• Obesity
• Drug abuse
• Severe chronic illness
• Malignancy

13. • Left upper extremity
shows necrotizing fasciitis
in an individual who used
illicit drugs. Cultures grew
Streptococcus milleri and
anaerobes (Prevotella
species). Patient would
grease, or lick, the needle
before injection

14. Sixty-year-old woman who
had undergone postvaginal
hysterectomy and repair of a
rectal prolapse has a massive
perineal ulceration with foul-
smelling discharge. Cultures
revealed Escherichia coli and
Bacteroides fragilis. The
diagnosis was perineal
gangrene.

15. Necrotizing fasciitis at a possible site of insulin injection in the
left upper part of the thigh in a 50-year-old obese woman
with diabetes.

16. Pathophysiology
Infection of superficial fascia
Release of enzymes and proteins
Necrosis
Horizontal spread of infection(not apparent)
Vertical spread of infection9deep structures)
Thrombosis
Ischemia
Tissue necrosis

17. SIGNS AND SYMPTOMS
• Local pain, swelling and erythema.
• Severe, constant pain.
• The margins of infection are poorly defined,
with tenderness extending beyond the
apparent area of involvement (unlike
cellulitis).

18. SIGNS AND SYMPTOMS
After 2-4 DAYS
• The area develops tense edema, extending beyond the margin of
erythema.
• There may be bullae, indicating skin ischemia . These may become
hemorrhagic.
• Skin becomes discolored, progressing to grey necrosed skin which breaks
down.
• The subcutaneous tissues have a wooden-hard feel . Fascial planes and
muscle groups are not palpable.
• There may be crepitus due to subcutaneous gas.

19. SIGNS AND SYMPTOMS
• Pain sensation may progress from intense
tenderness to anesthesia as the nerves are
destroyed.
• There may be a broad erythematous tract in
the skin along the route of the infection.
• Lymphangitis is rarely seen .
• malaise, tachycardia ± fever and dehydration

20. SIGNS AND SYMPTOMS
Days 4-5 approximately:
• Hypotension and septic shock develop.
• Patients become confused and apathetic.
• Fournier's gangrene is a rapidly progressive
form of infective NF of the perineal, genital or
perianal regions, leading to thrombosis of the
small subcutaneous vessels and necrosis of
the overlying skin.

21. INVESTIGATIONS
• Blood tests
• Bedside finger test
• Microbiology
• Radiology

22. MANAGEMENT
• The initial surgery is the most important determinant
for survival. The debridement must be extensive, with
adequate margins so that no infected tissue remains.
• Following initial debridement, the wound must be
observed closely. Surgical debridement is repeated
daily until the infection is controlled.
• When the infection is controlled, daily dressings are
required under sedation.
• Closure of the wound is by secondary suturing ± skin
grafts. Vacuum-assisted wound closing devices may
assist healing.

23. Antibiotic Regimens
• The antibiotic regime will depend on the site of infection,
patient allergies and culture results. Examples of recommended
regimes include (all drugs given intravenously):Benzylpenicillin
plus clindamycin plus gentamicin.
• If penicillin-allergic, meropenem plus clindamycin plus
gentamicin. Review the need for gentamicin daily.
• Piperacillin-tazobactam and clindamycin, or benzylpenicillin and
clindamycin.

24. Non-surgical treatment
• Non-surgical measures include close monitoring and
general supportive treatment in an intensive care
setting with antimicrobial treatment.
• Nutritional support is required from day one, owing to
the high protein and fluid loss from the wound (similar
to major burns). In severe cases, patients may need
twice their basal calorie requirements. Nasogastric
feeding may be helpful.
• Broad-spectrum antibiotics.

25. COMPLICATIONS
• NF carries a significant mortality rate,
particularly if marine organisms
• The deep tissue infection may lead to vascular
occlusion, ischemia and tissue necrosis. There
may be nerve damage and muscle necrosis.
• Large areas of tissue loss may require skin
grafting, reconstructive surgery or amputation
.

26. PROGNOSIS
• Even with surgery, the mortality rate is 20-
40%.
• Increased mortality is associated with delays
in diagnosis, poor surgical technique and
diabetes.