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Necrotizing Fasciitis (NF)  Fourneir’S Gangrene  Diagnosis  Treatment  Outcomes © by Author

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Necrotizing Fasciitis (NF)  Fourneir’S Gangrene  Diagnosis  Treatment  Outcomes © by Author Serious skin and soft tissue infections Metallidis Symeon Infectious Diseases Specialist Lecturer at Aristotle University of Thessaloniki © by author ESCMID Online Lecture Library ( ) first described by Hippocrates: “…when the exciting cause was a trivial accident or a very small wound … the erysipelas would quickly spread widely in all directions. Flesh & bones fell away in large quantities …. There were many deaths”. • This is not dissimilar to what we see today. © by author ESCMID Online Lecture Library Outline Overview of Serious skin and soft tissue infections Clinical/ Pathological signs Risk Factors Type 1 vs. Type 2 Necrotizing Fasciitis (NF) Fourneir’s Gangrene Diagnosis Treatment Outcomes © by author ESCMID Online Lecture Library Cellulitis © by author ESCMID Online Lecture Library Skin Normal Flora Mostly gram-positive bacteria staphylococci micrococci corynebacteria (diphtheroids) Propionibacterium acnes © by author ESCMID Online Lecture Library NSTIs are rare ~ 1000 cases/yr in US or 0.04 cases/1000 person yrs Recent literature suggested that they are increasing. © by author ESCMID Online Lecture Library require extensive ICU resources! United Kingdom (1995 ~ 2006) 0.24% of ICU admissions necrotizing fasciitis 21 days [survivors]: 32 days, [non-survivors] : 12 days Cost: $71,000 ~ $83,000 © by author ESCMID Online Lecture Library Decreased little over the last 30 yrs despite improvements in medical care. In the United Kingdom (1995 ~ 2006), p’ts with NSTIs had a mortality of 41.6%. Improvements in outcome continue to require early diagnosis early & aggressive surgical debridement administration of appropriate antibiotics & optimization of underlying© by medical author comorbidities . ESCMID Online Lecture Library Necrotizing infection of genital & perineal region in 1764, by Baurienne Fournier’s gangrene in 1883 & 1884, by French dermatologist & venereologist Jean Alfred Fournier Numerous other terms: hospital gangrene, necrotizing erysipelas, suppurative fasciitis, clostridial gangrene, & gas gangrene. Necrotizing fasciitis © by author In 1951, by Wilson ESCMID Online Lecture Library are classified in numerous ways & often for specific reasons. Uncomplicated soft tissue infections superficial infections, such as cellulitis, impetiginous lesions, furuncles, & simple abscesses, that can be treated with surgical incision alone. Complicated soft tissue infections, such as infected ulcers, infected burns, & major abscesses, require© by significant author surgical interventions. ESCMID Online Lecture Library A more useful classification ( ): nonnecrotizing VS necrotizing infections necrotizing infections aggressive surgical management. divided into specific types based on, anatomy (e.g., Fournier’s, Ludwig’s angina) depth of involvement (e.g., necrotizing adipositis, fasciitis, or myositis) microbial source of infection© by author (types 1/2/3) combination of microbial source & depth (i.e., clostridial cellulitis, nonclostridial anaerobic cellulitis) ESCMID Online Lecture Library Necrotizing Fasciitis (NF) Definition A subcutaneous infection of fascia and fat which may or may not spare the skin. © by author ESCMID Online Lecture Library Type 1 infections : , the most prevalent form of NSTI, (55% ~ 75%) • Type 2 infections: , caused by group A Streptococcus. (Some authors also consider community-associated MRSA as type 2) • Type 3 infections : also , attributed to Clostridium species or rare virulent microbes (Vibrio vulnificus or Aeromonas© speciesby author) ESCMID Online Lecture Library TYPE 1 NSTI A of aerobic & anaerobic bacteria infection Streptococcus spp., Staphylococcus spp., Enterococcus spp. & Enterobacteriaceae family (E.coli, Acinetobacter spp., Pseudomonas spp. & Klebsiella spp.). Bacteroides© by spp. author ESCMID Online Lecture Library Type 1 NF 2/3 of cases have mixed aerobic and anaerobic infections The bugs: The average case had 4.6 isolates Staphylococcus aureus Streptococci Enterococci Escherichia coli Peptostreptococcus © by author Preveoella and Porphyromonas Bacteroides fragilis Clostridium ESCMID Online Lecture Library TYPE 1 NSTI Polymicrobial NSTIs tend to occur on perineum & trunks of immunocompromised p’ts. Classic example: Predisposing factors: • Common: & • Other: , , , , ,© by author , , ESCMID Online Lecture Library Left upper extremity shows necrotizing fascitis in an individual who used illicit drugs. Cultures grew Streptococcus milleri and anaerobes (Prevotella species). Patient would grease, or lick, the needle before injection. © by author ESCMID Online Lecture Library Type 1 NF Primarily includes 3 categories (locations) of infection Diabetes Mellitus- infections of the feet Cervical necrotizing fasciitis- infection of the neck Fournier’s Gangrene- infection of the perineum © by author ESCMID Online Lecture Library Diabetes Mellitus © by author ESCMID Online Lecture Library Prevalence of Diabetes and Diabetes- Related Lower Extremity Complications In 2002, the prevalence of diabetes in the United States was 18.2 million people (6% of population).1 Approximately 15% of Americans with diabetes will develop a foot ulcer during their lifetime.2 In a cohort of 1,666 diabetics, over a period of 24 months the incidence of foot infection was 36.5 infections per 1,000 persons© by authorwith diabetes per year.3 1. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf. Accessed December 27, 2005. 2. Singh N et al.ESCMID JAMA. 2005;293:217–228. Online Lecture Library 3. Lavery LA et al. Diabetes Care. 2003;26:1435–1438. Bacteriology of Diabetic Foot Infections: The SIDESTEP (Ertapenem vs Piperacillin/Tazobactam) Study 473 specimens obtained at baseline (multicenter trial) After debridement; mostly tissue specimens Cultured at single research laboratory Results 1,148 aerobic and 492 anaerobic organisms isolated 50% aerobes only 42% aerobes and anaerobes 3% only anaerobes © by author Average (range) of isolates (per positive culture) Aerobes: 2.8 (1–8) Anaerobes: 2.1 (1–9) ESCMID Online Lecture Library Citron DM et al. Bacteriology of diabetic foot infections (DFI): 1640 isolates from 473 specimens [abstract]. IDSA; 2005. Cervical Necrotizing Fasciitis © by author ESCMID Online Lecture Library TYPE 1 NSTI Another example : Bacterial penetration fascial compartments of head & neck rapidly progressive gangrenous cellulitis life-threatening airway obstruction • Most associated with (78%~90% ) • Other causes: • trauma, © by author • tongue piercing, • neoplasm, • & other parapharyngeal infections. ESCMID Online Lecture Library TYPE 1 NSTI (submandibular space infection) & usually caused by mouth anaerobes, such as Fusobacterium spp., anaerobic Streptococcus spp., Peptostreptococcus spp., Bacteroides spp., & spirochetes, which are – usually susceptible to© penicillin by author & clindamycin . ESCMID Online Lecture Library Fournier’s Gangrene (FG) First described by French verenologist Jean Alfred Fournier who witnessed a rapidly progressing gangrene of the penis and scrotum of 5 previously healthy young men. A polymicrobial necrotizing fasciitis (NF) of the perinium, perianal© by area, author or genitals. It may involve either men or women. ESCMID Online Lecture Library Fournier’s Gangrene Found in the perineal area- it is an infection caused by penetration of the gastrointestinal or urethral mucosa by bacteria. Characterized by an abrupt onset with severe pain which may spread rapidly to the anterior abdominal wall, gluteal© by muscles, author or the scrotum and penis in males. ESCMID Online Lecture Library Epidemiology of FG Not very common. On average 97 cases were reported each year from 1989 to 1998. Mostly age 30-60, although all ages have been reported Effects men 10:1 over© by females. author This may be due to better perineal drainage in females through vaginal secretions. ESCMID Online Lecture Library © by author ESCMID Online Lecture Library FG following vasectomy © by author ESCMID Online Lecture Library TYPE 2 NSTI Caused by group A Streptococcus (Streptococcus pyogenes) either alone or in association with S. aureus. may be accompanied by toxic shock syndrome(~ 50%) In contrast to type 1 NSTI, type 2 NSTI can occur in any age group & without predisposing medical conditions. Predisposing factors: , , , © by author , , ESCMID . Online Lecture Library TYPE 2 NSTI Over the last 10 yrs, has been increasingly seen as a monomicrobial cause of NSTI. Community-associated MRSA associated with NSTI clone USA300 (Panton-Valentine leukocidin cytotoxin) • In some communities, > 15% of NSTI [Most]: necrotizing infection of subcutaneous tissue & skin [Increasing]: more severe invasive diseases (necrotizing ©fasciitis by author & pyomyositis ) ESCMID Online Lecture Library MRSA: epidemiology © by author Witte W. Community-acquired methicillin-resistant Staphylococcus aureus: what do we need to know? Clin MicrobiolESCMID Infect 2009; 15 Suppl Online 7:17-25. Lecture Library CA-MRSA © by author ESCMID Online Lecture Library Chua K, et al. Clin Infect Dis 2011. CA-MRSA: high risk patients Athletes (wrestlers, football players) Chronic illness Nursing home, jails, IVDU Danger for epidemics (4 Cs): Contact Crowding Contaminated surfaces Cleanliness© by author NSTIs BSIs ESCMID NecroticOnline pneumonia Lecture Library TYPE 3 NSTI Clostridium spp. are G (+), spore-forming anaerobic rods normally found in soil & GI tract. Classically associated with trauma
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