Current approach to diagnosing and treating necrotizing fasciitis
DOI:
https://doi.org/10.12775/JEHS.2024.67.49189Keywords
Necrotizing fasciitis, Necrotizing fasciitis diagnosis, Necrotizing fasciitis treatment, Necrotizing soft tissue infections, Surgical debridementAbstract
Introduction: Necrotizing fasciitis is an infrequent yet highly fatal bacterial infection characterized by widespread necrosis of fascia and subcutaneous fat tissue. Though initial symptoms resemble typical infection, necrotizing fasciitis progresses rapidly triggering acute phase response. Individuals with advanced age, chronically ill, immunocompromised, or abusing alcohol are especially susceptible to developing necrotizing fasciitis. In order to reduce mortality, early diagnosis and appropriate treatment are indispensable.
Aim of the Study: Aim of this study is through evaluating existing literature to outline the contemporary diagnostic strategies and emerging therapy options for necrotizing fasciitis.
Description of the State of Knowledge: Primary diagnostic methods involve clinical evaluation and surgical exploration, complemented by fresh frozen sections for rapid diagnosis and the finger test. Diagnostic imaging incorporates the use of magnetic resonance imaging, computed tomography and ultrasound. The treatment is mostly centered around surgical debridement and antibiotic therapy. Therapies that display potential efficacy include low-dose radiotherapy, hyperbaric oxygen therapy, and the use of intact fish skin grafts for tissue reconstruction after successful treatment. The emerging approach includes therapy targeting systemic inflammatory response syndrome, sepsis induced coagulopathy and critical illness related corticosteroid insufficiency.
Conclusions: The management of necrotizing fasciitis primarily depends on traditional methods. Fast identification and proper treatment are pivotal in reducing the mortality rate. Recognizing the significance of addressing the acute phase response in necrotizing fasciitis treatment introduces new possibilities for therapeutic interventions. Further research is vital to evaluate the existing approaches to necrotizing fasciitis management and explore new diagnoistic and therapeutic alternatives.
References
Chen LL, Fasolka B, Treacy C. Necrotizing fasciitis: A comprehensive review. Nursing. 2020;50(9):34-40. doi:10.1097/01.NURSE.0000694752.85118.62
Rahim GR, Gupta N, Maheshwari P, Singh MP. Monomicrobial Klebsiella pneumoniae necrotizing fasciitis: an emerging life-threatening entity. Clin Microbiol Infect. 2019;25(3):316-323. doi:10.1016/j.cmi.2018.05.008
Puvanendran R, Huey JC, Pasupathy S. Necrotizing fasciitis. Can Fam Physician. 2009;55(10):981-987.
Salati SA. Necrotizing fasciitis a review. Pol Przegl Chir. 2022;95(2):1-8. doi:10.5604/01.3001.0015.7676
Donaldson PM, Naylor B, Lowe JW, Gouldesbrough DR. Rapidly fatal necrotising fasciitis caused by Streptococcus pyogenes. J Clin Pathol. 1993;46(7):617-620. doi:10.1136/jcp.46.7.617
Wong CH, Song C, Ong YS, Tan BK, Tan KC, Foo CL. Abdominal wall necrotizing fasciitis: it is still "Meleney's Minefield". Plast Reconstr Surg. 2006;117(7):147e-150e. doi:10.1097/01.prs.0000219079.65910.54
Chou PY, Hsieh YH, Lin CH. Necrotizing fasciitis of the entire head and neck: Literature review and case report. Biomed J. 2020 Feb;43(1):94-98. doi: 10.1016/j.bj.2019.08.002.
Wilke J, Schleip R, Klingler W, Stecco C. The Lumbodorsal Fascia as a Potential Source of Low Back Pain: A Narrative Review. Biomed Res Int. 2017;2017:5349620. doi:10.1155/2017/5349620
Wilke J, Schleip R, Yucesoy CA, Banzer W. Not merely a protective packing organ? A review of fascia and its force transmission capacity. J Appl Physiol (1985). 2018;124(1):234-244. doi:10.1152/japplphysiol.00565.2017
Wallace HA, Perera TB. Necrotizing Fasciitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; February 21, 2023.
Al-Qurayshi Z, Nichols RL, Killackey MT, Kandil E. Mortality Risk in Necrotizing Fasciitis: National Prevalence, Trend, and Burden. Surg Infect (Larchmt). 2020;21(10):840-852. doi:10.1089/sur.2019.277
Pejman Davoudian, Neil J Flint, Necrotizing fasciitis, Continuing Education in Anaesthesia Critical Care & Pain, Volume 12, Issue 5, October 2012, Pages 245–250, https://doi.org/10.1093/bjaceaccp/mks033
Stegeman SA, Nijhuis I, van Leeuwen AM, Bonsing BA, Steenvoorde P. The value of frozen section biopsy in diagnosing necrotizing fasciitis: proposal of a new grading system. J Tissue Viability. 2012;21(1):13-16. doi:10.1016/j.jtv.2011.10.002
An TJ, Benvenuti MA, Mignemi ME, Thomsen IP, Schoenecker JG. Pediatric Musculoskeletal Infection: Hijacking the Acute-Phase Response. JBJS Rev. 2016;4(9):e4. doi:10.2106/JBJS.RVW.15.00099
Sverdrup B, Blombäck M, Borglund E, Hammar H. Blood coagulation and fibrinolytic systems in patients with erysipelas and necrotizing fasciitis. Scand J Infect Dis. 1981;13(1):29-36. doi:10.1080/00365548.1981.11690363
Hysong, Alexander A. MD*; Posey, Samuel L. MD*; Blum, Deke M. MD*; Benvenuti, Michael A. MD; Benvenuti, Teresa A. BA; Johnson, Samuel R. BS; An, Thomas J. MD; Devin, Jessica K. MD; Obremskey, William T. MD, MPH; Martus, Jeffrey E. MD; Moore-Lotridge, Stephanie N. PhD; Schoenecker, Jonathan G. MD, PhD. Necrotizing Fasciitis: Pillaging the Acute Phase Response. The Journal of Bone and Joint Surgery 102(6):p 526-537, March 18, 2020. | DOI: 10.2106/JBJS.19.00591
Hua J, Friedlander P. Cervical Necrotizing Fasciitis, Diagnosis and Treatment of a Rare Life-Threatening Infection. Ear Nose Throat J. 2023;102(3):NP109-NP113. doi:10.1177/0145561321991341
Bonne SL, Kadri SS. Evaluation and Management of Necrotizing Soft Tissue Infections. Infect Dis Clin North Am. 2017;31(3):497-511. doi:10.1016/j.idc.2017.05.011
Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009;208(2):279-288. doi:10.1016/j.jamcollsurg.2008.10.032
Peetermans M, de Prost N, Eckmann C, Norrby-Teglund A, Skrede S, De Waele JJ. Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect. 2020;26(1):8-17. doi:10.1016/j.cmi.2019.06.031
Singh DK, Kapoor R, Yadav PS, et al. Morbidity and Mortality of Necrotizing Fasciitis and Their Prognostic Factors in Children. J Indian Assoc Pediatr Surg. 2022;27(5):577-584. doi:10.4103/jiaps.jiaps_222_21
Hietbrink, F., Bode, L.G., Riddez, L. et al. Triple diagnostics for early detection of ambivalent necrotizing fasciitis. World J Emerg Surg 11, 51 (2016). https://doi.org/10.1186/s13017-016-0108-z
T Goh, L G Goh, C H Ang, C H Wong, Early diagnosis of necrotizing fasciitis, British Journal of Surgery, Volume 101, Issue 1, January 2014, Pages e119–e125, https://doi.org/10.1002/bjs.9371
Paz Maya, S., Dualde Beltrán, D., Lemercier, P. et al. Necrotizing fasciitis: an urgent diagnosis. Skeletal Radiol 43, 577–589 (2014). https://doi.org/10.1007/s00256-013-1813-2
Wong C.H., Khin L.W., Heng K.S., Tan K.C., Low C.O.: The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med., 2004; 32(7): 1535–1541. doi: 10.1097/01.ccm.0000129486.35458.7d.
Breidung D, Malsagova AT, Barth AA, et al. Diagnostic and prognostic value of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) based on an 18 years' experience. J Plast Reconstr Aesthet Surg. 2023;77:228-235. doi:10.1016/j.bjps.2022.11.061
Wu H., Liu S., Li C., Song Z.: Modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) Score System in Diagnosing Necrotizing Fasciitis: A Ne-sted Case-Control Study. Infect Drug Resist., 2021; 14: 2105–2112. doi: 10.2147/IDR.S313321.
Masood Q., Zainab A., Zil A.E. et al.: Imaging studies to diagnose necrotizing fa-sciitis: a noninvasive approach for clinician. MOJ Surg., 2017; 5(3): 203‒204. doi: 10.15406/mojs.2017.05.00111.
Kim K.T., Kim Y.J., Won Lee J. et al.: Can necrotizing infectious fasciitis be diffe-rentiated from nonnecrotizing infectious fasciitis with MR imaging? Radiology., 2011; 259(3): 816–824. doi: 10.1148/radiol.11101164.
Clark ML, Fisher KL. Sonographic Detection of Necrotizing Fasciitis. Journal of Diagnostic Medical Sonography. 2017;33(4):311-316. doi:10.1177/8756479317701412
Anaya D.A., Patchen Dellinger E.: Necrotizing Soft-Tissue Infection: Diagnosis and Management. Clin Infect Dis., 2007; 44(5): 705–710.
Wronski M., Slodkowski M., Cebulski W., Karkocha D., Krasnodebski I.W.: Ne-crotizing fasciitis: early sonographic diagnosis. J Clin Ultrasound., 2011; 39(4): 236–239. doi: 10.1002/jcu.20766.
Martinez M., Peponis T., Hage A. et al.: The Role of Computed Tomography in the Diagnosis of Necrotizing Soft Tissue Infections. World J Surg., 2018; 42(1): 82–87. doi: 10.1007/s00268-017-4145-x.
Zacharias N., Velmahos G.C., Salama A. et al.: Diagnosis of necrotizing soft tis-sue infections by computed tomography. Arch Surg., 2010; 145(5): 452–455. doi: 10.1001/archsurg.2010.50.
Hakkarainen T.W., Kopari N.M., Pham T.N., Evans H.L.: Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outco-mes. Curr Probl Surg., 2014; 51(8): 344–362. doi: 10.1067/j.cpsurg.2014.06.001.
Dueppers P, Bozalka R, Kopp R, et al. The Use of Intact Fish Skin Grafts in the Treatment of Necrotizing Fasciitis of the Leg: Early Clinical Experience and Literature Review on Indications for Intact Fish Skin Grafts. J Clin Med. 2023;12(18):6001. Published 2023 Sep 16. doi:10.3390/jcm12186001
A Schwartz Robert, MD, MPH, 13.06.2023, Necrotizing Fasciitis Empiric Therapy, Medscape, https://emedicine.medscape.com/article/2012058-overview?form=fpf , Accessed 12.01.2024.
Marongiu F, Buggi F, Mingozzi M, Curcio A, Folli S. A rare case of primary necrotising fasciitis of the breast: combined use of hyperbaric oxygen and negative pressure wound therapy to conserve the breast. Review of literature. Int Wound J. 2017;14(2):349-354. doi:10.1111/iwj.12607
Menichetti F, Giuliano S, Fortunato S. Are there any reasons to change our behavior in necrotizing fasciitis with the advent of new antibiotics?. Curr Opin Infect Dis. 2017;30(2):172-179. doi:10.1097/QCO.0000000000000359
Huang C, Zhong Y, Yue C, He B, Li Y, Li J. The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg. 2023;18(1):23. Published 2023 Mar 25. doi:10.1186/s13017-023-00490-y
Cianci P, Sato R. Adjunctive hyperbaric oxygen therapy in the treatment of thermal burns: a review. Burns. 1994;20(1):5-14. doi:10.1016/0305-4179(94)90099-x
Levett D, Bennett MH, Millar I. Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Database Syst Rev. 2015;1(1):CD007937. Published 2015 Jan 15. doi:10.1002/14651858.CD007937.pub2
Anheuser P, Mühlstädt S, Kranz J, Schneidewind L, Steffens J, Fornara P. Significance of Hyperbaric Oxygenation in the Treatment of Fournier's Gangrene: A Comparative Study. Urol Int. 2018;101(4):467-471. doi:10.1159/000493898
Flam F, Boijsen M, Lind F. Necrotizing fasciitis following transobturator tape treated by extensive surgery and hyperbaric oxygen. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(1):113-115. doi:10.1007/s00192-008-0653-4
Sartelli M, Coccolini F, Kluger Y, et al. WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections. World J Emerg Surg. 2022;17(1):3. Published 2022 Jan 15. doi:10.1186/s13017-022-00406-2
Dhawan G, Kapoor R, Dhamija A, Singh R, Monga B, Calabrese EJ. Necrotizing Fasciitis: Low-Dose Radiotherapy as a Potential Adjunct Treatment. Dose Response. 2019;17(3):1559325819871757. Published 2019 Aug 28. doi:10.1177/1559325819871757
Morgan MS. Diagnosis and management of necrotising fasciitis: a multiparametric approach. J Hosp Infect. 2010;75(4):249-257. doi:10.1016/j.jhin.2010.01.028
Norrby-Teglund A, Muller MP, Mcgeer A, et al. Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach. Scand J Infect Dis. 2005;37(3):166-172. doi:10.1080/00365540410020866
Cawley MJ, Briggs M, Haith LR Jr, et al. Intravenous immunoglobulin as adjunctive treatment for streptococcal toxic shock syndrome associated with necrotizing fasciitis: case report and review. Pharmacotherapy. 1999;19(9):1094-1098. doi:10.1592/phco.19.13.1094.31589
Rietveld JA, Pilmore HL, Jones PG, et al. Necrotising fasciitis: a single centre's experience. N Z Med J. 1995;108(995):72-74.
Darenberg J, Ihendyane N, Sjölin J, et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis. 2003;37(3):333-340. doi:10.1086/376630
Iba T, Levy JH, Raj A, Warkentin TE. Advance in the Management of Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation. J Clin Med. 2019;8(5):728. Published 2019 May 22. doi:10.3390/jcm8050728
Arishima T, Ito T, Yasuda T, et al. Circulating activated protein C levels are not increased in septic patients treated with recombinant human soluble thrombomodulin. Thromb J. 2018;16:24. Published 2018 Sep 28. doi:10.1186/s12959-018-0178-0
Nishida O, Ogura H, Egi M, et al. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016). Acute Med Surg. 2018;5(1):3-89. Published 2018 Feb 5. doi:10.1002/ams2.322
Warner P, Fields AL, Braun LC, et al. Thrombocytopenia in the pediatric burn patient. J Burn Care Res. 2011;32(3):410-414. doi:10.1097/BCR.0b013e318217f91b
Lin JJ, Wu CT, Hsia SH, Chiu CH. Bullous impetigo: a rare presentation in fulminant streptococcal toxic shock syndrome. Pediatr Emerg Care. 2007;23(5):318-320. doi:10.1097/01.pec.0000270166.62991.8c
Levi M, de Jonge E, van der Poll T. Plasma and plasma components in the management of disseminated intravascular coagulation. Best Pract Res Clin Haematol. 2006;19(1):127-142. doi:10.1016/j.beha.2005.01.027
Calandruccio JH, Grear BJ, Mauck BM, Sawyer JR, Toy PC, Weinlein JC. Infection, an issue of orthopedic clinics, volume 48–2. 1st ed. New York: Elsevier Health Sciences; 2017
Akca S, Haji-Michael P, de Mendonça A, Suter P, Levi M, Vincent JL. Time course of platelet counts in critically ill patients. Crit Care Med. 2002;30(4):753-756. doi:10.1097/00003246-200204000-00005
Nancy F. Crum, Braden R. Hale, Sharon E. Judd, Matthew L. Lim, Mark R. Wallace, A Case Series of Group A Streptococcus Necrotizing Fasciitis in Military Trainees, Military Medicine, Volume 169, Issue 5, May 2004, Pages 373–375, doi:10.7205/MILMED.169.5.373
Murthy T. Blood transfusion practices in sepsis. Indian J Anaesth. 2014;58(5):643-646. doi:10.4103/0019-5049.144676
Mica L, Simmen H, Werner CM, et al. Fresh frozen plasma is permissive for systemic inflammatory response syndrome, infection, and sepsis in multiple-injured patients. Am J Emerg Med. 2016;34(8):1480-1485. doi:10.1016/j.ajem.2016.04.041
Straat M, Müller MC, Meijers JC, et al. Effect of transfusion of fresh frozen plasma on parameters of endothelial condition and inflammatory status in non-bleeding critically ill patients: a prospective substudy of a randomized trial. Crit Care. 2015;19(1):163. Published 2015 Apr 15. doi:10.1186/s13054-015-0828-6
Umemura Y, Yamakawa K, Ogura H, Yuhara H, Fujimi S. Efficacy and safety of anticoagulant therapy in three specific populations with sepsis: a meta-analysis of randomized controlled trials. J Thromb Haemost. 2016;14(3):518-530. doi:10.1111/jth.13230
Fan Y, Jiang M, Gong D, Zou C. Efficacy and safety of low-molecular-weight heparin in patients with sepsis: a meta-analysis of randomized controlled trials. Sci Rep. 2016;6:25984. Published 2016 May 16. doi:10.1038/srep25984
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165-228. doi:10.1007/s00134-012-2769-8
Annane D, Pastores SM, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Crit Care Med. 2017;45(12):2078-2088. doi:10.1097/CCM.0000000000002737
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