Necrotising fasciitis

Necrotising fasciitis

Meleney’s synergistic gangrene and Fournier’s gangrene are variants of a similar disease process. Necrotising fasciitis results from synergistic polymicrobial infection, most commonly a group A β -haemolytic Streptococcus in combination with Staphylococcus , Escherichia coli , Pseudomonas Proteus , Bacteroides or Clostridium ; 80% of patients have a his tory of previous trauma/infection and over 60% of cases commence in the lower extremities. Predisposing conditions include diabetes mellitus, smoking, penetrating trauma, pressure sores, immunosuppression, intravenous drug ab perineal infection (perianal abscess, Bartholin’s cysts) and skin damage/infection (abrasions, bites, boils). Summary box 45.1 Necrotising fasciitis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Classical clinical signs include oedema stretching beyond visible skin erythema; a woody-hard texture to the subcutane ous tissues; an inability to distinguish fascial planes and muscle Frank Meleney , 1889–1963, American surgeon in the First World War, then became a Professor at Columbia Medical School in New Y ork, NY , USA. Jean Fournier , 1832–1914, French dermatologist, also described tertiary syphilis. Caspar Bartholin (Secundus) , 1655–1709, Professor of Medicine, Anatomy and Physics, Copenhagen, Denmark, described these glands in 1677. groups on palpation; disproportionate pain in relation to the a ff ected area, with associated skin vesicles and soft-tissue crep - itus ( Figure 45.9 ). Lymphangitis tends to be absent. Early on, patients may be febrile and tachycardic, with a very rapid pro - ve gression to septic shock. Radiographs, which should not ha delayed urgent treatment, may demonstrate air in the tissues. , Management should commence with urgent fluid resus - - citation, monitoring of haemodynamic status and adminis - tration of high-dose intravenous broad-spectrum antibiotics. This is a surgical emergency and the diseased area should be leeding tis - debrided as soon as possible until viable, healthy , b use, sue is reached. Early surgical review and further debridement is advisable, together with the use of vacuum-assisted dress - ings. Early skin grafting in selected cases may minimise protein yperbaric oxygen therapy and fluid losses. Where available, h after debridement may be helpful. Mortality of between 30% and 50% can be expected, even with prompt opera tive inter - vention.

Surgical emergency Polymicrobial synergistic infection 80% have a history of previous trauma or infection Rapid progression to septic shock Urgent resuscitation, antibiotics and surgical debridement Mortality 30–50%

Figure 45.8 Cellulitis affecting the left leg (courtesy of St John’s Institute for Dermatology, London, UK).

Necrotising fasciitis

Meleney’s synergistic gangrene and Fournier’s gangrene are variants of a similar disease process. Necrotising fasciitis results from synergistic polymicrobial infection, most commonly a group A β -haemolytic Streptococcus in combination with Staphylococcus , Escherichia coli , Pseudomonas Proteus , Bacteroides or Clostridium ; 80% of patients have a his tory of previous trauma/infection and over 60% of cases commence in the lower extremities. Predisposing conditions include diabetes mellitus, smoking, penetrating trauma, pressure sores, immunosuppression, intravenous drug ab perineal infection (perianal abscess, Bartholin’s cysts) and skin damage/infection (abrasions, bites, boils). Summary box 45.1 Necrotising fasciitis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Classical clinical signs include oedema stretching beyond visible skin erythema; a woody-hard texture to the subcutane ous tissues; an inability to distinguish fascial planes and muscle Frank Meleney , 1889–1963, American surgeon in the First World War, then became a Professor at Columbia Medical School in New Y ork, NY , USA. Jean Fournier , 1832–1914, French dermatologist, also described tertiary syphilis. Caspar Bartholin (Secundus) , 1655–1709, Professor of Medicine, Anatomy and Physics, Copenhagen, Denmark, described these glands in 1677. groups on palpation; disproportionate pain in relation to the a ff ected area, with associated skin vesicles and soft-tissue crep - itus ( Figure 45.9 ). Lymphangitis tends to be absent. Early on, patients may be febrile and tachycardic, with a very rapid pro - ve gression to septic shock. Radiographs, which should not ha delayed urgent treatment, may demonstrate air in the tissues. , Management should commence with urgent fluid resus - - citation, monitoring of haemodynamic status and adminis - tration of high-dose intravenous broad-spectrum antibiotics. This is a surgical emergency and the diseased area should be leeding tis - debrided as soon as possible until viable, healthy , b use, sue is reached. Early surgical review and further debridement is advisable, together with the use of vacuum-assisted dress - ings. Early skin grafting in selected cases may minimise protein yperbaric oxygen therapy and fluid losses. Where available, h after debridement may be helpful. Mortality of between 30% and 50% can be expected, even with prompt opera tive inter - vention.

Surgical emergency Polymicrobial synergistic infection 80% have a history of previous trauma or infection Rapid progression to septic shock Urgent resuscitation, antibiotics and surgical debridement Mortality 30–50%

Figure 45.8 Cellulitis affecting the left leg (courtesy of St John’s Institute for Dermatology, London, UK).

Necrotising fasciitis

Meleney’s synergistic gangrene and Fournier’s gangrene are variants of a similar disease process. Necrotising fasciitis results from synergistic polymicrobial infection, most commonly a group A β -haemolytic Streptococcus in combination with Staphylococcus , Escherichia coli , Pseudomonas Proteus , Bacteroides or Clostridium ; 80% of patients have a his tory of previous trauma/infection and over 60% of cases commence in the lower extremities. Predisposing conditions include diabetes mellitus, smoking, penetrating trauma, pressure sores, immunosuppression, intravenous drug ab perineal infection (perianal abscess, Bartholin’s cysts) and skin damage/infection (abrasions, bites, boils). Summary box 45.1 Necrotising fasciitis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Classical clinical signs include oedema stretching beyond visible skin erythema; a woody-hard texture to the subcutane ous tissues; an inability to distinguish fascial planes and muscle Frank Meleney , 1889–1963, American surgeon in the First World War, then became a Professor at Columbia Medical School in New Y ork, NY , USA. Jean Fournier , 1832–1914, French dermatologist, also described tertiary syphilis. Caspar Bartholin (Secundus) , 1655–1709, Professor of Medicine, Anatomy and Physics, Copenhagen, Denmark, described these glands in 1677. groups on palpation; disproportionate pain in relation to the a ff ected area, with associated skin vesicles and soft-tissue crep - itus ( Figure 45.9 ). Lymphangitis tends to be absent. Early on, patients may be febrile and tachycardic, with a very rapid pro - ve gression to septic shock. Radiographs, which should not ha delayed urgent treatment, may demonstrate air in the tissues. , Management should commence with urgent fluid resus - - citation, monitoring of haemodynamic status and adminis - tration of high-dose intravenous broad-spectrum antibiotics. This is a surgical emergency and the diseased area should be leeding tis - debrided as soon as possible until viable, healthy , b use, sue is reached. Early surgical review and further debridement is advisable, together with the use of vacuum-assisted dress - ings. Early skin grafting in selected cases may minimise protein yperbaric oxygen therapy and fluid losses. Where available, h after debridement may be helpful. Mortality of between 30% and 50% can be expected, even with prompt opera tive inter - vention.

Surgical emergency Polymicrobial synergistic infection 80% have a history of previous trauma or infection Rapid progression to septic shock Urgent resuscitation, antibiotics and surgical debridement Mortality 30–50%

Figure 45.8 Cellulitis affecting the left leg (courtesy of St John’s Institute for Dermatology, London, UK).